Alternatives to the DSM

 

In the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) the American Psychiatric Association speaks to the limitations of what they call a "categorical approach" to making diagnoses.

 

Specifically they point out that the use of categories to describe conditions while useful, would be more ideal if all conditions had clearly defined boundaries so that there would never be confusion as to which diagnosis a person might have. In other words it would be nice if everyone with a particular condition had exactly the same symptoms that would manifest in exactly the same way, and if it were impossible to have more than one condition at the same time. 

 

However, this is not how things are in our world and in spite of some potential alternatives they determined that the categorical approach was the best of the available options. Nevertheless, in this article we describe two such alternatives for the sake of comparison and better understanding what an alternative system might look like.

 

The Dimensional Model

One proposed alternative is The Dimensional Model. Using such an approach would allow professionals to look at all symptoms on a scale as opposed to taking a dichotomous approach where a symptom is either present or absent. For instance, if one symptom is lethargy the current categorical approach forces a mental health professional to determine is a person is or is not lethargic. However, a dimensional approach would instead ask how lethargic the person is. On a scale of 1 to 10 for instance the person may be a zero, may be a four, a seven, etc.

 

This approach offers more flexibility than the current approach that says you're either lethargic or you're not. At the same time however, it is still a subjective measure and there will still be uncertainties. With the categorical approach it might be required that a person be lethargic to be given a certain diagnosis. With the dimensional model, we'd have a similar problem. At what point is lethargy considered impactful enough to be considered a symptom? Is a four simply a nuisance that you can deal with, while a five is suddenly part of a disorder? Again someone would need to draw what becomes an inherently arbitrary line in the sand.

 

The Person-In-Environment System

The National Association of Social Workers published a book offering their own alternative to the categorical system used by the American Psychiatric Association. They too point out the inherent risks of labeling which include bias and discrimination, as well as dehumanization. Yet they recognize that the benefits of a classification tool outweigh the risks. They do caution however that while the risks of classification should not prevent the development and use of a classification tool, it should encourage consideration of how such an instrument should be developed and used.

 

The Person-In-Environment (PIE) System attempts to offer a means of classifying "emotional, mental, and social problems", an alternative label for the term "mental disorders". As the name implies the PIE system considers the impact of a person's environment in their level of functioning.

 

The PIE system considers environmental issues, mental issues, and physical issues recognizing that they will all interact with one another. It also draws attention to both strengths as well as problems had by a person. It examines the relationship of these factors to the duration and severity of the person's presenting problem. The authors also point out that the PIE system is not a diagnostic tool, but rather a classification system: an instrument to aid in collecting and sharing information designed to help a person in need. It is not intended to replace the DSM, but rather to enhance it.

While any system such as this one will be inherently more thorough in collecting information about a person from an overall and holistic approach, that very same trait also makes such an approach more cumbersome and lengthy to use. As a result, such a system may not be as quickly and easily adopted as a simpler and less complex model like the categorical approach used in the DSM.

 

At this time, no single model has been offered as an option that is without flaws, and so while various models of diagnosing a person are worth discussion, the current system of using categories (i.e. diagnoses and labels) remains in use.

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