DSM Disorders Disappear in Statistical Clustering of Psychiatric Symptoms (2024)

My current psychiatrist figured out my main issues after talking to me for 15 minutes. Sent me off to a psychologist back up his assumptions before prescribing anything. Recommended therapists who specialize in the area I needed support in.

The psychologist I went to was great as well (after seeing one that was a terrible). She did a lot of testing (three sittings lasting around two hours) but said the tests were really just to rule out other things. The important part were the conversations.

My life improved tremendously after that.

Asking you “do you have trouble concentrating?” is lazy (at least, on its own. Asking a patient to perform a self-assessment is not bad medicine necessarily). A doctor should also be evaluating your concentration in other ways.

My own personal experience with psychologists and psychiatrists, is most of them don’t go by the text of the DSM, they go by the understanding of various disorders they’ve received from their teachers, mentors, supervisors, colleagues-which at times has a rather loose relationship with what the text of the DSM actually says-and once they’ve made their minds up as to what is the correct diagnosis, then-when required for a formal report-they look at the DSM text and work out how to justify their diagnostic decision by relating what the text says to the evidence at hand

The DSM isn’t the source of those question inventories. There are different question sets for different conditions that each have their own source, often a set of researchers or an institution that has put in some work to study and test them. Some of the more obscure question inventories are even paid material that clinicians (or their offices, more accurately) are supposed to license.

I caution against the clinicians who do rapid-fire diagnostics and slap a label on the patient within minutes of talking to them. Some patients like this when the diagnosis matches what they already self-diagnosed or they want to hear, but in these cases some clinicians are just picking up on the hints the patient gave and mirroring it back to them.

This rapid diagnostic method is an easy way to improve your patient satisfaction scores (important for performance measures at some clinics, especially when PE or corporate gets involved) and it’s an obvious way to free up some time in a clinician’s busy day.

There is a growing problem of lazy providers who try to speedrun the diagnosis and send patients on their way with a prescription for something and a request for a follow up appointment. During COVID when controlled substance prescribing rules were loosened for remote appointments there were even pill mills that would advertise for specific diagnoses on TikTok and then incentivize the providers to see as many patients per day and prescribe them all Adderall because it turned them into repeat customers for the recurring prescriptions. There was a whistleblower who revealed that they were measured on their rates of prescribing controlled substances and discouraged from prescribing alternatives with lower abuse/addiction potential even when patients admitted to having drug abuse problems. This is an extreme example but don’t discount the incentive for your provider to shorten your appointment for selfish reasons, not because the patient’s condition is obvious and easy to diagnose accurately within minutes.

To be fair, for the practitioner this shouldn't be a question about objective capital-letter Truth, it's one throw of darts representing a self-reported aspect of self-experience and self-perception.

As someone who has designed questionnaires for a public health agency, reading the article made me feel we should've fully randomized the order of appearance of individual questions, including the 'front-matter' stuff like self-reported gender, age, education, marital status.

As someone who got quite upset about a particular questionnaire's formulations at the tender age of 10, I'd now say let's not get too wrought up about this, a questionnaire can be a valid tool but it will also always be a somewhat blunt tool, so let's use it bluntly: don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out. If it's about me then it's about how I feel about it, now, and I can choose to feel extremely good or bad or fairly somewhat well-nigh indifferent about sh*t, just here and now. As the one being questionnaired, I also have the right to lean into the questions and bend the outcome as I see fit. Been there, done that.

This is probably exacerbated by the closure of mental institutions where you could see in person what the textbook means exactly.

Trying to understand diseases just by the text (and not even considering differential diagnosis) is an exercise in frustration. And I feel more professionals lately are just "Chinesing room" it instead of having actual experience

To be clear, ADHD, despite having "disorder" in the name, is actually a syndrome: a complex of symptoms that, when recognized together, indicate that a certain set of interventional treatments will likely be applicable.

Diagnosing someone with a syndrome does not indicate any knowledge is available on the cause (etiology) of the symptoms. Many different things can cause the same set of symptoms. But if a certain treatment ameliorates anything qualifying as that syndrome, regardless of the upstream cause, then the diagnosis of the syndrome (and so the existence of the syndrome as a concept) is useful, even if it's not informative.

The DSM actually covers two very different categories of what we might call "mental" illnesses: neurocognitive illnesses, and neuroendocrine (or neurohormonal) illnesses.

Neurocognitive illnesses — structural problems with the brain or its cells (think Parkinson's Disease, or ALS, or Lewy Body dementia) — are usually traceable to specific etiologies, as each one usually has either a very unique presentation of signs and symptoms, or has unique markers that can be assayed/biopsied for.

Neuroendocrine illnesses, on the other hand, are almost always syndromes. Many different upstream problems (genetic, toxic, nutritive, auto-immune, etc) can potentially cause the same small menagerie of messenger-chemicals to get out of whack, and due to this, many different upstream problems end up looking like the same few "templates" of symptoms. If you can put the particular out-of-whack messenger-chemicals back into whack with drugs that do that, then you've fixed the symptoms — which doesn't fix the upstream problem (if it even can be fixed), but does fully compensate downstream for the upstream problem.

It does not logically follow that different symptoms -> different causes.

(Fire can cause smoke, heat, soot, etc. Depending on the wind and other conditions, only some of them may be observable.)

One root cause can manifest in different ways depending on interactions with other factors.

The genetic basis for ADHD is well studied and points to a single set of core causes.

but diagnostic names for groupings of common symptoms,

caused by seemingly completely unrelated stuff ranging from childhood trauma, to a staph infection or mercury leak in a tooth root.

Any ADHD diagnosis includes checking for any other mental or physical issue that could explain the symptoms. Any when anything else is ruled out AND it can be established that the person always struggled with those symptoms (ideally that they were present in childhood) will you get a diagnosis.

Furthermore we know that ADHD has a genetic link. You have a 40% chance to have it when your parent has it. While we don't know every detail about how ADHD develops, we know it is something you are born with.

I am so sick that people pretend that ADHD is some vague concept. No, it is vague for you because you are ignorant about it.

Yes, ADHD can show up very differently in people. Which is not surprising because people happen to be different. Covid-19 can have widely different symptoms between people, doesn't mean it is not real.

As an ADHD person when I interact with other with ADHD people, yes there are huge differences but there is always a shared understanding. I never have the feeling the person has a completely different thing. There is always shared understanding.

I think the most obvious conclusion is not that the DSM is bunk, but that some of things it groups together might be better to group separately. The real question of course is which grouping corresponds better to the group responding the same way to a similar intervention. After all the point diagnosing is to put people into groups so we can learn from the patterns of similar people to figure out better treatments.

In the end, a diagnosis only helps the patient if it enables a treatment, hopefully an effective one. If you have a cluster of symptoms with two possible causes, and there is no difference in the care for the patient, what's the point of further differential diagnosis?

Fwiw I think it’s patently obvious behaviors can influence people, but in my mind they influence the avenue of expression - they don’t create disorders from scratch. So like e.g. body image would be the underlying disorder, and if it expresses as bulimia or anorexia or cutting could be somewhat “socially contagious”.

None of these hold up under actual studies. It’s the domain of wishful thinking that sadly preys upon people desperate for answers. Some times the placebo effect works for a while, but usually people just end up with a cabinet full of supplement bottles and a history of fad diets with no progress on their condition.