by Shirin M.
Every mental disorder in a single book—convenient right? Well not exactly.
This book is known as the Diagnostic and Statistical Manual of Mental Disorders (DSM), and it helps mental health professionals diagnose patients with mental disorders. The DSM breaks down each disorder into a checklist of symptoms that an individual must tick off to officially be labeled with a specific disorder. Why is this label so important? Well, it’s a bit like when your best friend moves away for university—a bittersweet moment. Living without them will be challenging, but you know they will benefit from this experience. Similarly, receiving a diagnosis can be hard to cope with, but it also provides access to resources like medication, therapy programs, and exam accommodations at school. So, having a book like the DSM can be very helpful for both the mental health professional and the patient.
However, setting such specific requirements for a diagnosis means that not everyone will make the cut—even if they could benefit from the resources that come with being labeled. So, what happens to these outliers?
Think of it like this. If you were stopped at a never-ending stop light on a deserted road, would you just sit there waiting until the end of time? Chances are that you, like me, would give it a total of 3 minutes before looking both ways and carrying on with your day. Mental health professionals are just like us! They don’t shoo their patients away if they need help—they “break the rules” to address the needs of patients who do not meet diagnostic criteria.
An example of such a rule break is if someone visits a mental health professional for concerns about stress but does not meet the requirements for the DSM-defined social anxiety disorder. So, the mental health professional gives them a low-level diagnosis like adjustment disorder instead, defined as a negative reaction to a stressful event. What happens here is called “fudging” the diagnosis—labelling an individual even when they do not meet the official criteria. A 2010 study on diagnostic ambivalence revealed that psychiatrists will openly admit to fudging to help their patients gain access to treatment options. When asked why, they shared that the DSM did not translate very well into practice and the “real world.” With each new edition, the Diagnostic and Statistical Manual of Mental Disorders (DSM) undergoes refinement of its criteria, leading mental health professionals to face a dilemma. They find themselves in a situation where they must carefully consider the consequences of deviating from the established criteria, commonly known as ‘fudging,’ while also balancing their ethical obligation to uphold the principle of truth-telling.”. This sends a strong message that the DSM is not perfect, and making a mental health diagnosis can essentially reduce to “gaming the system”.
So, what is the solution here? Should mental health professionals keep “fudging” their diagnoses to help their patients? I think the answer is clear. One option is to say goodbye to the DSM and say hello to practical alternatives!
One example is the Hierarchical Taxonomy of Psychopathology, or HiTOP. This alternative promises to provide mental health professionals with a better way of diagnosing mental disorders, especially for those who do not fit the DSM’s one-size-fits-all approach. Rather than categorizing mental illness, HiTOP takes advantage of a continuum model, identifying a range of behaviours between healthy and severe. Different components of mental illness are split into their own spectrum, which all come together to create an individual’s HiTOP profile.
Let’s return to the example of diagnosing someone with adjustment disorder instead of social anxiety disorder. The DSM clearly states that a diagnosis of social anxiety disorder requires an individual to almost always feel anxious in social environments and avoid them whenever possible. You either meet these criteria, or you don’t. HiTOP, on the other hand, recognizes social anxiety as a dimension between healthy and severe. After all, social anxiety may occur in some situations and not others, like if you only fear public speaking. This way, HiTOP allows mental health professionals to capture individual differences and not fret about whether someone meets an exact number of symptoms.
With HiTOP, people no longer must fit the diagnosis—the diagnosis will fit them.
