The Perils of the DSM-V?

Quite some time ago, friend of the blog Walter Olson of Overlawered opined on the proposed revisions to the DSM-IV, soon to be the DSM-5, which will apparently include some brand new mental disorders therein.  (He also tweeted a link to a related news report). The DSM, of course, is the The Diagnostic and Statistical Manual of Mental Disorders, a thick volume published by the American Psychiatric Association which purports to list (and include the elements of) a host of mental disorders.  Daily, it is used by practitioners – from psychiatrists to primary care physicians – to diagnose particular mental conditions, from potential tobacco addiction to post traumatic stress disorder. It’s often called “the Bible of the profession.” Predictably, Plaintiffs’ experts often use the mighty tome – haphazardly, more likely than not – to advance their clients’ cases.

Olson linked to a piece he wrote for the Cato Institute, in which he speculates that the liberalization of standards for preexisting mental disorders and the addition of new disorders – such as Internet Addiction Disorder and Mild Neurocognitive Disorder – will result in a flurry of new claims for benefits, discrimination, and such.  Certainly, plaintiffs’ retained testifying experts – and local treating physicians and mental health providers advocating for their patients in personal injury lawsuits – may seize upon these new diagnoses.  However, many of these experts and plaintiff friendly treaters do not actually employ the formal DSM criteria when making these diagnoses in the first place.  Whatever you say about the merits or lack thereof of the DSM-IV, many plaintiffs’ experts and treaters shoot from the hip when making these mental diagnoses.  When they see a patient claiming psychological symptoms following a traumatic incident, they immediately leap to a PTSD diagnosis without employing the specific multi-axial diagnosis process.  Further, when called upon to analyze the factors set forth in Axis IV, which requires an analysis of  – or at the every least, knowledge and consideration of – other environmental or psychosocial factors contributing to the patient’s condition, these providers almost never conduct any independent evaluation.

The DSM-IV-TR provides that the mental health professional consider a number of factors when performing a multi-axial diagnosis, including such things as the following:

  • Source of psychosocial and environmental problems interview with patient and parents?
  • Positive stressors
  • Problems with primary support group?
    • Death of a family member
    • Health problems in the family
    • Disruption of family by separation
    • Divorce or estrangement
    • Removal from the home
  • Problems related to social environment
    • Death or loss of a friend
    • Living alone
    • Difficulty with acculturation
    • Adjustment to life transition (such as retirement)
    • Adjustment to life-cycle transition
  • Occupational Problems?
    • Unemployment
    • Threat of job loss
    • Stressful work schedule
    • Difficult work conditions
    • Job dissatisfaction
    • Job Change
    • Discord with boss or co-workers?
  • Economic Problems?
    • Extreme poverty
    • Inadequate finances
    • Insufficient welfare support
  • Housing Problems?
    • Homelessness
    • Inadequate housing
    • Unsafe neighborhood
    • Discord with neighbors or landlord
  • Problems with access to health care services?
  • Problems with primary support group
  • Problems related to interaction with legal system/crime
    • Litigation
    • Arrest or incarceration or victim of crime?
  • Other psychosocial and environmental problems?

Yet, in the rush to reach a diagnosis, the professional often fails to consider many of these as alternatives to the event being litigation.  (Also neglected is secondary gain syndrome, an ailment which Plaintiff’s retained testifying experts never seem to diagnose.). Thus, we can always rely on plaintiff’s testifying experts to fail to do what the DSM instructs.  This can be helpful when cross examining or deposing these experts before trial.  Even plaintiff friendly treaters, in their attempts to get one patient out the door so the next one can come in, do not traditionally take all of the steps suggested by the DSM-IV or analyze the factors of a full multi-axial diagnosis. So, as with any list, people skip steps, particularly when they feel they can. In this setting, defense counsel can sometimes actually benefit from the extraordinary detail of the publication by highlighting all of the portions of the guidelines that the expert failed to consider or make a part of his or her analysis.

So, even when the DSM-5 arrives, we can still count on these individuals to take short cuts. (Although we’re a bit concerned about this “Internet Addiction Disorder.”  Might we here have that?).

(Hat tip also to these two tweets from Jay Hornack a/k/a Panic Street Lawyer: here and here).


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