Since I last wrote about the impending DSM-5, Dr. Ronald Pies’ blog post appeared in World of Psychology here at Psych Central. I found Pies’ post, Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal, interesting on several levels. Foremost was the fact that Pies calls for a replacement of the DSM that sounded hauntingly familiar.
Storytelling is very Canadian, eh?
Pies’ suggested approach to replace the current DSM diagnostic tool looked a lot like something already being used by Canadian psychiatrist Dr. Tim Bilkey. Bilkey has diagnosed over 3400 adolescents and adults at his ADHD clinics in Ontario.
The approach suggested by Pies and practiced by Bilkey focuses on the patient as a whole, taking into account their life story, and the patient’s own subjective worldview.
I can’t resist pointing out that Pies began his post with a quote from another Canadian physician (Sir William Osler, 1849-1919) who also put the emphasis on the patient, rather than a disembodied list of symptoms. Maybe we Canadians are onto something, eh?
A behind-the-scenes peek
I was surprised when I read in Pies’ blog post, “…many psychiatrists routinely ignore the DSM in their clinical practices.” Pies, who is himself a psychiatrist, suggests that the current DSM criteria that rely on lists of symptoms should be scrapped in lieu of a more practical and useful model.
The clincher that brought my first interview with Dr. Bilkey to mind was Pies’ statement that:
“Most experienced clinicians listen carefully to the patient’s personal and family history; weigh this narrative in light of some general diagnostic categories, and arrive at a “gestalt” understanding of their patient’s condition.”
What’s your story?
The word “narrative” is another word for story (Webster’s Ninth New Collegiate Dictionary). And if anyone’s got stories, it’s us ADHDers. I’m no expert in other mental health conditions, but I know one thing for sure: when it comes to ADHD, we’re much more than the sum of our symptoms. We’re tragicomedies; we’re melodramas; we’re family sagas; we’re epic.
Depending on our symptoms, our comorbidities, and many other factors, our particular flavor of ADHD will tell one story or another.
As far as stories go, Dr.Bilkey’s come up with 10 ADHD classics. He created these narratives, which he calls patient profiles, to help frontline medical doctors recognize ADHD in their patients (in Canada, it’s frequently a family physician who is first approached, and sometimes makes a diagnosis of ADHD). Bilkey uses these profiles as part of his diagnostic toolkit to diagnose ADHD in teens and adults.
As part of his re-visioning of a diagnostic tool, Pies says, “For disease entities that have highly variable presentations, more than one prototype would be provided.” Bingo! We’re right back to Bilkey’s 10 profiles.
Been there, done that
I don’t know if this approach has been developed for use in diagnosing other psychiatric conditions; it could be that, in the field of ADHD, we’re blessed with forward-thinking, innovative clinicians and researchers who are ahead of the game.
Pies is advocating a similar approach to diagnose all psychiatric disorders. In the meantime, as Pies points out, a new version of the DSM is a foregone conclusion. Nonetheless, I found Pies’ behind-the-scenes look (in addition to my talks with Dr. Bilkey), at how psychiatrists actually diagnose fascinating. It may be that even more practitioners will opt for a more wholistic approach in the future, making the DSM-5 look more like fiction than fact. Only time will tell.
If you’re interested in this diagnostic approach, check out Dr. Bilkey’s ADHD screening tool here (you might just find your own story): FAST Minds™ and Patient Profiles
For more in-depth discussion, read Dr. Pies’ blog post, and especially the comments that follow, Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal.