Mental health

Beyond the Confines of the DSM V

The DSM V shows us what is “wrong” with patients, and it can limit our understanding of and compassion for those who have truly endured significant challenges.

Stephanie Lee, DO, MS

Stephanie Lee, DO, MS, is a psychiatry resident at Good Samaritan Regional Medical Center in Corvallis, Oregon.

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On a warm Wednesday afternoon, I was driving back home from my pediatric clerkship and decided to swing by the store to pick up ingredients for my new favorite recipe: mixing a hot chili bean sauce with string beans over rice. While I was waiting to check out, an old friend called and we got to talking about our experience on rotations. One question really made me think:

“What has been the best moment of your rotation so far?”

I turned this question over in my thoughts, replaying memories. I couldn’t help but recall subtle details about my conversations with patients—what their eyes looked like, how they softened or hardened when certain memories arose, the feeling in the room each time I walked in compared to right before I left.

The perception I had of the difference in finally being out of the textbooks and in the clinical setting was my experience with the elements of patient care I couldn’t see, only feel. Didactics rarely prepares you for dealing with the unseen, marginally capturing the nature of patient interaction. It’s something you must recognize for yourself.

‘Immersed in their essence’

Pediatrics in particular is a rotation that exemplifies this feeling. One thing I found especially interesting about the child in the clinic rather than the child on the page is their beautiful simplicity. They are completely immersed in their essence, untouched by societal conditioning. Their eyes revealed a deep comfort in the unknown of the vastness of this world.

They show me the meaning of “stillness.” Sometimes, when I am with them, they allow me to come back to that space. I feel a playful awareness that tells me I’m safe and I belong, with a need to unlearn the insecurities trained into me by adulthood.

I begin to remember a boy named Lucas*. He was an 8-year-old who shared a birthday with my father. He wore dark green pants with different colored socks and black shoes that had been well-worn and obviously played in. As I walked into our visit, he kept his eyes glued to his hands while his mother sat next to him. Her eyes were seasoned with haste and anticipation. She told me that his ADHD was getting worse and he had been more aggressive at school. A few moments later, she mentioned that her family was falling apart.

I looked over at Lucas and he continued to play with his hand, peeking at me for a few milliseconds before realizing I’d caught him, just to look back down. I noticed him glancing around the room in those few seconds when he thought I wasn’t looking. Despite all that was happening at home and school, his eyes were wide and full of innocent wonder. I saw a hidden spark that is often dampened in the eyes of children who have endured adverse events early on in life. There, I felt a soft heart yearning to be loved and understood, to belong and be seen.

The psychosocial/behavioral aspects of medicine

As osteopathic students, we are trained to observe and understand the psychosocial/behavioral aspects of medicine, equally alongside the biomechanical, neurological, respiratory-circulatory and metabolic models of patient care. I have taken special care to explore these aspects with my patients as I’ve grown to hold space for their painful reminiscence. I thank my patients, as they have deepened my prayers and meditation, while expanding my boundaries of compassion. They have deepened my understanding of the limitations to what we can do as healers.

The root of “Doctor” is Docere, “to teach.” It is said that we educate patients on how to live a healthier lifestyle, yet I believe the interaction happens both ways in the background. Upon meeting patients with troubled pasts, I sometimes realize that I too have hidden where they hide. Through pain, I’ve realized that our minds grow quite resilient and expansive.

Unfortunately, the DSM V has shown us what is “wrong” with patients like Lucas, and it limits our understanding of and compassion for those who have truly endured significant challenges. To simplify a patient to a DSM V classification has the potential to strip away many of their relevant past experiences and limit us to cataloging screenshots of what we see right now without context. It is difficult for patients like Lucas, whose personality, thoughts, and feelings appeared assigned to him by health care providers, parents, and teachers through the label of his diagnosis.

Beneath his diagnosis of ADHD, Lucas holds many more memories and perceptions that he may not have the mental faculties to express in this present moment. It is important that we compassionately and openly listen to our patients instead of being steered by a “one-size-fits all” conceptual roadmap of their experiences and current symptoms.

Humans are not meant to be boxed into categories. We have more complexity than the limitations of arbitrary definitions. If we can understand that a heart becomes hypertrophic due to physiological changes placing it under stress, why is it such a stretch to believe that certain behaviors in us are similar adaptations to psychological suffering?

The universal language of emotion

The heart of healing these patients is a shared understanding that our bodies are no longer living in that space; therefore, what was an evolved response to past stressors can be relived in the present.

It is a humbling thing to rediscover our own nature in others. The greatest lessons I have learned thus far is the application of osteopathic teachings in relation to others. It is learning to speak and tune in to the universal language of emotion that we all express in various intensities. The art of medicine is not only a mirror of who we are at our core, but also a display and dance with our past, present and future colliding with those of our patients and their families.

Through patient interactions, we get to see parts of ourselves that are hidden, and it is by shining light on these hidden parts of ourselves that we cultivate forbearance for the dimmer parts in others. This at last helps us hold space and treat complex psychological conditions and break free of the confines of the DSM V.

*name changed to preserve patient confidentiality

Editor’s note: This story was edited for The DO by David O. Shumway, DO. The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

Related reading:

How I navigated my grandfather’s death as a medical student

From medical skeptic to grateful and compliant: My recent patient’s transformation

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7 comments

  1. Arthur Lazarus, MD, MBA

    The DSM is not meant to to be confining; I’m sorry you feel that way. The DSM establishes a set of clinical criteria necessary to make a psychiatric diagnosis. Because treatment stems from diagnosis — not vice versa — you remain free to use your creativity and ingenuity in therapy and apply the art (and heart) of medicine to your patients. Medical textbooks do not breathe life into patients. That becomes your job once armed with medical knowledge.

    Reply

  2. Sam Garloff, DO

    I applaud both your insight and observations. The DSM 5-tr is not a text, not all inclusive and certainly not complete. It is a manual designed to provide the ability to allow discourse between multiple professions engaged in the treatment of patients. There certainly are those who rigorously adhere to the published symptom descriptions to make a diagnosis. They are not wrong, but certainly may miss nuances of the patient’s presentation leading to less than optimal intervention. I encourage you to continue to develop your skills of observation. I also most whole heartedly suggest that you engage in the study of transference. This will allow you to more fully understand the effect of patient interactions with you. Continue learning and continue your exploration of the human psyche. Docere, indeed.

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  3. Felix Toro, M.D.

    I will recommend you see the DSM, as the other methods of classifying diseases/disorders. Is no different than ICD, were history, signs, and symptoms are described to help you make a specific Hearth diagnosis, so you can develop a treatment program to help them. Their emotions, family, personalities also affect treatment of their Hearth Disease. So you adjust. Unfortunately we are still carrying the Stigma of Psychiatric disorders been the fault of family, personality ,or emotions. While it may play a larger role, we need to focus on the disorder/ Syndrome, if we are to help them.you need to combine both, and not vs. the other. Your sensitivity will help you much, just don’t forget the science.

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  4. Stephanie Lee

    Hello everyone, thank you for your comments. I believe there is value in seeing both the diagnosis and the person behind the diagnosis. My focus in this piece was mainly to focus on the patient and his story, and not invalidate the DSM-V. The DSM-V has historically been fruitful in speaking about the diagnosis and how to help patients in their journey. It’s important to have balance as we meet people where they are. Although I focused more on the person in this piece, I also want to highlight that there are multiple dimensions of understanding mental health. As someone who has been through my own healing and I continue to do so each day, I have learned to appreciate multiple viewpoints in mental health and have been grateful to have experienced the sensitivity and kindness in others, as well as the scientific background underlying the overall care. I hope this clarifies any confusion.

    Best,
    Stephanie

    Reply

  5. Amy Renshaw

    Stephanie, thank you so much for sharing this. It reminds me of of being back in my pediatric rotation when I was in medical school. Many of my patients and family have also experienced similar struggles with their mental health. I’ve seen some of my closest family members struggle with being boxed into a diagnosis and facing judgement because of that. A lot of them tell me it’s difficult to break free from the stereotypes of certain psychiatric diagnoses. When I read about Lucas, it reminds me of how environmental factors can really affect the health outcome of some of these patients. I think medicine is an all-encompassing craft, and I agree with you when you say mental health is multi dimensional. I also think it takes a lot of growth and self-reflection to write a piece such as this. I stay in support of your work!

    Reply

  6. TIN TIN MB,BS

    Fresh Perspective, I wish people spoke about this more it helps me understand a different viewpoint. It is important to help patients through a case-by-case basis. Often DSM and ICD coding do not always match the patient presentation. I appreciate the acknowledgement of other factors that contribute to the patient presentation.

    Reply

  7. CJ Rush DO, MS(MedEd)

    I sure hope you consider psychiatry as a possible path because you already possess what most of us psychiatrists believe is very important, a philosophical thought process. Your point is well taken and the reason why I emphasize the “Always rule out, Never rule in” rule when teaching 1st, 2nd year residents. DSM-V and its predecessors are guidebooks, not rulebooks. They provide a foundation for homing in on the diagnosis that can help create an evidence-based treatment plan. The specific diagnosis is also necessary to provide access to care for the those struggling. But that is another discussion for another day. Best of luck inyour journey.

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