Beyond the Confines of the DSM V

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

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