I'm happy to see such results be "properly" recognized. The DSM is imo helpful only as a baseline, especially in contexts where without it, doctors might have (significant) personal bias. And... this might ruffle some feathers with the "live and die by the book" crowd, but a good, perceptive doctor doesn't need the DSM to diagnose anything.

I've had video calls with a doc who took maybe 5 minutes at most of hearing subjective experiences to confidently reach a conclusion. I've also had a 45 minute "by the book" DSM-based session where boxes were being ticked... and the questions were f---ing *terrible*, if you pardon my French. "Do you have trouble concentrating" is terribly vague and can always be justified either way. Not to mention, it takes maybe a few moments to "catch on" on how to answer which questions; which seems to be a terrible way of introducing bias into the answers (as also mentioned in the article). Having someone describe their personal life is in many ways much better because it cannot be a rigid yes/no question.

And all this talk is without mentions of other aspects that also need addressing, like the continuous spectrum of many conditions...

I have had such bad experiences with psychiatrists and psychologists being contrarian and demanding filling in generic tests leading to no working solutions (aka you're depressed here's a prescription for an SSRI. Still depressed? We'll up the dose).

My current psychiatrist figured out my main issues after talking to me for 15 minutes. Sent me off to a psychologist back up his assumptions before prescribing anything. Recommended therapists who specialize in the area I needed support in.

The psychologist I went to was great as well (after seeing one that was a terrible). She did a lot of testing (three sittings lasting around two hours) but said the tests were really just to rule out other things. The important part were the conversations.

My life improved tremendously after that.

The DSM is not designed as a list of questions to use to ask patients, it’s designed to describe disorders.

Asking you “do you have trouble concentrating?” is lazy (at least, on its own. Asking a patient to perform a self-assessment is not bad medicine necessarily). A doctor should also be evaluating your concentration in other ways.

> I'm happy to see such results be "properly" recognized. The DSM is imo helpful only as a baseline, especially in contexts where without it, doctors might have (significant) personal bias. And... this might ruffle some feathers with the "live and die by the book" crowd, but a good, perceptive doctor doesn't need the DSM to diagnose anything.

My own personal experience with psychologists and psychiatrists, is most of them don’t go by the text of the DSM, they go by the understanding of various disorders they’ve received from their teachers, mentors, supervisors, colleagues-which at times has a rather loose relationship with what the text of the DSM actually says-and once they’ve made their minds up as to what is the correct diagnosis, then-when required for a formal report-they look at the DSM text and work out how to justify their diagnostic decision by relating what the text says to the evidence at hand

> I've also had a 45 minute "by the book" DSM-based session where boxes were being ticked... and the questions were f---ing terrible

The DSM isn’t the source of those question inventories. There are different question sets for different conditions that each have their own source, often a set of researchers or an institution that has put in some work to study and test them. Some of the more obscure question inventories are even paid material that clinicians (or their offices, more accurately) are supposed to license.

I caution against the clinicians who do rapid-fire diagnostics and slap a label on the patient within minutes of talking to them. Some patients like this when the diagnosis matches what they already self-diagnosed or they want to hear, but in these cases some clinicians are just picking up on the hints the patient gave and mirroring it back to them.

This rapid diagnostic method is an easy way to improve your patient satisfaction scores (important for performance measures at some clinics, especially when PE or corporate gets involved) and it’s an obvious way to free up some time in a clinician’s busy day.

There is a growing problem of lazy providers who try to speedrun the diagnosis and send patients on their way with a prescription for something and a request for a follow up appointment. During COVID when controlled substance prescribing rules were loosened for remote appointments there were even pill mills that would advertise for specific diagnoses on TikTok and then incentivize the providers to see as many patients per day and prescribe them all Adderall because it turned them into repeat customers for the recurring prescriptions. There was a whistleblower who revealed that they were measured on their rates of prescribing controlled substances and discouraged from prescribing alternatives with lower abuse/addiction potential even when patients admitted to having drug abuse problems. This is an extreme example but don’t discount the incentive for your provider to shorten your appointment for selfish reasons, not because the patient’s condition is obvious and easy to diagnose accurately within minutes.

The point is to make a differential diagnosis which isn't possible in 5 minutes. So if someone concludes after 5 minutes your psychiatric diagnosis, you can be almost sure they aren't following good practice for their profession. Or to use another word - malpractice.

Sounds like the field needs to acknowledge the weakness of prescriptivism similar to software engineering with design patterns. The need for diagnostic criteria is understandable - but it definitely should be up to the discretion of the doc.

> "Do you have trouble concentrating" is terribly vague and can always be justified either way

To be fair, for the practitioner this shouldn't be a question about objective capital-letter Truth, it's one throw of darts representing a self-reported aspect of self-experience and self-perception.

As someone who has designed questionnaires for a public health agency, reading the article made me feel we should've fully randomized the order of appearance of individual questions, including the 'front-matter' stuff like self-reported gender, age, education, marital status.

As someone who got quite upset about a particular questionnaire's formulations at the tender age of 10, I'd now say let's not get too wrought up about this, a questionnaire can be a valid tool but it will also always be a somewhat blunt tool, so let's use it bluntly: don't fret, put your mark into one of those five boxes, move on to the next question, done, over, out. If it's about me then it's about how I feel about it, now, and I can choose to feel extremely good or bad or fairly somewhat well-nigh indifferent about sh*t, just here and now. As the one being questionnaired, I also have the right to lean into the questions and bend the outcome as I see fit. Been there, done that.