What is the DSM?
Is the DSM useful,
even indispensable or is it "dangerous"?
In the year 2000,
can a psychiatrist be a good doctor if he doesn't use the DSM?
The French psychiatric
association against the DSM ?!
Can one speak
of a French exception in psychiatry?
Beyond the controversial
aspect of the title lies a much more serious problem, i.e. the differences
in working practices among psychiatric doctors. In some cases one might
even eliminate the word "doctor" in connection with the word "psychiatrist.
Why is the DSM rejected
by so many French psychiatric doctors, is it legitimate ? Is it possible
nowadays for a psychiatric doctor to totally deny the DSM? What alternative(s)
are there to the DSM?
is the DSM ?
is the role of a doctor ?
the DSM be ignored ?
can one be a good practitioner without using
Christian Vasseur view, President of the French Psychiatric Association
J Cottraux view, Anxiety Disorder Unit, neurological hospital of Lyon
questions to the conseil national de l'ordre des
it possible to respect the Madrid Declaration...
without using the DSM (or ICD) ?
about Switzerland ? D. Page's view, responsible for
the service de psychiatrie adulte, Hôpital de Prangins (Suisse)
why so much "hatred"?
is the DSM?
DSM IV according to the author.
In simple terms, the DSM is
the world's "bible" for psychiatric disorders. Its purpose is to offer
help in diagnosing and to enable specialists, throughout the world, to
have a common language in which to share the progress made in their experiences
in this field.
The DSM came into being in 1952,
followed by the DSM II in 1968, the DSM III in 1980 and the DSM IV in 1994
and the latest revision of the DSM IV TR in 2000.
is the role of a doctor?
* "The American Psychiatric
Association published a Fourth Edition of its Diagnostic and Statistical
Manual of Mental Disorders in 1994.
DSM-IV ’s Importance to Psychiatric
Diagnosis. The importance of the DSM IV in psychiatric diagnosis.
Diagnosis is the foundation
in any medical practice, and the twentieth century has seen a revolution
in the doctor's capacity to identify and treat certain illnesses which
have been poisoning the existence of mankind. (aapel "one only needs
to look at the improved life expectancy in rich countries")
Apart from its usefulness as
an aid in diagnosis, the DSM IV codification of mental illnesses facilitates
the process of collecting and recuperating research data, and helps researchers
to compile information for statistical studies.
The DSM IV codes are in accordance
with the international classification of illnesses, ninth edition, clinical
modification (icd-9-cm). The icd-9-cm is based on the WHO (world
health organization's) publication icd-9, which is used throughout
the world to facilitate the emergence of coherent medical diagnosis. ("Psychiatric
Diagnosis and the Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition", http://www.psych.org/public_info/dsm.pdf)
Q: What's so "Statistical"
about the Diagnostic and Statistical Manual of Mental Disorders?
R: The word "statistical" in
the name of the manual is a throwback to one of the original uses
of the DSM-to facilitate the collection of hospital statistics in the early
1950's and 1960's. Although psychiatric diagnoses are still an important
part of record keeping, the primary use of the DSM is "diagnostic." For
historical reasons, we have kept the name "DSM."
Q: What is the status of
R: ICD-10, the tenth revision
of the International Classification of Diseases, was published by the World
Health Organization in 1993. Although DSM-IV and DSM-IV-TR were developed
with the explicit goal of ICD-10 compatibility
a psychiatric doctor a doctor?
If one refers to the French
medical code of ethics: "reaching a
diagnosis is the first stage in patient care".
requires that the nature and the origin of an illness must be recognized
in order to treat it correctly". (please note the "conseil
de l'ordre" is very clear on this point)
do many psychiatric doctors not diagnose and do they have the right not
to do it?
Generally this is not a question
that a patient asks himself when consulting a psychiatric
Many choose to consult a psychiatric
doctor because he is a doctor, rather than a psychologist, a psycho-therapist
or a psycho-analyst who is not
So why ask this question?
Quite simply because there are
still many psychiatric doctors (in France) who refuse to diagnose
even when their patient request it of them.
state that, by refusing the very principle of a diagnosis, one is respecting
a human being is praiseworthy, isn't it?
Clearly not if one refers to
the medical code of ethics.
Concerning the first part of
the question, the problem is to know whether the doctor doesn't reach a
diagnosis or whether he chooses not to inform his patient.
Regarding their motivation I
can summarize as follows; "the human brain
cannot be considered like any other organ and a psychiatric diagnosis is
a psychiatric doctor have the right not to diagnose for purely philosophical
Certainly it is and I'm not
going to dispute the fact. But setting aside these "humanist" and necessary
considerations, is it possible to heal a person's suffering from a medical
point of view, without first reaching a diagnosis?
I believe that it is not, and
I will develop my reasons further on.
we use the DSM all as subscribe with psychoanalytical theories or are they
The problem is to know if he
is a "psychoanalyst" or a "doctor".
I don't see how a psychiatric
doctor can believe that he has a right not to diagnose and still call himself
a "psychiatric doctor".
If, as some people believe,
there cannot exist a diagnosis in psychiatry, a totally respectable theory
debate is not on this point), then there is no such thing as a "psychiatric
If you, patient, share the "humanistic"
viewpoint of the psychoanalytic theory, and if you consult a psychoanalyst,
then that is an "honest" contract. You will not be seeking a diagnosis
and you will not be given one.
I believe it is a "fraud", i.e.
non-respect of the medical code of ethics (like it is confirmed buy
the "conseil de l'ordre") and therefore non-respect of the human being),
when a psychiatric doctor refuses to give a diagnosis on the pretext that
he is also a psychoanalyst.
In this case, why see a doctor
if it's not with the aim of consulting "a doctor"!
The DSM is a diagnosis tool
and not a treatment's tool, I thus do not see why it would not be possible
to diagnose a patient on DSM criteria then to treat him/her by a form or
other of analytical therapy. Many studies were published by psychoanalysts
of reputation and who diagnosed the concerned patients on DSM criteria.
doctors believe, sometimes rightly, that a psychiatric diagnosis is stigmatizing
and even "counter productive".
my doctor may be trained and competent
to relieve me without necessarily make a diagnosis or give it to me?
It is true that the medical
code of ethics authorizes concealing
a diagnosis from a patient for a certain time, but that should only
be in exceptional cases.
Many (too many) psychiatric
doctors refuse to diagnose on "ethical" grounds. Well I'm sorry to have
to say this, but it is their sole duty to resign, because this attitude,
though morally respectable, is in fact "illegal". Allow me to explain myself.
Normally, a doctor is under
an obligation to diagnose and inform a patient. Anything else should remain
Even if this refusal is morally
respectable in the absolute, it becomes morally reprehensible if a patient
believes he is consulting a doctor when in fact, the person who refuses
to diagnose cannot be qualified as such. (In France medical insurance
cover medical treatment and not others)
the DSM be ignored in this day and age?
I don't care, debate is not
Whether or not a doctor has
the "ability" to relieve a patient is not an issue. The fact is, that as
a member of a professional body, he has certain moral
If a doctor relieves a patient
without diagnosing or informing him about the diagnosis, then he is not
acting as a medical practitioner but as a psychotherapist or psychoanalyst.
Worse still, he will be in contradiction
with "article 33 if he
prescribes "psychotrope" substances without first establishing a diagnosis.
Why is it that, at a time when
measures are being taken to regulate the practice
of psychotherapy, the title of "doctor" is still granted to those
who, for this reason, no longer exert the profession of "medical practitioner"?
On the one hand and on the orher
hand, Mr. Vasseur, president of the AFP, is scandalized
that there exist psychotherapists who are not qualified "doctors", while
at the same time implying that a psychiatric doctor should not behave as
a fully fledged "doctor" as it is stipulated in the medical code of ethics.
"Logical"? "Interesting" to say the least, but rather "baffling".
At the risk of repeating myself;
a psychiatric doctor is under an obligation to behave as a doctor. Not
because it is my opinion but because it is laid down in the regulations.
If a psychiatric doctor was
not a doctor, there would be no need for his profession to exist as he
would have the same role as others professions,
such as a psychologist.
The very existence of the term
"psychiatric medical specialist" implies the recognition of a medical specificity
i.e. professional doctors who are there to treat "mental disorders"!
Would it be possible to do without the DSM in the 21th century ? (or
Whether one considers the DSM
useful, or "harmful" and even "dangerous", one would have to be blind to
ignore that it has become the reference guide
Those who think they can go
against it are incredibly naïve.
The truth is that if one wishes
to "fight" against the DSM it can only be done from the inside. The general
tendency is for the DSM to hold a more and more important role; therefore
it is up to its "opponents" to make themselves heard and to make
things evolve in a direction which they consider "favorable".
you have to admit that the DSM is far from being perfect and it does
have certain disadvantages ?
The answer is "yes". The proof
is that (too) many French psychiatric doctors take on a disdainful,
amused or scornful expression when someone mentions the DSM. "As if this
guide could be of benefit to anyone." (One only has to read the remarks
of Dr. Vasseur, president of the French association for psychiatry,
to be convinced)
what, in your opinion, are the advantages of the DSM?
Nobody's denying the fact.
Of course a misuse of the DSM
can be dangerous if it's only use is to put a label on someone without
giving them the opportunity to change.
Nobody's saying that the diagnosis
is the be-all and end-all.
The question to ask is not "is
the use of DSM dangerous", but rather "is the NON USE of DSM even more
DSM would be not reliable?
Many specialists see the DSM
as something too arbitrary.
E.g. "You have only 5 points
out of 9 therefore you do not have such & such an illness" or inversely,
"you have 6 points out of 9 therefore you have such & such an illness."
In my opinion it's just the
opposite, because the DSM makes it possible to eliminate the arbitrary
and to give some sort of power and an existence to the patient.
For many people, receiving a
diagnosis is proof that their illness is being
recognized. e.g. "If I'm suffering this way, it's not because
I'm incapable or stupid, but because I'm ill."
In refusing to diagnose,
a patient is left feeling guilty about not being able to overcome his illness.
It seems to me that the role of any doctor (be he a psychiatrist or other),
is to treat patients. Wouldn’t you agree?
Furthermore, in the absence
of a common method for diagnosing, the patient becomes powerless. One informs
him of the diagnosis and he has no way of knowing what it’s based on. What
is worse is that he may consult another doctor and there’s a strong possibility
that he’ll be given a different diagnosis. That’s one of the reasons, in
my opinion, why those who disapprove of the DSM are also adverse to a diagnosis
because their diagnosis is based only on the arbitrary or on vague learning.
Even though the DSM may
be "arbitrary" in its "categories", everyone has the same "arbitrary" &
the same language at his disposal, which is far better than "unproved words
A patient suffering from borderline
personality disorder, for example, can easily recognize himself in the
DSM criteria concerning the illness and can thus adhere to the diagnosis
and the treatment. But how can one "naturally" recognize oneself as being
"at the limit of neurosis and psychosis"!
In my opinion, the DSM also
enables the practitioner to envisage every possibility and not to overlook
a pathology which one might not have considered initially;
The DSM is a starting point,
a basis on which to work, which makes it possible to figure out the problem.
For example, " you correspond to the criteria for borderline and avoidant
personality disorder and you are suffering from an eating disorder or depression".
All this is a mine of information and starting point for working in depth
and prescribing the treatment which is adapted to all these pathologies
as a whole and to this particular person.
And finally, I believe that
the DSM is not only useful, but indispensable for any good treatment even
if it is only a tool for diagnosing. (I shall develop this further on
in the text)
the DSM only useful for research and statistics?
If that is the case, then why
do so many published studies claim the opposite?
For example, many studies concerning
borderline personality disorder prove the "reproducibility" of the
results. Could it be that France, a great defender of human rights,
is one of the only countries which has not been blinded by the emergence
of one "DSM totalitarianism"?
Why do so many people recognize
themselves in our description of the disorder? Couldn't it be because
they all have many points in common?
Be that as it may. Supposing,
therefore, that the DSM is not reliable. OK. Then what "reliable" tool
would you suggest in its place, None? Then we are coming close to being
can one be a good practitioner without using the DSM?!
Many detractors of the DSM base
their judgement on the fact that it was originally a statistical tool.
However, many of these same detractors recognize that the DSM is useful
for everything connected with research, namely because it is necessary
to have a common base.
If in one country "influenza"
is called "throat infection", it will become "complicated" to analyse the
effects of the "influenza" on "my" population and to use the results of
the year 2000, is it possible to be a "competent"
psychiatric doctor whilst ignoring the DSM?
That's an interesting question.
Can one be a good practitioner in the year 2000 without using the DSM in
medical practice (with the patients)?
(I have a feeling that I'm
going to make myself a few new "friends")
Once again, I have never said
that the DSM was "wonderful" or "perfect". The proof can be seen in the
definitions of borderline personality disorder which we give on the website
and which are modeled from the DSM. I repeat "modeled"! But let's get back
to the question in hand.
Starting with the hypothesis
that "I can be a good practitioner without using the DSM". I therefore
consider myself to be a psychiatric doctor (which of course I'm not).
I am a doctor (and not a
psychologist etc.) I therefore apply my medical code of ethics which
33 «Diagnosing is the first step in treating any patient»
11 «A doctor has no right not to keep himself up to
date on medical progress, in every domain; clinical, biological, technological
33 The aim is to apply the treatment most suited to my patient.
"It would be considered
a mistake not to try to make a diagnosis, with all the necessary
care; to remain vague by leaving what follows to chance; or to prescribe
a standard treatment indiscriminately"
109 Every doctor... have to declare in front
of the "conseil départemental de l'ordre" that he knows the code
and to undertake itself under oath and written to respect it.
In order to do this, I do need
to use diagnostic tools. I cannot pull a diagnosis out of my hat. I normally
use the technique of the differential diagnosis (i.e. It could be that
,that or that).
Once a diagnosis has been established,
I provide the treatment best adapted to my patient, whether the treatment
be chemical or psychotherapeutic. (If I apply the same treatment to
all my patients, then I'm not respecting my medical code of ethics in respect
to the patient).
all this possible without using the DSM?
Article 11 « A doctor
has no right not to keep himself up to date on medical progress in
every domain; clinical, biological, technological etc… »
> The great majority
of current psychiatric studies are based on the DSM III R, the DSM IV or
the DSM IV TR. How could I possibly be aware of all the progress
made in medicine in this domain if, for example, I don't know about the
thousands of scientific publications concerning the population suffering
from a personality disorder and diagnosed as "borderline" but on DSM criteria!
Article 33 «It is considered
a mistake not to try to make a diagnosis with all the necessary care; to
remain vague by leaving what follows to chance; to prescribe a standard
> Very well then; I know
about the latest research, but I don't use the DSM as a diagnostic tool
for my patients.
> So how can I apply
the results of the different research on my patient if I haven't diagnosed
that patient according to the same diagnostic criteria of that same
> For example, I believe
that my patient's state is borderline; I base this assumption on the fact
that he is neither neurotic nor psychotic but "in between the two". And
I'm going to apply the results of studies carried out on "borderline" patients
but who were diagnosed on the DSM criteria? But what right do I have to
do that?! How can my patient be part of the same clinical population if
he is not diagnosed according to the same criteria?
Can I affirm that my patient
received the "right" treatment if I apply the results of a study to which
he might (probably) not even correspond?
> An example of the opposite;
I believe that my patient does not suffer from borderline personality disorder
because I don't think that he is on the border of neurosis nor of psychosis.
In fact my patient corresponds to the DSM criteria of borderline personality
disorder but I am totally unaware of this fact because I don't use this
diagnostic tool. Therefore my patient is not going to benefit from the
results of thousands of scientific studies which have been published about
this subject. I'm therefore going to apply a treatment which does not take
into account the progress made in this domain (why would I prescribe
the X molecule rather than the Y molecule for a patient even if studies
prove that the molecule X is better adapted to " DSM borderline cases").
Can I claim that my patient
received the "right" treatment if I didn't apply the results of studies
to which he corresponds?
It seems to me that things are
clear; crystal clear.
Even though the DSM may seem
to be, or is, a bad tool (a belief I do not share), it is a tool
which is used by hundreds of thousands of practitioners.
No researcher in the
world, who wishes to be published, can manage without it today !
By deciding to ignore the DSM
on "moral" grounds, I prevent my patient from benefiting from the treatment
which is the most capable of curing him.
How then could I not be "blameworthy"
in the eyes of my ethical code when I voluntarily exclude myself from the
international scientific community!
It would be nevertheless at
least very strange to claim that progress exists (before Freud, no neurosis
and psychosis or pervert) but that this one would have then stopped
a few years ago.
It is true that I have a right,
and even a duty, to act this way if I believe that the DSM is "harmful".
However, in such a case, it would also be my duty to resign as a "doctor
in medicine" because I would have made the decision to go against the code
of ethics of my order and against the code of public health, which obliges
me to respect my code and to integrate the results of scientific
Of course, I do have the possibility
to deny the studies carried out by the international community in the last
twenty years… but then how can I manage to convince anyone that I'm not
entering in communautarism and the sectarian attitude?
made in December 2OO2, by doctor Christian Vasseur, President of
the French Psychiatric Association (AFP)
(You'll notice that,
a)I said "psychiatric doctor" and didn't mention another profession
beginning with "psy" and, b)I use the word "ignoring" and not "criticizing")
If one refers to the surprising
remarks made by the president of the French psychiatric association,
it's rather through using the DSM that a psychiatric doctor becomes "incompetent"
Allow me to answer this question
with another question.
How (this is my opinion)
can a psychiatric doctor, who does not (advisedly) use the
DSM with his patient in his daily work, be "competent" (trained)
in a domain which is perpetually evolving, when he voluntarily deprives
himself of the majority of the world's scientific studies (studies which
he would denounces as being "non" scientific)!
point of view of Doctor J Cottraux, Anxiety Disorder Unit, neurological
hospital of Lyon
«Today it’s a matter of
classifications. As it is, we, AFP, are in a position to speak on this
subject since we denounced the abusive use
of the DSM and of the CIM 10 which may have been made in
the past ten years. We have organized meetings and symposiums; we have
regularly made publications and during the “Jubilee de l’Association
Mondiale de Psychiatrie” held in Paris in June 2000, the main part of the
French speeches focused on this matter...
It so happens that in France,
contrary to in other countries, we are fortunate to have a psychopathological
corpus already set up which has been added to over time and regularly questioned
in order to alter the relevance according to the evolution of society and
to medical knowledge. This has protected us
from the attraction of Anglo Saxon classifications which are based on statistics
and which are even challenged by the Anglo Saxons themselves.
practice is that of scientific and medical humanism in which the patient
is central. It is true that this attitude is often frowned
upon by the pharmaceutical industry and by the authorities who, either
through misunderstanding or concern for management and rational expenditure,
tempted to impose classifications on psychiatrists which, although benefiting
from international consensus, are not necessarily acceptable scientific
references for our practice.
Once again, we have denounced
any abuse as soon as it appeared and, at the moment, it
is only the authorities, the statisticians and the research units together
with the pharmaceutical industry who continue to refer to these classifications
which have been rejected by every practitioner»
Vasseur, «Disqualification de la PSYCHIATRIE», Association
Française de Psychiatrie December 2OO2)
Things couldn’t be clearer, could they? What did the AFP do?
From what I understand, it would
seem that the French psychiatric doctors are “humanists” (contrary to
the Anglo Saxons) and “protected” (the term used by C. Vasseur)
from Anglo Saxon classifications, clearly and mainly the DSM.
It would seem therefore that
the members of the French psychiatric association (AFP) are ”scientific”
whereas the rest of the planet is not since; “their scientific references
are not acceptable”. The objective is clear,
the DSM is not to be taken into consideration in France!
This answers an earlier question…a
reality is that a patient who consults a psychiatric doctor has absolutely
no idea who he is dealing with!
"I read, with interest,
your document on the DSM. (AAPEL, the 16 February edition, before inclusion
of this present account)
questions to the conseil national de l'ordre des médecins français
I think it evokes several
The nature of the DSM
One often forgets
that the DSM is a multi-axial classification which takes into account five
The absence of a simplistic view
|Axis 1- Clinical
Roughly mental disorders like depression, schizophrenia, etc)
|Axis 2- Personality
disorders, like "borderline", etc)
|Axis 3- General Medical
||(AAPEL: If the person
has some illnesses that could have an influence on the mental, like diabetes,
|Axis 4- Psychosocial and
||(AAPEL: Example educational,
economic, legal, etc)
|Axe 5- Global Assessment
||(AAPEL: Scale from 1
to 100 ex between 80 and 100 the person is "functional", lower 50 serious
problems , lower 30 delirious hospitalization may be necessary, etc)
Far from being simplistic,
it makes it possible to envisage the presence of several syndromes at the
same time; that of several personality disorders and the overall functioning
of the person in the face of his illness and of the events which take place
in his life (axis 4). It is therefore less simplistic than a nosography,
such as: psychosis or neurosis; perversions with which we often satisfy
ourselves in France.
The clinical aspect of the DSM
As you emphasized, the DSM
is compatible with the ICD-10 which was drawn up in Geneva by the WHO and
there is a "key" which makes it possible to pass from one to the other.
The DSM is not solely a
manual for researchers. it is used daily in
its abridged version by dozens of clinicians or those studying psychiatry
or psychology. It was not drawn up exclusively by partisans
of neurobiology, but by a group of experts who understood psychiatrists
Finally, it is an evolutionary
tool which is revised periodically and brought up to date as a result of
studies carried out in medical institutions as well as in clinical research
and in more fundamental research.
The European and "integrative" aspect of the DSM
It is worth noting that
in France the DSM was an unexpected, great success in book shops for Masson
editions. It is the reference for psychopathology,
despite (or maybe because of) its critics who are opposed to nothing
In fact, the DSM is not
especially American in its description of syndromes: It has just integrated
the data coming from French, German and, occasionally, Anglo Saxon psychiatry
in the 19th and 20th century, and systemized it. Its description of personality
disorders takes into account the data coming from classical psycho-analysis.
The ICD-10 has even criticized
the DSM for focusing too
much on a psycho-analytical description of obsessive-compulsive personality
disorder in contrast with existing data.
(anankastique) In: Féline A, Guelfi J., Hardy P. : Les
troubles de la personnalité, Flammarion, 2OO2).
think that this instrument, although not perfect and in constant evolution,
is the reference which is necessary for psychiatrists, psychologists and
doctors. Also, when widely distributed
in its abridged edition, it gives the patient access, in an intelligible
form, to the diagnosis to which he has a right". (Dr J Cottraux, Anxiety
Disorder Unit, Hopital Neurologique, Lyon) (author of numerous books)
questions were put to the "conseil national de l'ordre français"
it possible to respect the Madrid Declaration On Ethical Standards For
Psychiatric Practice without using psychiatric classification like the
DSM (or ICD) ?
- Is a psychiatric doctor,
both and above all, a doctor? (I suppose that the answer is yes, otherwise
he would lose his legitimacy with regard to a psychologist.)
- Does a psychiatric
doctor, like any other doctor, have a duty to respect the medical code
of ethics, especially articles 11, 33 and 35, in his daily tasks?
- For this reason, regardless
of his personal opinion of the DSM IV, can a psychiatric doctor ignore
it in his daily medical practice with his patients? ( There have been over
40,000 international, scientific and medical publications in the last 20
given by the "conseil de l'ordre" on 27 February 2OO4. - Dossier
"In reply to your Email
of 17 February 2OO4, I confirm that a psychiatrist,
like any other doctor, must respect the medical code of ethics in every
As for the DSM
IV, it is a classification for mental illnesses accompanied
by specific diagnostic criteria to be used as
a guide while diagnosing.
However, it does not cover
every circumstance which could justify a treatment, nor even the nature
of the treatment." (Dr. Louis-Jean Calloc'h, general Secretary of the
"conseil national de l'ordre des médecins).
couldn't be clearer. the reply is perfectly
It is clearly stipulated "in
every aspect". That confirms that a psychiatric doctor is under
an obligation to diagnose, to prescribe the treatment best adapted to the
illness and to keep himself informed about medical progress
the "conseil de l'ordre" specifies that the
DSM IV is a classification which has been drawn up to serve as a guide
in the process of reaching a diagnosis.
And since the psychiatrist is under
obligation to make the correct diagnosis,
to be aware of every progress made in medicine and to prescribe
the treatment best adapted to the illness….. and since that's impossible
without using the "international" classification,
that confirms that the use of the DSM
is not only desirable but "compulsory" in order to conform with medical
the final point mentioned by the "conseil de l'ordre", what to they say
exactly?… That "the DSM is a necessary
condition but that it is insufficient"
Please read the
"madrid declaration" from the
Psychiatric Association (WPA)
switzerland ? D. Page's point of view , doctor in psychology and psychotherapist
director of the psychiatric adult service, Hôpital de Prangins (Suisse)
We can read:
patients by providing the best therapy available
consistent with accepted scientific knowledge
and ethical principles... It is the duty of psychiatrists
keep abreast scientific developments,of
the specialty... It is the duty of psychiatrists
provide the patient with relevant information so as to empower
the patient to come to a rational decision according to personal values
"Psychotherapy by psychiatrists
is a form of treatment for mental and other illnesses and emotional problems...The
approach employed should be specific to the disease and patient's needs
...Therefore, the psychiatrist or other delegated qualified clinician,
should determine the indications for psychotherapy
and follow its development . In this context the
essential notion is that the treatment is the consequence of a diagnosis
and both are medical acts performed to take care of an ill person..." (Guidelines
concerning specific situations, chapter "ETHICS OF PSYCHOTHERAPY IN MEDICINE")
And if we add these facts:
diagnosis that a person is mentally ill shall be determined in accordance
with the internationally accepted medical standards. Physicians,
in determining whether a person is suffering from mental illness, should
do so in accordance with medical science..." (WPA Statement and
Viewpoints on the Rights and Legal Safeguards of the Mentally III - adopted
by the WPA General Assembly in Athens, l7th October, 1989)
Last... the WPA web site
include the "WPA Educational Programs (WPA EPs) ICD 10 Training
Kit - (in collaboration with WHO)"
it then possible to comply with these ethical rules without using the DSM
and the results of more than 40 000 studies ?
Another interesting point,
is the fact that the "association française de psychiatrie" is a
member of the WPA (http://www. wpanet .org/ generalinfo /members3.html).
How is it then possible to be, on the one hand a WPA member and on the
other hand claims words like "... authorities who... are tempted to impose
classifications on psychiatrists which, although benefiting from international
consensus, are not necessarily acceptable scientific references for our
Good question !
the moment, Switzerland favors the use of the ICD-10 (AAPEL:
That's only natural, since the ICD is the classification of the WHO, whose
headquarters are in Switzerland) in conformity with the decision taken
by the head doctors, psychiatrists and psychotherapists FMH- whereby it
has been established as the official classification for mental illnesses;
professionals also work with the DSM IV (TR), sometimes
simultaneously with the ICD-10.
why so much "hatred" towards this famous worldwide DSM on the part of a
fringe group in French psychiatry?
All health professionals
receive basic training in diagnostics; only doctors and psychotherapists
title which is protected by Swiss law and attributed to people who have
completed a university cycle in psychiatry, followed by 1,200 hours of
specialized training in a psychotherapeutic branch of their choice)
can pronounce a diagnosis which is medically legal. in this context, the
use of international classifications such as the ICD-10 or the DSM- IV
is clearly generalized.
This use offers various advantages
The international classifications
(DSM-10 or ICD-10) make it possible to use common denominators to describe
complex and "multi-axiales" illnesses
The international classifications
describe, on a phenomenological basis, symptoms of suffering presented
in an objective manner. This considerably limits the subjectivity of the
medical team in their perception of the problem.
The characteristics proposed
for the different types of suffering make it possible to establish a base
from which facilitates the putting into place of the most adequate treatment
and the measuring of its effects.
The descriptions in the international
classifications enable patients to identify and put a name to their suffering.
This has the effect of relieving him of the feeling that he is alone in
the face of his illness and enabling him to build up an alliance with his
therapist for the work he will have to do.
are the risks connected with the use of the DSM-IV or with the ICD- 10?
To be honest I can't see any!
However, if there is a risk
of any kind, it seems to me that it would come from the therapist's use
of them... or rather "misuse"! One example would be to use such classifications
without the patient's approval and without checking their exactness with
regard to the patient's life and experience. Another example would be to
consider that the difficulties and suffering described in the classification
are rigid and unchanging. Using these diagnostic categories without considering
if they are appropriate to the suffering and real life of a particular
patient, is another example of misuse.
international classifications are, and should be, a tool at the disposal
of both the therapist and the patient in order to help them to define,
as objectively as possible, the real suffering of a particular person in
a particular context at a given time. "They are clinical
and therapeutic tool which can also be used to asses the evolution of the
patient and the effectiveness of his treatment" (Dominique
Page, Psychologic HPP Service Director - Prangins Switzerland)
(D. Page has translated in french and in collaboration
with the Dr. Wehrlé both book of Marsha
Linehan on dialectical behavioral therapy for borderline personality
See also the pages
I think that the French are
holding an ideological war (I am over simplifying, of course. There
are very many French psychiatric doctors who, without renouncing the past,
do not reject the DSM).
France is the birthplace of
psycho-analysis which brought a "humanistic" view to psychological problems.
The basis being the "neurosis" and "psychosis" of Freud.
The Americans (I'm over simplifying
again) from the beginning tried to erase the "psychological" aspect
and concentrated more on the "biological and neurological" aspect of psychological
The ideologists on both sides
claim "you are denying the human spirit" against "you are denying science".
Any person with a minimum of
common sense is forced to admit that a human being is composed of both
body and spirit. In my opinion, anyone who denies the notion of spirit,
as well as anyone who denies the notion of body is, in fact, denying the
From the moment the French considered
the American attitude as "haughty" and "arrogant" (let's admit that
they are strong in this field), many in the profession totally rejected
the DSM in its entirety.
I fear that many French patients
have not yet finished paying the exorbitant price for this, and that, on
the pretext of protecting des acquis, many psychiatric doctors are plunging
us into an infernal spiral.
The actual truth is that the
DSM doesn't seem to be welcome in France. (One only has to read the
remarks of the French psychiatric association to see this).
The problem is that it is impossible
to reject the DSM without depriving oneself of the tens of thousands of
scientific studies which were based upon it!
Each person is free to either
put his trust in a doctor who uses the DSM as a diagnostic tool or to put
it in one who totally rejects it.
Psychotherapist and Founder
of the AAPEL association.
of madrid, psychiatry and ethics
right to be sick and dignity,(in french)
to his/her shrink about BPD,(in french)
Do we have the
right to ask the question of the training and competence of "shrinks"
French medical code of ethics,
to information and diagnosis
code of ethics
For those wanting to order
l'ouvrage "le DSM" en français
- Back to BPD summary page
All the information
in this site is aimed at helping people understand a "rather particular"
and puzzling kind of disease
But more especially,
to support everyone affected by it, sick or not. In any case, it
to see a therapist who specialises in this
field they can confirm or give an alternative diagnosis
The name of what
you’ve got doesn’t matter so much, getting the right treatment for the
right patient does
last update 2020
AAPELTM - All rights
Alain Tortosa, founder of the Aapel