Borderline personality disorder.
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?

 Introduction

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?

What is the DSM?

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.

* "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 the ICD-10?

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

If one refers to  the French medical code of ethics: "reaching a diagnosis is the first stage in patient care".

Also "medicine 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)

Generally this is not a question that a patient asks himself when consulting a psychiatric doctor.

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.

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 too simplistic".

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.

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 (the debate is not on this point), then there is no such thing as a "psychiatric doctor"!

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.

Some doctors believe, sometimes rightly, that a psychiatric diagnosis is stigmatizing and even "counter productive".

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 an exception.

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)

I don't care, debate is not here.

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 obligations

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"!

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 worldwide.

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".

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)

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 dangerous"

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 of wisdom".

• 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)

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 knowing everything.

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 study.

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 tells me:
• Article 33 «Diagnosing is the first step in treating any patient»

Article 11 «A doctor has no right not to keep himself up to date on medical progress, in every domain; clinical, biological, technological etc…»
• Article 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"
• Article 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).

.

Is 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 treatment indiscriminately»


> 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 research?

> 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 studies.

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?

 (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)!

«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.

Our 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, are 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» (C. Vasseur, «Disqualification de la PSYCHIATRIE», Association Française de Psychiatrie December 2OO2)

 

AAPEL: 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)
I think it evokes several questions
1) The nature of the DSM One often forgets that the DSM is a multi-axial classification which takes into account five dimensions.
 

Axis 1- Clinical Disorders	(AAPEL:  Roughly mental disorders like depression, schizophrenia, etc)
Axis 2- Personality	(AAPEL:  Personality disorders, like "borderline", etc)
Axis 3- General Medical Condition	(AAPEL: If the person has some illnesses that could have an influence on the mental, like diabetes, cancer, etc)
Axis 4- Psychosocial and stressors Factors	(AAPEL: Example educational, economic, legal, etc)
Axe 5- Global Assessment of Functioning	(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)

2) The absence of a simplistic view
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.
.
3) 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 and psychologists.
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.
.
4) 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 particular.
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).

I 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)

The following questions were put to the "conseil national de l'ordre français" mid-February 2OO4
- 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 years).

Reply given by the "conseil de l'ordre" on 27 February 2OO4. - Dossier LJC/SB/PS/EDA/D.04.057.900
"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 aspect.
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).

AAPEL: That couldn't be clearer. the reply is perfectly clear!

• 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 etc.
• Furthermore, 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 ethics.
• As for 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 World Psychiatric Association (WPA)
We can read:
"...Psychiatrists serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles... It is the duty of psychiatrists to keep abreast scientific developments,of the specialty... It is the duty of psychiatrists to provide the patient with relevant information so as to empower the patient to come to a rational decision according to personal values and preferences..."

"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:
"...A 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)"

Is 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 practice" ?
Good question !

"At 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; numerous professionals also work with the DSM IV (TR), sometimes simultaneously with the ICD-10.

All health professionals receive basic training in diagnostics; only doctors and psychotherapists (a 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.

.
What 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.

The 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 disorders)

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 disorders.

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 human.

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.

Alain Tortosa
Psychotherapist and Founder of the AAPEL association.

Declaration of madrid, psychiatry and ethics
The right to be sick and dignity,(in french)
Talking to his/her shrink about BPD,(in french)
Do we have the right to ask the question of the training and competence of "shrinks" ?,(in french)
French medical code of ethics, right to information and diagnosis
AAPEL's code of ethics
For those wanting to order l'ouvrage "le DSM" en français