Updated: Mar 16, 2022
Imagine you were seeking help from a psychiatrist or psychotherapist, and they told you that you were suffering with multiple mental health diagnoses. Would that feel overwhelming? Would you feel hopeful that some form of treatment would offer you help to get back to a place where you felt better? Unfortunately, this is the reality for many people and it’s all because of the way the field of psychiatry is currently being guided by the bible of diagnostics in the psychiatry field. That bible is the Diagnostic and Statistical Manual, now in its fifth edition, known as the DSM-V. This manual is a comprehensive guide to assessing and diagnosing mental illness. In the late 1980s, I was invited to take part in field trials for updating the criteria in the DSM. After speaking to leaders in psychiatric measurement at Columbia University, I learned there are two schools of thought when it comes to psychiatric diagnoses.
Lumpers tend to think of mental illness diagnoses as a spectrum. Splitters, on the other hand, go for discrete diagnoses and think in terms of yes or no when evaluating criteria. In the medical field, a splitter point of view is very useful–you either have an infection or you don’t, for example. The DSM-V relies on a splitter approach to psychiatric diagnosis, much to my chagrin. When it comes to mental illness, my view is that the splitter approach is not very useful.
Ignoring the lumper, or spectrum, approach has real-world consequences for patients.
Psychiatry is full of maybes. It’s not as clear-cut as a medical diagnosis because one person can have symptoms pointing to multiple diagnoses at one time. Not only that, but another person can have different symptoms that lead to the same diagnosis—or diagnoses. The brain is too complex to be subject to such a black-and-white way of viewing the patient. Some mental states are temporary–such as being under the influence of drugs or being in a state of shock. Other mental states only appear when triggered, such as experiencing an eve
nt that causes a flashback or a previously repressed memory to surface. Using a lumper approach to evaluating a patient allows practitioners to take possible environmental or situational context into account.
A Story of One Patient and Two Diagnostic Perspectives
In my book, The Promise of Psychedelics (published Ingenium Books, April 2022), I share the story
of a man we’ll call Tom. Here’s what we know about Tom:
He’s in his mid-twenties.
He was abused as a child.
He was bullied at school.
He doesn’t have many friends.
Tom is in the emergency room, tearful and sad, and considering self-harm. He also appears to be inebriated. This isn’t the first time he’s shown up like this in the emergency room, when tests have also confirmed he had drugs in his system. He’s been to his regular doctor over the past two weeks complaining about anxiety and panic attacks, which have been getting worse over the past year. He’s also having trouble at work.
Battle of the Diagnostic Perspectives
If I were Tom’s psychiatrist, using a lumper, or spectrum, perspective, I’d conclude that Tom has depression and an anxiety disorder on a background of trauma, low self-esteem, and self-harming behaviour, and is using self-medication as a coping mechanism. My assessment would describe Tom’s presenting behaviours without breaking them down into discrete diagnoses.
Using the splitter perspective that’s currently used in the DSM-V, Tom would end up with SEVEN different psychiatric disorders, including Major Depressive Disorder, Generalized Anxiety Disorder, Panic Attack Disorder and Post-Traumatic Stress Disorder.
If you were Tom, how would you feel upon hearing that you have seven different mental illnesses? Overwhelmed is a word that comes to mind.
While none of these diagnoses are wrong per se, viewing them as seven distinct conditions makes it difficult to determine an appropriate course of treatment.
A Case for Lumpers
A spectrum approach to diagnosis is a much more useful way of looking at mental illness and allows for more ways to consider treatment options. The fact is that many diagnoses go hand in hand. For example, it’s rare to see depression without accompanying anxiety. In terms of diagnosis, depression and anxiety should be considered as one condition, the presentation of which lies on a spectrum. Viewing the patient’s symptoms as parts of a whole demands the multimodal approach to treatment that I’ve described in earlier articles. The best thing we can do for patients with mental health challenges is to keep their humanity at the centre of everything we do to evaluate and treat them.
Learn more about Dr. Peter Silverstone, his book, The Promise of Psychedelics, and the new mental health therapy he and his team have developed.