Kudos, Awais, for an elegant discussion of the DSM's advantages and disadvantages, applications and limitations. Much could be said on each of the issues you raise, but I would like to focus on just one. In doing so, I suspect I will offend some of our colleagues, but that comes with the territory! Here is the crucial point: many adamant critics of the DSM-5--including too many psychiatrists--have simply failed to read the manual carefully, or to understand its clearly stated "instructions." Specifically, you rightly observe that,

"Mental health problems exist in a particular context of temperament, development, life story, and social circumstance, and cannot be divorced from this context."

Quite so--but this is fully consistent with the DSM-5's admonition. As the Manual itself notes (p. 19):

"The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms of the diagnostic criteria to make a mental disorder diagnosis."

In short, simply checking off symptoms cannot and does not constitute a psychiatric diagnosis—which requires a comprehensive case formulation. I would hazard a guess that very few users of the DSM-5 are aware of this critical point--and that even fewer take the time and effort to create a true case formulation for a newly-evaluated patient. And, yes--such a case formulation requires not only comprehensive professional training, but also medical understanding of the "biological factors" that partly constitute the case formulation.

There is a Buddhist saying: If you want the chicken to be a duck, and the duck, to be a chicken, you are going to be very unhappy! Many critics of the DSM want it to be something it is not intended to be, just as you say; namely, a deeply-probing guide into one's psychopathology. On the other hand, the DSM is also not a mere "Chinese menu" of symptoms which, when checked off, constitute a diagnosis.

I explore these issues in more detail in this piece for Psychiatric Times:


Thank you again, Awais, for a thoughtful and carefully nuanced discussion!

Best regards,


Ronald W. Pies, MD

Professor Emeritus of Psychiatry

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I have to tell you that I, a psychiatric consumer who has never heard of HiTop, immediately looked it up and started eagerly reading the excerpts of it on the Wikipedia page, just as I look up each ICD code on my lithium labs. 🙂 I appreciate your analysis of this cultural desire to use these diagnostic codes as markers of identity, and I’m interested in our moving beyond it. Looking forward to reading your newsletter, which my husband just told me about today.

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