Applying DSM criteria in a simple checklist fashion can result in significant clinical mistakes and overmedication, Giovanni A. Fava warns in his latest book, Clinical Judgment in Psychiatry: The Foundation of Optimal Treatment.
Because the DSM model is psychometric, disparate symptoms can receive equal weighting. When severity is determined by the number of symptoms, not their intensity or quality, those that are mild are easily conflated with those that are severe and incapacitating.
A second factor is no less critical in avoiding misdiagnosis and overtreatment: the DSM presumes that most symptoms are not iatrogenic in origin—in other words, not an adverse effect of medications taken. After witnessing decades of polypharmacy led by DSM overdiagnoses, Fava finds that premise implausible.
Although psychiatrists and clinical psychologists rely heavily on careful observation, description, and formulation, the literature advising them how best to reach such decisions is thin and oversimplifying. Due to overscheduling and patients’ limited insurance for reimbursements, psychiatrists may be “reluctant to postpone their actions and are often eager to rush to prescription.”
Because DSM criteria also decontextualize suffering and distress, patients and physicians frequently end up with one-sided explanations. The biomedical reductionism that pairs seamlessly with medicine’s commercial interests results not in precision medicine, but rather unneeded hospitalization, overuse of prescription drugs, excessive surgery, and inappropriate use of diagnostic tests. In such widespread scenarios, accurate diagnosis becomes haphazard, and iatrogenic harm a likelihood.
Measuring Allostatic Load
A professor of psychiatry based at the University at Buffalo, State University of New York, Fava served for 30 years as editor-in-chief of Psychotherapy and Psychosomatics (1992-2022), writing candidly of his field’s biases and blind spots: “I was always looking for papers that contained clinical insights.” Few advanced comprehensively what was needed.
One of Fava’s well-reasoned interventions is that the concept of vulnerability in patients is not limited to side effects but extends to iatrogenic factors. In addition, full consideration of medical harms and environmental stress should include a patient’s allostatic load—“the cumulative effects of [their] biopsychosocial experiences in daily life that involve chronic stress and life events.” These may include loss and death; divorce and separation; job loss and financial hardship; and trauma, discrimination, and anxiety tied to social insecurity and the effects of prejudice.
Third, Fava concludes, excessive reliance on checklist criteria is likely to “impoverish the clinical process” and clinical formulation itself, including of the kind that could anchor a patient’s informed consent for treatment, itself a condition for its success.
How to Reduce Bias
When evidence-based medicine was first popularized in the 1990s, a decade the U.S. devoted almost entirely to neuroscience and biomedicine, physicians were initially urged to draw on multiple sources of knowledge, to form comprehensive hypotheses, and then clinical decisions, aspiring for whole-person care.
Over time, however, Fava argues, “vested interests conveyed the message that there was only one option for treatment of a specific condition, and meta-analyses were the method to disclose the right option.” Physicians were urged to follow guidelines and avoid subjective interpretations. Unsurprisingly, given their near-perfect fit, diagnostic criteria soon morphed into treatment targets. Once a diagnosis was made, the preferred drug-based treatment was meant to seem automatic.
In guidelines where thresholds are frequently revised upward to encompass ever-larger numbers of patients, where the motivating research is often sponsored by those with a vested interest in the expansion, the prescribing clinician can easily overestimate a treatment’s advantages while downplaying what may be a high risk of vulnerability and adverse effects from treatment.
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Meanwhile, Fava notes, running parallel to the argument against subjective bias are two major structural sources of bias: excessive reliance on meta-analyses of short-term, industry-funded studies, and investigators setting clinical guidelines bearing substantial financial conflicts of interest in the treatments prescribed.
What Can Be Done?
One way to reduce these missteps in U.S. psychiatry is to remember that therapeutic targets are not predetermined, even by diagnostic manuals such as the DSM or ICD, but crucially depend on how well patients respond, at what pace, and with what degree of recovery.
A second path to reform is to acknowledge that psychiatry today is “the only medical specialty to disregard lifestyle” and to reframe its perspective and treatment focus accordingly. For instance, to factor in environmental and work-related stressors while encouraging improvements in diet and exercise, alcohol reduction, stress reduction, and changes to a sedentary lifestyle. That, in turn, means reconceiving treatment options beyond short-term efficacy to include longer-term responsiveness and a focus on what symptoms persist.
Clinical Judgment in Psychiatry provides succinct, targeted chapters on evaluation, staging, psychological well-being, the role of personality, health attitudes and behavior, and more. Rejecting DSM rigidity and abstraction, it advances a comprehensive diagnostic rationale for treatment paths that are sufficiently flexible to accommodate real-time adjustments and responses in a patient.
The fruit of decades of research and clinical experience, Clinical Judgment presses persuasively for achievable reforms that deserve careful consideration. Well-timed in advance of DSM-6 discussion and publication, the book encourages incremental care from multiple clinical strategies. If implemented even in part, its effects would be transformative, including for how we think about suffering, distress, and dysfunction.
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