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Psychiatric Diagnosis

By Lawrence B. Erlich, M.D. - Email:

In order to win a case that involves psychiatric injuries it is very important that the attorney understand what is said to be wrong with the plaintiff. That involves understanding psychiatric diagnosis. The system of psychiatric diagnosis is consistent and simple, but it is a bit strange to people not familiar with it.

The present psychiatric diagnostic system started with the publication of the Diagnostic and Statistical Manual of the American Psychiatric Association in 1960. This first attempt of organized psychiatric diagnosis was brief, not very effective, and strongly influenced by the thinking of Adolph Myer, M.D., the professor of psychiatry at Johns Hopkins.

Dr. Myer's mother was schizophrenic and this may relate to the fact that Dr. Myer felt that all mental illness was produced by reactions to life and was never inherited. In 1970 the second edition, called the DSM-II was published. It was a bit longer, a bit better organized, and based more on the biological and principles that dominate psychiatry today.

Sir William Osler, considered to have been America's greatest physician, stated that if you want to be healthy you have to chose your parents carefully. However, the DSM-II was still too brief and unscientific to be very useful. The breakthrough was in 1980 with the publication of the DSM- III. This edition was based on extensive research and the syndromes described were consistent and reliable. The late Seymour Pollack, M.D., who was professor of forensic psychiatry at USC, used to say that a psychiatrist was a physician who had a fondness for vagueness. The American Psychiatric Association was aware of this and therefore they went to great lengths to make the DSM-III precise and clear.

At this point psychiatric diagnosis was comparable in reliability to cardiology. The DSM-III introduced a system of diagnosis based of five "Axes." The reason for this is that Psychiatric Diagnosis psychiatric diagnosis is different from diagnosis in other fields of medicine in that the diagnosis and prognosis do not go together.

The same situation exists in the field of rehabilitation and a bit easier to explain this with regard to that field. What is important to a patient is not the name of his illness but how he is going to do. In medical terms, what is important is the prognosis, not the diagnosis. If I'm a patient you can call my illness anything you like as long as I am going to get better, and if I'm not going to get better, then I still don't care what you call it. Generally speaking, in medicine, young, healthy patients do well old, sick patients do poorly. The exception to this is the field of rehabilitation in which old, sick patients do well and young healthy patients do poorly. For example, one type of typical patient in rehab would be a 75 year old man with a stroke. He has worked hard all his life, so when he is told that he has to get up at seven in the morning, go down to physical therapy and work hard, then to go occupational therapy and work hard there, then to speech therapy for more hard work he knows what hard work is and he does it. On the other hand, the young patients are usually people who have had head injuries, from car accidents caused by drugs or alcohol. That sort of patient may have worked very little in his life, and having a head injury does not make such a person more responsible. They often do not cooperate with their therapy and they do not get better.

Similarly, in psychiatry the prognosis depends not on the patient's acute diagnosis but rather on the character of the patient. If the patient has an antisocial personality, (a compulsive liar) he is likely not to cooperate with his treatment. If he has a passive, dependent personality, he may also not cooperate because he enjoys being sick and getting attention, etc. For that and other reasons, psychiatric diagnosis is divided into five parts, called axes. They are the following:

  • Axis I: The acute diagnosis such as Major Depression, Schizoaffective Disorder, Paranoid State, etc. Psychiatric Diagnosis
  • Axis II: A personality disorder such as Paranoid Personality, Antisocial Personality, Dependent Personality, etc.
  • Axis III: Any relevant medical diagnoses
  • Axis IV: Stessors in the patient's life
  • Axis V: Level of function described on a scale of 0 (minimal function) to 100 (perfect function)

This system was developed for psychiatrists by the American Psychiatric Association. All of the research was done on psychiatrists. Using this system a psychiatrist in Portland Oregon will evaluate a patient and usually get the same results as a psychiatrist in Miami, Florida, New York, or any place else. However, no research has been done on psychologists, social workers, therapists, etc. There is no scientific evidence to suggest that these other disciplines can use this system consistently and no one can honestly say that he can testify to a diagnosis to the standard of reasonable medical certainty because there is no evidence of this for anyone but psychiatrists.