Reflections on DSM classification and its utility in primary care: case studies in "mental disorders"

This case series was conducted to demonstrate the limitations of the DSM system in primary care patients.

Sixty family health center patients free of mental disorders according to DSM-IV criteria completed monthly quantitative interviews, using multiple rating instruments, concerning the levels of psychiatric symptoms, presence of distress and/or a mental disorder, functional status, support, and stressors. In addition, a purposive sample of 16 subjects completed an in-depth qualitative interview concerning their situation at the time they crossed a DSM threshold. Data were collected from April 2000 to March 2001.

Overall, there were 14 subjects with distress alone, 6 subjects with subthreshold disorders, and 3 subjects with known transient (< 2 months' duration) threshold disorders. Thus, even with the incomplete longitudinal data in this study, the clinical needs of 23 (38%) of the original 60 subjects were inadequately met by the DSM criteria. From the 10 subjects who crossed a DSM threshold and completed a qualitative interview, we selected 5 case studies with the most complete and complementary quantitative and qualitative data to illustrate several findings regarding the utility of the DSM classification in primary care. First, these cases show that psychological symptoms and DSM disorders vary considerably. Second, distress and subthreshold disorders are often seen in primary care patients. Third, the crossing of a DSM threshold corresponds to extreme levels of psychological symptoms and may therefore represent symptom severity. Fourth, psychological symptoms are often linked to physical illness. Finally, the context in which these symptoms and disorders develop often produces complex dynamic patterns.

The current DSM system failed to adequately reflect the spectrum and context of mental illness in patients from a predominantly low-income, Hispanic primary care population.