By Dr. Anthony Policastro

The American Psychiatric Association publishes a book titled the Diagnostic and Statistical Manual of Mental Disorders. It sets up criteria for physicians to make a diagnosis of a mental disorder. 

When I was practicing full time, many of the patients I saw had ADHD. There were 18 criteria to make the diagnosis of ADHD. I would list them in the medical record to confirm their presence. There were eight criteria for making the diagnosis of what is called Oppositional Defiant Disorder. There were 14 criteria for diagnosing what is called Conduct Disorder.

I would not only record the criteria in the records, but I would also show them to the parents. This was especially true for Conduct Disorder. Some of the early criteria included things like picking fights, animal cruelty and fire starting. 

If I had a patient with those symptoms, I would then show the parents what kinds of things followed them. Those things include armed robbery, rape and murder. It allowed me to emphasize that the time for psychiatric help was before it got to that point.

As an example of how the manual worked, I will share the criteria list for individuals with a Narcissistic Personality Disorder.

DSM defines Narcissistic Personality Disorder (NPD) as a condition of “a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

• Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements) 

• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love 

• Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions) 

• Requires excessive admiration 

• Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations 

• Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends 

• Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others 

• Is often envious of others or believes that others are envious of him or her 

• Shows arrogant, haughty behaviors or attitudes.”

So a physician who suspects that his patient has this diagnosis would record the criteria in the chart. The physician would make sure that there was a minimum of five of the criteria as noted in the list. This allows for specific criteria and not just a feeling that a person has a certain mental health diagnosis. Overall, the DSM criteria help standardize the approach to mental health diagnoses.