Thursday, May 26, 2005

Psychiatry's Call to Revise the DSM

In the JAMA issue that arrived today in the mail is a provocative commentary by Dr. Paul McHugh, Psychiatrist at Johns Hopkins. It's sure to raise some blood pressures.


"The DSM currently admits close to 300 mental and behavioral disorders. Given that clinical appearnces forge diagnoses, a particular patient can satisfy the criteria for several disorders and many dissimilar patients can meet criteria for the same disorder. Because the manual fails to identify what underlies the symptomatic expression of condition, it cannot suggest intelligible principles relating one disorder to another or illuminate why certain of them bunch together."

He also make the good observation that the DSM is dramatically different from the physicians ICD - The ICD is organized around disorders causes like cancers, infections, or autoimmunes diseases, not behaviors or symptoms like stomach ache or irritability.

"The DSM is not systematic in that way. Being appearance driven, it is similar to a naturalist's field guide with the advantages and disadvantages of such...They enhance accuracy of identification; therefore, they are reliable but do not explain distinctions."

What we are seeing in the epidemic of behavioral diagnoses among school age children is a direct consequence of this. Very diverse groups of children diagnosed by behavioral checklists as having ADD or ADHD, PDD-NOS or Aspergers, bipolar, or OCD are not frequently missed for the differences they have, they can be cornered into inappropriate pharmacological treatments.

McHugh wonders whether psychiatrists have not revised the DSM along more etiological grounds because "they await further advances in the basic sciences." But surely a stronger drive toward distinguishing different etiologies could only be helpful?

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