What about DSM?
To be sure: I believe that an objective, independent review of the DSM-5 process and its proposed changes would be in the profession’s best interest and might marginally enhance the public’s confidence in psychiatry. In my view, the National Science Foundation would be best equipped to provide such a review. However, I believe more radical changes must be made. With or without an independent review of DSM-5, the DSM framework is simply not serving everyday clinicians very well. As Aaron Mishara, MD, and Michael Schwartz, MD, recently observed, “. . . DSM-III’s logical empiricist agenda inserted a wedge between clinician and clinical researcher which still has not been appropriately addressed.”6
I appreciate the perils of suggesting a radical re-thinking of a diagnostic system that has been in place, with many variations, for over 30 years. Nevertheless, I believe that a very different kind of diagnostic model is needed. In brief, I am proposing the following:
1. Changing the name of our classification scheme to the Manual of Neurobehavioral Disease, or MND. This name helps eliminate the confusing Cartesian split between mind and body, implied in the present “mental disorder” designation—a problem explicitly acknowledged in the introduction to the original (1994) DSM-IV. The new MND title also allows for the (continued) inclusion of conditions such as Alzheimer, Huntington, and Parkinson disease, which markedly alter behavior, cognition, and mood. That said, I could also live with, simply, Manual of Psychiatric Disorders.
2. Emphasizing the crucial importance of suffering and incapacity as hallmarks of disease (etymologically, disease) and omitting from the MND’s list of disease entities any condition that lacks these features. This does not mean, however, that non-disease conditions or situations should not be within the purview of psychiatric care; for example, there is no reason a psychiatrist shouldn’t help a family struggling with the death of a parent, or the breakup of a marriage—although neither situation constitutes “disease.”
3. Separating clinical descriptions of disease (“prototypes”) from research-oriented criteria while also ensuring that the two levels of descriptions are compatible. The prototypical descriptions would be aimed at giving the clinician a rich, holistic, phenomenological understanding of a disease—emphasizing the “inner world” of the patient—rather than a “one from column A, one from col-umn B” list of criteria. The research-oriented criteria could appear as an appendix to the main MND text or as a separate document. This “two-tiered” system of diagnosis has its roots in the writings of Hughlings Jackson, and the clinical/research separation I advocate was also re-cently suggested by Prof Joel Paris.7
4. Regarding psychiatric classification not as an end in itself, but as a means toward the effective relief of certain kinds of human suffering and incapacity. Thus, rather than viewing diagnostic categories as reified “objects”—like rocks or trees—they would be understood instrumentally; ie, as tools in the service of medical-ethical goals. As Dr Joseph Pierre8 has observed, “. . . clinicians do not in general fret over what does or does not constitute a disease. . . . If, for example, a patient’s arm is broken in a car accident, a doctor doesn’t lose sleep pondering whether this represents ‘broken bone disorder’ or simply an expected response to an environmental stressor—the bone is set and the arm is casted . . . mental disorder or not, clinicians working in ‘mental health’ see it as their calling to try to improve the lives of whomever walks through their office door seeking help.” Precisely!
5. Regarding biological data as supporting, but not defining, disease categories. In so far as “biomarkers” and biological data are found to correlate with specific disease categories, this information should become part of the supporting text of the MND. But diagnosis would remain essentially “clinical” (from Gk klinikos “of the [sick]bed”).
6. Applying the principle of parsimony, usually expressed in terms of Occam’s Razor—ie, “entities should not be multiplied beyond what is necessary.” This does not mean deliberately reducing or increasing the number of diagnostic categories, but rather retaining only those categories that are absolutely necessary and that entail substantial suffering and incapacity. Thus, some conditions that involve merely “disapproved of” behaviors, without substantial suffering or functional impairment, would no longer count as instantiations of disease.