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DSM IV

DSM IV

It is clear that the leadership of DSM-IV, and of DSM-III before it, views psychiatric diagnosis in the DSM system as something that should be based on “pragmatism.”

Accurate diagnosis is absolutely crucial in SVP hearings because the potential outcome is so consequential—involuntary incarceration in a psychiatric hospital that may well last a lifetime. In no other clinical or forensic situation does so much ride on the presence or absence of a psychiatric diagnosis.

The polemics between Drs Pies and Wakefield and Horwitz (“An Epidemic of Depression,” Psychiatric Times, November 2008, page 44) have validity, but their commentaries did not touch on the real bone of contention. Dr Pies does not believe that just because psychosocial precipitators of a depression—specifically, bereavement—are known, somehow the significance of the depression should be viewed differently.

Suppose your new patient, Mr. Jones, tells you he is feeling “really down.” He meets all DSMIV symptomatic and duration criteria for a major depressive episode (MDE) after having lost his wife to cancer 2 weeks ago. Should you diagnose major depressive disorder?

Traditionally, affective and interpersonal traits such as egocentricity, deceit, shallow affect, manipulativeness, selfishness, and lack of empathy, guilt or remorse, have played a central role in the conceptualization and diagnosis of psychopathy. In 1980 this tradition was broken with the publication of DSM-III. Psychopathy- renamed antisocial personality disorder- was now defined by persistent violations of social norms, including lying, stealing, truancy, inconsistent work behavior and traffic arrests.

The distinction between psychopathy and ASPD is of considerable significance to the mental health and criminal justice systems. Unfortunately, it is a distinction that is often blurred, not only in the minds of many clinicians but in the latest edition of DSM-IV.

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