Dilemma Of Psychiatric Diagnostics Dsms And Beyond

Some mental disorders arise through stressful life circumstances. Others emerge more from constitutional infirmities. Nature-nurture arguments do not help us much in unraveling such intertwined complexities, unless discrete genetic differences can be discovered, as in fragile X and Williams syndrome (Chapter 14). Ultimately psychiatric thought must continue to be guided by a careful appreciation of the evolving stories of selves in action on the stage of life. Neither the "brainless" psychiatry of the middle of the 20th century, nor the "mindless" variety of the past 30 years should be taken to represent the most we can achieve. The future should yield a synthesis. However, since we have been unable to unambiguously link most mental functions to brain functions and have only been able to pinpoint biological causes for a few rare genetic disorders, we have been left no other option than to categorize mental disorders on the basis of outward symptoms. Hopefully brain imaging and new chemical measures will soon become more prominent tools in diagnostics. Meanwhile, problems of diagnostic specificity and individual sensitivity remain to be resolved (Chapter 6).

Kraepelin's original taxonomy described the outlines of major psychiatric categories still accepted today. His textbooks had clear descriptions of syndromes that we now recognize as schizophrenia, various phobias, depression, and anxiety disorders with their links to obsessions and compulsions. The modern standard classification schemes, ever since the DSM-1 of 1951, have clearly followed the Kraepelinian outline, although the early versions were well spiced with psychoanalytic perspectives on depth psychological issues.

This approach has been refined through three more cycles, with the current DSM-IV (APA, 1994) and its European counterpart, International classification of Diseases, Tenth Edition (ICD-10) (WHO, 1992), providing extensive descriptive guidance. Today's diagnostics are largely based on "what" symptoms constitute a disorder, with silence on the issues of "why" or "how" a disorder emerges from underlying psy-chobiological substrates. Still, the "multiaxial" approach of DSM-IV acknowledges psychological, (Axis I and II) as well as organic, psychosocial, and environmental concomitants (Axis III, IV, and V, respectively). While Axis I provides a Kraepelinian set of diagnostics of major psychiatric categories, Axis II offers a dimensional scheme for evaluating personality problems. This serves as a coherent way for clinicians to communicate pragmatically without worrying too much about unresolved etiological questions.

Although difficulties with previous versions of the DSM have been reduced, many still regard it as only a provisional scheme that needs substantial improvement (McHugh and Slavney, 1998). Several inconsistencies between DSM-IV and ICD-10 remain: for instance, in the way the two sets of guidelines handle somatoform and personality disorders, a discrepancy that contributes to international misunderstandings. The forces to construct a DSM-V are presently being marshaled, but it remains controversial whether this approach still reflects sustained progress toward a scientifically defensible solution or simply an essential stop-gap measure that is socially needed until the etiology of psychiatric disorders are revealed. If the scheme does not carve disturbed human nature at its joints, it may actively impede scientific progress, especially where only a "natural" subset of a presumably homogeneous disorder will respond well to the therapy being evaluated.

The extent to which diagnostic schemes are influenced by societal standards is highlighted by the disappearance of homosexuality as a psychiatric disorder in the more recent versions of the manual. Partly, this has arisen from the scientific evidence that to some degree homosexuality reflects a natural variation in the organization of gender-specific brain circuitries during the second trimester of gestation (Chapter 4). It also partly reflects the emergence of new human rights movements. Scientific advances and cultural tensions will continue to permeate diagnostic practices since some "disorders" are only extremes of normal human temperamental variability (especially among the Axis II disorders), while others, to put it metaphorically, are more likely to reflect "broken parts" in the brain (most abundantly in the severe Axis I disorders). The issue of attention deficit hyperactivity disorder (ADHD) is an especially poignant example since so many children are given medications that may have potent and less than desirable long-term effects on the nervous system (Moll et al., 2001).

All simple symptom-based approaches, such as the diagnosis of ADHD, are bound to remain controversial to some extent, for there are many useful ways to conceptualize every phenomenon. It is only possible to move forward substantively on biologically based diagnostic criteria if we can objectively monitor the relevant brain systems and resulting infirmities at an organic level (Castellanos and Tannock, 2002). Such work is now advancing on various diagnostic categories (Chapters 6, 7, 11, and 14). However, continuing ambiguities create a pressure to include more and more qualifiers. The emerging problem with the complexity of DSM-IV is evident in the proliferation of subcategories of mood disorders that can defy common sense. DSM-II had only 8 types, but by DSM-IIIR there were 97, and according to Paul McHugh (2001), if you consider all the subcategories and specifiers in DSM-IV, one could categorize 2665 subtypes. This problem may continue to be endemic to appearance-based classification systems, since small differences often compel notice. The "success" of DSM-IV may partially explain the current estimate that about 28 percent of the population in America fulfill one or another of the criteria for a bona fide psychiatric diagnosis (Regier et al., 1998).

A major goal is now to seek deeper levels of understanding, which confronts us with a series of interlocking dilemmas. Epistemologically, we must resolve what major disorders objectively exist, and we must be able to specify how we know they exist, above and beyond mere surface symptoms. This question—of how we go about measuring what actually exists at an ancient neuropsychological level—has gotten a spectacular boost in the past decade from molecular biological and modern brain imaging techniques. However, so far neither brain-based criteria nor core emotional processes of the evolved aspect of the mind appear prominently in psychiatric practice (Chapter 21).

A fuller recognition of basic emotional imbalances at the core of many psychiatric disorders may also help reverse a growing problem of modern psychiatry—the marginalization of patients by making them mere consumers of pills rather than agents in reconstructing meaningful human relationships and life insights. When the neuropeptides are finally harnessed for therapeutic purposes (Chapter 21), we may find that they work most effectively in social contexts comparable to those in which such neurochemistries first found their appointed roles in brain/mind evolution (Chapter 20). If so, some of the new medications may work optimally only when we help re-create those environments, perhaps through some type of Meyerian "sociopsychobiological" synthesis. Obviously, psychiatric disorders will continue to be permeated and modified by hosts of meta-emotional factors—above all, individual capacities for affective self-regulation and thoughtfulness.

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