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Monday 14 May 2012

DSM5 - Danger signs on the road to a paradigm shift in diagnosis of childhood disorders

A Warning Sign on the Road to DSM-V:
Beware of Its Unintended Consequences
Psychiatric Times
By Allen Frances
June 26, 2009

The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V. Fortunately, the NIMH is now embarked on a fascinating effort to effect the real paradigm shift of basing diagnosis on biological findings. Unfortunately, this is years [if not decades] from fruition… So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality… Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system. With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities…
I think of the APA response to Dr. Frances’ article as a nasty-gram written by Dr. Alan Schatzberg, then President of the APA [under investigation at the time by the U.S. Senate for financial impropriety]. It did say that the DSM-III and DSM-IV were outdated and hadn’t kept up with current thinking and the advances of science, but then they accused Drs. Spitzer and Frances of having financial motives behind their complaints.

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