The World Health Organisation started classifying the causes of death in the International Classification of Diseases (ICD). In the sixth revision it extended its classification to causes of morbidity as well as mortality and a chapter was added for psychiatric disorders (which don't cause death as such). The americans have always run a parallel DSM system. ICD-9 and DSM-II were essentially the same.
Criticism of psychiatric diagnosis led to the DSM-III revision, which attempted to define psychiatric disorders using operational criteria. Although it may have been technically atheoretical in its approach, it encouraged a biological understanding of mental illness as due to brain disorder. The misguided hope has been that reliable diagnoses will equate with standardised biological tests developed by advancing neuroscience (eg. see blog by Allen Frances, who has also been critical of DSM-5 because of its potential expansion of the boundaries of psychiatric diagnoses). DSM-IV abolished the distinction between organic and functional disorders as they are all seen as brain disorders (see previous post).
There were of course diagnostic systems before ICD-6 and DSM-I, but it is the authority attached to diagnostic descriptions since DSM-III that causes problems. However important classification may be for scientific communication, it is also essential to realise that diagnosis is also about the reasons why a person has developed problems. Focusing on a single word entity distracts diagnosis from obtaining this personal understanding.
Idealised diagnostic descriptions are not entities as such. This truth has been lost in the pursuit of DSM-5, which should be abandoned. There are alternative ideas about comprehensive diagnosis which could be developed (eg. see World Psychiatric Association (WPA) conference report). Allen Francis has recently suggested in NYTimes that a new organisation is needed to take over from the American Psychiatric Association, but I'm not quite sure why he doesn't consider WPA.
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Alternate diagnostic systems are already out there - even in the US. There is the system invented by Johns Hopkins. There is the Psychodynamic Diagnostic Manual or PDM - the product of collaboration between 6 nonpsychiatric organizations. All of these groups including international organizations seem to be suggesting that a classification system is needed. Many psychologists treat people based on the basis of test results. There is obviously no obstacle to other systems of comprehensive diagnosis.
In fact, McHugh and Slavney in their NEJM editorial this week discuss the difference between checklist diagnoses and comprehensive assessments and they correctly conclude that checklists "deprive psychiatrists of the sense that they know their patients thoroughly."
The problem with demagoguing the DSM is that it takes the clinical method and training used by psychiatrists out of the loop and caricatures psychiatric treatment.
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