DSM needs to return to its origins

Following my previous post, I just wanted to be clearer about why I am not advocating totally abandoning psychiatric diagnosis. My position may seem surprising as essentially I agree with the critics of psychiatric diagnosis. Biomedical diagnosis has failed in the sense that mental disorder is not due to brain abnormalities. Symptoms and signs in psychiatric assessment are about mental, not bodily functioning. Psychiatric diagnosis and biomedical assessment act as a means of avoiding the uncertainty and pain of people's life stories.

Yet, I'm not the only psychiatrist that has given a priority to personal assessment rather than psychiatric diagnosis. Nor am I the only one that does not see mental illness as a brain disease. There has always been this conflict in modern psychiatry, since the origins of the asylums and the introduction of the anatomoclinical understanding of disease in medicine in general. Particularly in American psychiatry, the biomedical assumption was undermined by the views of Adolf Meyer (eg. see previous post). As Erwin Stengel (see my mention of him in another previous post) wrote in his review of psychiatric classification in 1959:-

Recently, the attitude of many psychiatrists towards the conventional type of classification has become one of ambivalence, if not of cynicism. This attitude derives partly from a low estimation of diagnosis, which in large areas of psychiatry has remained imprecise and has proved a poor guide to prognosis and therapy. Also, the concept of mental disorder, which in Kraepelin's view closely approximated that of physical disease, has changed in such a way that a conventional medical diagnosis no longer seems applicable. In many schools, especially in America, mental disorders are viewed as reactions of the personality to known or unknown pathogenic factors (Stengel, 1959).

In other words, there was a time when psychiatrists were much more aware of the limitations and problems of psychiatric diagnosis. DSM-I used the term 'reaction' throughout the manual, influenced by the ideas of Meyer. For example, functional disorders were called "disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain" and this included manic depressive and schizophrenic reactions. There was no pretence that mental disorder is due to brain abnormalities.

Now that it is apparent that DSM-5 has failed (eg. see previous post), we need to undo each of the steps taken along the way. DSM-IV dropped the functional-organic distinction, which needs to be reinstated (see previous post). DSM-III encouraged a biological view of mental illness and introduced operational criteria, but did not improve diagnostic validity. DSM-II was not too different from DSM-I, but dropped the term 'reaction'. Conceptually the DSM process has been totally misguided, and we need to rethink and return to basic principles if there is ever going to be a DSM-6.