Thursday, September 3, 2009

Preserving Irrelevance?

I agree with Drs Schatzberg, Scully, Kupfer and Regier. In my busy clinical practice, I do not see DSM-IV doing justice to clinical reality. Less than 25% of my patients have a genuinely good syndromatic fit with specific DSM diagnoses.

With diagnostic criteria strictly applied, I find myself with numerous NOS diagnoses with little in terms of treatment or prognosis utility. Preserving the current DSM structure would make it increasingly irrelevant to clinical practice.

DSM-IV seems to misconstrue how psychiatric diagnosis is made in real-world clinical situations which seem to parallel GK Chesterton’s famous quote “you can only find truth with logic if you have already found truth without it.” While a paradigm shift may be clearly disruptive, that is what psychiatry needs at this juncture to keep classification relevant to day today clinical practice.

While advances in neurobiology may help resolve some of our diagnostic stalemates, the complex sequential interaction between neurobiology, changing adaptive demands, and existential issues may continue to make psychiatric diagnosis a moving target.

Although a literature review seems to be an important avenue in the DSM revision, we must not overvalue it because we could easily get sidetracked by a circular situation in which literature is based on classification and vice versa.

Prevesh Rustagi, MD

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