Magazine article Clinical Psychiatry News

Crafting the DSM-IV. (Reader Counterpoint)

Magazine article Clinical Psychiatry News

Crafting the DSM-IV. (Reader Counterpoint)

Article excerpt

In a front-page article in the August 2001 issue, Dr. Paul McHugh's recommendations for a radical makeover of the DSM in its fifth edition planned for 2007 were reported. He criticized DSM-IV for its emphasis on clinical appearance as opposed to psychologic or biologic essence, and indulged in the unfortunate ad hominem practice of stating that many disorders exist "only in the mind of the examiner," liening these portions of the DSM-IV to witchcraft.

After reading this, I removed my pointy hat, put aside my broomstic, and examined Dr. McHugh's proposed remedy, a classification involving disease, dimension, behavior, and life story.

The diseases are the real disorders, the ones we used to call organic, such as dementia and bipolar disorder. Dimensional disorders address an individual's constitution and sound a lot lie Axis II to me. Behavior disorders involve drug dependence and anorexia nervosa, while life story (thin Axis IV here) includes job-related anxiety. Oddly enough, posttraumatic stress disorder was not mentioned.

This debate is a variation on the age-old philosophical argument between Aristotelian empiricists and Platonic idealists. The former view reality as emerging from assembled empirical data; the latter believe that truth emerges from the realm of ideas. The DSM-IV is more Aristotelian; Dr. McHugh is Platonic.

The problem is that his proposal is really not so different from what we have, but imposes certain constraints on the classification system. It forces assumptions that disorders of behavior are not disease based, opening the door for judgment rather than treatment. It attempts to enshrine in the nosology the idea that some disorders are real biologic diseases while others are simply problems involving failures of learning, behavior, or life circumstance.

But what are we to mae of data indicating that specific brain functional deficits are associated with obsessive-compulsive disorder (supposedly dimensional) and that both medication and psychotherapy reverse these abnormalities? …

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