Towards a genuinely medical model for psychiatric nosology

The Diagnostic and Statistical Manual of Mental Disorders (DSM) [1] is the object of unrelenting criticism [2-7]. The first page of a leading psychiatry textbook says, "there is little reason to believe that these categories are valid" [8]. Clinicians say DSM categories ignore important aspects of many patients' problems. Teachers report that reification of diagnoses leads students to neglect important phenomenology [8,9]. Researchers protest requirements to use DSM categories that do not map well to neuroscience hypotheses [10]. Non-professionals are skeptical about disorders defined by committees. And, physicians in other areas of medicine cannot help but wonder why psychiatric diagnosis is so problematic.The current crisis in psychiatric nosology originated in the solution to a previous crisis. In the early 1970s, psychiatry awoke from a long dream to find itself floating on a couch in the backwaters of medicine. A wake-up call came when a 1973 article in Science reported that 12 "pseudopatients," who pretended to hear hallucinations, were hospitalized and received a diagnosis of schizophrenia, even though they acted normal after admission [11]. More positive calls came from psychiatrists reporting remarkably selective responses to new medications [12], from researchers identifying genetic influences [13], and from new proposals for diagnostic criteria [14].By the late 1970s, psychiatry was eager to establish its scientific credibility, and the unreliability of psychiatric diagnosis was an obvious problem. For instance, the DSM-II definition for Depressive Neurosis was: "an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession" [15]. Is depression after loss of a favorite cat "excessive?" One diagnostician would say, "Yes," another, "Obviously not!" Such unreliability made research impossible, and psychiatry's scientific aspirations laughable.The solution was the DSM-III