1 - Classification of psychiatric disorders and their principal treatments

Summary

A kind of thought compulsion, a logical and aesthetic necessity, insists that we seek for well-defined, self-contained, clinical entities; but unfortunately our subjective need is no proof of the reality of which we desire.

(Hoche, 1910)

Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical studies have shown extremely high rates of comorbidity among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception.

(Kupfer et al., 2002, p. xvii)

Introduction

Why, you may well ask, has a book about treatment found it necessary to begin with a section on diagnosis? Since the introduction of DSM–III (American Psychiatric Association, 1980), diagnosis has seemed to become the ‘holy grail’ of psychiatry. Yet currently, diagnosis is in the doghouse, as the quotations above, spanning nearly a hundred years, illustrate. But, even though we despair at regular intervals, we continue to want a nice clean system that allows psychiatric patients to be pigeon-holed by clever clinicians who then have both an explanation of a disorder and its solution. For the hope has always been that if a specific diagnosis is made correctly, that the proper and best treatment will follow almost automatically.