Hector Warnes' Comments

Carlos R. Hojaij: “DSM-5: The Future of Psychiatric Diagnosis” or Continuing the Psychiatry DiSMantlement

             I must agree with Professor Hojaij’s disappointment with the last classification of the American Psychiatric Association. It is indeed a quagmire that yields under one’s feet because there are no clear boundaries; phenomenology is blurred with other psychopathologies; there are far too many overlapping of various dimensional symptoms and signs; and there is no clear validation of the outcome measures that would justify the term nosology.

             I can hardly find discreet pathologies. Rather, we are finding more and more diagnosis of false positives and of frequent co-morbidity. I understand that there were about 400 experts from 13 countries, including clinicians, scientists and social investigators, contributing to this, adding and subtracting new entities without regard for the definition of the disease or disorder that should be included or ruled out.  Unlike our colleagues in other branches of Medicine, we seem to be growing and growing in disarray and not establishing a clear boundary of the normal and the pathological (Canguilhem 1965).

             A definite pathology is a failure of health and has its characteristic signs and symptoms. It may affect the whole body or its parts and its etiology, pathology and prognosis may or not be known for the time being. The question of bereavement exclusion is unacceptable because grief may last for more than two months and frequently overlaps with other depression and or somatic symptoms.

             We measure the loss of health by the gravity of the organic crisis which may be surmounted by a homeostatic or allostatic mechanism set in motion allowing a new physiological order to compensate.

             Far reaching research has centered in four main types of illnesses (diseases): infectious, deficiency, genetic and physiological. We are becoming aware that most mental illnesses are responding to one or more of these factors from within or from without. Of course, the brain is the orchestra director of this stimulus response at determined brain circuits, or at the deepest level molecular mechanisms that are set in motion.

             Just to point out the complexity of the psychobiosocial or molecular or translational medicine, there are a group of mitochondrial diseases which are dysfunctional organelles in the mitochondria (the generator of energy) which result in a host of illnesses including anemias, dementia, hypertension, retinopathy, lymphoma, seizures and neuro-developmental disorder.  Perhaps not unrelated are the former Neurasthenia (which has become neural exhaustion), debilitating fatigue, neuromyasthenia, encephalomyelitis, chronic Epstein-Barr virus infection, chronic infectious mononucleosis, myalgic encephalomyelitis and others.  These patients reduce their activity to less than 50 percent of its premorbid state and often are treated by psychiatrists, rheumatologists, neurologists and so on.

             About half a century ago, I was very impressed by Eliot Slater's 1965 follow up study of hysteria which, after more than a year in retrospect, ended up with the "wrong diagnoses" (“errors of diagnosis were prominent”) because its evolution proved that there were many neurological, physiologic and medical pathologies originally thought to be psychiatric.

             Is there a road to a final nosology of mental disorders? We are drifting away from categorical classification and finding more a pot pourri that keeps on changing. We have not as yet found clear cut scientific, nor clinical, nor epistemogical frameworks to diagnose the illness. However, studies of genomics have identified risk loci with shared effects on five major psychiatric disorders. These findings published in the Lancet in 2013 brings us closer to the understanding of the number (about five) of spectrum disorders that have been noted.

             Andrés L. Heerlein (2015) has also written a lucid and fair review on the limits of the DSM-5.

References: 

Adam D. Mental health: On the spectrum. Nature 2013; 496 (7446): 416-8.

Andreasen NC.  DSM and the death of Phenomenology in America: an example of unintended consequences. Schizophrenia Bull 2007; 3: 108-12.

Canguilhem G. The normal and the pathological. New York: Zone Books; 1991.

Slater E. Diagnosis of hysteria. Brit. Med. J.  1:1395-1399, 29 May 1965.

Craddock N, Owen MJ. The Kraepelinian dichotomy-going, going…but still not gone. Br J Psychiatry 2010; 196; 92-5.

Cross Disorders group of the psychiatric genomics consortium. Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. The Lancet 2013; 381 (9875): 1371-9.

Heerlein AL. Aproximándose al DSM-5: un avance en psiquiatría? Revista Argentina de Psiquiatria.  (Supl) 2015; 26; 3-11.

November 16, 2017