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Evid Based Mental Health 16:2-3 doi:10.1136/eb-2012-100987
  • Expert review

Drop the language of disorder

Editor's Choice
  1. Richard P Bentall1
  1. 1Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
  2. 2Psychology Department, University of Auckland, Auckland, New Zealand
  3. 3Mental Health Sciences Unit, University College London, London, UK
  1. Correspondence to Professor Peter Kinderman, Institute of Psychology, Health and Society, University of Liverpool, Liverpool L69 3GL, UK; p.kinderman{at}liverpool.ac.uk

INTRODUCTION

We may be on the cusp of a major paradigm shift in our thinking about psychiatric disorders. The proposed revision of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) of Mental Disorders franchise for the classification and diagnosis of human distress, which will lead to the 5th edition (DSM-V), has served as a catalyst for a wide range of criticism (most notably at www.ipetitions.com/petition/dsm5/). This has identified serious inadequacies in the specific proposed revisions, and has also highlighted scientific, philosophical, practical and humanitarian weaknesses in the diagnostic approach to psychological well-being, underpinning the DSM. This debate provides the opportunity to propose a more scientific grounded and clinically useful system.

Problems with diagnosis

Diagnostic systems in psychiatry have always been criticised for their poor reliability, validity, utility, epistemology and humanity. With great effort, and standardised approaches, it is possible for reliable diagnoses to be generated. But such practices are rarely adopted in clinical settings, and as we know, it is entirely possible to reliably diagnose invalid diagnoses (the mere agreement between diagnosticians is no guarantee that diagnoses correspond to meaningful clusters of symptoms, with distinct pathophysiology and aetiology, which predict the effectiveness of particular treatments).

The poor validity of psychiatric diagnoses—their inability to map onto any entity discernable in the real world—is demonstrated by their failure to predict course or indicate which treatment options are beneficial, and by the fact that they do not map neatly onto biological findings, which are often non-specific and cross diagnostic boundaries. For example, depression and anxiety disorders are so comorbid that it is often arbitrary which diagnosis is given to a patient; schizophrenia symptoms are usually accompanied by mood …

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