• G B Mitropoulos.
• 5th Department, Psychiatric Hospital of Attika, Αthens, Greece.
• Psychiatriki. 2018 Jul 1; 29 (3): 249-256.

AbstractThe use of diagnostic manuals in psychiatry is generally necessitated by the lack of tests that would corroborate psychiatric diagnosis. Criticism towards the today prevailing DSM-ICD diagnosis traditionally regards among others such problems as hyponarrativity, biologism, "death of phenomenology", and a questionably valid over-fragmentation of diagnosis. Lately, and especially after the appearance of the 5th edition of DSM (2013), criticism focuses at such issues as lack of validity, having failed to adopt a dimensional model, not adequately relying on genetics and neurobiology, and impeding, rather than facilitating, research into the etiology of mental disorders, the DSM becoming an "epistemic prison". The former problems seem to derive from the fact that the operationalist criteria are often uncritically adopted as the ultimate authority in diagnosis, instead of being merely guides, as intended originally and explicitely; the latter problems have been made more evident since the emergence of the American RDoC research initiative, which not only points to an alternative, more valid classification of mental disorders, but also aspires to signal a move of psychiatry tοwards precision medicine, having as its main dogma that mental disorders are disorders of brain circuits, which are expressed as complex syndromes. In this paper, the historical and epistemological context of the emergence of DSM is examined; its achievement in terms of diagnostic reliability as well as clinical utility is not negligible, especially taken into consideration the climate of virtual diagnostic arbitrariness which characterized the (American) psychiatry before 1980, with obvious consequences for the authority of the specialty. Then, the potential of the new era of genetics, neurobiology and analysis of the "big data" for generating a novel approach to psychiatric diagnosis and classification is put into consideration, while it remains unknown in what way the findings of RDoC could lead and be translated into a new classification system. Moreover, the particularity of the psychiatric object, the clinical significance of the categorical approach to diagnosis, as well as the need for a "irreducible psychological level of explanation" are discussed. In our view, today, the DSM-ICD diagnosis lies between two different and potentially opposing demands and tendencies: on the one hand, the demand for the individual, subjective and phenomenological particularity of the mentally ill to be taken into consideration (a demand that sometimes underestimates the need for clinical communication); on the other hand, the (largely future) vision for more and more analysis of biological data in the name of a yet to be clarified personalized therapy (the very notion of diagnosis becoming potentially redundant). Finally, considering the particularity of the psychiatric object, we conclude that matthe DSM-ICD approach, with its categorical diagnoses and its descriptive operational criteria, despite its inherent imperfections and inadequacies, continues to have a place in psychiatry as an essential bridge/interface between clinic and research data, as a common clinical language, and as an epistemic hub; and that prerequisites for diagnostic validity should be sought both in the cells of RDoC and in those theoretical approaches which examine human subjectivity as such, included phenomenology and psychoanalysis.

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