Insight Matters
Spring, 2004

EDITORIAL

PSYCHIATRIC DIAGNOSIS IN 2020: Not Your Father's DSM!
by Henry A. Nasrallah, M.D., Editor

Is the DSM IV showing its age? A growing plurality of clinicians and researchers think so, and for many reasons.

Clinical diagnosis is the foundation of specific and appropriate medical care. Ideally, diagnosis can also inform about etiology and pathophysiology. I was trained during the era of DSM II, a diagnostic schema now regarded as primitive. The advent of DSM III was a major psychiatric milestone, a triumph of reliability over chaotic subjectivity. However, diagnostic validity remained elusive through the subsequent revisions of DSM III R and DSM IV. So where are we heading and what will DSM "N" be like in the future?

There are several indications that the DSM will steadily evolve towards a more scientific diagnostic system, with a major departure from operational criteria that exclusively utilize signs and symptoms divulged by the patient towards objectively measureable criteria.. Furthermore, the future DSM is likely to address some complex and unresolved clinical issues such as the axis I/axis II dichotomy, the relevance of psychiatric and physical comorbidities, and the lack of biological markers for specific diseases. In addition, the future DSM is likely to be informative regarding the premorbid and developmental evolution of the illness, and may include a staging of pathology as well as biological mechanisms.

Advances in molecular genetics and neurobiology will inevitably influence the form and substance of future psychiatric nosology and diagnosis. A dimensional rather than categorical schema of psychopathology should emerge, based on genetic loading, gene expression and genetic/experiential interactions. In their recent breakthrough discovery Caspi et al (Science, 2003) demonstrated that the transduction of life event stress into clinical depression occurs in persons with the short polymorphism of the serotonin transporter [5-HTT] gene while people with the long polymorphism appear to have the resilience and are protected from depression . This revelation has set in motion the evidence-based integration of biological and psychosocial risk factors into diagnostic validity. Furthermore, the elucidation of the bidirectional influences of gene/environment interactions will open the door to the unchartered territory of targeted prevention or, at least, a rational guide for modifiers and modulators of the illness, which can be incorporated into the diagnostic constructs.

The DSM of the future will have far less pejorative valence than past or current DSM's. It will also be a perpetually evolving rather than a static descriptor of the patient's changing psychopathology over time. DSM IV offers a label or a pigeonhole that patients wear or are boxed into for the rest of their lives while the DSM diagnosis of the future is likely to change as a patient ages, responds to treatment, develops new adaptive skills, triumphs over disability and emerges from disability. The brain is an ever-changing organ as neurobiological research has revealed, and thus, diagnostic constructs are bound to change concomitantly over time.

It should not come as a surprise that the amazing neuroplastic potential of the brain may lead to radically different diagnostic constructs, treatment modalities and prevention measures. The future DSM may bear little resemblance to its ancestral paradigms, but then, so will psychiatry itself.

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