DSM-V will soon be with us and the interest in what changes will shape mental health practice is increasing. Many will be familiar with some aspects of the debates and discussions, but this book brings together one aspect in sharp focus It is a selection of papers from the Deconstructing Psychosis Conference in February 2006, one in a series titled The Future of Psychiatric Diagnosis: Refining the Research Agenda, sponsored by The American Psychiatric Association, the WHO and the US National Institute of Health. Most of the chapters have already been published in Schizophrenia Bulletin, but this volume brings them together and adds a forward by Darrell Regier and an introduction by Jim Van Os to give a more thorough sense of continuity.
The conference aimed, as might be guessed, to deconstruct the notions of psychosis that had informed DSM IV. It also wanted to look to removing the disparities, conflicts and inconsistencies that had previously existed between the DSM and ICD classifications. Finally, it hoped to set a course for the research agenda that would guide the formation of DSM V, particularly in the etiology and pathophysiology of the disorders.
There are a number of diagnosis-specific groups working on different aspects of the DSM-V, and this is only one. This particular conference dealt with issues concerning schizophreniform illnesses, bipolar disorder and psychotic depression, although not what they call functional psychotic states such as paranoia or psychoses associated with dementias or neurological disorders. There is considerable emphasis on recent developments in neurochemistry, but also in the fields of genetics, neuropharmacology and neuroimaging, epidemiology, transcultural research, early intervention and post-mortem research. Following the first phase of deconstruction the participants began to assess the evidence for both categorical and dimensional representations of psychosis, and considered clinical thresholds as to what may be clinical and what may be subclinical psychosis.
The focus of the book is defined by the inadequacy of DSM-IV-R to give reliable, robust and clinically useful diagnostic classifications in the light of improved knowledge, especially in neurobiology, since the last editions. The emphasis seems to be on what is clinically useful, both for the clinician and the client.
Each of the ten chapters, eleven if you count the overview of the conference itself, considers one of these main themes. They are all collaborative efforts, except for one, which speaks to the sense of purpose and focus of the various authors.
Among the issues considered is the sense that may disorders evolve over a life-course. They change in presentation and intensity. The debate also considers the development of disorder spectra, a dimensional-categorical hybrid system of classification that would allow for differences in different domains of presentation, symptomatology and functioning to be incorporated into a diagnostic appraisal, taking in some of the advantages that this has shown in the current Axis II diagnoses. For example, they note that psychosis associated with major depressive disorder is often characterised by other impairments in attention, executive function and memory, and yet do not fit so easily into one category or another. Obsessive-Compulsive Disorder is another highlighted as another area that often cross-cuts the current diagnostic criteria and categories. A third area of consideration was the prevalence of somatic features in a range of disorders, and a fourth was the influence of demographic features, in particular gender and culture, although others may also be important.
The book is densely packed with argument and debate and is unlikely to appeal to any but specialists in the field. It is probably not designed for the general audience. It does not purport to be the final word in the dialogue, but does significantly advance the discussion. It is clearly recognised that the high days of categorical positivism, nailing definitions and categories for all time, has long passed, and DSM-V, and its development should be seen as being in continual revision and reflection. It should be a living document. However, the very structures that can support such an ambition has to address the paradox that structures tend to be relatively fixed, immobile and inflexible.
It is unlikely that we have seen the last iteration of this debate before DSM-V finally appears. Many scholars, researchers and interested clinicians await the next one.
© 2011 Mark Welch
Mark Welch, British Columbia.