The release of the DSM 5 in May 2013 unleashed a storm of controversy. Initially there was a great deal of disappointment that DSM 5 was essentially the same as DSM-IV with only modest changes. The changes were largely of a housekeeping nature: reordering, repositioning and making some adjustments to diagnostic criteria.
Criticisms have come from two directions: on the "left" groups that place more emphasis on psychosocial factors in understanding and treating psychiatric illness. These groups have decried the biological reductionism of DSM. On the "right" the reverse criticism has been made i.e. that there is inadequate incorporation of new findings from neuroscience.
One of the principal critiques of the Diagnostic and Statistical Manual is that it is based purely on an objective descriptive approach. This approach has been referred as a neo-Kraepelinian system in recognition of the pioneering work of Emile Kraepelin whose painstaking observations led to the early delineation of psychiatric syndromes.
This approach began with DSM-III and did achieve one of its principal goals of improving the reliability of psychiatric diagnosis. However the validity of the DSM categories has remained problematic.
Interrater reliability among the DSM 5 categories is extremely variable. For example there is good reliability for the diagnoses of PTSD, bipolar 1 and binge eating disorder. There is very poor interrater reliability for major depressive disorder, generalized anxiety disorder and antisocial personality disorder.
The DSM system has also led to major problems with so-called comorbidity. Because of overlapping diagnostic criteria many patients are diagnosed with multiple disorders. For example a patient who meets criteria for PTSD may quite readily also meet criteria for major depression/dysthymia/borderline personality disorder. In reality the patient may have only one underlying condition when identified at the neurobiological level. The existence of false comorbidity makes prediction of treatment effects erratic and undermines the validity of research studies.
Have we advanced sufficiently in our understanding of the neurobiology of psychiatric disorders and childhood development to construct a new paradigm?
I believe that we have and I have proposed that the new paradigm could be based on two foundational sciences: affective neuroscience and attachment theory.
Jaak Panksepp pioneered affective neuroscience and identified seven basic emotional systems within the mammalian brain. He has elucidated the key brain regions and neural circuits involved in the generation of emotional states. This system can form the basis for a new classification of psychiatric disorders. Attachment theory provides the social and interpersonal context for understanding human psychology and psychiatric disorder.
The combination of these two models could provide a comprehensive and heuristic paradigm for the future practice of psychiatry and psychology.
Eppel A: Paradigms Lost and the Structure of Psychiatric Revolutions in Australian & New Zealand Journal of Psychiatry Volume 47 Issue 11, November 2013 p.992-994