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Why the clinical utility of diagnostic categories in psychiatry is intrinsically limited

Brian Koehler
New York, NY, United States

Aug 22, 2018 — 

This editorial by Mario Maj, founder and editor of World Psychiatry and past president of the World Psychiatric Association is very important.

Brian Koehler

World Psychiatry. 2018 Jun; 17(2): 121–122.

 Why the clinical utility of diagnostic categories in psychiatry is intrinsically limited and how we can use new approaches to complement them

 Mario Maj 1

Excerpts from this important editorial:

 “It is becoming increasingly evident that the usefulness of diagnostic categories in psychiatry has been overemphasized. These categories have been initially charged with implications in terms of pointing to a specific treatment and prospectively a specific etiology and/or pathogenesis, in complete analogy with the other branches of medicine. More recently, they have been more modestly charged with relative, not absolute, pragmatic implications in terms of guiding the formulation of a management plan and the prediction of outcomes (the two main elements of “clinical utility”)1. The underlying concept has been that we are dealing with “patterns” of intercorrelated reported experiences (in medical jargon, symptoms) and observed behaviours (in medical jargon, signs) which allow significant inferences about further course and management, whereas there is no assumption that these patterns are all “natural kinds” (i.e., discrete disease entities marking a real division in nature)2. Indeed, improving the clinical utility of psychiatric diagnoses has been the declared main objective of both the DSM‐5 and, even more explicitly, the ICD‐11" 

 "Unfortunately, even these more modest implications of diagnostic categories in psychiatry have turned out to be overestimated…A clear reflection of this state of affairs can be found in the survey by First et al4 that appears in this issue of the journal, in which a large sample of users of either the ICD‐10 or some edition of the DSM rated those diagnostic systems as having the lowest utility in “selecting a treatment” and “assessing probable prognosis”, whereas they were perceived to be much more useful for meeting administrative requirements, communicating with other health professionals, and teaching trainees or students. Indeed, both research evidence and clinical experience tell us that patients sharing the same psychiatric diagnosis often respond differently to a given treatment, and patients with different psychiatric diagnoses may respond similarly to a given treatment (not to mention the wide variability of outcomes in people receiving the same diagnosis)."

 "Alternative approaches to the ICD/DSM are currently being developed."

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