In 1980, the American Psychiatric Association introduced panic disorder in the DSM-III and provided diagnostic criteria for that new disorder 1. At that time, several Asian psychiatrists manifested a resistance to use the new diagnosis, due to the lack of a corresponding terminology in their native languages 2. This would have not happened if in DSM-III a prototype had been provided as an example or illustrative case.

Actually, one prototype may not be sufficient to make a diagnostician fully understand a particular disorder, especially if it has a variety of clinical presentations, as is the case for panic disorder (the so-called “many faces of panic disorder” 3). Moreover, prototypes from one country might not fit well in another country where culture and beliefs are different. For example, southern Thai women with gastrointestinal symptoms, who would be labeled as having panic disorder by Western psychiatrists, may present themselves as having “rook lom” (“wind illness”) 4. This comes from the traditional belief that humans are composed of four elements: earth, water, wind (lom), and fire.

In this particular context, the panic disorder prototype for Thai clinicians could be adapted as follows: “Patients who match this prototype have many clinical presentations. In southern Thailand, they may have initial symptoms of feeling the “lom” moving upward in the abdomen and the patient may try to push down on the abdomen in an attempt to force the “lom” out. Then the “lom” may still continue to move upward and compress the heart, causing their hearts pounding fast and hard, which may be followed by rapid and deep breathing, and later developing dizziness or headache. Most of them have a fear of “lom” moving into the head, which would cause unconsciousness, or death…”. So, when applying the prototype approach for psychiatric diagnosis, the content needs to be adapted to suit specific cultures and contexts.

Regarding the clinical utility of prototype matching, I agree with Westen's view that it is clinically helpful and easy to use in everyday practice. Clinicians in both low and middle income countries, who see 50–100 or more cases per day in their outpatient settings, may find the prototype approach to be more practical than extensive interviews to explore fulfillment of the diagnostic criteria of conventional classifications. However, research psychiatrists may not prefer this alternative approach to recruit their patients, due to the necessity to collect homogeneous samples for research purposes and reduce research risk 5.

To sum up, using both the operational and prototype matching approaches for diagnosing psychiatric patients should be recommended. Prototype matching together with operational approaches such as the DSM-like format (diagnostic criteria with arbitrary cutoff points) would aid trainees in clearly understanding mental disorders and would help clinicians to develop mental representations of different kinds of disorders.


  1. Top of page
  2. References
  • 1
    American Psychiatric Association. Diagnostic and statistical manual of mental Disorders, 3rd ed. Washington: American Psychiatric Association, 1980.
  • 2
    Udomratn P. Panic disorder in Thailand: a report on the secondary data analysis. J Med Assoc Thai 2000; 83: 115866.
  • 3
    Ley R. The many faces of Pan: psychological and physiological differences among three types of panic attacks. Behav Res Ther 1992; 30: 34757.
  • 4
    Udomratn P, Hinton DE. Gendered panic in southern Thailand. In: Hinton DE, Good BJ (eds). Culture and panic disorder. Stanford: Stanford University Press, 2009: 183204.
  • 5
    Yanos PT, Stanley BS, Greene CS. Research risk for persons with psychiatric disorders: a decisional framework to meet the ethical challenge. Psychiatr Serv 2009; 60: 37483.