The failures of the American ‘Diagnostic and Statistical Manual’ (DSM) should be a wake-up call to European psychiatry to return to, and recover, its psychopathological tradition [1]. The question that remains is: To what purpose?

Two major groups comprise most critics of the newest DSM-5 revision. One group criticizes DSM because it tries to categorize, as if they were medically and scientifically valid, psychiatric symptoms, which are mainly social constructions; let us call this the postmodernist view. This group throws into doubt the biological and scientific validity of diagnoses such as manic-depressive illness and sometimes even schizophrenia.

Another group criticizes DSM because it categorizes explicitly on non-scientific (called ‘pragmatic’) grounds [2, 3]; diagnostic definitions are based on whether DSM leaders feel it would be better or worse for the profession, for insurance reimbursement, or lawsuits or whether certain drugs are to be preferred or discouraged. These ‘pragmatic’ criteria trump our best scientific evidence, which may call in some cases, for instance, for definitions that encourage medication use, or might be more prone to lawsuits, or might be less reimbursable. Not surprisingly, nature does not follow the ‘pragmatic’ wishes of APA leaders, and genetic/biological/pharmacological studies often fail when using DSM definitions.

This is not a minor problem: because of its ‘pragmatism’, the DSM system systematically dooms, and has doomed, scientific research in psychiatry for two generations.

So the second critique is the opposite of the first: DSM is a problem not because it is too medical, but because it is not medical enough; it is not based on science, and hence, it impedes scientific progress. Let us call the second critique the medical view. One presumes here that medicine should be based on science, which means identifying when diseases are not present, as well as when they are. Note that the word ‘medical’ is not equivalent to ‘biological reductionism’, as is commonly presumed, because when diseases are not present, then a biological approach is not supported by scientific medicine [4].

I believe that psychopathology matters because it will allow us to identify clinical pictures (what used to be called by Kraepelin and others Zustandsbilden) more accurately [5]. Then, those clinical pictures can be studied scientifically, and we may determine, as Kraepelin taught (and Jaspers followed him on this general structure), that they are sometimes biological diseases (Krankheiten; such as manic-depressive and psychotic states due to neurosyphilis), sometimes likely diseases with undefined exact causes and subtypes (Krankheitsprozessen; such as dementia and schizophrenia and manic-depressive illness), sometimes extremes of personality traits (as Kretschmer described) [6], and sometimes none of the above, but rather understandable reactions to life stresses or problems (as Jaspers and Viktor Frankl among others described) [4].

In other words, psychopathology precedes nosology. We need careful description of symptoms and experiences before we can know whether any diagnoses exist, and which ones.

This is the medical critique of DSM and the scientific rationale for psychopathology.

The specific perspective of some colleagues, such as Berrios, seems to be more in the tradition of the postmodernist critique. They focus on the social construction of psychiatric diagnoses, emphasize historical quillets, and then conclude that almost all diagnostic definitions are hopelessly relative to cultural/social/historical constraints; thus, they emphasize symptoms, rather than diagnoses [7]. This approach, which is not inconsistent with some biologically oriented views (such as the NIMH Research Domain Criteria) [8], contains a major flaw. It presumes that symptoms reflect biology. But this assumption is refuted by that same history of psychiatry which is proclaimed as being so important. We have whitewashed the history of the greatest biological/scientific success in psychiatry. General paralysis of the insane was a syndrome that turned out to have a single biological cause: syphilis, producing a wide variety of manic, depressive, psychotic, and cognitive symptoms.

Psychopathology matters. But we should be careful about infusing our psychopathology with postmodernist assumptions that lead us to ignore scientific realities.

If we pursue psychopathology scientifically, we will find that some clinical pictures are disease processes, which turn out to be specific biological diseases, not social constructions. And we will find that some clinical pictures are social constructions that reflect personality extremes or social problems or existential dilemmas of living. I think Karl Jaspers' overall way of thinking, if not every detail of his opinions in 1913, supports this way of thinking as does Kraepelin's overall approach, and that of many other great guides from the European tradition of nosology and psychopathology, who may have differed in their own time on other matters (like Kretschmer and Frankl and even Freud).

DSM has been unscientific in its approach and content, and simplistic and inaccurate in its psychopathology. Let us revive psychopathology and science at the same time. Europe can give the lead to America again and help us out of the dead-end of DSM, if it leaves its postmodernism aside.


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