Psychiatric Diagnosis and Classification - ResearchGate

32 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION
presence for a diagnosis is neither necessarynor sufficient. Each one of the
ICD and DSM diagnostic entities is defined bythree rubrics: a) specific
phenomenology, b) signs and symptoms and c) rules that exclude the
diagnosis being made in certain circumstances. The DSM definition, in
addition, calls for ``clinicallysignificant impairment or distress'', meaning
that disruption in social, occupational, or other areas of functioning must
accompanythe set of observable phenomena. While the intent of this criterion
was to distinguish mental disorders from dailyexperiences of distress
and broaden the clinical focus beyond symptoms, this criterion blurs the
construct of functioning with the definition of mental disorder. For so-called
``physical disorders'' e.g. diabetes or tuberculosis), clinical significance is
not required for diagnosis. Putting ``distress'' or ``impairment in functioning''
as a necessaryprerequisite for diagnosis of a mental disorder is of little
use if these are not operationalized or independentlyassessed [27]. Besides,
this approach has major implications for receiving treatment or services.
The lack of ``distress or impairment'' would preclude a diagnosis, and
would disallow earlyprovision of care that could prevent the disorder
worsening. It would impair research and subjects without impairment
would be excluded from studies to identifythe cause or treatment of the
disorder.
Manypatients in primarycare settings fall into sub-threshold diagnostic
categories, particularlythose with depression as noted above. In deciding
when to initiate treatment, functional change maybe even more important
than discrete symptom profiles. Recognizing and treating depression as a
comorbid condition in patients with other medical illnesses represents an
additional challenge for the primarycare physician. In anxietydisorders, it
remains questionable whether the current ICD-10 diagnosis of generalized
anxietydisorder, defined bya six month minimum duration and four
associated symptoms, is the most appropriate option. Using this definition
a substantial proportion of disabled subjects with lesser levels of anxiety,
tension and worrying remain outside the diagnostic criteria, and hence may
go untreated.
The uncoupling of disabilityfrom diagnosis would allow the examination
of the unique prognostic significance of disabilityand the interactive relationship
and direction of change in symptomatology and functioning
following interventions. It would allow the development of more rational
forms of intervention, including rehabilitation strategies, which are specificallytargeted
to improving functioning byaltering individual capacityor
modifying the environment in which the person lives in order to improve
real life performance. It would also underscore efforts to make changes at
the level of health policyand the need to deal with larger social issues such
as stigma in order to improve access to care and social participation of
psychiatric patients.