Hi XXXXXXX

Well, this is a debatable question - whether a diagnostic system is needed in psychiatry or not...

I would think that it is necessary and would like to put forth the following reasons for the same:

1) It offers a SYSTEMATIC way to approach a case. We know that for most psychiatric illnesses, the etiology is multi-factorial and multiple issues like social and psychological issues are involved; hence, having a systematic diagnostic system will ensure that all areas are explored systematically, and nothing is missed out.

2) It ensures UNIFORMITY and RELIABILITY in diagnosis. Having a standard diagnostic system ensures that clinicians all over the world have a common, universal yardstick for identifying psychiatric disorders. For example, if a patient is diagnosed to have a particular psychiatric disorder by one doctor, then subsequently even if he has to see another doctor, the diagnosis will be easily understood by everyone - because there is a uniform diagnostic system. Even if this patient is seen in a different part of the world, that doctor will be able to clearly understand the patient's diagnosis.

3) Having specific and well-defined criteria improves the ACCURACY of the diagnosis. For example, the diagnostic criteria established in the DSM and ICD have been formulated after extensive research, analysis and trials. So, clinical diagnoses made using such scientifically proven criteria makes the diagnosis precise and accurate.

4) Having clear diagnostic criteria and check-lists, it makes it EASY for clinicians, even non-psychiatrists, to easily identify psychiatric disorders. For example, if a person has "five criteria for two weeks", then a diagnosis of a major depressive disorder can be made. This removes any ambiguity or difficulty in the diagnosis.

5) The diagnostic categories also incorporate clear-cut subtypes, specifiers and severity indicators. Severity indicators (mild, moderate, severe) help the clinician make treatment plans according to the severity, as well as monitor progress. Additional subtypes signifying remission (e.g. partial remission or complete remission) are an added advantage while following up patients on treatment.

6) When it comes to research, a proper diagnostic system is extremely useful. Any kind of study like incidence, prevalence and other epidemiological studies or interventional studies like RCTs will not be possible without clearly established diagnostic criteria.

A diagnostic system like the DSM-IV-TR is a good choice, but there are still a few drawbacks, which could be improved:

- We know that many psychiatric disorders exist in a continuum. Having a strictly categorical approach to diagnosis may have a risk of under- or over- diagnosing disorders. So, I would propose that a more slightly more dimensional approach would help in understanding a patients problems better.

- The diagnostic system should be more culturally-sensitive. For example, in many cultures, people may not be open about expressing psychological symptoms. This is more true in the Asian countries, where people express their distress as somatic symptoms, rather than as psychological symptoms. For example, depression may not present with obvious low mood or decreased interest, but with multiple vague somatic symptoms and socio-ooccupational dysfunction. So, if these people are evaluated with the DSM criteria, many may not fulfill the criteria for MDD, but still they would be suffering from depression.

- By having strict diagnostic catergories, clinicials may have a tendency to give some diagnosic labelto each and every person who comes in distress. For example, if a person has a overwhelming stress, which he has difficulty coping with it, he has to be given a diagnostic label of an "adjustment disorder" or "post-traumatic stress disorder". My arguement is that when we know that severe stress can naturally be overwhelming and cause coping difficuliies to anyone, why should the person be branded as having "disorder"? So, the diagnostic system should be sensitive to normal emotional reactions and emotional difficulties which can be natural in certain situations, and not "pathologize" every problem into a "disorder"

So, in conclusion, I would say that though it is essential to have a diagnostic system, for more accurate, uniform and reliable diagnosis, yet it should be culturally appropriate, sensitive to normal and situational variations in human behaviour and emotions, and have a more dimensional approach - thereby looking at the person as a whole and fosus on his /her distress, rather than just trying to push him / her under some diagnostic category.


- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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