DSM-III and the Taxonomic Stew

Psychiatry is freighted with many cumbersome problems not the least of which are its theoretical models and nosological systems. With the advent of DSM-III, the rumbles of controversy about both these areas will undoubtedly become louder and perhaps more importunate.

At issue is the function and serviceability of diagnosis in psychiatric and psychoanalytic practice. Does DSM-III correct the deficiencies of previous nosological schemes? Will it be considered, as have its predecessors an exercise in futility? How relevant will it be to the cause for which help is sought? Will it illuminate etiology? Sharpen prognosis? Help our patients get well faster? Lest answers to these questions prove embarrassing to contemporary architects of classification, we must concede that diagnosis does invite a frivolous expectation of miracles. Nomenclature can hardly be expected to do what years of clinical practice and empirical research have failed to do in identifying specific determinants of emotional illness, definitively predicting outcome, selecting the proper kind of treatment, and matching patients with therapists.

The shortcomings of diagnosis are many and we may rightfully agonize about these. What makes diagnosis difficult is that emotional illness does not limit itself to a restricted area of functioning. It involves the individual as a totality including biochemical, physiological, intrapsychic, interpersonal, and other social dimensions. The patient, his family, and the therapist may accent different aspects of a problem. Thus an individual who seeks therapy because of somatic symptoms, impotence, and insomnia may tempt a diagnosis of psychophysiological disorders. His family may lay the blame on his drinking habits and frequent bouts of intoxication. This would point to alcoholism as a diagnosis. His therapist, on the other hand, may detect a masked hopelessness and inner despair and tend to label him a depressive reaction. As psychotherapy proceeds, elements of anxiety,