Overdiagnosis, underdiagnosis, synthesis
a dialectic for psychiatry and the DSM
pp. 105-124
in: Joel Paris, James Phillips (eds), Making the DSM-5, Berlin, Springer, 2013Abstract
Defining the borders of mental illness is challenging due to the lack of established validity for psychiatric disorders, a diagnostic system based largely on reported symptoms, and the highly subjective nature of distress and functional impairment. Consequently, debates about the potential perils of overdiagnosis (e.g., false positives) and underdiagnosis (e.g., false negatives) with new diagnostic revisions are ongoing as we prepare for the release of DSM-5. Such debates are rooted in the many different and often conflicting applications of psychiatric diagnosis, with clinical work generally favoring lowered diagnostic thresholds on the one hand and the work of rationing of healthcare resources necessitating higher thresholds on the other. Deciding what should or should not be considered a mental disorder in DSM can only be resolved by a pragmatic analysis of contextual utility. A philosophically satisfying, scientifically grounded, and economically viable model of future psychiatry should more formally acknowledge a continuum of mental illness and mental health, apply research evidence-based guidelines regarding optimal interventions along this continuum rather than assuming pharmacotherapy is a panacea, and concede that specialty care provided by psychiatrists must be integrated within the larger scope of mental health care.