Abstract
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.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Pies R. How “objective” are psychiatric diagnoses? (guess again). Psychiatry. 2007;4:18–22.
Frances A. A warning sign on the road to DSM-5: beware of unintended consequences. Psychiatric Times [Internet]. 26 Jun 2009 [cited 1 Aug 2012]. www.psychiatrictimes.com/display/article/10168/1425378.
Frances A. Opening Pandora’s box: the 19 worst suggestions for DSM5. Psychiatric Times [Internet]. 11 Feb 2010 [cited 1 Aug 2012]. http://www.psychiatrictimes.com/dsm/content/article/10168/1522341.
Angell M. The illusions of psychiatry. New York Review of Books [Internet]. 14 Jul 2011 [cited 1 Aug 2012]. http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry Accessed 1 July 2012.
Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970;126:983–7.
First MB, Pincus HA, Levine JB, Williams JBW, Ustun B, Peele R. Clinical utility as a criterion for revising psychiatric diagnoses. Am J Psychiatry. 2004;161:946–54.
Pierre JM. Deconstructing schizophrenia for DSM-5: challenges for clinical and research agendas. Clin Schizophr Relat Psychoses. 2008;2:166–74.
Pierre JM. The borders of mental illness in psychiatry and the DSM: past, present, and future. J Psychiatr Pract. 2010;16:375–86.
Pierre JM. Mental illness and mental health: is the glass half empty or half full? Can J Psychiatry. 2012;57(11):651–8.
Double D. The limits of psychiatry. BMJ. 2002;324:900–4.
Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ. 2002;324:886–91.
Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2005;62:593–602.
Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2005;62:617–27.
Moffitt TE, Caspie A, Taylor A, et al. How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychol Med. 2010;40:899–909.
Smith R. In search of “non-disease”. BMJ. 2002;324:883–5.
Grob GN. Origins of DSM-I: a study in appearance and reality. Am J Psychiatry. 1991;148:421–31.
Grob GN. The forging of mental health policy in America: World War II to new frontier. J Hist Med Allied Sci. 1987;42:410–46.
Ghaemi SN. Nosologomania: DSM & Karl Jaspers’ critique of Kraepelin. Philos Ethics Humanit Med. 2009;4:10.
Menninger K. The vital balance: the life process in mental health and illness. New York: Viking; 1963.
Shorter E. A history of psychiatry: from the era of the asylum to the age of Prozac. New York: Wiley; 1997.
Horwitz A. Creating mental illness. Chicago: The University of Chicago Press; 2002.
Double DB. What would Adolf Meyer have thought of the neo-Kraepelinian approach? Psychiatr Bull. 1990;14:472–4.
Meyer A. The mental hygiene movement. Can Med Assoc J. 1918;8:632–4.
Cohen S. The mental hygiene movement, the development of personality and the school: the medicalization of American education. Hist Educ Q. 1983;23:123–49.
The Committee on Nomenclature and Statistics of the American Psychiatric Association. Diagnostic and statistical manual: mental disorders. Washington, DC: American Psychiatric Association; 1952.
Wilson M. DSM-III and the transformation of American psychiatry: a history. Am J Psychiatry. 1993;150:399–410.
Spitzer RL, Williams JBW. American psychiatry’s transformation following the publication of DSM-III. Am J Psychiatry. 1994;151(3):459–60.
Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; 2007.
Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry. 2008;69(6):935–40.
Patten SB. Does almost everyone suffer from a bipolar disorder? Can J Psychiatry. 2006; 51:6–8.
Patten SB, Paris J. The bipolar spectrum—a bridge too far? Can J Psychiatry. 2008; 53:762–8.
Duffy A. Does bipolar disorder exist in children? A selected review. Can J Psychiatry. 2009; 52:409–17.
Spitzer RL, First MB, Wakefield JC. Saving PTSD from itself in DSM-5. J Anxiety Disord. 2007;21:233–41.
Rosen GM, Taylor S. Pseudo-PTSD. J Anxiety Disord. 2007;21:201–10.
Wakefield JC, Horwitz AV, Schmitz MF. Are we overpathologizing the socially anxious? Social phobia from a harmful dysfunction perspective. Can J Psychiatry. 2005;50:317–9.
Lane C. Shyness: how normal behavior became a sickness. New Haven: Yale University Press; 2007.
Sciutto MJ, Eisenberg M. Evaluating the evidence for and against the overdiagnosis of ADHD. J Atten Disord. 2007;11:106–13.
King M, Bearman P. Diagnostic change and the increased prevalence of autism. Int J Epidemiol. 2009;38:1224–34.
Balon R. The DSM, criteria for sexual dysfunction: need for a change. J Sex Marital Ther. 2008;34:186–7.
Moser C, Kleinplatz PJ. DSM-IV-TR and the paraphilias: an argument for removal. J Psychol Human Sex. 2005;17:91–109.
Miller G, Holden C. Proposed revisions to psychiatry’s canon unveiled. Science. 2010; 327:770–1.
Wakefield JC. Diagnosing DSM-IV—Part 1: DSM-IV and the concept of disorder. Behav Res Ther. 1997;35(7):633–49.
Wakefield JC. The concept of mental disorder: diagnostic implications of the harmful dysfunction analysis. World Psychiatry. 2007;6:149–56.
Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavioral change. New York: The Guilford Press; 1999.
Szasz TS. The myth of mental illness: foundations of a theory of personal conduct, revised edition. New York: Harper and Row; 1974.
Rosenhan DL. On being sane in insane places. Science. 1973;179:250–8.
Kendell RE, Cooper JE, Gourlay AJ, Copeland JR, Sharpe L, Gurland BJ. Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. 1971;25:123–30.
Kendell RE. Psychiatric diagnosis in Britain and the United States. Br J Psychiatry. 1975;9:453–61.
Pagura J, Katz LY, Mojtabai R, Druss BG, Cox B, Sareen J. Antidepressant use in the absence of common mental disorders in the general population. J Clin Psychiatry. 2011; 72(4):494–501.
Khan A, Leventhal RM, Khan SR, Brown WA. Severity of depression and response to antidepressants and placebo: an analysis of the food and drug administration database. J Clin Psychopharmacol. 2002;22(1):40–5.
Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008;5(2):e45.
Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level metaanalysis. JAMA. 2010;303(1):46–53.
Kass LR. Beyond therapy: biotechnology and the pursuit of happiness. http://biotech.law.lsu.edu/research/pbc/reports/beyondtherapy/beyond_therapy_final_report_pcbe.pdf. Accessed 1 July 2012.
Farah MJ, Illes J, Cook-Deegan R, Gardner H, Kandel E, King P, et al. Neurocognitive enhancement: what can we do and what should we do? Nature Rev. 2004;5:421–5.
Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, et al. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008;456:702–5.
Larriviere D, Williams MA, Rizzo M, et al. Responding to requests from adult patients for neuroenhancements: Guidance of the Ethics, Law and Humanities Committee. Neurology. 2009;73:1406–12.
Hirschfield RMA, Keller MB, Panico S, Arons BS, Barlow D, Davidoff F, et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277(4):333–40.
Coyne JC, Schwenk TL, Fechner-Bates S. Nondetection of depression by primary care physicians reconsidered. Gen Hosp Psychiatry. 1995;17:3–12.
Rost K, Zhang M, Fortney J, Smith J, Coyne J, Smith GR. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry. 1998;20:12–20.
Angermeyer MC, Matschinger H, Riedel-Heller SG. Whom to ask for help in case of a mental disorder? Preferences of the lay public. Soc Psychiatry Psychiatr Epidemiol. 1999;34(4):202–10.
Aoun S, Pennebaker D, Wood C. Assessing population need for mental health care: a review of approaches and predictors. Ment Health Serv Res. 2004;6(10):33–46.
Magruder KM, Calderone GE. Public health consequences of different thresholds for the diagnosis of mental disorders. Compr Psychiatry. 2000;41(2 Suppl 1):14–8.
Helmchen H, Linden M. Subthreshold disorders in psychiatry: clinical reality, methodologic artifact, and the double-threshold problem. Compr Psychiatry. 2000;41(2 Suppl 1):1–7.
Rucci P, Gherardi S, Tansella M, Piccinelli M, Berardi D, Bisoffi G, et al. Subthreshold psychiatric disorders in primary care: prevalence and associated characteristics. J Affect Dis. 2003;76:171–81.
Kessler RC, Merikangas KR, Berglund P, Eaton WM, Koretz DS, Walters EE. Mild disorders should not be eliminated from the DSM-V. Arch Gen Psychiatry. 2003;60:1117–22.
Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 survey’s estimates. Arch Gen Psychiatry. 2002;59:115–23.
Schulze B. Stigma and mental health professionals: a review of the evidence on an intricate relationship. Int Rev Psychiatry. 2007;19(20):137–55.
Henderson C, Thornicroft G. Stigma and discrimination in mental illness: time to change. Lancet. 2009;373:1928–30.
Sartorius N. Stigma: what can psychiatrists do about it? Lancet. 1998;352:1058–9.
Kaysen S. Girl, interrupted. New York: Turtle Bay Books; 1993.
Mattisson C, Bogren M, Nettelbladt P, Munk-Jorgensen P, Bhugra D. First incidence depression in the Lundby Study: a comparison of the two time periods 1947-1972 and 1972-1997. J Affect Disord. 2005;87:151–60.
Eaton WW, Kalaydjian A, Scharfstein DO, Mezuk B, Ding Y. Prevalence and incidence of depressive disorder: the Baltimore ECA follow-up, 1981–2004.
Robins LN, Helzer JE, Weismann MM, Orvaschel H, Gruenberg E, Burke Jr JD, et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41:949–58.
Regier DA, Kaelber CT, Rae DS, Farmer ME, Knauper B, Kessler RC, et al. Limitations of diagnostic criteria and assessment instruments for mental disorders: implications for research and policy. Arch Gen Psychiatry. 1998;55:109–55.
Pies R. The ideal and the real: how does psychiatry escape the DSM-5 “Fly-bottle?”. Bull Assoc Adv Philos Psychiatry. 2010;17(2):18–22.
Spitzer RL, Wakefield JC. DSM-IV diagnostic criteria for clinical significance: does it help solve the false positives problem? Am J Psychiatry. 1999;156:1856–64.
Pierre JM. Mental disorder vs. normality: defining the indefinable. Bull Assoc Adv Philos Psychiatry. 2010;17(20):9–11.
Frances A. Problems in defining clinical significance in epidemiologic studies. Arch Gen Psychiatry. 1998;55:119.
van Os J, Hanssen M, Bijl RV, Ravelli A. Strauss (1969) revisited: a psychosis continuum in the general population? Schizophr Res. 2000;45:11–20.
Insel T, Cuthbert B, Garvey M, et al. Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748–50.
Pincus HA, Frances A, Davis WW, First MB, Widiger TA. DSM-IV and new diagnostic categories: holding the line on proliferation. Am J Psychiatry. 1992;149:112–7.
Goldman HH, Grob GN. Defining “mental illness” in mental health policy. Heal Aff. 2006;25(3):737–49.
Substance Abuse and Mental Health Services Administration. Final notice establishing definitions for (1) children with a serious emotional disturbance, and (2) adults with a serious mental illness. Fed Regist. 1993;58:29422–5.
Ustun B, Kennedy C. What is “functional impairment”? Disentangling disability from clinical significance. World Psychiatry. 2009;8:82–5.
Spitzer RL. Diagnosis and need for treatment are not the same. Arch Gen Psychiatry. 1998;55:120.
Mechanic D. Is the prevalence of mental disorders a good measure of the need for services? Heal Aff. 2003;22(5):8–20.
First M, Halon R. Use of DSM paraphilia diagnoses in sexually violent predator commitment cases. J Am Acad Psychiatry Law. 2008;36:443–54.
First M, Frances A. Issues of DSM-IV: unintended consequences of small changes: the case of paraphilias. Am J Psychiatry. 2008;165:1240–1.
Green R. Is pedophilia a mental disorder? Arch Sexual Behav. 2002;31:467–71.
Maj M. Are we able to differentiate between true mental disorders and homestatic reactions to adverse life events? Psychother Psychsom. 2007;76:257–9.
Philips J, Frances A, Cerullo M, Chardavoyne J, First M, Ghaemi N, et al. The six most essential questions in psychiatric diagnosis: a pluralogue part 2: issues of conservatism and pragmatism in psychiatric diagnosis. Philos Ethics Humanit Med. 2012;7:8.
Kupfer DJ, Dr. Kupfer defends DSM-5. Medscape psychiatry [Internet]. 1 Jun 2012 [cited 1 Aug 2012]. http://www.medscape.com/viewarticle/764735.
McMahon DM. Happiness: a history. New York: Atlantic Monthly Press; 2006.
Mojtabai R. Americans’ attitudes towards psychiatric medications: 1998-2006. Psychiatr Serv. 2009;60:1015–23.
Pierre JM. Final comment. Bull Assoc Adv Philos Psychiatry. 2010;17(20):12–3.
Addington J, Cadenhead KS, Cannon TD, et al. North American Prodrome Longitudinal Study: a collaborative multisite approach to prodromal schizophrenia research. Schizophr Bull. 2007;33(30):665–72.
Correll CU, Hauser M, Auther AM, et al. Research in people with psychosis risk syndrome: a review of the current evidence and future directions. J Child Psychol Psychiatry. 2010;51(40):390–431.
Ruhrmann S, Schultze-Lutter F, Klosterkotter J. Probably at-risk, but certainly ill—advocating the introduction of a psychosis spectrum disorder in DSM-V. Schizophr Res. 2010; 120:23–37.
Morrison AP, French P, Stewart SLK, Birchwood M, Fowler D, Gumley AI, et al. Early detection and intervention evaluation for people at risk of psychosis: multisite randomized controlled study. BMJ. 2012;344:e2233.
Woods SW, Walsh BC, Saksa JR, et al. The case for including attenuated psychotic symptoms syndrome in DSM-5 as a psychosis risk syndrome. Schizophr Res. 2010;123:199–207.
Fusar-Poli P, Bonoldi I, Yung AR, Borgwardt S, Kempton MJ, Valmaggia L, et al. Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Arch Gen Psychiatry. 2012;69(3):220–9.
Yung AR, Phillips LJ, Nelson B, et al. Randomized controlled trial of interventions for young people at ultra high risk for psychosis: 6-month analysis. J Clin Psychiatry. 2011; 72(4):430–40.
Simon AE, Umbricht D. High remission rates from an initial ultra-high risk state for psychosis. Schizophr Res. 2010;116:168–72.
McGorry PD. Risk syndromes, clinical staging and DSM V: new diagnostic infrastructure for early intervention in psychiatry. Schizophr Res. 2010;120:49–53.
Corcoran CM, First MB, Cornblatt B. The psychosis risk syndrome and its proposed inclusion in the DSM-V: a risk-benefit analysis. Schizophr Res. 2010;120:16–22.
Yang LH, Wonpat-Borja AJ, Opler MG, et al. Potential stigma associated with inclusion of the psychosis risk syndrome in the DSM-V: an empirical question. Schizophr Res. 2010;120:42–8.
McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, Cosgrave EM, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Arch Gen Psychiatry. 2002;59:921–8.
McGlashan TH, Zipursky RB, Perkins D, Addington J, Miller T, Woods SW, et al. Randomized, double-blind trial of olanzapine versus placebo in patients prodromally symptomatic for psychosis. Am J Psychiatry. 2006;163:790–9.
Cornblatt BA. The New York high risk project to the Hillside recognition and prevention (RAP) program. Am J Med Genet. 2002;114:956–66.
Amminger GP, Schäfer MR, Papageorgiou K, et al. Longchain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo- controlled trial. Arch Gen Psychiatry. 2010;67:146–54.
Morrison AP, French P, Walford L, et al. Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomized, controlled trial. Br J Psychiatry. 2004;185:291–7.
Walker EF, Cornblatt BA, Addington J, et al. The relation of antipsychotic and antidepressant medication with baseline symptoms and symptom progression: a naturalistic study of the North American Prodromal Longitudinal Sample. Schizophr Res. 2009;115:50–7.
Carpenter WT. Anticipating DSM-V: should psychosis risk become a diagnostic class? Schizophr Bull. 2009;35:841–3.
Helzer JW, Kraemer HC, Krueger RF, Wittchen HU, Sirovatka PJ, Regier DA, editors. Dimensional approaches in diagnostic classification: refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Association; 2007.
Frances A. How to avoid medicalizing normal grief in DSM5.Psychiatric Times [Internet]. 16 Mar 2010 [cited 1 Aug 2012]. http://www.psychiatrictimes.com/topics/content/article/10168/1538825.
Mojtabai R, Olfson M, Sampson NA, Jin R, Druss B, Wang PPS, et al. Barriers to mental health treatment: results from the National Comorbidity Survey Replication. Psychol Med. 2011;41(8):1751–61.
McGorry PD. Issues for DSM-V: clinical staging: a heuristic pathway to valid nosology and safer, more effective treatment in psychiatry. Am J Psychiatry. 2007;164(6):859–60.
Batstra L, Frances A. Diagnostic inflation: causes and a suggested cure. J Nerv Ment Dis. 2012;6:474–9.
Stein DJ, Philips KS, Bolton D, Fulford KWM, Sadler JZ, Kendler KS. What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychol Med. 2010;40:1759–65.
First MB, Wakefield JC. Defining ‘mental disorder’ in DSM-V. Psychol Med. 2010;40:1779–82.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2013 Springer Science+Business Media New York
About this chapter
Cite this chapter
Pierre, J.M. (2013). Overdiagnosis, Underdiagnosis, Synthesis: A Dialectic for Psychiatry and the DSM. In: Paris, J., Phillips, J. (eds) Making the DSM-5. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-6504-1_8
Download citation
DOI: https://doi.org/10.1007/978-1-4614-6504-1_8
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-1-4614-6503-4
Online ISBN: 978-1-4614-6504-1
eBook Packages: MedicineMedicine (R0)