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The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis

James Phillips1*, Allen Frances2, Michael A Cerullo3, John Chardavoyne1, Hannah S Decker4, Michael B First5, Nassir Ghaemi6, Gary Greenberg7, Andrew C Hinderliter8, Warren A Kinghorn29, Steven G LoBello10, Elliott B Martin1, Aaron L Mishara11, Joel Paris12, Joseph M Pierre1314, Ronald W Pies156, Harold A Pincus1617185, Douglas Porter19, Claire Pouncey20, Michael A Schwartz21, Thomas Szasz15, Jerome C Wakefield2223, G Scott Waterman24, Owen Whooley25 and Peter Zachar10

Author Affiliations

1 Department of Psychiatry, Yale School of Medicine, 300 George St., Suite 901, New Haven, CT 06511, USA

2 Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 508 Fulton St., Durham, NC 27710, USA

3 Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 260 Stetson Street, Suite 3200, Cincinnati, OH 45219, USA

4 Department of History, University of Houston, 524 Agnes Arnold, Houston, 77204, USA

5 Department of Psychiatry, Columbia University College of Physicians and Surgeons, Division of Clinical Phenomenology, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA

6 Department of Psychiatry, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA

7 Human Relations Counseling Service, 400 Bayonet Street Suite #202, New London, CT 06320, USA

8 Department of Linguistics, University of Illinois, Urbana-Champaign 4080 Foreign Languages Building, 707 S Mathews Ave, Urbana, IL 61801, USA

9 Duke Divinity School, Box 90968, Durham, NC 27708, USA

10 Department of Psychology, Auburn University Montgomery, 7061 Senators Drive, Montgomery, AL 36117, USA

11 Department of Clinical Psychology, The Chicago School of Professional Psychology, 325 North Wells Street, Chicago IL, 60654, USA

12 Institute of Community and Family Psychiatry, SMBD-Jewish General Hospital, Department of Psychiatry, McGill University, 4333 cote Ste. Catherine, Montreal H3T1E4 Quebec, Canada

13 Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA 90095, USA

14 VA West Los Angeles Healthcare Center, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA

15 Department of Psychiatry, SUNY Upstate Medical University, 750 East Adams St., #343CWB, Syracuse, NY 13210, USA

16 Irving Institute for Clinical and Translational Research, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA

17 New York Presbyterian Hospital, 1051 Riverside Drive, Unit 09, New York, NY 10032, USA

18 Rand Corporation, 1776 Main St Santa Monica, California 90401, USA

19 Central City Behavioral Health Center, 2221 Philip Street, New Orleans, LA 70113, USA

20 Center for Bioethics, University of Pennsylvania, 3401 Market Street, Suite 320 Philadelphia, PA 19104, USA

21 Department of Psychiatry, Texas AMHSC College of Medicine, 4110 Guadalupe Street, Austin, Texas 78751, USA

22 Silver School of Social Work, New York University, 1 Washington Square North, New York, NY 10003, USA

23 Department of Psychiatry, NYU Langone Medical Center, 550 First Ave, New York, NY 10016, USA

24 Department of Psychiatry, University of Vermont College of Medicine, 89 Beaumont Avenue, Given Courtyard N104, Burlington, Vermont 05405, USA

25 Institute for Health, Health Care Policy, and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St., New Brunswick, NJ 08901, USA

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Philosophy, Ethics, and Humanities in Medicine 2012, 7:3  doi:10.1186/1747-5341-7-3

Published: 13 January 2012


In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.