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We are in an age when psychiatric diagnosis is under the spotlight—and all its unsightly blemishes are being revealed. Instead of smooth lines separating each condition we have jagged craters of uncertainty. Psychiatrists are accused of creating pathology where none exists, and, therefore, by implication exposing patients to dangerous treatments with all their adverse effects. As Allan Frances in his book Saving Normal (2013) writes:
“In aggregate, the new disorders promoted so blithely by my friends would create tens of millions of new ‘patients.’ I pictured all these normal-enough people being captured in DSM-5’s excessively wide diagnostic net, and I worried that many would be exposed to medication with possibly dangerous side effects …”
This case for restricting diagnosis to a minimum of conditions, for which we have firm and unassailable data, appears completely convincing. This could be called the minimalist or Hairshirt diagnostic approach.
But there is another argument to make, which is equally compelling. Time after time I have seen patients who, when I have explained a diagnosis, however imperfectly, smile in relief and say, “Good, I’m so relieved, I thought I must be the only person in the world to be like this.” Even if the condition is improperly described, has no obvious links to any other form of pathology, or in colloquial terms is completely wacky, it has substance to the people who are suffering from it. This could be called the Validation diagnostic approach.
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