The six most essential questions in psychiatric diagnosis: a pluralogue. Part 4: general conclusion

Abstract

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis – the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances’ responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first – what is the nature of psychiatric illness – and that in some manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders – and future nosologies – as far more complex and uncertain than we have imagined.

Learning from the past and looking to the future: Emerging perspectives for improving the treatment of psychiatric disorders

“…One major initiative in this regard is the "RDoc" programme of the National Institute of Mental Health (Casey et al, 2013;Cuthbert, 2014;Cuthbert andInsel, 2010, 2013;Phillips et al, 2012;Simmons and Quinn 2014). The RDoc programme does not stand in opposition to current clinical classifications since, as implied, it is a research-driven enterprise which aims to better classify trans-diagnostic dimensions of disease within a biological framework.…”

“…In recent years, mirroring interest in neural circuits, "Network Pharmacology" and "Systems biology" (Galizzi et al, 2013;Kotaleski and Blackwell, 2010;Mei et al, 2012;Nussinov et al, 2011;Phillips et al, 2012;Silverman and Loscalzo, 2012), there has been a move towards phenotypic screening. That is, studies of biological actions performed in integrated systems rather than on single cells/proteins, and using a diversity of functional readouts from cellular signalling to neuritic outgrowth to synaptic transmission to (in vivo) behaviour (Lee et al, 2011;Penrod et al, 2011;SamsDodd, 2013;Swinney, 2014;Swinney and Anthony, 2011;Winchester et al, 2014).…”

“…The study of networks is often subsumed under the term "Systems" biology and now profits from extensive computerized modelling and the application of Graph Theory. This refers to mathematical models of complex networks, their organisation and operation in health, their dysfunction in disorders like schizophrenia and depression, and strategies for their restitution (Bolding et al, 2012;Fornito and Bullmore, 2015;Kotaleski and Blackwell, 2010;Mei et al, 2012;Millan 2006;Phillips et al, 2012;Sams-Dodd, 2013;Van den Heuvel and Fornito, 2014).…”

Le jardinier et le botaniste. Proposition d’une organisation minimale de la sémiologie psychiatrique pour l’étudiant en médecine

“…Cette logique de botaniste à l'oeuvre dans le projet des RDoC a été créée avec la volonté d'augmenter la validité scientifique des diagnostics psychiatriques [12], en attribuant un fondement neurobiologique unique à chaque trouble psychiatrique diagnostiqué et de réaliser ainsi une classification à proprement parler « taxinomique » [26,55]. Cependant, les discussions nombreuses sur la validité et la précision scientifique des entités diagnostiques en psychiatrie [8,12,23,[40][41][42][43] ne doivent pas faire sous-estimer la pertinence et l'utilité clinique des approches épidémiologiques pragmatiques pour définir une maladie [20,26,33].…”

“…»). En psychiatrie, les discussions portant sur les classifications semblent s'être focalisées principalement sur les aspects nosographiques [8,12,23,[40][41][42][43]. Les aspects sémiologiques semblent étonnamment laissés de côté.…”