Sunday, 18 October 2009

More Anti Kraep

Good summary in the obit of Robert Kendall.


'And what of Kraepelin, would he approve? Well he was having doubts about his own dichotomy back in 1920, “No experienced psychiatrist will deny that there is an alarmingly large number of cases in which it seems impossible, in spite of the most careful observation, to make a firm diagnosis…. It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses and this brings home the suspicion that our formulation of the problem may be incorrect”.'

Another good article:

Changes in classification will accompany the improvements in understanding of pathogenesis. These will require clinicians to embrace classifications that are both more complex (more categories or, perhaps, dimensions) and also simpler (because they map on to the biology of the illness more closely). These developments have much to offer patients and the professional standing of psychiatry. Most patients want to be given an unambiguous and accurate diagnosis, but psychiatrists are understandably reluctant to be too dogmatic in the early stages of psychotic illness, recognising that the cross-sectional picture may change longitudinally – often frustrating patients, leading to diagnostic revisions between categories and creating an impression that psychiatrists are indecisive or incompetent. Moving to a spectrum concept (be it with categories or dimensions) with recognition of overlapping pathogenetic factors and varying expression (dependent upon both genetic risk and environmental exposure) would allow a confident and clear diagnosis to be offered (perhaps ‘psychosis-spectrum illness’ or ‘mood–reality disorder’), with a clear explanation that some specific tests and a period of observation will help to clarify the likely course of illness and response to treatment. This would be greatly preferable to the current situation and the inevitable consequences of damage to the therapeutic alliance caused by diagnostic revisions.

The Kraepelinian dichotomy has been useful for a hundred years. Now it is time to move on.

1 comment:

Marian said...

" impression that psychiatrists are indecisive or incompetent." (my emphasis)

Is it really just an impression?...