North American Perspectives: Toward a DSM for Primary Care
The issue of how best to expand psychiatric classification to meet the challenges of primary care is one of the most interesting and innovative aspects of psychiatric classification at this time. The development of modern systems of classification in the last 150 years initially began with a focus on severely ill inpatients, which led to classification of psychotic disorders. Then, largely under the influence of Freud, and changes in practice habits that resulted from the development of psychoanalysis, psychiatrists became increasingly interested in outpatients and the classification of the less severe conditions. This has been the most important development in psychiatric diagnosis during the last 80 years. We are now finding that our classification is not working very well in primary care settings, a situation that has important theoretical and practical implications. One basic problem has been the lack of a widely accepted definition of what constitutes a mental disorder, of where one draws the line between normality and pathology. This is particularly pertinent in primary care settings in which one must ascertain whether the degree of discomfort experienced by a patient is sufficient to qualify for a diagnosis of a mental disorder. Unfortunately, definitions of mental disorders work least well in delineating the boundary between normality and pathology. Moreover, this boundary is likely to vary greatly from culture to culture and the definition is also likely to depend on the availability of practitioners to treat the disorders that have been defined. When there is a scarcity of practitioners to provide care, it becomes a luxury to define the less severely ill people as having a mental disorder.
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