Joel Paris

The categories used in psychiatric diagnosis are based on observation of signs and symptoms, rather than on pathological processes. One can make use of a few signs, such as facial expressions associated with depression or the flight of ideas associated with mania. But what clinicians mainly use for diagnosis are symptoms, the subject experiences reported by patients. Psychiatrists have little knowledge of the processes that lie behind these phenomena. Thus psychiatric diagnoses, with very few exceptions, are syndromes, not diseases.

DSM-5 is not 'the bible of psychiatry' but a practical manual for everyday work. Psychiatric diagnosis is primarily a way of communicating. That function is essential but pragmatic__ategories of illness can be useful without necessarily being 'true.' The DSM system is a rough-and-ready classification that brings some degree of order to chaos. It describes categories of disorder that are poorly understood and that will be replaced with time. Moreover, current diagnoses are syndromes that mask the presence of true diseases. They are symptomatic variants of broader processes or arbitrary cut-off points on a continuum.

What is actually observed in so-called 'biplar children'? If you read the research reports carefully, they describe broad and persistent emotional dysregulation. Although these children have mood swings, they do not develop manic or hypomanic episodes. They are moody, irritable, oppositional and likely to misbehave__ike all children with disruptive behavior disorders. Their grandiose thinking usually consists of little beyond boastfulness. No evidence from genetics, neurobiology, follow-up studies or treatment response shows that this syndrome has anything in common with classical bipolarity.

The main reason why clinicians may not diagnose personality disorders is that they think that doing so supports therapeutic pessimism. Recent research has shown this is not true; most patients get better, either with time or with treatment, that the prognosis is actually better than in many patients with severe mood and anxiety disorders.