Abstract
Shall I compare thee …
With the release of DSM-5, psychiatrists worldwide have been moved to Shakespearean extremes of emotion. There is an aura of both excited anticipation and anxious apprehension and a sense that change is afoot. But is it? The question is how to gauge any change and specifically what to use as a comparison. The obvious choice is its progenitor DSM-IV. But how much of a change is there really? And is it much improved? One would like to surmise that DSM-5 ‘art more lovely and more temperate’; alas, in reality, this conclusion may not be fitting. Why?
Since the beginning of the revision process, DSM-5 has quite rightly been under intense scrutiny and has been subjected to ‘rough winds’ that have tested its fortitude and changed its course. For example, its daring objectives of subsuming pathophysiology and putative biomarkers within diagnoses, and possibly linking aetiology with therapy and prognosis have been gradually supplanted with less ambitious goals. Thus, DSM-5 is indeed quite ‘temperate’ but not necessarily ‘more lovely’ as it has opted for a further increase in diagnoses and the ‘creation’ of disorders where, perhaps, there were none before. This view has been widely promulgated and it reflects the frenzy that has consumed psychiatry of late because of diagnostic flux. The latter is perhaps a ramification of adhering to a classificatory framework that is inherently awry. A sample of this milieu of discontent and disaffection is featured in this issue of the Journal, which coincides with the release of DSM-5.
Providing a resplendent Viewpoint, David Healy explains how catatonia has resurfaced and discusses why, although it is included in DSM-5, its fate remains uncertain, partly because our familiarity with its clinical manifestations has all but faded (Healy, 2013). This is all the more remarkable given that up to 10% of inpatients may have catatonic symptoms and hence he urges that we recognise catatonia and embrace its use. Arguing antithetically, Frances and Chapman urge strongly that we resist adopting the diagnosis of Somatic Symptom Disorder, as it risks mislabelling medical illness as mental disorder (Frances and Chapman, 2013). Instead, they suggest we remain loyal to Adjustment Disorder because it is simply more accurate.
In addition to discussing DSM-5, this issue of ANZJP also celebrates the 50th anniversary of the College. To mark this, Robert Goldney provides an effulgent retrospective of publications from 1967 onwards that have addressed the theme of suicidal behaviour in this Journal (Goldney, 2013). Hilario Blasco-Fontecilla continues the melody in a letter on the clustering of suicide and its conceptualisation as a contagion (Blasco-Fontecilla, 2013). Leo Sher then improvises and notes the drivers to suicidal behaviour in men, in particular the role of testosterone (Sher, 2013). Echoing this ostinato, somewhat tangentially, Vidyendaran Rudhran describes a disturbing but equally fascinating instance of ‘phallicide’, a term concocted to describe auto-penile amputation as a possible means of suicide (Rudhran et al., 2013).
Examining the working needs and functionality of those with severe mental illness, Harvey and colleagues discuss the strategies that can be used to enhance employment opportunities for those with psychosis (Harvey et al., 2013). Their industrious work draws additional commentary from Vera Morgan and Geoffrey Waghorn (Morgan, 2013; Waghorn, 2013) whose sentiments resonate with the views of Helen Lockett and Clive Bensemann (Lockett and Bensemann, 2013). The theme of employment, and more so when to call a stop to work, is also discussed, briefly (Wijeratne and Peisah, 2013).
The research articles in this issue contend with negative attitudes, affect and forensic mental health care. Jeremy Skipworth and colleagues discuss capacity to consent (Skipworth et al., 2013) and Brin Grenyer and colleagues discuss aggression in mental health patients (Grenyer et al., 2013), whereas, taking a broader view, Emma Barrett and colleagues investigate the mental health correlates of anger in the general population (Barrett et al., 2013). Pointing the lens more specifically, Malcolm Battersby and colleagues discuss how Vietnam veterans with comorbid alcohol misuse and psychiatric and medical conditions can be managed (Battersby et al., 2013) and Judy Pasco and colleagues discuss obesity and its relationship with both positive and negative emotions (Pasco et al., 2013).
Finally, when considering the ups and downs of the past five decades and the role of the College and psychiatry in general, it is difficult to find a better model than that of bipolarity, which, with its vicissitudes of mood, accurately mirrors the complexity of psychiatric practice and our professional development. It is therefore fitting that Johan Schioldann reminds us of an example of translational psychiatry in the hands of John Cade, who experimented on guinea pigs, then on himself and then studied patients; in doing so he resurrected the use of lithium and ‘changed the face of psychiatry’ (Schioldann, 2013). Psychiatry has certainly matured and become much more sophisticated over the past 50 years. Since the time of John Cade it has built and rebuilt bridges with neurology, psychology and general medicine and continues to delve into its neurobiological underpinnings. All of these necessary and sterling efforts have resulted in a plethora of publications all searching for a home and this need has been met by an expansion in open access publishing (Hunt et al., 2013).
What the College will look like in another 50 years’ time, and indeed what will be the nature of psychiatric practice, is anybody’s guess, but of one thing we can be certain: ‘so long as men can breathe or eyes can see’ curiosity of the mind will continue to be. In this regard, it is important that psychiatrists remain at the helm of their profession, but it is unclear whether DSM-5 will facilitate this.