Psychopathology in neuropsychiatry: DSM and beyond

The case reports described in this article indicate that current neuropsychiatric practice is strongly limited by reliance on the Diagnostic and Statistical Manual of Mental Disorders (DSM). Knowledge of new psychopathology that will enable the neuropsychiatrists and neuroscientists identify specific areas of brain dysfunction is essential to modern practice of neuropsychiatry. Today, less than 20% of neuropsychiatry and neuroscience programs teach such psychopathology.The development of brain imaging and metabolic measurement technologies; the continuous and rapid introduction of many new pharmaceutical agents into clinical care; and the various, detailed editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) have all shaped modern psychiatric training and thus future psychiatric practice. This "shaping" is observed most often in the teaching of psychopathology and of mental status examinations, both currently focusing on how to recognize and elicit the clinical features needed to apply the criteria set by the DSM. Once DSM criteria are met, a best-choice treatment plan based on DSM diagnosis is selected from an array of pharmacotherapy algorithms. It is assumed that the known reliability of the DSM system maximizes the likelihood that these diagnostic decisions are valid and treatment choices are therefore appropriate. Descriptive psychopathology that goes beyond the DSM is primarily relegated to historical consideration and rarely pertains to issues regarding patient care.