Qui di seguito riporto un interessante intervento critico della tendenza recente in psichiatria a fare tante malattie quanti sintomi e a parlare di 'comorbidità' quando più sintomi sono presenti. Questa tendenza appare trasformare e svuotare il concetto di 'malattia' in semplice presenza di sintomi con una tendenza al moltiplicarsi così delle malattie. Le classificazioni psichiatriche attuali, di cui il DSM IV è il paradigma, stanno trasformandosi in liste sempre più numerose di 'malattie' che portano anche a includere comportamenti e stati d'animo 'normali'. Questa tendenza presta il fianco all'accusa di psichiatrizzare tutti i comportamenti umani, e al conseguente sospetto di voler prescrivere un farmaco per ogni comportamento o stato d'animo.

da: http://boards.medscape.com/[email protected]@.29f6fac4!comment=1&cat=All

Bipolar Disorder in DSM-V (Part II): Diseases or Comorbidities?
Nassir Ghaemi, MD, Psychiatry/Mental Health, 01:33PM Oct 15, 2009

This great nation is, by virtue of our democracy, a highly non-heirarchical place. It seems that this leveling tendency has seeped into our psychiatric nosology too. Most clinicians appear to take it for granted that all diagnoses are created equal.

If you meet criteria for dysthymia, generalized anxiety disorder (GAD), and major depressive disorder (MDD) - then, you have three diseases. But nature does not tend to be so generous; most of us get one disease at a time.

When diagnoses overlap so much, in my view, we either have no disease, or one disease with many symptoms; rarely do we have multiple diseases at once. I see all the time, for instance, that a patient with bipolar disorder is also diagnosed with adult ADHD (because of the concentration impairments of depression or mania), a sleep disorder (due to manic insomnia), social phobia (due to anxiety occurring along with depressive isolativeness), GAD (due to anxiety occurring in both mood phases or in mixed episodes), and substance abuse (sometimes occurring only during manic episodes due to impulsivity).

There are such things as polysymptomatic diseases.

If we were to give each symptom a diagnosis, then 5 diseases would constantly happen at once. It is truer to nature to identify these polysymptomatic diseases when present, and to take a hierarchical approach when diagnosing them, compared to monosymptomatic conditions. If each symptom gets a diagnostic label, and then a drug, we produce today's nosologomania and polypharmacy, the causally connected flipsides of the contemporary psychiatric coin.

I thought we went to medical school to identify diseases that underlie symptoms, not the reverse.

DSM-V, from the process I've observed so far, does not seem to be grappling with this problem. Instead, the utility and reality of "comorbidities" is accepted, and a premature equivalence between symptoms and diagnoses is made. Lip service is paid to disease concepts, but diagnostic relevance is undercut by simply saying we don't know etiologies and thus we cannot apply those disease concepts to our nosology. Symptoms seem to be all we have, and our treatments only manage symptoms anyway.

This somewhat postmodernist skepticism ignores some things we do know: Lithium, for instance, completely cures the disease of manic-depressive illness in a notable subgroup of patients; they never have another episode or even symptom in their lives, according to some studies. In a study in press (OJ Bienvenu et al) a review of genetic studies found that bipolar disorder is 84% heritable, similar to Alzheimer's dementia and schizophrenia, in contrast to MDD which is only about 40% heritable . Bipolar disorder and schizophrenia have almost no cross-cultural or cross-national variation in frequency according to an international comorbidity survey study; MDD and anxiety diagnoses vary markedly. The case for a disease concept seems strong for bipolar disorder and schizophrenia, and in one case we even have a cure. The symptom oriented approach may be more relevant to those other 390 DSM diagnoses which indeed may not represent diseases of the brain and body in the traditional definition of an abnormality of an organ symptom with a specific physical etiology and a stereotypic constellation of symptoms and outcome. (Not knowing the specific physical etiology does not invalidate the application of the disease concept if the other aspects are present; e.g., Alzheimer's dementia).

DSM-V may seek to relabel symptoms as dimensions, and continue to avoid the hard work of identifying those large-scale diseases, like schizophrenia and manic-depressive illness, which overshadow the symptomatic presentations of psychiatric conditions.