DSM: IMPLICATIONS

Over the past two decades we have witnessed a systematic expansion of diagnostic criteria in developmental age with a progressive tendency to interpret every deviation from the statistical norm as a sign of psychopathology.

The error is not new psychiatry has always worked in this way and today this attitude is repeated with a well documented obstinacy and surprisingly little problematisation during mainstream clinical debates.

The reality is simple though often ignored neuroatypicality is not synonymous with clinical dysfunction and a difference is not necessarily an impairment but the classificatory system that governs contemporary psychiatry

and specifically the DSM-5-TR does not seem interested in this distinction.

The DSM is not and has never been an epistemological tool we are faced solely and exclusively with a nosographic system designed to ensure communicative uniformity and operational standardisation.

In other terms it is not intended to understand the human mind but to categorise it. This yes can be useful in insurance or epidemiological contexts and can certainly facilitate the work of the clinician but it becomes dangerous when it is used as a primary filter to read the complexity of development.

Let us take a child with non impairing autistic traits or with atypical attentional profiles but functionally

adequate in their own environment. In the DSM categorical model the implicit question is do these traits fall

into a sufficiently recognised pattern to deserve a nosographic label.

In the dimensional model the one we would actually need the question would be different do these traits cause clinically significant distress or relevant functional impairment in the specific life context of the individual.

The problem of course is not the manual but the way it is used as if it were a diagnostic guide and not an administrative map.

The result is an inflation of diagnoses in children who show atypical but not dysfunctional developmental trajectories with increasing confusion between neurological variability normal within the human range neurodivergence atypical but stable and functioning configurations psychopathology disorganisation distress

and clinical impairment.

In doubt diagnosis is made; not for clinical reasons but to respond to external demands.

The diagnosis becomes a pass a code to enter on a form rather than a tool for understanding and it is here

that psychiatry bent to the logic of compliance loses its critical function.

A clarification is necessary this is not about denying the existence of neurodevelopmental disorders but about redefining the boundary between difference and dysfunction because a clinical system unable or worse unwilling

to do so risks becoming itself a generator of stigma.

The real question is not whether this child is diagnosable but is this child dysfunctional for themselves or only for the environment in which they live. When the answer is the latter clinical practice should look less at the DSM

and much more at the context.

Medicalising atypicality in the absence of real impairment is not early intervention.

It is a semantic abuse and a refined form of social exclusion disguised as help.

- Dr. D'mitrij Alexie Romanov

Specialist in Child Psychiatrist