Misdiagnosing normality: Psychiatry's failure to address the problem of false positive diagnoses of mental disorder in a changing professional environment

Background: In psychiatry's transformation from primarily an asylum-based profession to a community-oriented profession, false positive diagnoses that mistakenly classify normal intense reactions to stress as mental disorders became a major challenge to the validity of psychiatric diagnosis. The shift to symptom-based operationalized diagnostic criteria in DSM-III further exacerbated this difficulty because of the contextually based nature of the distinction between normal distress and mental disorder, which often display similar symptoms. The problem has particular urgency because the DSM's symptom-based criteria are often applied in studies and screening instruments outside of the clinical context and by non-mental-health professionals. Aims: To consider, through selected examples, the degree of concern, systematicity and thoroughness-and the degree of success with which recent revisions of the DSM have attended to the challenge of avoiding false positive diagnoses. Method: Conceptual analysis of selected criteria sets, with a focus on possible counterexamples to the claim that DSM criteria imply disorder. Results: Psychiatry has so far failed to systematically adjust its diagnostic practices to confront the problem of false positives. Flaws in criteria, which can be recognized immediately by lay people, remain unaddressed or are addressed on a hit-or-miss random basis years after the flaw has been introduced, even though the issue is purely conceptual and is not sensitive to any new research information.