Rethinking psychosis: the disadvantages of a dichotomous classification now outweigh the advantages.

Emil Kraepelin would clearly recognize his 19th century dichotomy within current operational classifications of psychosis. However, he might be surprised at its survival, given the extent to which it has been undermined by the weight of currently available empirical evidence. The failure of this evidence to influence diagnostic practice reflects not only the comfortable simplicity of the dichotomous approach, but also the fact that this approach has for many years continued to receive support from some areas of research, particularly genetic epidemiology. This, however, is changing and findings from genetic epidemiology are being reappraised. More importantly, the potential of molecular genetics to indicate biological systems involved in psychopathology has been recognized, and with it the potential to develop diagnostic classifications that have greater biological validity. Crucially, this will facilitate diagnostic schemes with much greater clinical utility, allowing clinicians to select treatments based on underlying pathogenesis. Recent molecular genetic findings have demonstrated very clearly the inadequacies of the dichotomous view, and highlighted the importance of better classifying cases with both psychotic and affective symptoms. In this article we discuss these issues and suggest ways forward, both immediately and for DSM-V and ICD-11. If psychiatry is to translate the opportunities offered by new research methodologies, we must move to a classificatory approach that is worthy of the 21st century.