Diagnosis and the DSM: A Critical Review
Palgrave Macmillan just published my book “Diagnosis and the DSM: A Critical Review“. Below a summary of what I discuss:
In 2013 the American Psychiatric Association launched the fifth edition of its diagnostic handbook: the DSM-5. The publication of the DSM-5 mobilized me to review the assumptions and evidence underlying the manual and discuss the social and cultural context within which the handbook is developed and used. End users often take for granted that an instrument like the DSM-5 (an impressive 991-page book published by a highly prestigious professional society) provides us with an accurate basis upon which to draw far-reaching conclusions about people’s mental health. Indeed, by means of this respected handbook, professionals and laypersons alike make important decisions about the presence or absence of psychological conditions in themselves and in others.
In popular press, the DSM is frequently coined as ‘the bible of psychiatry’ and this is precisely how the handbook seems to function: people believe in its accuracy and legitimacy, largely without question. The manual could also be said to function somewhat at the base of the economy of psychiatry. After all, the DSM not only facilitates a belief system, but also survives as an important economic device for managing the flow of money invested into mental health care. It is on the basis of this classificatory system that decisions are made on issues such as the reimbursement of treatments, the right to financial aid and the allocation of means across health care providers.
With this book I argue that the value of the DSM-5, and previous versions of the handbook, should not be taken for granted: the manual should be closely assessed and discussed. End users of the DSM-5 should not assume that the handbook is ‘good’ or ‘useful,’ but become cognisant of its strengths and weaknesses, including its theoretical underpinnings and its position in historical debates on the scientific status of psychiatry and clinical psychology.
This book consists of two chapters in which I discuss the reliability and validity of the DSM.
The first chapter focuses on the reliability of the DSM-5 and previous versions of the handbook. In the early days of psychiatry, diagnosis didn’t begin from checklists of symptoms, but from elaborate prototypical descriptions of a diverse range of psychopathology. Guided by administrative purposes these descriptions gave rise to classification systems such as the DSM. An important impetus for the switch to checklist-based diagnosis can be found in harsh discussions on the fundaments and the practice of psychiatry during the nineteen sixties and seventies. In these years, psychiatry was in crisis: several academic researchers demonstrated that psychiatric diagnosis was unreliable, critical scholars pointed to weak points in the overall ethos of psychiatry, and societal changes challenged the practice of psychiatry. A group of so-called neo-Kraepelinian psychiatrists responded to the malaise in the discipline by defining psychiatry as a strictly medical discipline and thus replacing the method of diagnosis with a criteria-based system. Checklist-based diagnosis is often believed to be more scientifically sound than narrative-based diagnosis. However, in this chapter I demonstrate that this is not the case: anno 2013 psychiatric diagnosis is by no means more statistically reliable than it was 40 years ago. The main thing to have changed in the last decades is the standard upon which statistical reliability is based and evaluated. If the fact of the ever-increasing relaxation of these statistical standards of evaluation continues to be ignored, we simply continue to invest in the fantasy that psychiatric diagnosis with the DSM is more reliable than ever before. Moreover, to this day the plethora of problems addressed by critical researchers in the nineteen seventies (such as the issue of hasty decision-making and the problem of reification) remain entirely unresolved and, thus, continue to pose a fundamental challenge for contemporary psychiatric diagnosis.
The second chapter focuses on how the DSM-5 takes context into account and discusses the kind of entity the DSM considers mental disorders to be. The main argument I make is that in the DSM the context of the individual (i.e., the life history, social circumstances, and cultural background) is thought to play only a minor moderating role in relation to symptom formation and expression. Moreover, as the manual follows a sign-based logic it coheres with the assumption that biological irregularities lie at the basis of mental distress. In this way the DSM cultivates a rather naïve essentialistic view of mental disorders, which is certainly not supported by relevant evidence. In this chapter, starting from phenomenological psychiatry and Lacanian psychoanalysis, I make a plea for a ‘reflexive’ approach to psychopathology. Such an approach does not neglect problem-specific or disorder-specific regularities, but assumes that typical configurations never (unequivocally) apply to single cases, thus demanding a casuistic approach to diagnosis.
The theoretical assumptions underlying diagnostic systems like the DSM are rarely reflected upon or questioned. This might be why people rarely propose an alternative system of diagnosis, one that could accommodate a broader understanding of mental health problems. It is my hope that this book will, at the very least, motivate a more critical discussion of psychiatric diagnosis.