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Human Nature Review 2003 Volume 3: 334-338 ( 23 June )
URL of this document http://human-nature.com/nibbs/03/dsm.html
Advancing DSM: Dilemmas in Psychiatric Diagnosis
Edited by Katherine A. Phillips, Michael B. First, and Harold Alan Pincus
Washington, DC: American Psychiatric
Reviewed by Christian Perring, Ph.D., Department of Philosophy, Dowling College, New York, USA.
Whatever one's attitude toward the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), it is a book that is hard to ignore. In the popular press, it is frequently described as the psychiatrists' bible, although this metaphor is probably only apt if psychiatrists are given the role of skeptical priests. They were trained with it, they have to use it in their professional work and it is occasionally helpful to refer to when talking with patients, but they often don't think it provides any deep insights into mental illness, and there are many parts of it they do not believe in at all. Clinical psychologists and social workers tend to be even less committed to it. However, it is the document that has been adopted by most bureaucratic and legislative organizations from managed care and governmental health organizations to law courts to determine when people should be entitled to treatment or their psychological state may be relevant to assessing their responsibilities for their actions.
Given its importance, there should be a great deal of interest in the creation of the next edition. Two of the editors of Advancing DSM were instrumental in creating the fourth edition of DSM; Michael First was editor of the text and criteria, and Harold Alan Pincus was Vice-Chairperson of the DSM-IV Task Force. It is tempting to look at the table of contents for signs of alliances and new ideas that might hint at possible changes in DSM-V. For example, it is interesting that First is co-author with Jerome Wakefield of one of the chapters, since it suggests that Wakefield, who has in the last decade become widely known for his controversial "harmful dysfunction" account of the nature of mental disorder, may have influence in drawing up a definition of mental disorder for DSM-V. It is also striking that W. John Livesley contributes a chapter on personality disorders, since he is known for his critical attitude towards their current classification; the reader may speculate that the editors of DSM-V may be open to a rather radical reformulation of their classification. However, such speculation is reminiscent of Kremlinology, and assumes that the APA already has a fixed agenda and is using this book to start to hint their plans to the public. In their Introduction, the editors of Advancing DSM explain that they hope the book will spur interest and research in preparation for the next edition, and it behoves us to take them at their word. The next few years should be a time of intense discussion of what sorts of changes to DSM will best serve psychiatry and society, and this book should be taken as a contribution to that discussion.
The nine chapters of this book raise some of the most important issues facing psychiatric diagnosis and classification. Some chapters are of course more interesting than others from a theoretical and philosophical point of view. Eric Caine's chapter on "Determining Causation in Psychiatry" emphasizes the complex nature of the causation of psychopathology, which should be obvious to anyone familiar with the current psychiatric literature. He examines two examples, Fen-Phen and Huntington's disease, to illustrate the ways that psychopathology can be caused. He argues that the DSMs have tended to give a false impression that the etiology of mental disorders is understood, and he recommends that the next edition should be based only on available rigorous evidence and predictive validity for therapies and prognoses. It is unclear to what extent imposing such a requirement would mean a radical revision of DSM. The chapter by Ming T. Tsuang et al sets out "Insights from Neuroscience for the Concept of Schizotaxia and the Diagnosis of Schizophrenia." "Schizotaxia" refers to the unexpressed genetic predisposition to schizophrenia, and the authors say that it is a clinically meaningful condition, although they acknowledge that the clinical utility of the concept "remains something of a promissory note" (p. 119). They relate this to the independent issue of whether psychosis should be essential to a diagnosis of schizophrenia. Clearly, the Tsuang et al believe that the future of the category of schizophrenia lies in relating it more closely to its genetic origins, and this may require loosening its connection to some of the symptoms with which is has been historically associated.
In another chapter, David Steffens and K. Ranga Rama Krishnan discuss "Laboratory Testing and Neuroimaging." They argue that as tests for some mental disorders become available, this will have important implications for diagnostic categories. They set out some general principles related to testing, and use the example of Alzheimer's disease (AD) to show their implications. Some genetic variations are related to AD, but the genetic tests are by no means perfect and they carries significant costs, both financial and social. The availability of some tests may provide reason to abandon a concept of AD as a single disease entity, but an alternative option is to retain the concept but recognize that it has several etiological subtypes. The authors also consider the possibility of adding a new axis to DSM as a way of recognizing the growing importance of available testing methods, but they are cautious in their recommendations. Their chapter gives the impression that while we are getting closer to the day when specific tests are available for mental illness, it will still be many years before they play a major role in diagnosis.
Another speculative chapter is that by Phillips et al who consider "Should the DSM Diagnostic Groupings Be Changed?" Like Steffens and Krishnan, they observe that most of DSM is neutral to the etiology of mental disorders, and disorders are classified with respect to their symptoms, but the authors look forward to a time when it will be possible to group mental illnesses according to their causes. After setting out some of the general concerns relevant to this issue, they discuss in more detail four more concrete questions, whether DSM should include a group of obsessive-compulsive spectrum disorders, whether somatoform disorders should be moved to different sections of DSM, whether delusional and nondelusional variants of disorders should be combined, and whether DSM should include a section of stress-related disorders. They make particular recommendations on each of these issues, but more generally they admit that it would be premature to rearrange DSM on the basis of etiology and pathophysiology. The authors are particularly aware of the tension between the dual aims of DSM, to serve the needs of both clinicians and researchers, and they suggest it might be useful to create a separate manual for researchers, that included "proposed diagnostic criteria, axes, subtypes, or new groupings of disorders based on recent findings on pathogenesis, such as genetic data, neuroimaging findings, or biological markers" (p. 77). They recognize that this proposal may widen the gap between clinical practice and research, but they apparently do not find this problem to outweigh the potential advantages of a new manual. In the short chapter "Multiaxial Assessment in the Twenty-First Century," Alan Gruenberg and Reed Goldstein also address proposals for changing the DSM axes. The purpose of the multiaxial system is to highlight the different dimensions relevant to understanding a person's psychological problems. The authors acknowledge some limitations of the system presented, such as the limited attention paid to early developmental stressors. They mention the widely shared view that in classifying personality disorders is best done using a dimensional approach rather than the current categorical approach, and they recommend further research into this. With many of the other authors in this collection, they say that genetic predisposition to mental disorders is increasingly relevant to their classification, but they also emphasize the relevance of psychosocial and family environments during development. While they briefly list possible new axes that could be added to the current system, they do not discuss these in any detail.
Livesley's chapter on "Diagnostic Dilemmas in Classifying Personality Disorder" is one of the most critical of DSM in this collection. He points out the poor correspondence between the diagnostic categories of personality disorders in DSM-IV-TR and the typical presentations of patients. He also lists a host of empirical problems with the DSM categories, and refers to these as "probably fatal flaws" and comments that those categories "were never more than arbitrary ideas based on expert opinion" (p. 153). He proceeds to survey the literature in some detail, but his final conclusion is that "the architects of DSM-V might have to accept from the outset that it may not be possible to achieve an empirically based classification that meets all other requirements of an official classification" (p. 182). In his detailed discussion, however, he does come to some tentative conclusions. He argues that a dimensional approach is preferable to a categorical approach, although he acknowledges that the desire to retain continuity between DSM-V and the previous editions may outweigh considerations of diagnostic validity. Similar considerations are relevant to the question of whether to have a separate axis for personality disorders, but Livesley is clear that scientifically and clinically, it makes more sense to have them on the same axis as other mental disorders. His rich chapter provides a wealth of information on current research and repays careful reading.
"Subthreshold Mental Disorders" by Harold Alan Pincus, Laurie McQueen and Lynn Elinson addresses an issue that has received a great deal of attention from critics of DSM. This is the question of when less severe psychological problems should count as mental disorders. The authors focus on the case of subthreshold forms of depression, and they define "subthreshold conditions" as those that do not meet the full symptomatic or duration criteria but nevertheless "cause clinically significant distress or impairment" (p. 131). Of course, this definition flags a worry that criteria for what counts as clinically significant may be being smuggled in without sufficient scrutiny. The question for subthreshold conditions is really when they are clinically significant, and it is this that needs elaboration. The authors report that a literature review shows that there has been little consensus on how to define subthreshold conditions, and this makes it difficult to draw any general conclusions from previous studies. They recommend caution in proposing new diagnostic categories for subthreshold conditions at least until there is much stronger case for them, and this will require further empirical study that takes into account a wide variety of factors.
One of the most refreshing chapters is by David Reiss and Robert Emde, making the case that "Relationship Disorders are Psychiatric Disorders" since it resists the reductionist trends in psychiatry to see all psychological problems as brain dysfunctions. The authors start by defining relationship disorders as "distinctive, severe, persistent, painful, and dangerous patterns of relationships between two or more people." They explain that these patterns are classifiable and standardized tests are being developed. These disorders have a recognizable clinical course and have well-recognized patterns of comorbidity with other psychiatric disorders. They respond to specific treatments including individual psychotherapy, conjoint family therapy, and even pharmacotherapy. The authors proceed to consider possible reasons why relationship disorders have not been included in DSM and they show how those concerns can be assuaged. They argue that it should be no more difficult in providing clear criteria for relationship disorders than it is for individual disorders and they survey some recent attempts to provide such criteria, along with specific examples as illustrations. They propose that relationship disorders should be added to Axis II, and argue that such an addition would be helpful to both clinicians and researchers. Finally, they argue that while there are important concerns about ethical, clinical and legal problems associated with the creation of categories of relationship disorders, these problems can be adequately addressed. It is a little surprising that the authors do not address in more detail the common philosophical, or one might even say ideological, belief that psychiatric disorders must as a matter of conceptual or definitional truth be principally attributable to individuals rather than groups of people. After all, this is part of the explicit definition of mental disorder given in the Introduction of DSM-IV-TR. Clearly, there are significant conceptual issues that need addressing here, and philosophers should be well equipped to address them.
Those interested in the philosophy of psychiatry will find much food for thought in the chapter by Wakefield and First, "Clarifying the Distinction Between Disorder and Nondisorder." They explain that it is important to distinguish between mental disorders and other conditions including normal intense emotional reactions, social deviance, personal unhappiness, lack of fit between an individual and a specific social role or relationship or environment, and socially disapproved or negatively evaluated behavior in general. This is especially motivated by concerns within the psychiatric profession and the general public that mental disorders are being overdiagnosed, and ordinary human problems are being medicalized. They call this the false-positives problem, and they spell out the wide range of clinical, research and social concerns that it raises. They examine the strengths and weaknesses of the current DSM-IV-TR definition, which have been discussed at length elsewhere. Unsurprisingly, the authors are inclined to adopt Wakefield's well-known "harmful dysfunction" account of mental disorder. It is disappointing that they scarcely mention the existence of a considerable body of literature that finds serious flaws in this account, although they do address some general sorts of concerns that have been raised. They suggest however, that the false-positives problem stems not so much from the defects of the current definition but rather a failure to abide by that definition in the DSM criteria sets. They examine a number of different cases to illustrate their claim here. For example, DSM-IV-TR would count someone who had just lost their job and had experienced 2 weeks of depressed mood, diminished pleasure in usual activities, insomnia, fatigue, and a diminished ability to concentrate on work tasks as having major depression. Wakefield and first argue that such symptoms are a normal reaction to such a loss, and do not give reason to believe that there is a psychological dysfunction. They argue that the criteria for adjustment disorder, substance abuse, acute stress disorder, conduct disorder and separation anxiety are also overinclusive, counting as mental disorders conditions that do not involve internal dysfunctions of individuals. Wakefield and First also point out that the attempt to reduce false positives through requiring that symptoms be "clinically significant" is unhelpful because it is circular -- the whole point of a definition of mental disorder is to explain the meaning of what should count as clinical significance, and so it cannot simply appeal to such a notion in its definition. They suggest that definitions of mental disorder should attempt to focus on the essence of the dysfunction that is the cause of the mental disorder. Furthermore, they emphasize that there is a dysfunction when a person's symptoms do not match the context. As they explain, "A dysfunction exists when a person's internal mechanisms are not able to function in the range of environments to which they were designed to respond. Thus, one can construct a test for dysfunction by specifying an environment in which the function is designed to manifest itself; if the function is not manifested in that environment, there is likely a dysfunction" (p. 51). Wakefield and First's call to bring the DSM criteria for mental disorders in line with the DSM definition of mental disorder is certainly to be welcomed. It is likely that their emphasis on clarifying the distinction between normal reactions and internal dysfunctions could lead to improved formulations of psychiatric criteria in many cases. However, their reliance on a concept of dysfunctional mechanisms within a person, often supported by reference to functions of internal mechanisms as set out by evolutionary psychology, is problematic. As many critics have pointed out, evolutionary psychology is in no position to give us a clear picture of what counts as normal function, and it is debatable whether it ever will be. Furthermore, even if we did could use evolutionary psychology for this purpose, there are reasons whether it is appropriate to use the standards of evolutionary fitness for survival in conditions that existed long before the creation of any human civilizations of the last our thousand years for our standards of normality in the twenty-first century. (This point applies as much to standards of physical health as is does to mental health.) Many will worry that the desire for DSM to clothe itself in the garb of scientific respectability will result in smuggling in a host of ideological and normative assumptions under the guise of scientific objectivity. A strong case can be made that rather than basing criteria for mental disorder on dubious science or pseudoscience, we be better served by encouraging an open public discussion of the normative bases of our psychiatric categories and with the aim of reaching broad agreement.
Given the limitations of size of the collection, it of course leaves out many important topics and perspectives, but there have been a number of books and journal articles on similar topics published in recent years, so there is balance in the wider literature. Overall, this is an excellent collection of papers on controversial issues in psychiatric diagnosis. The quality of both writing and scholarship is high, and the editors have included a wide range of different viewpoints. Advancing DSM merits the attention of clinicians, psychiatric researchers, philosophers of psychiatry, medical sociologists, and anyone else interested in the formulation of future diagnostic categories.
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© Christian Perring.
Perring, C. (2003). Review of Advancing DSM: Dilemmas in Psychiatric Diagnosis edited by Katherine A. Phillips, Michael B. First, and Harold Alan Pincus. Human Nature Review. 3: 334-338.