When psychologists have written
about diagnostic classification, they have generally taken a somewhat critical
stance to the American Psychiatric Association’s Diagnostic and Statistical
Manual (DSM).  The politics behind
this are relatively simple.  In the last
few decades the divide in the USA between psychologists, who generally have
Ph.D.s, Psy.D.s, MSWs, or other degrees in clinical psychology, and
psychiatrists who have M.D.s from medical schools, seem just as entrenched as
ever.  Increasingly, psychologists
provide talk and behavior therapy while psychiatrists write prescriptions.  The average time a patient spends talking
with a psychiatrist to get a refill of medication is ridiculously small —
there is barely enough time to ask whether there have been any changes in
symptoms recently, whether the patient’s life is dramatically worse than
before, and possibly whether the patient has a method of paying for the
medication or needs some free samples, and then the prescription is written and
the patient is out of the office.  In
contrast, psychologists normally talk to patients once a week for 45-50 minutes
for several sessions, sometimes for a few weeks, sometimes for a more
protracted period of several months, or very occasionally for years.  Psychologists tend to get a detailed picture
of the patient’s whole life and the complexities of their relationships with
other people.  When there are
antagonisms between the disciplines, psychiatrists may accuse psychologists of
talking for weeks and weeks without actually helping the patient, while
psychologists accuse psychiatrists of using a reductionist medical model that
simply sees the patient as a collection of symptoms in need of
alleviation. 

Of course, the two sides are not
always so neatly separated.  In the last
twenty years, psychologists have largely come to accept that psychotropic
medications can be helpful to patients, and may even help the process of
psychotherapy.  On the other side, there
are many psychiatrists who still believe that psychotherapy is very important
mode of treatment for a wide array of mental disorders, and that it is often
essential to help the client gain psychological insight into his or her
problems and gain a new perspective.  
Furthermore, the publication of Rethinking the DSM suggests that
psychologists have come to realize that that since the reimbursement side of
the mental health profession is so dominated by the diagnostic codes of DSM,
they have to live with it and the best way to make improvements to the
classification system is through giving careful constructive criticism.  The book is a collection of 11 papers on a
variety of approaches to the classification of mental illness, divided into
three sections.  The first, with just
two papers, provides an introduction and background to the topic.  The second, with three papers, addresses
methodological considerations.  The
third, with the remaining six papers, proposes alternative approaches to
classification.  Nearly all of the
authors are members of university psychology departments in the USA and the
rest of the world.  It is striking that
unlike comparable publications of the American Psychiatric Association, this
American Psychological Association publication does not even list the degrees
held by the contributors to the volume, a small example of the "cultural
difference" between the two professional groups.

This cultural difference extends to
ways of paper writing.  While these
papers are scholarly and careful, they tend to be more open to a diverse
collection of ideas.  The authors are
more liable to frame their own ideas as the expression of their own personal
views rather than as scientific fact or conjecture.  Arthur Houts, in his paper "Discovery, Invention, and the
Expansion of the Modern Diagnostic and Statistical Manuals of Mental
Disorders" starts out in his first sentence saying, "This chapter
is biased and unbalanced."  Authors
refer to a wider range of other books, including philosophy, anthropology,
social psychology, and even some literary theory, as well as the standard
psychiatric literature.  As a whole this
is a stimulating collection of articles, although there were no papers that
really stood out as major contributions to the field.  Some of the papers present ideas for new approaches to
classifying mental disorders which are intriguing but largely programmatic and
untested, so it is hard to know if they are really viable — this applies, for
instance, to "Assessing Psychopathology: A Narrative Approach," by
Oscar Goncelves et al, "Operationalized Psychodynamic Diagnostics: A New
Diagnostic Approach in Psychodynamic Psychtherapy," by Wolfgang Sneider at
al., and "Simplifying Diagnosis Using a Prototype-Matching Approach:
Implications for the Next Edition of DSM," by Drew Western et al. 

The previously mentioned paper by
Houts is one of most tightly argued pieces. 
Houts sets out his claim that the rapid expansion in the number of DSM
diagnoses with each edition (a 300% increase in four decades) is a serious
problem.  He suggests that the new
diagnoses are not discoveries but are social inventions, and that they pose a
threat to the credibility of the mental health field.  Houts does an excellent job of setting out the necessary
information and the different theoretical perspectives that could be useful in
understanding the creation of diagnostic categories, covering both scientific
methodology, sociology of science, and the analogy between physical medicine
and mental health medicine (typically, psychologists tend to avoid the useful
term "psychiatry").  This
paper continues a running dispute that he has had with Jerome Wakefield on this
topic, and here he replies to the claims that Wakefield makes in defending the
expansion of DSM, and it is when he gets to these issues that he really hits
his stride.  Houts presents a compelling
case that the expansion of diagnoses is not in fact comparable to that in
physical medicine, and he concerns he spells out about the expansion need to be
taken seriously.

Ann Douchette’s paper on
"Child and Adolescent Diagnosis: The Need for a Model-Based Approach"
is interesting.  She summarizes some
recent thought on the classification of mental disorder in young people paying
particular attention to DSM and IDEA, the Individuals with Disabilities
Education Act.  She points out that DSM-IV
has neglects the idiosyncrasies of child and adolescent emotional
disorders, and both it and IDEA ignore the importance of family and other
contextual circumstances.  In DSM-IV,
relationship problems are relegated to Axis IV V-codes, and this tends to
confirm the policies of managed care and other bureaucracies that such problems
are not serious.  Douchette cites
evidence that in fact those problems are just as serious as other mental
disorders.  She further recommends that
classification should use broad disorder groupings, based on a psychometric
approach that includes confirmatory factor analysis (CFA) and item response
theory (IRT).  She explains both of
these briefly, and her paper includes many references for those who are
interested in more details.

One of the best known authors in
this collection, John Kihlstrom, gives the final paper, "To Honor
Kraepelin …: From Symptoms to Pathology in The Diagnosis of Mental
Illness."  He provides a useful
overview of the history of theories of diagnostics and the nature of
disease.  Unfortunately, his conclusion
is rather tame — he points out that psychology and psychiatry should move
beyond diagnosis through symptoms to discovering the underlying pathology of
disorders.  This is an idea that most
current researchers endorse, although most also acknowledge that our
understanding of mental illness does not provide us with enough certainly to do
this in any of the central cases of mental disorder. 

Overall, there is probably too much
overlap between the different papers here, and the editors should have insisted
on editing down most of the papers that wanted to include an overview of
different approaches to the classification of mental illness.  It might have also been helpful for authors
to include more concrete examples of the problems of the current classification
schemes and how it could be improved. 
Nevertheless, it is important to encourage more dialog among mental
health professionals on the nature of diagnosis, and Rethinking the DSM
should do just that. 

© 2003 Christian Perring. All
rights reserved.

Christian Perring, Ph.D., is Chair of the Philosophy
Department at Dowling College, Long Island, and editor of Metapsychology
Online Review.  His main research is on philosophical issues in
medicine, psychiatry and psychology.

Categories: Philosophical, MentalHealth