The Diagnostic and Statistical Manual of Mental Disorders (known
to its friends and enemies as the DSM) is a classification of mental disorders
published by the American Psychiatric Association. The current edition of the
DSM, DSM-IV, was published in 1994 (although a text revision, DSM-IV-TR,
containing minor textual revisions, followed in 2000). The DSM seeks to
describe and classify all mental disorders. Within its pages can be found
descriptions for hundreds of mental disorders — types of schizophrenia,
depression, anxiety disorders and so on — and also less well-known conditions —
nicotine dependence, nightmare disorder, and mathematics disorder, for example.
A new edition, DSM-V, is due to in 2010, and A Research Agenda for DSM-V
seeks to stimulate research and discussion prior to work on DSM-V commencing.

A Research Agenda for DSM-V is a dull though worthy read, but an
extraordinary document. The book doesn’t consist of plans for DSM-V but rather
of plans for plans — a series of "white papers" outlining research
priorities in various areas relevant to psychiatric classification. It is a
testament to the extraordinary success of the DSM that such a book should be
published, and not only published but published in paperback. Scientific
research papers on most topics get read, it is said, by an average of somewhere
between zero and one readers, and yet research proposals related to
psychiatric classification now find a mass readership. The very term
"white paper", used by the editors to describe the chapters, is more
normally associated with plans produced by the offices of nation states. Though
partly bluster, such self-importance is basically justified. The DSM is an
exceptionally important classification system. Psychiatric patients in the
U.S., but also increasingly around the world, receive a DSM diagnosis, and the
diagnosis they receive may well determine the kind of treatment they are given,
and indeed, in many health care systems, whether they are considered worthy of
treatment at all. Given that millions of people world-wide suffer from mental
disorders, changes to the DSM can potentially effect the lives of as many
people as changes in the policies of most nation states.

The six "white papers" that make up A Research Agenda for
DSM-V are intended to stimulate research and discussion prior to the start
of the official revision process that will culminate in the publication of
DSM-V. The six chapters concern fundamental methodological issues (how to
define "disorder", the meaning of "validity", the
differences between the DSM and the ICD), the possible contributions of
neuroscience, and of developmental science, problems with personality disorders
and relational disorders, the relations between mental disorder and disability,
and cross-cultural issues. The chapters on basic methodological issues,
personality disorders, and disability, are more concrete in their suggestions
than the others, and for this reason both more readable and more useful. In
contrast the chapters on neuroscience, developmental science, and
cross-cultural issues basically say "these areas will be important in the
future, but we don’t quite know how yet".

In many cases the problems now faced by the DSM are rooted in its
success. Because the DSM has come to be used extensively outside the United States issues to do with cross-cultural diagnosis have become
especially pressing. The chapter on culture and psychiatric disorder is one of
the longest in the book, and experts on cross-cultural issues were also
assigned to the groups writing all the other chapters. Although this concern is
admirable, much of the discussion remains strangely parochial. Pressures
arising from the oddities of the financing of U.S.
health-care are evident (see, for example, the discussion on pages 102-103,
concerning problems with getting reimbursement for routine monitoring of the
emotional and mental development of children). Even from a European
perspective, the discussion of Relational Disorders seems quaint. Families are
assumed to consist of a married couple caring for a couple of children, and the
aim of marital therapy is considered to be the prevention of divorce. Such
examples highlight the difficulties of achieving cross-cultural relevance, and
bring into sharp focus the oddity of the American Psychiatric Association
controlling a classification that is now of global importance.

The DSM-III,
published in 1980, sought to be a purely descriptive classification that made
no use of unproven etiological assumptions. It was hoped that this would render
the DSM acceptable to mental health professionals working within different theoretical
frameworks. An ongoing theme of A Research Agenda for DSM-V is that the
descriptive syndromes included in the DSM have become so embedded in
psychiatric research as to be potentially problematic. Most studies use DSM
criteria to select subject populations. If it turns out that the syndromes
included in the DSM map onto genuine disorders this will cause no problems —
all cases with a particular DSM label will be fundamentally alike and
psychiatric research will eventually discover how. Unfortunately, it
increasingly seems likely that some theoretically interesting populations do
not map on to DSM categories, and such groups are currently under-researched.
If, for example, some sub-group of those with a particular DSM diagnosis share
a genetic abnormality, or a drug can help a population that cuts across current
categories, this is likely to be missed by researchers. Unfortunately, while
there is some consensus that research based on DSM categories may make little
progress, it is less clear what researchers should do instead. The introduction
to the collection states that "research exclusively focused on refining
the DSM-defined syndromes may never be successful in uncovering their
underlying etiologies" and adds that some "as yet unknown paradigm shift
may need to occur." (p. xix) Ironically, it is at the very point that the
DSM has achieved global dominance, that such doubts in the way forward have
become mainstream.

To sum up, the DSM is currently of such great importance that books
providing some indication as to how the DSM might evolve, such as A Research
Agenda for DSM-V, are also important. Like government white papers the
white papers included in A Research Agenda for DSM-V carry the hallmarks
of having been written by committee — at their best they are authoritative and
comprehensive, at their worst they are bitty and over-long. Although an
important book, A Research Agenda for DSM-V is tough going. Despite
being aimed at all mental health professionals, only the diligent will reach
the end. Even the less than diligent, however, will benefit from flicking
through its pages.

© 2003 Rachel
Cooper

Note that this
book is available free as an Adobe Acrobat download from American Psychiatric Publishing. 
Click here.

Rachel Cooper, Ph.D., Lecturer in Philosophy, Institute for
Environment, Philosophy and Public Policy, Furness College, Lancaster University,
UK

Categories: Philosophical, MentalHealth