This book argues that the needs of medical insurance and the
pharmaceutical industry are diverting the Diagnostic and Statistical Manual
(DSM) of the American Psychiatric Association from its true intention of
describing natural kinds of mental disorder. Despite the helpful summaries at
various points, it is a little difficult to discern this argument amongst the
detail of the book. Moreover, the conclusions at each stage seem to be reached
rather idiosyncratically, often with apparently inadequate exploration of the
underlying assumptions. Nor did I find sufficient discussion of what I consider
to be some of the major issues about the validity of DSM.

It is not surprising that DSM is used for insurance purposes. The
International Classification of Diseases (ICD) was introduced to record causes
of death. It was in the 6^th edition that a chapter for mental
disorders was added, thus extending the remit of the classification to
morbidity as well as mortality. The assumption that mental disorders can be
classified is bound to lead to the use of the labels for giving a number to an
insurance claim.

The problem is that people rarely fit a simple numbering system.
Insurance codes are manipulated to obtain payment for treatment. There is also
a more fundamental issue here about psychiatric diagnosis. Reducing people’s
mental health problems to a single word diagnosis may not encapsulate adequate
understanding of the reasons for their symptoms and behavior. Nor, in
particular, did I find any discussion in the book of the value of using
operational criteria for defining mental disorders. The change from DSM-II to
DSM-III introduced these sets of rules to be followed to make diagnoses of the
different syndromes. Previously the disorders were defined by typical
descriptions of the different presentations. Such an approach was regarded as
too vague leading to unreliable application of psychiatric diagnosis. But maybe
it led to a more valid description of psychiatric syndromes.

There is also little doubt that treatment can affect the use of
psychiatric diagnosis. Evidence exists that the wish to use lithium for the
treatment of manic-depressive illness contributed to the shift away from
overdiagnosing schizophrenia. Over recent years, the concept of bipolar
disorder, which has replaced manic-depressive illness, encourages the use of
so-called mood stabilizers in treatment. The use of psychiatric diagnosis is
arbitrary to some extent and not an exact science.

Let me give an example of where I got lost in the argument of the book.
Cooper seems to insist on defining dysfunction as evolutionary dysfunction.
True, DSM-IIIR and subsequent versions added "a significantly increased
risk of suffering death, pain, disability, or an important loss of freedom"
to its list of associations with mental disorder. But this is just one option.
Primarily, mental disorder is considered a "manifestation of behavioural,
psychological, or biological dysfunction in the individual". To my mind,
for functional mental illness the abnormality is a psychological dysfunction.
The problem is gaining sufficient agreement about what counts as a failure of
mental functioning.

Cooper also considers DSM-IV right to suggest that there is no clear-cut
distinction between bodily and mental disorders. She justifiably realizes that
DSM-IV cannot support this argument by suggesting it is thereby avoiding
reductionism. Maybe I have too eccentric a view of the concept of mental
disorder. I do not see any necessary reason why the physical processes that
underlie mental disorder should be any different from those that affect our
normal and everyday mental activity and behavior. I think it is important to
talk about whether symptoms have a psychological or physical origin, unlike
Cooper apparently. Objectifying people cannot be helpful in treatment and this
is the danger of an overemphasis on psychiatric diagnosis. I do not think DSM
is as potentially important as Cooper makes out.

She genuinely believes that DSM could "cut nature at the
joints". If this is the case we surely would have defined some natural
categories by now. She tentatively suggests that schizophrenia and depression
may be in such a class. However, there are those who believe in the unitary
hypothesis of psychosis, thus not defining schizophrenia as separate.
Similarly, people presenting with depressive symptoms commonly overlap with
other affective disorders. I am not saying there is nothing to be gained by
attempting to classify. However, we do need to acknowledge its limitations.
Diagnosis is rarely more than an attempt to put into words how one person’s
presentation overlaps with another. There may well be similarities. But to
place too much emphasis on reifying these similarities into natural kinds is,
to my mind, almost certainly doomed to failure.

Cooper does attempt to refute arguments, such as
those of Hacking and McGinn, that mental disorders cannot be natural kinds. To
be honest, I am not sure if I fully follow her at this stage – there are no
helpful summaries here. Nor do I think it fair to use Huntington’s disease as
her example of a plausible natural kind of mental disorder. In many ways it is
really a physical disorder in which the abnormality of triplet repeat on
chromosome four has now been clearly demonstrated. I suspect Cooper is arguing
that if we go on long enough we will eventually establish the biological basis
of certain functional mental illnesses. This has always been the belief of
mainstream psychiatry, but it still has not been realized. Maybe it never will.

I may be being unfair in my reading of this book. Read it yourself to
find out. However, don’t say I haven’t warned you about the work you will have
to put into understanding what Cooper is trying to say.

 

© 2006 Duncan Double

 

Duncan Double, Consultant Psychiatrist and
Honorary Senior Lecturer, Norfolk Mental Health Care Trust and University of
East Anglia, UK; Website Editor, Critical
Psychiatry Network.

---

 

Response by Rachel Cooper.  Received January 8, 2006

 

First, I’d like to
thank Duncan Double for reviewing my book. He’s quite right in saying that Classifying
Madness is heavy on details. Classifying Madness is an academic book
in the philosophy of psychiatry. It is aimed at philosophers of science and
medicine, and at mental health professionals with some knowledge of the
philosophy of science, and it won’t be of much interest to anyone else. Double
is also quite right in pointing out that the aims of Classifying Madness are
limited and that there are many interesting questions about the DSM that
I don’t consider.

In the book I
address two fundamental questions: The first half of the book considers whether
it is possible to construct a classification of mental disorders that is "natural",
in the sense that it "carves nature at the joints". I propose an
account of disease according to which whether a condition is a disease is not
merely a matter of biological fact, but also involves value-judgements. I claim
that it is plausible, however, that at least some types of mental disorder are
natural kinds. If I am right, mental diseases should be thought of in a way
analogous to the way in which we think about weeds. Weeds are unwanted plants,
thus whether a daisy is a weed is at least in part a value-judgement, but types
of plant that are generally considered to be weeds – daisies, buttercups,
stinging nettles – are natural kinds. Similarly, I suggest, the claim that
schizophrenia is a disease is in part a value-judgement, but it may well be the
case that types of schizophrenia and depression are natural kinds.

On the account of
natural kinds that I propose, for a mental disorder to be a natural kind
entails only that cases of that disorder are fundamentally and objectively
similar. Double is right to suspect that I think that the groundings of such
similarities will in many cases, but not always, turn out to be biological. As
I think that some mental disorders will turn out to be natural kinds, I think
that the DSM project of using empirical research to try to find natural kinds
of disorder makes sense.

The second half of
the book considers epistemic problems. Even if types of mental disease are
natural kinds there may be reasons why a classification system that reflects
their natural structure will be hard to achieve. I argue that classification is
theory-laden and thus that the DSM can only be as good as current psychiatric
theory. In addition I show that the DSM has been substantially affected by the
needs of medical insurance and by the marketing practices of pharmaceutical
companies. As a consequence, I conclude that the categories of the DSM are
unlikely to reflect the true structure of the domain of mental disorders in the
foreseeable future.

 

© 2006 Rachel
Cooper

 

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

Categories: Philosophical