[jmde]

This paper is interesting to read, but confusing in my opinion and sort of misled.

I'm not sure what point the author seems to be making about the DSM. They seem to be stating something along the lines of "The DSM isn't successful because it's atheoretical, it's successful because it adopted a biological theory, and because its emphasis on reliability facilitated sociopolitical control by the psychiatric profession." But later they recognize that the DSM isn't successful, seeming to contradict themselves.

The theory of the DSM goes far beyond biology, being explicitly neo-Kraepelinian and to some extent psychodynamic in nature, although that would probably not be acknowledged by any of the DSM's authors unless you pressed them on it. The success and failure of the DSM has everything to do with sociopolitical factors and the biological and nonbiological tenets of neo-Kraepelinian classification, and not on "atheoretical versus natural" or "scientific versus nonscientific" or "ontological versus nonontological" or "descriptive versus theoretical" or "ontological versus epistemological" or any of those sorts of distinctions.

The DSM adopted Kraepelinian categories and assumptions, shoehorning psychodynamic theories into this framework in some cases, and then further elaborating the system with very biological criteria. It essentially asserts that the major Kraepelinian categories are valid, that mental illness is discretely distinguished from normality or wellness, and that its categories reflect disruptions of biological systems that can be determined by certain patterns of biological observations. It further asserts that reliability is a central feature of classification and assessment. Some of these assumptions have been accepted, cementing its success, but some assumptions have been rejected by the community, leading to the current crisis that the author recognizes. Underlying all of this are sociopolitical factors, such as professional practice conventions, boundaries, and laws, and popular perception, that have both augmented the DSM, but also undermined it by highlighting the political processes underling its continued use.

The question is not whether a classification system is atheoretical or natural, or descriptive versus natural, or ontological versus epistemological, it's what criteria or theoretical principles are used to derive the system. In the case of psychiatric classification, the tension historically, even with the DSM itself, has not been about "atheoretical" versus "natural" systems, it has been about whether classification systems are at the level of behavior, which is proximate to the phenomena of interest and relatively tractable, or biology, which is proximate to the causes of those phenomena, but relatively intractable due to those causes being unknown. It's a bit like trying to classify species, genera, etc. without knowledge of genetics. You can proceed with a biology-based classification system under the assumption that your understanding is close enough, or you can acknowledge that you don't understand it and rigorously classify lifeforms based on what you do understand. Or you can try to do something intermediate. None of these are "natural" or "atheoretical," they're just at different levels of analysis. Another analogy might be found in computer science: do you derive document/file ontologies based on biology, or something like unsupervised AI classification? People like to assume that going down to a lower level of scientific analysis is always better, and it might be, but it might also not be, depending on your goals.

[jrapdx3]

Having quite a bit of experience with the DSM since DSM-II, the article gives a fairly coherent history of the document, and is correct that the advent of DSM-III signaled a radical departure from the earlier, and much less useful versions.

The theoretical underpinnings have been an issue in hot debate since the DSM-III was in preparation. The deliberately descriptive nature of the classification has been opposed by many critics who favor a more "casual" medical classification or proponents of other theoretical systems.

Stakeholders in the recent and very prolonged gestation of DSM-5 fell into two main groups, let's call them researchers vs. clinicians, or splitters vs lumpers. The splitters were groups interested in having very specific criteria that sharply distinguished diagnostic categories which of course suits research agendas. OTOH clinicians, aka lumpers, were more interested in the intermediate cases, like typical patients, that don't fit into highly distinct categories at all well.

An alternative scheme was dimensional classification, which runs orthogonally to the standard descriptive schema, inasmuch as behavioral dimensions such as low mood are frequently encountered among many existing disorders. To clinicians this idea had much appeal since it would most usefully reflect symptom-oriented treatment modalities.

Whatever scheme is chosen it will have shortcomings. There is really insufficient information at present to form a basis for any given theoretical approach. It is quite apparent that there are biological, social, physical, political and other phenomena that contribute to development of illness of all kinds, including psychiatric disorders.

In this brief comment it's barely possible to scratch the surface of the concepts and assumptions underlying the idea of "mental illness", however I think the article is discussing issues tangential to those confronting psychiatrists who grapple with management of the very disorderly nature of psychiatric disorders.

The present diagnostic scheme is a practical compromise of many points of view about disorders in general and specific disorders in detail. The DSM is the field's attempt to find a language to discuss the great challenges in understanding and healing very complex situations about which science has only fragments of information.

IMO the relevance of the thousands of "theories" concerning human behavior is yet to be determined. We need to have a great deal more knowledge about the functional connections of the human organism in consideration of the near-infinite range of neural, endocrine and immune system signaling and interaction before it's appropriate to establish meaningful theories in the human behavioral domain.

[jahsjahs]

Whenever discussion of the DSM arises, I tend to revert to Ian Hacking's critique of the guide (http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest).

I'm a big fan of his contributions in the philosophy of science, which perhaps gives his opinion more weight than it should on psychiatric matters (Rewriting the Soul, and Mad Travellers are excellent books).

Is this criticism mistaken though?

[jrapdx3]

Unfortunately I'm not familiar with Hacking's piece, and I'll be very interested in reading it. On a first run-through many of the expressed doubts and concerns have been aired extensively in the 19 years between publishing DSM-IV and DSM-5.

As I said a repeating theme is the tension between what researchers want and what's useful in clinical practice. With a foot in both camps, I have sympathies with both points of view. Perhaps no one set of criteria is universally suitable.

As an non-psychiatric example I've been interested in the body's regulation of calcium balance. When it's negative calcium is lost and results in thinning bones, in full form it's osteoporosis, a disabling condition to be sure. One aspect is calcium loss through the kidneys. The measure is 24hr calcium excretion in the urine. The point is for clinical purposes 200mg/24hr is significant, but researchers studying the problem would probably select 250 or 300mg/24hr because it defines a more homogeneous group.

IOW the cutoff point for having or not having a disorder is soft, indistinct and somewhat arbitrary. If a person loses 199mg/24 hours does that not count as a potential problem?

As Hacking says, the DSM is a work in progress. There are many messy issues in real world practice of medicine including psychiatry. The DSM is a composite of a hundred philosophies, I too have high regard for some philosophers, but the DSM is a philosophical nightmare by any measure.

I've long since memorized parts of the DSM, and I can recite those in my sleep, but always take it, like all science literature with ample quantities of salt.

The saying goes if you like sausage, don't watch how they make it. The DSM is like sausage, and politics, a very messy production. But for all its quirks, and there are many, there is really nothing better for its main purposes. As long as it's not always taken literally, and with healthy doses of clear thinking, it is sometimes very useful, and sometimes not.

Thanks for bringing up your excellent question. I don't think I've answered it very well. A thousand different criticisms would be easy to conjure, but kind of a bottom is that for all the pot shots no one has come up with with anything that is even close to being as applicable in so many different settings.