[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.