The DSM system
In retrospect it can be said that this book was originally published in Dutch during the decline of critical psychiatry and antipsychiatry. Interest in the philosophy of psychiatry was waning. Criticism aimed at improving matters of principle and practice in what was considered a hard and repressive system, began losing its voice. Reflection on the significance of concepts and theories gave way to scientific, and in particular empirical orientation. That road was paved to a significant extent by the system of classification in the American Diagnostic and Statistical Manual of Mental Disorders (DSM). Its third edition, called in short the DSM III, appeared in 1980, and the DSM IV, in 1994. This system was so crucial to the further development of psychiatry, that we must take a look at it.
The DSM III and IV are rooted in the idea that for many psychiatric disorders only the symptoms are known, which present in constant or changing combinations. Classification therefore has to be based on sorting these symptoms. The cause is only mentioned when a disorder clearly emanates from a bodily deviation, such as is the case in Alzheimer’s disease or the consequences substance abuse. For the rest, description of the disorders is limited almost entirely to description of the symptoms. In the service of empirical research, criteria are set for the number and gravity of the symptoms. These are necessary for determining a diagnosis. Enabling empirical research is one of the explicit goals of the DSM system.
It uses the term “mental disorders,” not illness or disease. By this, functional problems are stressed rather than structural changes. The concept of mental disorder is defined as follows: “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example the death of a beloved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (i.e. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.”
The concept of distress is directly comparable to the concept of suffering I described in Chapter V, and the concept of disability with the concept of dysfunction. The term “abnormality” which I used is described differently, but is very much associated with what I called a biological discontinuity. An important difference is that in Chapter V, I propose that suffering, dysfunction, and abnormality are a conjunctive cluster, while the DSM is satisfied with a disjunctive cluster: either one or the other is sufficient to determine the existence of a disorder – expanding the “universe” of psychiatric disorders beyond my own description.
The DSM system does not meet Szasz’s criterion for disease, namely the presence of a physicochemical deviation of the body. Szasz has always adhered to this description. In contrast, the DSM-system clearly rejects the biomedical concept of illness in favor of a biopsychosocial concept.
The DSM’s definition is so broad, that it requires the additional condition that the identified syndrome or pattern must be clinically relevant. But as “clinically relevant” is not further explained, it remains more or less a carte blanche for the psychiatric diagnostician. This can be illustrated with a simple example. Suppose someone has serious ophidiophobia (fear of snakes). If such a person lives in an area where there are no snakes, there can hardly be any clinical relevance to speak of: the chance of a confrontation with a snake would be limited to a nature program on television or a visit to the zoo. However, if the same person lived in an area rich with snakes, the disorder could have clinical relevance.
The condition that the syndrome “must not be merely an expectable and culturally sanctioned response to a particular event” is questionable. This changes the focus from the description of symptoms to their significance. The archetype is the occurrence of the symptoms of a depressive disorder after the loss of a loved one. In this case, the reaction is to be considered normal. One wonders whether the appearance of such symptoms after the loss of a job or prospect for the future (for instance, due to a disabling somatic illness) could not be considered normal reactions as well. This is highly relevant, as by far the majority of first depressions appear after such an important setback or crisis.
By formulating explicit criteria for different disorders, the DSM system immensely stimulated empirical research, as well as contributing greatly to a more uniform use of symptoms, disorders, and diagnoses. The reliability of psychiatric diagnoses worldwide is greatly enhanced since the introduction and use of the DSM-system. The system has also contributed much to a uniform use of terminology throughout the world. It would not be exaggerating to state that the system has completely changed daily practice and protocol in psychiatry, particularly as in the past dynamic and especially, psychoanalytical views dominated.
However, the validity of the different categories remains an open question. What exactly is a mental disorder? Do mental disorders exist in the real world, or are they but manmade patterns that are imposed on reality? Which factors, in addition to clinical relevance, determine that a certain cluster of symptoms is established as a disorder? Kleinman suggested in 1988 that psychiatric diagnoses derive from categories. These “categories are the outcomes of historical development, cultural influences, and political negotiation.” So doing, Kleinman exposed the difficult formation of the mental disorder concept, as well as the untenability of a biomedical disease concept in psychiatry.
The DSM system is not a diagnostic one, but one of classification. For the difference between the two, see my remarks in Chapter V, section 2.1. So the DSM system does not pretend to offer tools for treatment per category. It is usable for recognizing groups of different symptoms as disorders in people all over the world. This makes it clinically reproducible and usable, even though additional factors about the manifestations and specifics in the individual case are necessary in order to design a treatment plan.
The system is not suitable as a basis for important decisions in a legal context, such as establishing the necessity of involuntary commitment, criminal responsibility, eligibility for a disability pension, or the state of someone’s driving skills. These determinations involve a different dimension of reality, necessitating additional information, as clearly stated in the introduction to the DSM Manual. In daily psychiatric practice the diagnostic system is used for these matters, even though it is neither designed nor suitable for such.
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