Daily Archives: August 18, 2010

Controversies Surrounding Classification

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The history and evolution of the Diagnostic and Statistical Manual of Mental Disorders (DSM) has taken many twists and turns in its 58 year history.  Its recent ascension to preeminence, as the multi-disciplinary diagnostic tool of choice, has brought it under no small amount of scrutiny.  It could be argued that one reason for that ascension is that its contributors, including Dr. Robert L. Spitzer, have gone to great lengths to make it as atheoretical as possible. Atheoretical, defined as “not based on or concerned with theory.”  (http://www.merriam-webster.com/)  Without, the proposition that our current diagnostic “bible” is atheoretical is theme that is under a great deal of scrutiny, and can certainly be disputed from a number of different perspectives.

Before we delve into the DSM itself, let us consider the title.  It is clear that ‘mental disorder’ is a technical term, because people do not normally use it in nontechnical, everyday social interactions. It is a term coined by scientists to serve a certain function in science. So the question is whether specialists use it to express an ordinary or a technical concept; and, if the latter is the case, whether that concept is theory laden. But these are quite difficult questions, for specialists happen to disagree on what concept the technical term ‘mental disorder’ should express. (Gaete, 2008)  Thus, it could be argued that the selection of the term ‘mental disorder’, by nature of its origin as a technical term, gives rise to an underlying theoretical basis that gives the meaning the definition; thereby making the theoretical neutrality of the DSM impossible.  Hence, there is considerable discontent about what constitutes a ‘mental disorder,’ and that definition is essentially determined is made by a community who is not atheoretical by nature.

Nonetheless, an atheoretical attempt was made.  With the 1980 revision of the DSM-III, Spitzer and associates acknowledged sensitivity to the division between psychoanalytic and biological explanations of mental disorders.  Consequently, the determination was made that the DSM-III would be theory neutral in order for the classification to be more accessible to all mental health professionals.  (Blaney & Millon, 2009, p. 44)

There is sentiment, however, that the lack of a theoretical foundation stymies the progress of all the disciplines that employ the DSM-III and its predecessors.  If all of the principal clinical syndromes or personality disorders could be logically derived from a systematic theoretical foundation, this would greatly facilitate an understanding of psychopathology, organize this knowledge in an orderly and consistent fashion, and connect the data it provides to other realms of psychological theory and research, where they could then be subjected to empirical verification or falsification.  (Millon, 2000, para. 1)  The real question remains, if we choose a framework, which framework should we choose?

Some would suggest that we not possibly “carve nature at the joints,” as Millon suggests, if we continue to delude ourselves with a top-down approach to taxonomy.  Essentialist top-down ‘expert-driven’ approaches to taxonomy were rejected in the biological sciences in the 18th and 19th centuries.  They are flawed because they are based on the unsupportable assumption that it is possible, a priori, to know the true essence of a category.  We cannot develop a progressive scientifically based nosology shaped by a single expert-driven conception of psychiatric illness no matter how wise its advocate.  (Kendler, 2009)

Instead, Kendler would suggest we move toward a broader reaching, empirical, bottom-up nosology.  If our current methods for validating psychiatric disorders, including description, genetics, imaging, treatment response and follow-up studies, reflect aspects of an objective truth out there in the world and we want our nosology to describe those truths with increasing accuracy, the only way to achieve this is to assure ourselves that each periodic revision of our manuals contains improvements on its predecessor. That is, changes are only made on the basis of convincing evidence that, using an agreed upon set of validators, the new diagnostic criteria improve upon the performance of their predecessor. (Kendler, 2009)

In closing, we should consider carefully our changes to the upcoming revision of the DSM.  We should be conscious of the “top-down” nosological framework of classification and make rational attempts to challenge those top-down assumptions in our daily clinical experiences.  And finally, we should consider the ramifications of the clinical definitions and concepts that we use to convey the details of our findings.  Perhaps, after this discussion, we can conclude that Dr. Carole Patrick was right… there are no value free definitions.  (Patrick)


Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Gaete, A. (2008, Dec). The concept of mental disorder: A Proposal. Philosophy, Psychiatry & Psychology : PPP, 15(4), 327-340. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1759881121&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Kendler, K. S. (2009, Dec). An historical framework for psychiatric nosology.  Psychological Medicine, 39(12), 1935-1942. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1939354861&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Millon, T. (2000, Spring). Reflections on the future of DSM axis II.  Journal of Personality Disorders, 14(1), 30-42. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=52013136&sid=2&Fmt=4&clientId=4683&RQT=309&VName=PQD

Patrick, C. (Producer). (n.d.). Defining abnormality video [Webcast]. Available from http://idcontent.bellevue.edu/content/CAS/HS/513/hs513abnormality.html.

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Roles of Cross Cultural Influences in Diagnosis

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Before we can begin exploring deviations from the norm as it relates to a specific culture, it is extremely important that we define exactly what is meant by the word culture.  Culture is defined as the customary beliefs, social forms, and material traits of a racial, religious, or social group.  It could also be defined as the set of shared attitudes, values, goals, and practices that characterizes an institution or organization. (culture, 2010)

As with any definition, it comes with limitations.    Given the changing nature of our social world and given the efforts of individuals to adapt to such changes, culture can best be viewed as an ongoing process, a system or set of systems in flux. (Lopez & Guarnaccia, 2000, p. 574)  Constant change is the rule with and within any given subset or group of people.  Any generalization regarding a population should come with a specific guideline as to whom it would apply, and more specifically, over what period of time the cultural generalization encompasses.   Attempts to freeze culture into a set of generalized value orientations or behaviors will continually misrepresent what culture is. (Lopez & Guarnaccia, 2000, p. 574)  While the representation may prove valid for a period of time, it is inevitable that the research will date itself; thereby propagating the perpetual need for new and innovative research.

A related limitation of the values-based definition of culture is that it depicts people as recipients of culture from a generalized “society” with little recognition of the individual’s role in negotiating their cultural worlds.  A viable definition of culture acknowledges the agency of individuals in establishing their social worlds. (Lopez & Guarnaccia, 2000, p. 574)  Simply because I am a white male from Omaha doesn’t necessarily mean that I have assumed all the traits that could be used to label or otherwise describe that general population.  Exceptions are abundant in every generalization about a specific populace.

An important component of this perspective is the examination of intra-cultural diversity.  In particular, social class, poverty, and gender continue to affect different levels of mental health both within and across cultural groups. (Lopez & Guarnaccia, 2000, p. 575)  In order to be truly inclusive of all the various aspects a culture has to offer, we would have to adopt a multi-layered approach to our cultural studies.  We all wear many hats, and it is a disservice to not examine all of them.  Similarly, it is unfair to assume that those intra-cultural differences affect different cultural populations the same.

Culture is linked to the way emotions, mental distress, social problems, and physical illness are perceived, experienced, and expressed.  Beliefs about what constitutes illness and what can be done about it vary considerably across cultures.  (Bhui & Dinos, 2008, p. 411)  We have established that in some cases a diagnosis has the potential to become a self-fulfilling prophecy.  Even a correct diagnosis may have a negative impact on a specific client.  The cultural connotations associated with a specific diagnosis can play a role in the effect it has on your individual client.  Before we diagnose, need to consider the socio-cultural context of the illness.  For example, a mental health diagnosis may have real implications for a member of the US Armed Forces.

As immigration into the United States continues to accelerate, we must ready ourselves for the influx of clients from the underdeveloped, or the developing world.  Mental health diagnostic constructs and subsequent treatment practices designed in developed countries are often used in the provision of care in the developing world and in care practices for ethnic minorities, asylum seekers, and refugees.  However, there are concerns about the limitations of using mono-cultural outcome measures in these culturally diverse contexts. (Bhui & Dinos, 2008, p. 411)  Our interview process is currently dependant on interviewing and subsequently interpreting the responses from our clients.  Given the complexities of our global community, it is suitably difficult to make underlying cultural assumptions.

In closing, while there are definitive benefits to the standardization of diagnosis techniques, we need to understand and appreciate that those standard one size fits all solutions may not always been the most appropriate way to proceed with accessing the mental state of a culturally diverse client.

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Bhui, K., & Dinos, S. (2008, Dec). Health beliefs and culture: Essential considerations for outcome measurement. Disease Management & Health Outcomes, 16(6), 411-419. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=36400847&site=ehost-live

Lopez, S. R., & Guarnaccia, P. J. (2000). Cultural psychopathology: Uncovering the social world of mental illness. Annual Review of Psychology, 51(1), 571-598. Retrieved from http://web.ebscohost.com.ezproxy.bellevue.edu/ehost/pdf?vid=6&hid=113&sid=f275d2f9-b3c8-458b-9968-29981a5cf4c1@sessionmgr114

culture. (2010). In Merriam-Webster Online Dictionary.  Retrieved March 16, 2010, from http://www.merriam-webster.com/dictionary/culture