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)

References

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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One thought on “Controversies Surrounding Classification

  1. Constance Beranek

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