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The Conceptual Evolution of DSM-5Review - The Conceptual Evolution of DSM-5
by Darrel A. Regier, William E. Narrow, Emily A. Kuhl,and David J. Kupfer (Editors)
American Psychiatric Publishing, 2010
Review by Roger K. Blashfield, Ph.D.
May 24th 2011 (Volume 15, Issue 21)

The official classification in the United States for the various types of psychopathology is known as the Diagnostic and Statistical Manual of Mental Disorders (DSM).  This system was first published in 1952, and new editions have appeared about every 10 years since that time.  The DSM-5 currently is scheduled to appear in 2013.  Across the various editions, there have been a number of changes including the names and numbers of recognized categories of mental disorders, how categories are defined, the size of the manuals, the amount of supporting information, etc.  The revolutionary edition in this series was the DSM-III which was the brainchild of an American psychiatrist named Robert Sptizer and a group of like-minded, empirically oriented psychiatrists who were determined to change diagnosis and classification.   Spitzer and his colleagues are often called neo-Kraepelinians because their guiding principles were similar to those of the early 20th century German psychiatrist named Emil Kraepelin, who like Linneaus in botanical classification, was the originator modern psychiatric classification.  What makes these editions of the DSMs interesting is the degree of controversy that they have stimulated.  The political issues associated with psychiatric classification, both within psychiatry, within the various mental health fields associated with psychiatry, and within the broader cultural context of American society, are fascinatingly complex.  The DSM-II was attacked because it included “homosexuality” as a mental disorder category.  The revolutionary DSM-III was attacked for its anti-psychoanalytic approach to psychopathology.  The DSM-III-R and the DSM-IV attracted the ire of feminists who viewed psychiatry as a male-dominated profession that was determined to pathologize normal women for their emotions and interpersonal behaviors.

The DSM-5, even prior to its publication, has also attracted controversy.  Robert Spitzer and Allen Frances (leader of the DSM-IV editions) have been sharply critical of the approach taken to the DSM-5.  Given the financial success of the DSMs (supposedly the revenue from the DSM-IV was about $6.5 million dollars – a huge source of income for the American Psychiatric Association which has slightly less than 40,000 members), the strong stands taken by various constituent groups regarding this proposed new classification should not be surprising.

The Conceptual Evolution of DSM-5, published by the American Psychiatric Association, and edited by four authors including the two psychiatrists who are organizing the DSM-5 (Kupfer and Regier), is a collection of short papers by a wide range of authors.  The intent of the book was to provide an overview of the ideas, the research, and the organizing principles that would be used while the details of the DSM-5 were being hammered out. 

The Conceptual Evolution of DSM-5 contains sixteen chapters organized under five headings:

The validity of higher-order diagnostic groupings

Dimensional approaches to classification

Assessing functional disability

Cultural and gender expression of psychopathology

Developmental, life-span issues in psychopathology

What I learned from this collection of chapters were three things.  First, just as the DSM-III was viewed as a “neo-Kraepelinian” classification, the DSM-5 can be thought of as the NIMH approach to classification.  Any future historical analysis of the DSM-5 will require an understanding of the politics and internal workings of the NIMH since one of the two leaders of the DSM-5 had previously been a leader at NIMH and since the early work on the DSM-5 changes were supported through grants coming from this agency.  The author (Hyman) of the first chapter in this edited book had served as a director of NIMH.

Second, the empirical issue that has driven the changes in the DSM-5 is the comorbidity problem.  This problem was an outgrowth from the changes associated with the revolutionary DSM-III.  The empirical issue which was the stimulus for the DSM-III was poor diagnostic reliability.  Thus, the DSM-III proposed diagnostic criteria in order to make the diagnostic process more like a cookbook.  The result was the reliability problem became less of an issue (at least in research), but what appeared instead was the “comorbidity” problem.  The comorbidy problem refers to the fact that most patients with a mental disorder meet the diagnostic criteria for multiple disorders.  The patient with one and only one mental disorder is an unusual individual.

Third, the authors of the DSM-5, like the authors of the DSM-III, are attempting to make a revolutionary change in the DSMs.  The revolution with the DSM-5 is its focus on assessment issues (see the chapters in this book on measuring functional impairment) and an emphasis on dimensional approaches to the measurement of psychopathology (see the first two subsections of the book).

To me, the disappointing aspect of this edited book is that, despite its apparent goal of focusing on a “conceptual evolution,” the chapters are largely atheoretical and ahistorical.  Generally, the authors of the chapter do not articulate the theoretical ideas that have guided their thinking nor do they attempt to articulate the philosophy of science principles that they believe should determine how classificatory decisions are to be made.  An exception was a chapter by Helzer in which he described “a bottom-up” approach to classification that is similar to the principles of operant (Skinnerian) psychology in which researchers gather large amounts of data and theory is derived upwards from this foundation of empirical facts.  The other striking feature of the chapters is that most were also ahistorical.  There were no extended analyses of what had been accomplished in earlier editions.  Now was there any comment on how the authors of these earlier systems had responded to the controversies that their work generated.  The major controversies that are surrounding the DSM-5, such as the large financial turf associated with control of this classification, the apparent research focus that seems to avoid the need of clinicians, the importance of categorical thinking in the human conceptual systems, and the coordination of the American DSM with international classification, are largely ignored in this book. 

A better introduction to the conceptual issues with the DSM is contained in an earlier work by Sadler (2005).  A well-written, terse analysis of classification from a clinical perspective was written by Kendell (1975) which, even though somewhat old now, still contains a penetrating analysis of the pros and cons associated with dimensional approaches to psychiatric classification.  An edited book by Millon and Klerman (1986) contains a wide-ranging set of ideas that represent possible alternative approaches to classifying mental disorders.  Finally, a fascinating overview of the issues associated with classification, but within the context of a different science, is Yoon’s (2007) Naming Nature.

 

References

Kendell, R.E.  (1955).  The Role of Diagnosis in Psychiatry.  London: Blackwell Scientific Publications. 

Millon, T. & Klerman, G.L. (Eds.) (1986).  Contemporary Directions in Psychopathology: Toward the DSM-IV.  New York: Guilford Press.

Sadler, J.Z. (2005).  Values and Psychiatric Diagnosis.  New York: Oxford University Press.

Yoon, C.K. (2009).  Naming Nature: The Clash between Instinct and Science.  New York: W.W. Norton and Company.

 

© 2011 Roger K. Blashfield

 

Roger K. Blashfield, PhD is a Professor Emeritus from Auburn University.  He was on the DSM-IV workgroup for the personality disorders and currently is on an ICD-11 workgroup.  He has published two books related to classification.

 


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