In the space of seven short chapters, British philosopher Rachel Cooper embarks upon a critical examination of the DSM-5 released in May 2013 with exemplary clarity. This is done without resorting to "any generalised 'anti-psychiatry' critique" of a previous generation (39). Unlike her analysis a decade earlier of the revised DSM-IV, Cooper is less overtly concerned with the conceptual status of mental or psychiatric disorders. Then, in "What is Wrong with the DSM?" in the March 2004 issue of History of Psychiatry, she cast doubt on whether the Manual's categories unequivocally constitute a set of natural kinds in the way attributable to the basic entities such as chemical elements studied by the natural sciences.
Categorizing mental disorders for both practitioner and patient has remained fiercely contested. Even a cursory retrospective glance at the Enlightenment period, for example, witnessed a succession of taxonomies, each aiming to unshackle itself from the persistent grip of misleading theological and ethical, metaphysical and epistemological frameworks. These included the Nosologica Methodica (1763) of François Sauvages de Lacroix, the Träume eines Geisterschers (1766) of Immanuel Kant, and the Synopsis Nosologiae Methodicae (1769) of William Cullen soon to be succeeded by the Anthropologie in pragmatischer Hinsicht (1796/1797) of Kant, the Nosologie philosophique (1798) of Philippe Pinel, and the Inquiry into the Nature and Origin of Mental Derangement (1798) of Alexander Crichton. The same tensions, if not necessarily the same categories, recur in the work of subsequent generations, tensions Paul Ricoeur in his 1981 paper, "Psychoanalysis and Hermeneutics," depicted as "half-hermeneutical" and "half-naturalist," as simultaneously tantamount to an archaeological and a teleological enterprise. With that in mind, let us now turn to the opening chapters of Rachel Cooper to do with what she calls "controversies of process" in the production of the DSM-5 before concluding with its "issues of content" exemplified by autistic spectrum disorders.
Culturally speaking in the Anglophone world, the Manual effectively sets the bounds of mental disorder and normality in the mass media. As readers of Metapsychologywould know, the Diagnostic & Statistical Manual of Mental Disorders, revised about every decade and a half, attempts to categorize all psychiatric disorders and their diagnostic criteria encountered in the United States. Hence, especially since its third 1980 edition, the Manual has become central to clinicians and researchers alike as well as the reigning guide for public health policy, for government and private health insurers, and for the pharmaceutical industry. What Cooper is at first interested in is the lobbying by groups to influence or protect what is included in or excluded from the Manual given the funding implication or social stigma at stake. More precisely, she is less concerned with blunt opposition to classifying mental disorders under such banners as "Labels are for jars, not people" (xiv, 22) and more with whether or not people are being classified appropriately.
Accordingly, the first chapter introduces changes to the DSM-5 under the chairmanship of David Kupfer and Darrel Regier by turning to their manifesto edited with Michael First in A Research Agenda for DSM-V (2002). There, it had been hoped that a purely descriptive classification, one untrammelled by theoretical commitments, would overcome previous difficulties, thereby helping professionals operating with different (sub)disciplinary frameworks on the one hand and accommodating the identification and treatment of patients not conforming to existing diagnostic categories on the other hand. Despite the hopes for initiating a radical shift in classification by virtue of advances in the neurosciences, developmental psychology, and inter-cultural studies, the DSM-5 ended by regrouping disorders presumed to have common origins. Despite relatively "modest" changes in disorders and criteria, Cooper rightly contends that "the devil is in the details" (3). Any new diagnoses or expanded categories, she continues, alter perceptions of behavioural problems to the point where medical or pharmacological intervention becomes justified or where the source of the problem is attributed to the individual alone rather than to familial, educational, or socio-political domains. Examples of this abound, especially those affecting children and adolescents: the diagnostic retention of hyperactivity disorder or attention deficit, the introduction of disruptive mood dysregulation disorder, and the removal of the formerly distinctive Asperger's syndrome (and, one might add, the continuing neglect of Galina Sukhareva's prescient 1926 study of childhood schizoid personality disorders). The future impact of such shifts, as Cooper realises, is difficult to predict given "the economic, cultural, and bureaucratic contexts within which diagnoses are made" (12).
One potent contextual factor whenever new diagnostic conditions or boundaries are introduced is the role of the pharmaceutical industry. Not only does the American Psychiatric Association benefit from commercial advertising in its journals and sponsorship of its annual meetings, but also from grants for "education, advocacy and research" (13). Notwithstanding efforts to reduce potential conflicts of interest amongst the task force and work groups responsible for the DSM-5, Cooper's second chapter highlights a number of disquieting factors. Notable examples include, firstly, how a year before the Manual's release, 69% of its task force "reported having ties to industry" (14); secondly, how "gift relationships" and their accompanying obligations persist beyond temporary cessation of ties by members (15); and, thirdly, the continued pharmaceutical lobbying for "splitting" of categories into "subtypes," especially in the realm of depression and, most controversially, in the case of disruptive mood dysregulation amongst children (16ff.).
Chapter Three turns to other points of tension owing to several "mutually incompatible aims" affecting the Manual. These include the need to make the Manual profitable; to "protect the status of psychiatry relative to other mental health professions"; to "ensure the cooperation" of other professionals in their use of the Manual; and to "maintain compatibility" with the World Health Organization's International Statistical Classification of Diseases & Related Health Problems and its fifth chapter devoted to mental and behavioural disorders (21; cf. 57-59). No mention, however, is made by Cooper of the Organization's companion volume, International Classification of Functioning, Disability & Health, which takes account of both individual and environmental factors. In the American Psychiatric Association's attempts to counteract growing disaffection, Cooper focuses upon the recent development of web-based comments about drafts of the Manual which garnered "a huge response," yet did not "allow for the viewing of comments" (24), possibly resulting in repetitive if not redundant responses. Public consultation, she cautions, need not be solely aimed at gathering overlooked information. It can be directed at "promoting a feeling of inclusion" as well as managing if not dissolving dissent as in the case of advocating that myalgic encephalomyelitis (or chronic fatigue syndrome) be treated as a physical, not psychiatric, illness (24, 26). Cooper herself contends that greater patient involvement in future is not only to be expected, but should be welcomed. It is not merely a question of whether patient-researchers, for example, might know more than their clinicians, but also of the contrasting perspectives and questions they can bring to bear as dramatically demonstrated in the British example of troubling reactions to serotonin (28).
The next three chapters principally attend to "issues of content" and the reliability of field trials before concluding with an argument for multiple classifications. Chapter Five more specifically focuses upon the much publicised change to autistic spectrum disorders. In brief, this now enlarged category with a reduced set of symptoms subsumes both Asperger's and Rett's syndromes for example and, as Cooper notes, will have repercussions upon "the overall rates of those diagnosed with some sort of autism-related disorder" (41). The small field trials conducted before publication can prove "to be a poor predictor of changes in prevalence" (42). Indeed, the reliability of field trials of the Manual's diagnostic criteria has been questioned because of the inconsistent handling of measures of the observed proportion of agreement by clinicians and the proportion of agreement expected by sheer chance (50ff.). Rather than examining, for example, how Prader-Willi and Angelman syndromes might fare where affected children might meet the spectrum's criteria, Cooper pinpoints how David Kupfer, head of the DSM-5 task force, openly admits to the aim of reducing the numbers diagnosed and hence reducing the costs to government and insurance (45) despite the Manual's "unprecedented" note that previous diagnoses ought to be upheld (46). The other major change to the autistic spectrum category noted by Cooper in passing is the introduction in the DSM-5 of a new disorder, "social (or pragmatic) communication" (42). So, irrespective of the Manual's implication that both categorised disorders are mutually exclusive, individuals within the highly heterogeneous spectrum may or may not have a communicative disorder and vice versa. That, as Cooper observes, could find those children no longer fulfilling revised diagnostic criteria are in danger of "losing educational and therapeutic services" (44; cf. 48, n. 1).
There are at least two issues Cooper seems to have set aside in Chapter Five. First of all, the DSM-5 does not confront what might be meant by the very notion of "spectrum." For instance, does the Manual construe "spectrum" to refer to a closed, clinically diagnosed population, that is, to those who had already presented a set of more or less severe symptoms with or without co-morbidities? Or does the Manual conceive of "spectrum" as referring to an ongoing continuity of traits between the clinically diagnosed and the wider population, perhaps, one is tempted to add, to the point of including associated traits that happen not to be formally recognised by the Manual itself? Or again, does the Manual avoid conceptualising "spectrum" as a constellation of symptoms and thereby ignoring crucial similarities and differences amongst, say, syndromes manifesting autistic-like traits such as Down and Rett, Angelman and Prader-Willi, or even Joubert and Smith-Lemli-Opitz?
In the second place, there is the introduction of social (pragmatic) communication disorder in the DSM-5, which is defined as a persistent difficulty traceable from childhood onwards with verbal (and non-verbal) communication, be it spoken or written (or, presumably, signed), but not explicable by low cognitive ability. Yet the Manual omits any critical investigation of what is meant by "pragmatic." The past generation has witnessed pragmatics virtually becoming reified to the point where clinical appraisals of it, on the one hand, slide indiscriminately from "aspects" and "features," "skills" and "abilities" to "deficits" and "disorders," and, on the other hand, produce, as seen in the case of the 1987 Prutting & Kirchner protocol, a veritable hodgepodge of aspects that blur its omnibus quest for "the communicative effects of various linguistic and cognitive deficits" in clinical settings (1987, p. 105). At no point does the Manual explicitly appear to recognise the complex developmental relationships between speech accompanying action, speech detached from action, and cognitive awareness and therefore impairment, short of the dysphasia characterising the Landau-Kleffner syndrome, is not just with "communication" broadly speaking, but with perceptual and kinetic, verbal and conceptual kinds of transposition.
Although Cooper has pursued neither of these issues in Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, her dissection of the Manual's field trials, only briefly mentioned above, further demonstrates the acuity of her analysis beyond the careful attention she gives to the socio-economic contexts shaping so much of the DSM-5.
© 2014 R.A. Goodrich
R.A. Goodrich is an associate of the A.R.C. Centre for the History of Emotions (University of Melbourne) and of the European Philosophy & History of Ideas Research Group (Deakin University), co-edits the online refereed arts-practice journal, Double Dialogues, and co-ordinates with Maryrose Hall a longitudinal project investigating behavioural, cognitive, and linguistic development of higher-functioning children within the autistic spectrum and related disorders.