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Related Topics
Rethinking the DSMReview - Rethinking the DSM
A Psychological Perspective
by Larry E. Beutler and Mary L. Malik (editors)
American Psychological Association, 2002
Review by Christian Perring, Ph.D.
Aug 19th 2003 (Volume 7, Issue 34)

When psychologists have written about diagnostic classification, they have generally taken a somewhat critical stance to the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). The politics behind this are relatively simple. In the last few decades the divide in the USA between psychologists, who generally have Ph.D.s, Psy.D.s, MSWs, or other degrees in clinical psychology, and psychiatrists who have M.D.s from medical schools, seem just as entrenched as ever. Increasingly, psychologists provide talk and behavior therapy while psychiatrists write prescriptions. The average time a patient spends talking with a psychiatrist to get a refill of medication is ridiculously small -- there is barely enough time to ask whether there have been any changes in symptoms recently, whether the patient's life is dramatically worse than before, and possibly whether the patient has a method of paying for the medication or needs some free samples, and then the prescription is written and the patient is out of the office. In contrast, psychologists normally talk to patients once a week for 45-50 minutes for several sessions, sometimes for a few weeks, sometimes for a more protracted period of several months, or very occasionally for years. Psychologists tend to get a detailed picture of the patient's whole life and the complexities of their relationships with other people. When there are antagonisms between the disciplines, psychiatrists may accuse psychologists of talking for weeks and weeks without actually helping the patient, while psychologists accuse psychiatrists of using a reductionist medical model that simply sees the patient as a collection of symptoms in need of alleviation.

Of course, the two sides are not always so neatly separated. In the last twenty years, psychologists have largely come to accept that psychotropic medications can be helpful to patients, and may even help the process of psychotherapy. On the other side, there are many psychiatrists who still believe that psychotherapy is very important mode of treatment for a wide array of mental disorders, and that it is often essential to help the client gain psychological insight into his or her problems and gain a new perspective. Furthermore, the publication of Rethinking the DSM suggests that psychologists have come to realize that that since the reimbursement side of the mental health profession is so dominated by the diagnostic codes of DSM, they have to live with it and the best way to make improvements to the classification system is through giving careful constructive criticism. The book is a collection of 11 papers on a variety of approaches to the classification of mental illness, divided into three sections. The first, with just two papers, provides an introduction and background to the topic. The second, with three papers, addresses methodological considerations. The third, with the remaining six papers, proposes alternative approaches to classification. Nearly all of the authors are members of university psychology departments in the USA and the rest of the world. It is striking that unlike comparable publications of the American Psychiatric Association, this American Psychological Association publication does not even list the degrees held by the contributors to the volume, a small example of the "cultural difference" between the two professional groups.

This cultural difference extends to ways of paper writing. While these papers are scholarly and careful, they tend to be more open to a diverse collection of ideas. The authors are more liable to frame their own ideas as the expression of their own personal views rather than as scientific fact or conjecture. Arthur Houts, in his paper "Discovery, Invention, and the Expansion of the Modern Diagnostic and Statistical Manuals of Mental Disorders" starts out in his first sentence saying, "This chapter is biased and unbalanced." Authors refer to a wider range of other books, including philosophy, anthropology, social psychology, and even some literary theory, as well as the standard psychiatric literature. As a whole this is a stimulating collection of articles, although there were no papers that really stood out as major contributions to the field. Some of the papers present ideas for new approaches to classifying mental disorders which are intriguing but largely programmatic and untested, so it is hard to know if they are really viable -- this applies, for instance, to "Assessing Psychopathology: A Narrative Approach," by Oscar Goncelves et al, "Operationalized Psychodynamic Diagnostics: A New Diagnostic Approach in Psychodynamic Psychtherapy," by Wolfgang Sneider at al., and "Simplifying Diagnosis Using a Prototype-Matching Approach: Implications for the Next Edition of DSM," by Drew Western et al.

The previously mentioned paper by Houts is one of most tightly argued pieces. Houts sets out his claim that the rapid expansion in the number of DSM diagnoses with each edition (a 300% increase in four decades) is a serious problem. He suggests that the new diagnoses are not discoveries but are social inventions, and that they pose a threat to the credibility of the mental health field. Houts does an excellent job of setting out the necessary information and the different theoretical perspectives that could be useful in understanding the creation of diagnostic categories, covering both scientific methodology, sociology of science, and the analogy between physical medicine and mental health medicine (typically, psychologists tend to avoid the useful term "psychiatry"). This paper continues a running dispute that he has had with Jerome Wakefield on this topic, and here he replies to the claims that Wakefield makes in defending the expansion of DSM, and it is when he gets to these issues that he really hits his stride. Houts presents a compelling case that the expansion of diagnoses is not in fact comparable to that in physical medicine, and he concerns he spells out about the expansion need to be taken seriously.

Ann Douchette's paper on "Child and Adolescent Diagnosis: The Need for a Model-Based Approach" is interesting. She summarizes some recent thought on the classification of mental disorder in young people paying particular attention to DSM and IDEA, the Individuals with Disabilities Education Act. She points out that DSM-IV has neglects the idiosyncrasies of child and adolescent emotional disorders, and both it and IDEA ignore the importance of family and other contextual circumstances. In DSM-IV, relationship problems are relegated to Axis IV V-codes, and this tends to confirm the policies of managed care and other bureaucracies that such problems are not serious. Douchette cites evidence that in fact those problems are just as serious as other mental disorders. She further recommends that classification should use broad disorder groupings, based on a psychometric approach that includes confirmatory factor analysis (CFA) and item response theory (IRT). She explains both of these briefly, and her paper includes many references for those who are interested in more details.

One of the best known authors in this collection, John Kihlstrom, gives the final paper, "To Honor Kraepelin …: From Symptoms to Pathology in The Diagnosis of Mental Illness." He provides a useful overview of the history of theories of diagnostics and the nature of disease. Unfortunately, his conclusion is rather tame -- he points out that psychology and psychiatry should move beyond diagnosis through symptoms to discovering the underlying pathology of disorders. This is an idea that most current researchers endorse, although most also acknowledge that our understanding of mental illness does not provide us with enough certainly to do this in any of the central cases of mental disorder.

Overall, there is probably too much overlap between the different papers here, and the editors should have insisted on editing down most of the papers that wanted to include an overview of different approaches to the classification of mental illness. It might have also been helpful for authors to include more concrete examples of the problems of the current classification schemes and how it could be improved. Nevertheless, it is important to encourage more dialog among mental health professionals on the nature of diagnosis, and Rethinking the DSM should do just that.


2003 Christian Perring. All rights reserved.

Christian Perring, Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island, and editor of Metapsychology Online Review.  His main research is on philosophical issues in medicine, psychiatry and psychology.


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