Diagnosis and the DSM

A Critical Review

S. Vanheule

• Publisher: Palgrave Pivot
• Year: 2014
• ISBN:
  9781137404688
• Topic: Medicine
• Subtopic: Nursing

This book critically evaluates the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Through analysis of the history of psychiatric diagnosis and of the handbook itself, it argues that the DSM-5 has a narrow biomedical approach to mental disorders, and proposes a new contextualizing model of mental health symptoms.

1

Dynamics of Decision-Making in the DSM: The Issue of Reliability

Abstract: In this chapter, Stijn Vanheule examines the reliability of the DSM-5 and of previous versions of the handbook. In the early days of psychiatry, diagnosis started from elaborate prototypical descriptions of diverse types of psychopathology. The author discusses how and why these were replaced by classification systems such as the DSM-5. This rather sudden shift in the method of diagnosis is discussed in terms of the fundaments of psychiatric practice during the 1960s and 1970s. During these years, psychiatry was in crisis: several academic researchers demonstrated that diagnoses were unreliable, critical scholars pointed to weak points in the overall ethos of psychiatry, and societal changes challenged the actual practice of psychiatry itself. A group of so-called neo-Kraepelinian psychiatrists responded to this malaise by defining psychiatry as a strictly medical discipline, thus, switching to a criteria-based method of diagnosis. However, Vanheule demonstrates that with the DSM-5 psychiatric diagnosis is no more statistically reliable than it was 40 years ago. The main thing to have changed over the years is the standard upon which statistical reliability is evaluated. This change conveniently supports the popular, but false, conclusion that the DSM-5 bought psychiatric diagnosis into a more reliable status than ever before. Moreover, the key problems that critical researchers had been addressing in the 1970s remain unresolved.

Vanheule, Stijn. Diagnosis and the DSM: A Critical Review. Basingstoke: Palgrave Macmillan. DOI: 10.1057/9781137404688.0005.

Publications on diagnosis since the DSM-III often mention the heroic effort made by many in terms of improving its reliability in psychiatry. This is illustrated in the DSM-5 (p. 5), where it states that the “DSM has been the cornerstone of substantial progress in reliability.” Indeed, while many proponents of the DSM admit that its validity still poses an unresolved problem, most seem to believe that the manual facilitates a relatively reliable assessment of human suffering. Underlying this line of reasoning is the idea that in the pre-DSM epoch a certain Babylonian confusion of tongues posed problems for psychiatry: different theories existed next to one another and the concepts used to refer to different disorders were not properly operationally defined, allowing diagnosticians’ personal interpretations to strongly guide their diagnostic assessments. With the use of descriptive criteria since DSM-III, all of this changed: finally a sufficiently unambiguous language was found to allow a more rigorous evaluation of observable behaviors. However, the commonly accepted idea of “substantial progress in reliability” is not a proven fact, but an assumption that deserves closer examination.

The issue of reliability is complex and cannot be disconnected from the question of how one thinks of diagnosis as such. In the early days of psychiatric thinking, diagnosis started from prototypes: handbooks described different forms of psychopathology, which were documented with an array of clinical illustrations. Clinicians made use of these prototypical descriptions in assessing and describing the extent to which a given patient’s complaints resembled those depicted in the literature, usually ending with categorical assertions on the kind of pathology a patient was suffering from. In this chapter I argue that this prototype-based method of diagnosis lost momentum under the pressure of non-clinical concerns, culminating in a singular focus on classification. The DSM-I (1952) and II (1968) illustrate what remains left of diagnosis when classification is its main target. Below I argue that in the 1970s the issue of the reliability of diagnosis became a high priority. During those days, psychiatry was in crisis due to (at least) three important influences: empirical studies began to demonstrate the unreliability of psychiatric decision-making, critical scholars questioned the ethos of psychiatry, and societal changes facilitated a shift toward quantifying mental health policies. The DSM-III (1980) thrived on this crisis and promised a new era of scientific stringency. Prototype-based diagnosis was discredited, while criterion-based diagnosis along the principles of biomedical thinking was hyped. On this point, it is often assumed that since the 1980s psychiatric diagnosis made great progress. I contend that the statistical reliability of the DSM is seriously overestimated. In 1997 H. Kutchins and S.A. Kirk made such a claim, but the field trials conducted for the DSM-5 in particular illustrate that the “good news parade” on the reliability of the DSM hid its weaknesses for decades. Nevertheless, let us start where it all began and first discuss the shift from prototype-based to criterion-based diagnosis.

From prototype to checklist: a brief history

The checklist-based approach to diagnosis that can be found in the DSM-5 is relatively new to the discipline of psychiatry. Before the DSM-III, psychiatric diagnosis usually started from prototypes. At that time, psychiatric handbooks did not contain lists of items, but “clinical pictures”: narrative descriptions of different forms of psychopathology. Indeed, the prototypical approach is as old as psychiatry itself and can already be found in the work of the alienist Philippe Pinel. In his book A Treatise on Insanity, Pinel (1806) not only reviews key principles of his new discipline, including the moral and medical treatment of insanity, but also provides a study of different “species” of “mental derangement” (Pigeaud, 2001). Guided by Immanuel Kant’s (1764) suggestion that the diagnostic notions of general medicine might be applied to insanity, and inspired by Thomas Sydenham’s (1624–1689) suggestion that diseases should be studied with the method that botanists use in their study of plants, Pinel supposed that kinds of insanity could be discerned. Hence his belief in the project of collecting a nosology of disorders.

In Pinel’s view, the insane is subject to all kinds of passions. By observing and listening to patients, writing up their history, and treating them in institutions, he aimed to grasp how passions play a role in different conditions (Pigeaud, 2001). Along this way he made distinctions between curable and incurable patients, and between kinds of derangement “depending upon diversities of temperament, habits, intellectual ability, the faculties principally affected, and other causes” (D.D. Davis in: Pinel, 1806, p. ii). More specifically, Pinel discerned five forms of mental derangement: melancholia, mania without delirium, mania with delirium, dementia, and idiotism. He details these so-called forms of derangement qua the symptoms patients reported as well as clinically observable characteristics. Each specific condition he discerns is marked by distinctive modes of behaving and relating, which he illustrates by means of clinical cases from the Bicêtre Hospital in Paris, as well as historical cases drawn from the literature. Moreover, Pinel aimed to grasp broader patterns underlying specific conditions, such as the typical course and prognosis of a given condition. Obviously Pinel’s approach to mental illness focused on describing the original form, or basic type, of the five disorders he discerned; hence the idea that he engendered a prototypical approach to diagnosis.

After Pinel, the prototypical approach long dominated the field of psychiatry. In handbooks outlining different mental illnesses, attention was often paid to the patient’s present mental state, patterns at the level of etiology and illness history, and typical prognosis and outcomes. Clinical vignettes of particular patients whose problems fitted in very well with the overall clinical picture were included. Some authors, like Eugen Bleuler (1934), who generally followed an inductive approach to the classification of disorders (Moskowitz & Heim, 2011), strongly emphasized the psychological mechanisms connected to specific conditions, like disturbances of association in schizophrenia. Others, like Emil Kraepelin (1921), who followed a more deductive approach, started from biological conjectures (Weber & Engstrom, 1997).

The main difference between such a prototype-based approach and the checklist method of the DSM is that diagnosis qua prototypes focuses on sets of characteristics. Particular behaviors and complaints are not evaluated separately, but examined in terms of patterns that make up a person’s functioning. Moreover, prototypical diagnosis usually starts from demonstrative cases and clinical vignettes, based on which the clinician evaluates whether a given person’s problems match those described in the literature. DSM diagnosis, by contrast, focuses on individual symptoms and signs, leaving aside the question as to how these may relate to one another along an underlying structure. Consequently, the DSM seems to assume that diagnostic criteria are independent of one another and are therefore additive in nature. The DSM’s additive view on diagnostic criteria is particularly reflected in the DSM-5’s severity assessment. Whereas previous versions of the DSM held on to a strict categorical approach, assuming that patients either have a diagnosis or not, the DSM-5 suggests that some disorders manifest in various degrees. This is illustrated in the DSM-5’s (pp. 490–491) category “alcohol use disorder”: the more criteria¹ a person meets, the more severe the condition is thought to be. Such an approach might seem sensible, yet what it leaves out of consideration is the qualitative weight certain characteristics might have: individuals with few symptoms might nevertheless suffer deeply from their condition. Given that mental disorders are defined as disturbances that are associated with “distress or disability” in the DSM-5 (p. 20), the qualitative aspect of subjective suffering in relation to mental symptoms should not be neglected.

The first two editions of the DSM (DSM-I and II) also provided prototypical descriptions of mental disorders, but these descriptions were elaborated very poorly. For example, in the DSM-II (p. 33) schizophrenia is characterized with a paragraph of only a 128 words, in which no reference to clinical case material is made. Likewise, subtypes of schizophrenia are described with very brief explanations. For example, the specific description of the hebephrenic type of schizophrenia offers a mere 35 additional words.² It mentions clinical characteristics like “disorganized thinking” or “silly and regressive behavior and mannerisms,” but doesn’t document or operationalize how these typically manifest in clinical practice. References to other authors who might have discussed such characteristics in previous work are also lacking. Compared to the detailed clinical analyses in classic handbooks like that of Bleuler (1934), who devoted 72 pages to his discussion of schizophrenias, the description of specific psychiatric conditions in the early versions of the DSM is extremely concise, and in fact more stereotypical than prototypical in nature.

One reason why the first versions of the DSM were elaborated so poorly is that initially American psychiatrists didn’t believe in the relevance of elaborating mere classificatory diagnostic systems (Strand, 2011). On the one hand, they had a holistic mental health concept, and assumed that mental illnesses “were precipitated by a combination of psychological and environmental etiological factors that were mediated by the constitution or predisposition of the individual” (Grob, 1991, p. 422). On the other hand, they conceived illness in individual terms, which made them focus on the patient rather than on the illness qua abstract category (Grob, 1991). If categorical classification was only of marginal interest to US psychiatrists in the first part of the twentieth century, then why did the American Psychiatric Association decide to publish a handbook like the DSM? The answer to this question cannot be found in the field of clinical psychiatry, but in the work of epidemiologists and statisticians, who aimed to quantify mental distress. In order to make population overviews of different psychiatric conditions they needed straightforward, clearly delineated disorder categories that could be assessed relatively simply.

Serious interest in psychiatric statistics emerged in the mid-nineteenth century, and as large-scale census studies took off in the early twentieth century, the need to develop standardized classification schemes was placed high on the agenda. In 1918 the American Medico-Psychological Association and the US National Committee for Mental Hygiene published the first Statistical Manual for the Use of Institutions for the Insane. This manual counts 37 pages and provides a basis for quantitative data collection. It contains sample forms for the administration of patients as well as brief narrative descriptions of 22 mental diseases, spread across 16 pages. Notably, these descriptions are brief, amounting to less than a page. They mainly consist of summaries and descriptions of symptoms and differential diagnostic remarks. Clinical psychiatrists criticized the manual, yet “Despite such criticisms, the Statistical Manual became the definitive nosology of the interwar years and went through no fewer than ten editions between 1918 and 1942” (Grob, 1991, p. 426). A growing desire to develop a standard nomenclature for psychiatry motivated these revisions. At the side of clinical psychiatry, an impetus to elaborate such classification was found in the work of Emil Kraepelin. While describing and delineating illness entities was a major objective for him, his nosological descriptive approach nevertheless remained strongly narrative in nature.

World War II dramatically changed the overall view of mental disturbance. During these years, severe distress was observed in substantial numbers of soldiers and veterans. Psychoanalytic therapy outside traditional clinics proved to be highly successful in treating these young men, recognizing the link between their distress and the extreme environmental stressors they had been living through (Grob, 1991). However, existing classification schemas, like the Statistical Manual for the Use of Institutions for the Insane (which was strongly oriented toward residential psychiatry), were of little use in this context: “Only 10% of the total cases seen [by military psychiatrists] fell into any of the categories ordinarily seen in public mental hospitals” (DSM-I, p. vi). Since neurotic problems and trauma-related psychopathology were not represented in the manual, the US Army and Navy took to developing their own classifications to get hold of the magnitude of mental disorders among soldiers and veterans (Strand, 2011). Inspired by both this new classification system and the Statistical Manual for the Use of Institutions for the Insane, the American Psychiatric Association made it their business to develop its own statistical manual: the DSM-I was published in 1952.

The development of the DSM was obviously not solely motivated by clinical dilemmas, but by administrative concerns: bureaucrats and social scientists alike wanted to obtain statistics about mental health problems. The net effect of adopting such classificatory systems was that the concept “diagnosis” was narrowed down quite dramatically. If we look to the etymology of the concept – “diagnosis” stems from the Greek verb “diagignoskein,” which means “to discern” or “to distinguish,” as well as “to know thoroughly” (Harper, 2011) – we can conclude that the DSM was, and is, not so much interested in developing thorough knowledge about an individual’s mental health conditions, like traditional clinical psychiatrists were. From the outset, it simply focused on distinguishing between different disorders. Indeed, from its inception the DSM largely equated diagnosis with classification, leaving aside the elaborate narrative description of a patient’s global functioning. This is a reduction that remains neglected. This reduction is productive if one wants to quantify human problems, as it opens the possibility of statistical computation. However, this leaves us with the very serious question as to whether such a leaning toward categorization facilitates an accurate characterization of an individual’s mental suffering.

Indeed, as I further explain in Chapter 2, it could be argued that from its inception the DSM approached psychopathology in a naturalistic way, thus neglecting the subjective experience of psychopathology and above all its contextual embedment. Eventually, the DSM-I contained 106 disorders, a notable increase from the 22 disorders outlined in the 1918 Statistical Manual for the...

Table of contents

• Cover
• Title
• 1  Dynamics of Decision-Making in the DSM: The Issue of Reliability
• 2  Context and Diagnosis in the DSM: The Issue of Validity
• Bibliography
• Index