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Should social pragmatic communication disorder be included in DSM-5? On uncertainties, pragmatic considerations, and the psychiatric kind debate

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Abstract 

In this paper, we want to take a critical stance towards Tsou’s recent proposal that a neuro-oriented version of the homeostatic property cluster kind model (MPCK) should be an ideal for the DSM. Our strategy will be to discuss the creation of the Social Pragmatic Communication Disorder (SPCD) in DSM-5 to show the limits of MPCK as an ideal for the next DSM deliberations over a set of diagnoses revisions. We argue that an ideal model for the DSM should address the issues of deep uncertainties and pragmatic considerations to be useful in this context.

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Notes

  1. It should be noted that there are convincing critiques of the idea that autism spectrum is a disorder (see for instance Fenton and Krahn (2007) and Chapman (2021)). This is why in this paper, when possible, we will distance ourselves from the pathologizing view of autism promoted by the DSM. When analyzing the conception of autism presented in the DSM we will stick to its language and conceptualization for the sake of clarity, but we do not endorse this view.

  2. For Tsou, this is not to exclude the influence of social and cultural factors in the classification of mental disorders. While social and cultural mechanisms can explain the different expressions of mental disorders, biological mechanisms explain the presence of their core features (e.g., psychosis, depressed mood). Moreover, Tsou acknowledges that for some conditions to count as mental disorders in the DSM, they need to be associated with harmful consequences. However, this would not negate the fact that the DSM should classify mental disorders in relation to their neurobiological causal mechanisms. Only categories that are sustained by neurobiological mechanisms that cause harm would count as real mental disorders.

  3. Tsou’s account acknowledges the role of pragmatic considerations so long as they target causally distinctive biological kinds (Tsou 2022).

  4. This change was motivated mainly by the apparent lack of clinical utility of Rett syndrome as a manifestation of autism (see e.g., Towbin 2005; Walker et al., 2004). The conceptualization of autism as a spectrum was seen as the best solution to overcome issues regarding the different manifestations of autism (see e.g., Volkmar 2009).

  5. For more discussion on some of these views, see Amoretti, Lalumera and Serpico 2021

  6. It should be noted that according to a more recent study (Saul et al., 2021), it seems that only a very small percentage of children would have “pure” social communication difficulties only (below 1%). In the clinics, these profiles are not isolated, and usually come with language difficulties or autistic traits. We could therefore view SPCD as a crossover between these two diagnoses rather than a discrete entity, which would give credence to positions B and C described above. The position that social communication difficulties are a transdiagnostic symptom (D) does not consider the context of the prevalence of social difficulties, which appear to be even more pronounced in children with language impairments or in the autism spectrum than in the children population with emotional regulation or behavioural difficulties. However, more research is still needed.

  7. An institutional aspect to consider here is that even if one of the goals of the DSM-5 revision process was to ground changes on systematic evidence reviews, there was no strong requirement for the Work Groups to do so. As pointed out by Kendler and Solomon (2016), two main problems can be attributed to the SRC. First, it was created in 2009, after the Work Groups have begun to work on change proposals. Second, the SRC didn’t have the resources needed to establish an effective scientific literature review (see also Kendler 2013). Widiger and Crego (2015, see also Widiger et al., 2015) have provided evidence that Work Groups were not required to follow the Guidelines, making it a purely advisory document.

  8. We thank an anonymous referee for suggesting this additional example.

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Acknowledgements

We wish to thank Peter Zachar, Elisabetta Lalumera, Sarah Arnaud, Karine Larose and Martin St-André for helpful comments with previous versions of this paper.

Funding

This study was funded by Fonds de Recherche du Québec – Société et Culture – Postdoctoral fellowship.

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Authors and Affiliations

  1. Canada Research Chair On Epistemic Injustice and Agency (CRC-IAE), Postdoctoral Research Fellow, Center for Research in Ethics (CRE), C.P.6128,Succ. Centre-Ville, QC, H3C 3J7, Montreal, Canada

    Anne-Marie Gagné-Julien

  2. Centre Hospitalier Universitaire Sainte-Justine (CHUSJ), 3175 Chemin de La Côte-Sainte-Catherine, Montréal, Québec, H3T 1C5, Canada

    Andréanne Bérubé

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Both authors had the idea for the paper, literature search was performed by both authors (Anne-Marie Gagné-Julien focused on the philosophical literature and Andréanne Bérubé focused on the scientific literature. Both authors performed the analysis, and Anne-Marie Gagné-Julien critically revised the work.

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Gagné-Julien, AM., Bérubé, A. Should social pragmatic communication disorder be included in DSM-5? On uncertainties, pragmatic considerations, and the psychiatric kind debate. Euro Jnl Phil Sci 13, 29 (2023). https://doi.org/10.1007/s13194-023-00535-8

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