Abstract
While often dubbed “the bible of contemporary psychiatry” and widely hailed as providing “a benchmark” for the profession, on closer inspection the DSM is seen to be shot through with philosophical assumptions that restrict its theoretical cogency and limit it clinical efficacy. Hence, in the interests of enhanced patient-care it is important to think critically about the DSM, with a view to maximising its diagnostic strengths while minimising its weaknesses. The critical analysis undertaken in the present paper underscores the importance of not construing the DSM as a self-contained diagnostic tool but of viewing it, rather, as an indispensable component in a more comprehensive, multidimensional diagnostic process. More specifically, the contention is that the DSM’s diagnostic limitations evoke a biopsychosocial framework of application as their necessary corrective, notwithstanding the entrenched tendency to construe these approaches as oppositional. Further, it is contended that a hermeneutically informed biopsychosocial template has particular advantages as an integrating framework.
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Notes
The fourth edition of the DSM was published in 1994 (and revised in 2000). However, since the core philosophical presuppositions discussed in this paper were introduced with the publication of DSM-III and to date continue to be its predominant philosophical influences, this diagnostic manual will be referred to here simply as “DSM”, without differentiation between DSM-III and DSM-IV unless the context necessitates a more specific reference.
These criteria are often referred to as “Feighner criteria” after the Washington University psychiatrist who initially formulated them. As delineated by Moller (2008, p. 55), the general formulation is that: “in order to make diagnosis D, the patient must present with Symptom A together with one of the symptoms from the series B, C and E, but symptoms P. and O may not be present”.
Preparations for DSM-V are currently advanced, and publication is anticipated around May 2013.
To set these presuppositions in context and to clarify both how they are interrelated and how they pervade this diagnostic model, it is important at this juncture to register their Kraepelinian origins (i.e. deriving from the groundbreaking conceptual innovations introduced by Emil Kraepelin in the late nineteenth century). Referencing the 6th (1899) edition of Kraepelin’s Psychiatrie, Mundt and Backerstrass succinctly epitomise the nature, direction, and extent of Kraepelin’s continued influence on the conceptualisation of the core DSM model as follows (2005, p. 220):
Emil Kraepelin emphasised the medical model for psychiatric diagnosis, and made this model most pervasive in the history of psychiatry. According to his concept, diagnostic classification was based on the convergence of psychopathological symptoms, aetiology, course, outcome, brain morphology, and pathophysiology. Those patients who show the same characteristics in most of these domains can be considered as belonging to one nosological category which Kraepelin considered a “natural entity”. In his view, the research process follows a continued approximation to perfect accuracy by grouping patients ever tighter according to [these] criteria.
But notwithstanding his extensive tutelary influence, Kraepelin’s doctrines were not taken over unadulterated, but rather via a nine-point neo-Kraepelinian “credo” (as Harvard psychologist Gerald Klerman termed it) informing the conceptualisation of the DSM model (Decker 2007, p. 248). Of particular relevance for what follows are the emphatic neo-Kraepelinian contentions that: “Psychiatry is a branch of medicine”; “There are discrete mental illnesses”; “The focus of psychiatric physicians should be particularly on the biological aspects of mental illness”; “There should be explicit and intentional concern with diagnosis and classification” (indeed, the neo-Kraepelinians tended toward the view that “classification is diagnosis”); and that “Diagnostic criteria should be [explicitly] codified”.
For detailed technical analyses of the extent of Kraepelin’s ongoing pervasive influence on the DSM model notwithstanding refinements instantiated in DSM-IV and for textured commentary on possible future directions, the interested reader should consult the recent special issue of the European Archives of Psychiatry and Clinical Neuroscience (Vol. 258, Supp. 2, June 2008) devoted to this topic. The succinct Editors’ Introduction (pp. 1–2) and the contribution by Hans–Jurgen Moller (pp. 48–73) are of particular interest from the perspective of present concerns.
Strong DSM advocates may contend that clinicians could not fail to attend to the experiential, or “phenomenological”, dimension of the patient’s experience. While this may be so in an informal everyday sense, the point at issue here is that given its biomedical proclivities, its categorical focus and positivistic biases, this crucial dimension is not formally part of the DSM model. On the contrary, as already noted, the DSM continues to be motivated by the neo-Kraepelinian credo that “classification is diagnosis”. Moreover, the DSM’s strong biomedical orientation lends itself to treating the experiential as an epiphenomenon, to be quickly transcended in the interests of getting on with the business of concluding a “truly scientific” diagnosis.
“Mental pathology, Kraepelin proposed, could be divided into discrete disorders, distinguishable one from the other. Each with its own symptomatology and course; each with its own specific pathophysiology. Nosology [disease classification], according to Kraepelin should be the principal guideline in exploring the biological roots of mental pathology” (van Praag 2008, p. 29).
Briefly stated, Ghaemi’s thesis is that a biopsychosocial orientation has come to stand for an injunction to include a bit of everything, thereby facilitating the formulation of vague and indiscriminate diagnoses and treatment plans; and hence needs to be replaced by a methodologically-aware “pluralism”, which would avoid the problematic eclectic groundlessness. In effect, however, Ghaemi’s thesis is undermined by his conflation of eclecticism (which he rightly criticises) with biopsychosocial thinking, and his consequent rejection of the latter. Although space limitations preclude its comprehensive defence here, my contention—reflected in the delineation of strengths and possibilities that follows--is that a biopsychosocial orientation is in fact altogether compatible with the “pluralism” that Ghaemi advocates as an antidote to both “dogmatic” (biomedical) monism and eclecticism. Hence, in my view, his arguments in favour of pluralism actually reinforce the position defended here, although this is masked by his trenchant (but unjustified) condemnation of the “biopsychosocial model”. Further, I would contend that the hermeneutic framework delineated hereunder is as much needed to give an integrating focus to Ghaemi’s pluralism as to the biopsychosocial template under elaboration here.
Accordingly, I typically use the phrase template (or cognates such as framework, approach, orientation) rather than “model” to characterise a biopsychosocial orientation to psychiatric diagnosis and treatment, both to differentiate it from existing biopsychosocial “models” and because the latter term can have (positivistic, biomedical) connotations more commensurate with the aims and aspirations of the DSM approach than with this more expansive diagnostic framework (cf. McLaren 1998).
Importantly, it should also be borne in mind that, like the DSM itself, the biopsychosocial template needs to be conceptualised as a work in progress in need of continual revision and refinement. Hence, attention needs to be focussed on its strengths and possibilities as a counterbalance to the restrictive DSM model, and not equated with some outdated, or otherwise flawed, historical formulation. Accordingly, the aim here is to highlight some interrelated diagnostic possibilities inherent in this approach as a needed corrective for the DSM’s diagnostic limitations, and to indicate how a hermeneutic underpinning can help give it the requisite theoretical grounding to inure it against charges of groundlessness and eclecticism.
Cognisant that readers may not already be familiar with core tenets of hermeneutic philosophy, deriving from the work of theorists such as Dilthey, Heidegger, and especially Hans-Georg Gadamer, in what follows I have sought to elucidate the core biopsychosocial implications of a hermeneutic orientation in a way that does not presuppose prior acquaintance. But readers who would like to enhance their understanding of the philosophical background may wish to consult, e.g. Alcoff 1996: chs 1 & 2; Grondin 1994: chs VI & VII; Healy 2005: ch. 2.
In a recent contribution, Tim Thornton has challenged the tenability of the Windelband’s idiographic/nomothetic distinction, and hence the tenability of idiographic understanding as an integral component of comprehensive psychiatric diagnosis (Thornton 2008). While Thornton’s analysis clearly establishes that the idiographic and the nomothetic should not be construed as mutually exclusive and that it is indeed difficult to delimit clearly the boundaries between the two, I would nonetheless contend that, as the World Psychiatric Association enjoins, the distinction can, and should, be used to differentiate in practice between a preoccupation with categorical diagnosis and attention to the particularities of the individual case, and to underscore the point that an adequate diagnosis requires both. Accordingly, it would not do to dispense with this distinction notwithstanding its inevitably fuzzy boundaries.
See further Phillips (2004) for elaboration and defence of its ongoing, albeit evolving, significance in the diagnostic context.
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My thanks are due to the anonymous reviewers of my original manuscript. The paper has benefited significantly from revisions made in response to their comments.
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Healy, P. DSM diagnosis and beyond: on the need for a hermeneutically-informed biopsychosocial framework. Med Health Care and Philos 14, 163–175 (2011). https://doi.org/10.1007/s11019-010-9284-x
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DOI: https://doi.org/10.1007/s11019-010-9284-x