Abstract
It is widely agreed that the DSM-IV categorical framework (and its predecessors) have a number of problems (e.g., questionable reliability in the field, questionable validity, heterogeneity, unexplained comorbidity, an unsound concept of mental disorder) that have compromised its utility in research concerning mental illness. At the root of these problems is a substantial “lack of fit” between the DSM framework and the domain of mental illness. With the publication of DSM-5, it is appropriate to ask whether the process of revision leading from DSM-IV to DSM-5 has been sufficiently responsive to the problems with DSM-IV to justify continued use of DSM categories in either basic research concerning psychopathology or more applied clinical research. In this paper, I argue that the revision process has not been responsive to these problems and that, hence, DSM-5 categories ought not to be used in research concerning mental illness. Rather, alternative approaches should be developed, and I conclude with a discussion of three such alternatives.
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Notes
- 1.
These features are, of course, not specific to the domain of mental illness, but might be found in many areas of normal human functioning as well as in chronic and complex physical diseases.
- 2.
Although there are competing conceptions of the DSM categories (viz., harmful dysfunctions, clinical prototypes), the arguments presented in the text apply equally to both. In what follows, I will formulate the issues in terms of the harmful dysfunction view (see Wakefield 1992).
- 3.
“Atheoretical” criteria do not refer to either pathology or etiology.
- 4.
“Polythetic” criteria are disjunctive and their use is supposed to reflect the idea that mental disorders can manifest themselves in various ways across individuals with the same disorder.
- 5.
At a minimum, V codes draw attention to significant aspects of the context in which a putative mental disorder arises; but perhaps more important is that such problems are essentially implicated in a person’s current mental health condition, and are a critical component in understanding what is wrong (if anything) and what is likely to help. Arguably, from the point of view of research, information picked out by V codes is required for a realistic scientific analysis of the problems and processes involved in mental illness.
- 6.
Note that, in DSM-5, this multi-axial approach has been dropped, although V-codes have been retained.
- 7.
The reasons for being suspicious of the use of DSM diagnoses in research are also very good reasons for being suspicious of their use in the clinic, although I will not pursue that line of argument here (see Poland et al. 1994; Poland 2003; Spaulding et al. 2003). However, it should not be supposed that supplementing the diagnostic categories with V-codes and Axis 4 and 5 codes is sufficient for meeting either clinical or research challenges and hence for retaining the DSM categories for use in those contexts. The argument below suggests why this is the case with respect to research.
- 8.
Many conceptions of validity have been employed in the evaluation of research in psychology and psychiatry. Roughly speaking for present purposes, validity concerns (1) the empirical or theoretical integrity of a construct establishing that it picks out what it is supposed to be picking out (i.e., construct validity) and (2) empirical or theoretical relations between a construct and other variables of interest (i.e., predictive validity and related concepts.) This approach is a general approach widely employed in psychological research. In psychiatry, it is standard to employ a notion of validity introduced by Robins and Guze (1970) that concerns the establishment of empirical relations between a diagnostic category (or syndrome) and various “validators” established in five phases of validation research (viz., clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study.) Subsequently, additional validators (e.g., response to treatment) have been included (see Kendler 1980; Andreassen 1995). This second approach is supposed to imply the construct and predictive validity of diagnostic categories. In any event, the problems with the validity of DSM categories discussed in the text can be framed in terms of either approach to understanding what validity consists in. See also Kendell and Jablensky 2003.
- 9.
This line of argument strongly suggests that, at the time of the development and publication of DSM-III (American Psychiatric Association 1980), it was quite predictable that the strategy adopted by the developers of DSM-III would fail.
- 10.
See Wiecki et al., in press for discussion of strategies and techniques for resolving causal ambiguity (e.g., of the clinical symptom of impulsivity) using the resources of computational cognitive neuroscience.
- 11.
See Fair et al. 2012 for research concerning ADHD and heterogeneity of cognitive profiles in both normal and clinical populations.
- 12.
As observed by an anonymous reviewer, there may be states that are manifestly delusional in any cultural context; but nonetheless the delusional character of any such state is constituted by presupposed epistemic norms characteristic of the local culture and variation in such local norms can lead to variation in the character and significance of the delusion.
- 13.
The idea that DSM diagnostic categories pick out brain diseases is not explicitly assumed within the DSM, whereas the idea that DSM categories pick out harmful dysfunctions is explicitly expressed. However, the idea that mental disorders (as conceived in the DSM) are medical diseases, and indeed brain diseases, is widely assumed among “biologically oriented” psychiatric clinicians and researchers.
- 14.
This point does not mean that research concerning brain processes associated with depressive symptoms is not important; rather, it is that a pathology focus on the individual can lead to disproportionate emphasis on causal processes in the brain relative to those in the environment.
- 15.
The prevalence of comorbidity of DSM diagnoses (e.g., ADHD and learning disorders) is problematic at least because the co-occurrence of multiple disorders is causally ambiguous: i.e., two conditions can co-occur because they are two independent conditions or because they share a pathogenic cascade and one is the downstream consequence of the other or because they are each consequences of some common cause or because they share overlapping diagnostic criteria, etc. Such causal ambiguity is not resolvable within the atheoretical DSM framework, compromises research and clinical practices, and may point to the necessity of radically re-conceiving the domain in terms of a framework based on causal structure and processes.
- 16.
Continuity with DSM-IV is typically deemed important because radical changes would be too disruptive to both clinical and research practice; point 3 above is an acknowledgement of this that was added to the criteria for change late in the process. Early in the DSM-5 development process (see Kupfer et al. 2002) it was recognized to some extent that radical changes may well be required to be responsive to the problems of DSM-IV, as is partially acknowledged in point 4. What seems clear is that the tensions between these acknowledgements were never effectively resolved and that more conservative pressures were dominant.
- 17.
Although not directly relevant to the present chapter concerning research utility, it should be noted that the idea that DSM categories are clinically useful is questionable. See Poland 2003 for a discussion of how diagnostic categories like “schizophrenia” function as harmful stereotypes in clinical settings.
- 18.
See Spaulding et al. 2003 for an example of how a more rigorous clinical assessment might proceed in the case of severe mental illness.
- 19.
Note that the authors of DSM-III and DSM-IV issued various cautionary comments regarding the use of DSM categories; and see Hyman 2010 for a discussion of the mistake of reifying DSM categories. In research contexts this mistake takes the form of not recognizing that DSM diagnostic groupings are artificial in character. Given the various roles that DSM diagnostic categories have played in research, their toxic impact is not mitigated by either cautionary comments or discussions of the mistake of reification.
- 20.
See Wiecki et al., in press for a review of the various strategies and tools of “computational psychiatry” and examples suggesting the promise of the approach.
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Poland, J. (2015). DSM-5 and Research Concerning Mental Illness. In: Demazeux, S., Singy, P. (eds) The DSM-5 in Perspective. History, Philosophy and Theory of the Life Sciences, vol 10. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-9765-8_2
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