Abstract
In 1980, DSM-III adopted a descriptive approach to psychiatric diagnosis, creating checklists of unwanted behaviors to define and use as required criteria when posing each of several hundred diagnoses. The objective of this novel approach was to validate psychiatry as a scientifically legitimate branch of medicine, by enabling research into hopefully homogeneous groups of patients to pinpoint the implicit hypothesized physiological causes of the disorders the patients were presumably sharing. In each subsequent revision of the DSM including the DSM-5, however, no physiological criteria of any sort are included for any diagnosis, confirming the empirical failure of this attempt to substantiate the medical model of madness. The futile endeavor to validate countless human faults and suffering as medical diseases explains most of the “scientific” conundrums and controversies surrounding the release of DSM-5, including whether to include or exclude diagnoses, where to draw boundaries for each, and why clinicians still fail to agree on which diagnosis they should apply in a given case. Despite DSM-5’s insolvency, the essentially moral project of descriptive psychiatric diagnosis has today vast socio-economic ramifications that help to preserve it.
To appear in The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel, edited by Steeves Demazeux & Patrick Singy, in series History, Philosophy and Theory of the Life Sciences, Springer. Some parts of this chapter are adapted with permission from material in Mad Science: Psychiatric Coercion, Diagnosis, and Drugs, Transaction Publisher, 2013.
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Notes
- 1.
If one counts DSM-III-R (1987) and DSM-IV-TR (2000), DSM-5 is the seventh edition.
- 2.
This is a term of art with which we disagree and discuss in detail in Kirk et al. (2013).
- 3.
As its predecessors, DSM-5 states in several places that probable or definitive biomarkers for mental disorders or illnesses are lacking. Nonetheless, it does includes as “mental disorders” a number of diagnoses—for dementias, for example—whose criteria include evidence for a specified pathophysiological condition known to cause the presenting problem. Despite psychiatry’s historical role in managing senile older adults and others with organic psychoses and with degenerative brain diseases, the presence of these diagnoses is scientifically intriguing, as not all physical conditions with spectra of presenting psychological problems (e.g., epilepsy, diabetes) are so treated in the manual. Moreover, throughout the descriptive text that follows the criteria for each diagnostic category, sub-sections titled “Diagnostic Markers” or “Risk and Prognostic Factors” are frequently included. The relevant sub-section for Obsessive-Compulsive Disorder, for example, states the following: “Familial transmission is due in part to genetic factors (e.g., a concordance rate of 0.57 for monozygotic vs. 0.22 for dizygotic twins). Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum have been most strongly implicated” (APA 2013, p. 240). Since the DSM-5, like its predecessors, lists no references, these assertions (all questionable and publicly questioned in their assumptions, determinations, and interpretations) arguably constitute pseudo-scientific adornments.
- 4.
The medical illness metaphor is a conceit in that it states as fact that which has not yet been scientifically validated, namely that the behaviors defined as symptoms of mental illnesses are caused by biological dysfunction. The assertion that mental illnesses are physical illnesses has the powerful advantage of borrowing the language and causal model of biological disease to buttress the reputation of psychiatry, while obscuring the absence of any accepted scientific evidence for that claim. The “common vocabulary” that the DSM provides is that of the assumption and statement of illness, backed by the biomedical-industrial complex. The justification that “the DSM at least provides a common vocabulary” ignores (or exploits) the power of language to conquer rhetorically what cannot be validated empirically.
- 5.
Kappa is a chance-corrected measure of reliability, that is, inter-judge agreement or consistency. Kappa coefficients may range from 0.0 to 1.0, from no agreement to perfect agreement, respectively. The developers of DSM-III were the first to use kappa as a measure of diagnostic consistency. They considered kappa scores of .70 or higher to be satisfactory or good and those around .50 or lower to be no better than fair or poor (see Kirk and Kutchins 1992).
- 6.
Frances (2012a) writes that “mental disorders are constructs, nothing more but also nothing less. Schizophrenia is certainly not a disease; but equally it is not a myth. As a construct, schizophrenia is useful for purposes of communication and helpful in prediction and decision making — even if … the term has only descriptive, and not explanatory, power.”
- 7.
- 8.
Grass roots’ groups are not always genuinely grass roots. For example, the National Alliance on Mental Illness (NAMI), the principal “grass roots” mental health organization in America with a commitment to biological views regarding mental illness, receives between 60 % and 75 % of its annual budget from drug companies (see Kirk et al. 2013, pp. 16–17).
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Kirk, S.A., Cohen, D., Gomory, T. (2015). DSM-5: The Delayed Demise of Descriptive Diagnosis. 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_4
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