Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs

DSM-III, DSM-III-R, and DSM-IV dramatically changed the face of psychiatric classification. The reasonable-appearing but seminal changes of criteria-based diagnoses, a multiaxial system, an atheoretical stance, an attempt to reach greater concordance with the ICD system, and an evolving emphasis on empirical studies to support the validity of diagnoses initially evoked significant controversy. Criticisms included the loss of a psychodynamic footing, accusations of “sacrificing validity on the altar of reliability,” and apprehension about particular diagnoses being misused in forensic contexts. The process of creating revised DSMs has appeared relatively open to such input, however, and responsive to new findings. Why then do we have this effort now, expressing so many concerns about the DSM diagnostic process?

Descriptions and Prescriptions comprises 21 chapters written by diverse authors, a minority of whom are psychiatrists, deriving from a 1997 conference organized by the editor (who is also coeditor of the journal Philosophy, Psychiatry, & Psychology). Its purpose is to explore and make explicit values inherent in the DSMs: how diagnostic categories are selected or rejected, what gets counted as good evidence and what does not, what is deemed pathology and what is not. This is a logical extension of the current era’s Kuhnian recognition of the implicit roles of values in the process of science.

Several contributions offer illuminating historical perspectives. One example is Chris Mace’s description of the nosological career of “conversion hysteria.” Another is James Phillips’s contribution on the banner of “evidence-based treatment” and its associated technical knowledge, which threatens to devalue the practical knowledge instantiated in our personal neural nets—the art and craft of psychiatry. James Wakefield provides a particularly cogent critique of DSM diagnostic criteria for disorders of children and adolescents, and there are other well-written pieces, without too much overlap and without excessive philosophical jargon. Some contributions, however, seem to offer relatively little in the way of new findings, specific suggestions, or intellectual content. A chapter by a consumer basically offers a stance of general complaint without clear recommendations. Another offers the perspective of the National Alliance for the Mentally Ill on the stigmatizing influence of diagnoses and notes that DSM’s inclusion of several less severe disorders causes difficulties for parity legislation efforts. Another by an attorney chiefly discusses rules of evidence (e.g., the Frye and Daubert standards) but does not seem to aim clearly toward particular points. One chapter by a beginning psychotherapist observes that the language shift from a descriptive intake evaluation to its concluding formulation involves reduction to a merely technical account of a person and aims for reimbursable diagnoses. Michael Schwartz and Osborne Wiggins, both serious thinkers, object to “the hegemony of the DSMs” but just briefly mention their proposed alternative organizing principle of “ideal types,” adequately described only in other sources.

Do we need a book that often reminds us of what we think we already know? I believe we do. This work remains a thoughtful contribution, and even the somewhat limited chapters noted are, I think, important. Their presence exemplifies the editor’s inspired call for a democratic process, even more democratic than DSM has been thus far. After all, how else can we adequately develop a system to serve clinical and research needs that inevitably will be used for forensic, reimbursement, and other administrative needs, that will be used cross-culturally, and that will grow with time (and genetic and neuroscientific advances), yet not lose sight of the human being as addressed in the diagnostic process? What other way to address this but with the most comprehensive embrace and consideration for all these perspectives and attention to all stakeholders’ voices? How else can we aim for such an ambitious product, how can we adequately know ourselves, complicated beings “darkly wise and rudely great,” but through hovering attention simultaneously applied to all of the above?

In particular, I believe this volume has explicit value for all who serve on a DSM-V committee, as well as those with an interest in nosology or medical sociology, those with a critical role in psychiatric education, or those who simply have a philosophical bent (a non-DSM character trait).