The current diagnostic manuals

Derek Bolton

in What is Mental Disorder?

Published on behalf of Oxford University Press

Published in print February 2008 | ISBN: 9780198565925
Published online February 2013 | e-ISBN: 9780191754401 | DOI:

Series: International Perspectives in Philosophy & Psychiatry

The current diagnostic manuals

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As outlined in the Introduction, the two main questions to be addressed in this essay are first, are the norms of psychological function medical, or really social? and second, what is the validity of the distinction between mental disorder and normality, and in particular is there meaning, after all, in mental disorder? This first chapter takes a preliminary look at how these issues play out in the psychiatric diagnostic manuals, the ICD and the DSM.

The first section of this chapter briefly introduces the psychiatric diagnostic manuals to the reader unfamiliar with them, and illustrations of DSM-IV diagnostic criteria for several disorders are quoted in an Appendix to the chapter.

The second section of this chapter distinguishes three projects in the psychiatric diagnostic manuals: description of mental states and behaviours, regarded as symptoms, classification of symptoms into syndromes, and the diagnosis of a mental disorder. To increase the reliability of diagnosis, agreement between clinicians and researchers on what a particular condition is, and what counts as it being present or absent, the description of symptoms has been made as observational as possible. This methodology was recommended in the 1950s by the philosopher of science Carl Hempel, who worked in the empiricist tradition. It is remarked that while the description of symptoms may be made increasingly observational, they often still contain reference to abnormal psychological and behavioural functioning. Regarding diagnosis, it was noted that in general medicine diagnosis often specifies a cause of the symptoms or syndrome, but this has generally been dropped as a requirement for diagnosis of the mental disorders, partly because usually the cause is unknown, and partly because what is increasingly known is that causes of psychiatric conditions are likely to be complex: diverse and multifactorial. Apart from presence of a symptom syndrome, diagnosis of mental disorder is often taken to require significant distress or impairment. The diagnostic manuals also give explicit definitions of mental disorder, according to which its primary feature is association with distress, disability, or risk of adverse outcomes. It is further stated in the definitions that to count as a mental disorder a harmful condition has to involve a personal dysfunction, not to be just a matter of deviation from social norms. Further, in the lengthier DSM definition, it is stated that to count as a mental disorder a harmful condition must not be merely an expectable and culturally sanctioned response to a particular event, such as a major loss. In these ways mental disorder is distinguished from social deviance, on the one hand, and from normal reactions to life's adversities, on the other.

A major outstanding issue is the topic of section 1.3. While the description of symptoms may be made increasingly observational, they often still contain reference to abnormal psychological and behavioural functioning. Given that the phenomena being described are meant to be symptoms of disorders, this limitation to the aim of using purely descriptive, observational language is not surprising. Reference to abnormal functioning is of two main types: rupture of meaningful connections, and deviance from the level of functioning of some reference group. Both of these are problematic in various ways. Another kind of problem arises in those diagnostic criteria where there is no or no explicit reference to abnormal functioning; in these cases it may be that normal functioning is being included, e.g. normal reactions to life's adversities. In the lack of explicit attention to the norms being invoked in diagnosis, there remains the problem whether they might after all be social. Some of the diagnostic criteria sets do seem to invoke social norms – even if they are also medical norms. An important sign of the role of social factors is in the technical expression ‘clinically significant’ as applied to the conditions of interest, which turns out to refer to the fact that these are the kinds of conditions people have brought to the clinic, and thought by patient and physician to be in need of treatment. It is noted, finally, that the application of social norms and values within a group in which they are shared will typically exhibit agreement and reliability, thus mimicking simple observation of facts.

The fourth section considers another, related problem, the tension between reliability and validity of diagnosis. To the extent that diagnostic criteria are theory-free, can they really capture the difference between disorder and normality? Taking for granted that there is a difference, it seems plausible to suppose that diagnosis specifically of a disorder may have to involve theoretical assumptions. Some possible theories as to what mental disorder is are roughly characterized in this section, pending detailed consideration through the essay. They run in terms of deficit of meaning, lesions, subnormal functioning, and not functioning as designed in evolution. None of these are easy to detect by clinical observation, and non-disorder variants may be incorrectly diagnosed. In this way the project of achieving reliability of diagnosis of disorder seems to have been at the expense of validity. This tension is not easily resolved; options involve either temporary or permanent abandonment of the concept mental disorder for characterizing conditions currently in the psychiatric manuals.

In any case, moving on to the fifth section, problems with validity of the diagnosis of mental disorder were already identified in the 1960s critiques of psychiatry; they predate the drive for reliability, which only serves to exacerbate the problems, or to make them more transparent. Over and above the already major problem of reliability and validity of diagnosis of mental disorder there is the radical possibility that there may be no fully coherent, stable theory of mental disorder that would distinguish between when the mind is working properly, in order, and when it is failing to function properly, in disorder.

In the sixth section of the chapter the strengths of the psychiatric manuals are disentangled from their problems. The strengths have to do with construction of a clear language for communication about the conditions of interest and specifically for research into causes and treatments. Room for improvement there no doubt is, but no one has yet come up with a better kind of classification system for these purposes. However, clear description and classification of the conditions of interest is a project separable from the diagnosis of these conditions as mental disorders, this being the real target of the critiques of psychiatry – because social norms are being medicalized, because meaningful mental life in adverse circumstances is being pathologized. Distinguishing the various projects, purposes and problems of the psychiatric manuals in this way opens up the prospect of being able to have the advantages of the manuals without the disadvantages.

Chapter.  18869 words.  Illustrated.

Subjects: Psychiatry

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