Thursday, 25 February 2010

DSM-V and debates about what is a mental disorder

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a manual of Psychiatry published by the American Psychiatric Association (APA), is due in 2013. But, if you are interested in this topic, you can have a look at the APA website, where drafts of the articles (initial versions) written by the DSM-V group can be read and commented upon (until April 2010). The originality of the DSM is the fact that it does not only describe disorders, it gives the criteria to identify each disorder and a diagnosis. The definition of what is a mental disorder is at the core of this enterprise, and is the topic of many debate about the DSM.

The third version, the DSM-III (1980), was strongly orientated by an operationalist definition of what is a mental disorder. Spitzer and Endicott (DSM-III's editors) were influenced by the work of C. Hempel in Philosophy of Science. According to this approach, in order to define what is a mental disorder, we only need the experimental procedures which enable us to tell the conditions through which the concept can be applied. If we want to define what is cerebral activity, we only need to say that a subject has a cerebral activity iff, linked to encephalograph, we see indications of his brain activities on an encephalogramm. The authors tried to define mental disorder according to the operationalist approach. Of course, the main points of this strategy were to avoid any circular definition based on normality and to use the means provides by an empirical approach. As Spitzer said, mental illnesses are subcategories of medical disorders.

Wakefield, in his famous 1992 paper, shows that the DSM-III's idea of mental illness is at its core fonctionalist and not at all operationalist, by reinterpretating the whole definition in fonctionalist terms. He holds an hybrid position, which takes into account 1) harm and sufferings according to social value and 2) dysfunction, based in evolutionary theory. Wakefield's remarks were taken into account by the committee of specialists of mental health who enclosed a clinical criterion among the official criteria to define mental illness in the DSM-IV ("distress or impairment in social, occupational, or other important areas of functioning"), published in 1994.

So, what's new in the DSM-V ? 5 criteria are featured to define mental illness. Here they are :
  1. A behavioral or psychological syndrome or pattern that occurs in an individual.
  2. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning).
  3. Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals).
  4. That reflects an underlying psychobiological dysfunction.
  5. That is not primarily a result of social deviance or conflicts with society.
First, the emphasis on the biological nature of a mental disorder is obvious (criterion 4), and is absent from the DSM-IV (here are the criteria of the DSM-IV). Second, the etiology is more and more evacuated from the criteria. Compare : "Is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom", in the DSM-IV, and "The consequences of which are clinically significant distress;(e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)" in the DSM-V. The notion of risk (for the present distress or the disability to be the cause of death and pain) has disappeared. Third, the intensity of pain is taken into account into the DSM-V, which was not in the DSM-IV. Compare : "present distress" in the DSM-IV and "clinically significant distress" in the DSM-V. No universal scale is needed for this kind of scale. To be clinically significant, the scale is standardized by the patient himself.

Of course, all the anti-rationalists and all the anti-naturalists in the field of Psychiatry will be infuriated by the publication of the DSM-V. And it is not difficult to see why. I suppose that, as always, anti-DSM will state that the DSM-V is the product of the Western thought, that it holds a dogmatic approach, that it cannot account for behavior and disorder in non-Western areas of the World, and that it mixes up social features and behavioral syndromes. I wonder how long will they use the ineffective sophism of the origin to address the DSM. I wonder how long will they use old data (the debate about the presence of homosexuality in the DSM-II, in the 1960's and 1970's) to produce relevant, up-to-date and fruitful critics.

See also :
An article, by Anna Lieti, in Le Temps (19 février 2010) : "Tous des malades mentaux".
Wakefield, J. C, 1992, “The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values.” American Psychologist 47:(3) 373–88.
Mental illness (SEP)

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