Demazeux Steeves - The DSM-5 in perspective : philosophical reflections on the psychiatric Babel

Universit Bordeaux Montaigne, Pessac, France

Steeves Demazeux Associate Professor

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The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was soon proclaimed by its proponents to have achieved a scientific revolution, while its opponents accused it of being unscientific. Even if the terms science or scientific are mostly absent from the DSM (and even from much of the official proceedings surrounding the development of the several editions), it is clear that scientific progress, along with clinical utility, has been a key issue for assuring the legitimacy and the credibility of the American classification system. In particular, the original project of the DSM-III was to develop an atheoretical classification of mental disorders that would be progressively enriched and consolidated by the best empirical data available in the scientific literature.

In this chapter I show in what ways the DSM, dating back to the 1980s, has been informed by the ideal of scientific progress. My aim is not to evaluate the arguments for or against the scientific nature of the DSM as they have been brought forward and discussed in the public debate for purely promotional or polemical purposes. It is rather to highlight the kind of scientific optimism that has been a driving force in the recent history of the DSM. I argue that the nature of the scientific ideal of the DSM has remained the same over its three last editions, but that its effects and rationale have dramatically changed. Whereas scientific progress required that the DSM-III firmly espouse what I call here a permanent innovation principle, it would later paradoxically motivate, in the DSM-IV and especially in the DSM-5, an opposed principle that I call the principle of prudential conservatism.

The role of scientific progress in the DSM can be approached from at least three different perspectives: by focusing on fundamental, methodological , and particular issues. First, one may focus on the overall project of applying the scientific method to psychiatric nosology. Since the turning point in 1980, when the third edition was published, the DSM has been hailed as a significant reaffirmation on the part of American psychiatry of its medical identity and its commitment to scientific medicine (Klerman et al. , 37), the DSM attempted to achieve a more objective and rational approach by describing mental disorders in a manner that would be beneficial and reinforce psychiatry as a genuine branch of medicine.

A second way to consider scientific progress is to focus more specifically on the methodology for revising each edition of the manual over time. The novelty of the DSM-III was to encourage an ongoing process of revision by integrating better scientific information as soon as it became available in the literature. The DSM-III was primarily based on expert consensus, but the developers of the following editions have sought to adopt a more data-driven revision process. As we will see, the modalities of the revision process have evolved considerably with the different editions of the DSM, from the DSM-III-R to the DSM-5.

Finally, a third way to evaluate the scientific soundness of the DSM is to pay attention to all the particular decisions that have been made by the architects of the manual. When the time comes for revision, many proposals are discussed amongst the experts from the several subgroups of the Task Force committee. Fortunately or unfortunately, the final decisions are never made on solely scientific grounds. On the one hand, members of the Task Force are quick to recognize that they have to take into account several important non-scientific factors, such as the clinical utility of the modification, its accordance with the clinical tradition, its compatibility with International Classification of Diseases (ICD) codes, its clarity and simplicity for administrative purposes, and its potential harmful impact on public health as well as its potential impact on the health economy (American Psychiatric Association , xxxxi). On the other hand, it must be acknowledged that misconceptions and distortions of different kinds (corruption, intellectual shortsightedness, cultural biases, etc.) are likely to affect the final decisions, as they regularly do affect the results of any scientific process. The sector of psychiatry, which since the 1970s has become a major market in the health economy with strong ties to the pharmaceutical industry, is undoubtedly more prone to corruption today than in past decades.

The accusation that the DSM is unscientific has been made repeatedly in terms of each of these perspectives. Early on, several authors questioned the most basic assumptions of the DSM, arguing that the American classification system was grounded on shaky philosophical foundations (Zubin ). There have also been many criticisms focusing on the rationale and general methodology for revising the DSM, and of course many criticisms regarding particular decisions, both tiny and major, made by the experts recruited by the Task Force.

In the rest of this chapter, I focus on fundamental and methodological criticisms. Of primary importance is an examination of the causes of specific pitfalls or pseudo-scientific judgments that have led to erroneous local decisions (a good example of such a critique is provided by Wakefield in this volume). But it should be noted that these failures take place within the normal functioning of a scientific revision process. As long as this process is not systematically biased, the fact that some local decisions are contentious does not compromise the legitimacy of the scientific enterprise as a whole.

The publication of the DSM-III in 1980 is often presented as an event of capital importance in the history of modern psychiatry in the sense that it gave a redirection of the discipline toward a scientific discourse (Shorter , 302). A quote, reported by many commentators, summarizes quite well the scientific enthusiasm that surrounded the publication of the DSM-III. Its author is Gerald Maxmen, professor of clinical psychiatry at Columbia University, in a 1985 publication: