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A Critical View of DSM-5 from the
‘Historical Perspective’
University of Cambridge
Professor G E Berrios Heidelberg 4 April 2014
Amicus fidelis medicamentum vitae
DSM-5 methodological
historical
epistemological
DSM-‐5 can be explored from the following perspec:ves:
comparative e.g. ICD system
ontological
economic
statistical
political
sociological
HISTORICAL PERSPECTIVE ON DSM-5
Ø INTERNALIST: As compared with the DSM series & in relation to American Psychiatry.
Ø EXTERNALIST: As compared with international psychiatric classifications and in the context of the general debate on psychiatric taxonomy.
DSM-‐I (1952)
DSM-‐II (1968)
DSM-‐III (1980)
DSM-‐III-‐R (1987)
DSM-‐IV (1994)
DSM-‐IV-‐R (2000)
DSM-‐5 (2013)
First ideological break
-‐Psychoanaly:cal -‐ICD-‐harmonized -‐in-‐house -‐no influence abroad
-‐Natural kinds -‐Opera:onal defini:ons -‐Criterial -‐Diagnos:c -‐clinical + research -‐interna:onal -‐financial success
-‐same philosophy -‐same structure -‐changes affected object membership -‐increasing interna:onal control
Promise of a ‘paradigm shiN’ unfulfilled
Second ideological break ???
DSM series
Ø A very North American solution to their own psychiatric needs.
Ø Fine-tuned to their medical and economic structures.
Ø As long as it remained an internal affair there was no reason to worry about it.
Ø Criticism only became justified after it was claimed that DSM was:
a) context free, a-theoretical and universalizable. b) and hence, exportable tout court.
DSM-5
Cri:cism / Opposi:on came from:
disaffected experts
Medical Insurance Industry
international odd and bods
USA Counselling Societies
Pharma
Sectors of APA itself
Clinical & Public Health Committee
Scientific Review Committee
NIMH
DSM-5 Ø Most publicized DSM version so far. In the
public eye from the start. Ø Three original promises: Dimensionality,
Ethics & no multi-axiality. Ø In the making for very long: everyone had
time to give ‘opinion’. Ø This was a clever strategy for everyone was
made to feel that ‘DSM-5 was his thing’. Ø In practice, little external advice heeded. The
debate was internal: Working groups versus SRC, CPHC and Board of Trustees.
diachronic synchronic
aetiological
descriptive
categorical
dimensional
research
clinical
acute
chronic molecular
molar
taxonomic
pragmatic
Multidimensional frame for
‘classifications’ in general and DSM in
particular research
Clinical approach
DSM-‐5
Socio-‐economic
Aesthe:c
Classifica:ons are like polyhedrons gyra:ng within enclosed epistemes. Depending upon perspec:ve, some dimensions will appear to be more important or advanced than others. This may create the illusion of ‘progress’.
Epistemological Perspec:ves on mul:dimensional
objects:
Poli:cal
THE MEANINGS OF ‘CLASSIFICATION’
Ø Theories & rules for classifying (Taxonomy)
Ø Act of classifying (sortal act) (e.g. Diagnosis)
Ø Products of classifying (e.g. Periodic Table)
Berrios G E (1999) Classifica:on in Psychiatry: A conceptual History. New Zealand and Australian Journal of Psychiatry 33:145-‐160
CLASSIFYING: THE BASIC PRINCIPLES
Ø Classifying is the act of sorting ‘objects’ (based on some or all their features) into interrelated conceptual pigeonholes
Ø All classifications assume the existence of:
Kinds (natural or otherwise, e.g. periodic table)
Classes (families, groups, sets etc.)
Relationships (between groups)
CLASSIFICATIONS ARE MEANT TO:
Ø Organize & name (nomenclature)
Ø Release knowledge: horizontally (relating groups); vertically (linking up to mechanisms) outwardly (predicting new properties or objects).
Ø Provide moral & aesthetic reassurance
classification
Works best in universes that are closed & complete
Natural, artificial, systematically
related, relatable & unrelated.
TAXONOMY
‘CLASSIFICATION’ IS THE MOST COMPLETE SUB-TYPE OF GROUPING
GROUPING RULES
listing ordering
Used in universes in construction
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classification listing
TAXONOMY
EXAMPLES OF GROUPINGS
GROUPING RULES
ordering
natural Man-made
random
organized Animals Vegetables
Minerals
Planets stars
Weather patterns
Objects of art
Share origin & history (creation or
evolution)
Shared rules, structure, etc.
Nothing in common
Mental Disorders
People travelling in a plane
Material or abstract
Lottery draw results
Understanding Groupings
Listings, Orderings & Classifications
TWO APPROACHES TO PSYCHIATRIC CLASSIFICATION
RECEIVED VIEW
Ø mental disorders are natural objects Ø classifications are the bases of diagnosis
CONSTRUCTIONIST VIEW Ø mental disorders are hybrid objects Ø psychiatric classifications are cultural products
REDUCING AD ABSURDUM THE ‘RECEIVED VIEW’
If the functions of the brain are claimed to be stable, bounded & fully knowable (like other ‘natural systems’), in the future it should be possible to construct a complete “Periodic table of functions & their deficits” and thereby predict the existence of yet ‘unreported’ mental disorders.
(1834-1907)
(RDoCs have become a good example of this!)
WHICH TAXONOMIC CONCEPTS APPLY TO THE OBJECTS OF PSYCHIATRY?
Ø Current psychiatric classifications assume that
psychiatric ‘objects’ are natural kinds (like tumours, animals, flowers, metals, etc.)
Ø If thus, which is the natural taxon of Psychiatry? phenotype endophenotype genotype
Ø The objects of psychiatry are culturally configured neurobiological signals (hybrid)
Berrios G E (2008) Baillarger’s Essay on Classification. History of Psychiatry 19: 358
Hybrid object: Symptom (a)
‘Construction’ symptom- expression
Brain signal
(a) CONFIGURATORS i.e. styles of talking
about the body: personal, familial,
social, cultural, etc. P
rim
ordi
al s
oup
CAMBRIDGE MODEL FOR SYMPTOM-FORMATION: PATHWAY (a)
awareness domain
Biological & Semantic Components of the ‘Hybrid’ object in Psychopathology Berrios G E (2011) Psychiatry and its objects.
Rev Psiquiatr Salud Ment (Barc.) 4:179-‐182
CONCLUSIONS 1
Ø A ‘historical’ evaluation of DSM-5 can be made by comparing it with the rest of the DSM (internalist) or with classifications and debates at international level (externalist).
Ø DSM-5: -remains the most publicized of all DSM versions. -most of its original desiderata have not been fulfilled. -is not a classification but a ‘listing’. -it is a good compromise between antagonistic forces in the
USA. -conceptually, it is a multidimensional polyhedron, a rotated
version of earlier DSM efforts.
CONCLUSIONS 2
Ø Classifications are the highest form of grouping. Only classifications can release new information. Listings & orderings are useful for book-keeping.
Ø Since the 19thC, ‘psychiatric classifications’ have just been incomplete listings.
Ø DSM-5 was constructed on the view that: -mental disorders are ‘natural kinds’ -psychiatric groupings are ‘biological classifications’
Ø Mental Symptoms are culturally configured signals of neurobiological distress. They need new grouping rules. These must include cultural configurators as they have high predictive value.
