Philosophical Issues in Psychiatry II: Nosology
In March of this year, this book became even more relevant to those interested in psychiatric classification. The American Psychiatric Association Board of Trustees formed a DSM Steering Committee to make decisions about future changes in the DSM. Further, it was decided that the Steering Committee would use a concept of validators in accepting changes to DSM–5. Those proposing changes for DSM-5.1 will be well advised to understand the concept of validators as described in this book.
The book consists of 15 papers, presented at a 2012 conference, that reflect on aspects of validators, both the way in which validators were expressed in psychiatric classifications of the past as well as proposals for the future. Each paper is bookended by an Introduction and Comments, which are provided by different authors; these additional reflections add depth and are very helpful in providing context with regard to both the past and the future. As to the future, an excellent contribution by Michael First reviews a system that may be ready for clinicians about 2020 and is already available for researchers who want to organize findings that could impact a diagnostic system, the Research Domain Criteria being developed by the National Institute of Mental Health.
DSM has had reliability as a goal from the beginning. DSM-I (1952) not only attempted to provide reliability, it also suggested etiology in that about 70% of its conditions were seen to be mental reactions to stressors and about 30% focused on organic conditions. DSM-II (1968) removed the word reaction from the names of all conditions, retained organic etiologies, and introduced a few psychodynamic causes. DSM-III (1980), in an effort to enhance reliability, removed any psychodynamic etiologies and, through criteria sets, improved reliability. DSM-III-R (1987), DSM-IV (1994), and DSM-5 (2013) stayed close to the DSM-III model even though each of these editions changed almost all conditions from its predecessor at least somewhat in name or criteria set. Philosophical Issues in Psychiatry has little to say about DSM–I or –II, but it does provide a satisfying review of the values that drove DSM-III and –IV and, less so, DSM-5.
During the development of DSM-5 (2007-2012), we saw many nosologic tensions. Dr Kendler summarizes the nosologic tensions beautifully in 2 ways at the beginning of the book:
Nosologies have to serve at least two masters (not counting the administrative and insurance apparatus of health care)—researchers and clinicians. These needs are sometimes in conflict. Researchers want detailed, highly accurate diagnoses and typically ask more rather than fewer questions. Clinicians are always in a hurry and so for them the shorter and simpler the diagnostic criteria the better. The DSMs have tried to steer betwixt these two extremes, developing a single diagnostic manual for both communities (p xiii).
[Psychiatric nosology] is influenced by a range of tensions . . . clinician versus researcher, reliability versus validity, past versus future, psychiatry versus psychology, realism versus nominalism, descriptive versus etiological models, and surface versus deeper phenomenological characterization of psychiatric symptoms and syndromes (p xiii).
To address these tensions, this offering brings together ideas from historians, philosophers, psychologists, clinical psychiatrists, and research psychiatrists.
A valid classification, of course, remains a major goal in psychiatry, but if etiology-based or biomarker-based diagnoses are seen as characteristic of validity, there has been little gain in recent decades. DSM‘s neurologic conditions, substance-related conditions, and disorders identified in sleep laboratories have formed about 40% of recent DSM editions. As some have concluded, the field seems "stuck."
DSM-5 resolved none of the tensions that this book explicates so well. Those wanting a deep understanding of the tensions in psychiatric classification will gain much from this volume, an understanding that hopefully someone or some team will use to get psychiatric classification unstuck.
Author affiliations: George Washington University School of Medicine and Health Sciences, Washington, DC (Dr Peele); and Germantown, Maryland (Dr Jawaid).
Potential conflicts of interest: None reported.
J Clin Psychiatry 2014;75(10):e1193 (doi:10.4088/JCP.14bk09225).
© Copyright 2014 Physicians Postgraduate Press, Inc.
