Thursday, December 18, 2008


An article on the coming debates over DSM-V in the New York Times. Over at the Neuroethics & Law blog, Peter Reiner (pictured) emphasizes his worries about the influence of money on the decision-making process, and urges that all conflicts of interest should be avoided. Quite right too.
However, I don't envy the architects of DSM-V. They really have an impossible task. How to categorize all those disorders in the absence of any good causal theories? In the NYT article, Edward Shorter grumbles about the process, and he bemoaned the expansion of the DSM and the increase of the number of diagnostic categories over the years. But his solution is to restrict mental disorders to the severe cases of mood disorder and schizophrenia, and if DSM followed his recommendations, many people who currently get treatment for mental disorder would no longer be eligible for it, unless they were ready to pay out of pocket. The DSM architects are in a bind: they are meant to make their manual usable by clinicians, scientifically respectable, and also a tool to help people get help. They are also subject to a great deal of pressure from interested groups. The NYT article mentions parents of children diagnosed with bipolar disorder and sensory processing disorder, who have strong opinions about this. Of course, there are some scientific facts to help make the decisions, but much of the work is political. Whatever decisions the architects make, many people will say they got it all wrong and caved in to the other side. At the same time, it is hard to feel too much sympathy for those poor architects, given that they have insulated themselves from public scrutiny. With even Robert Spitzer outraged at their secrecy, they have given themselves a huge public relations disadvantage.
From a philosophical point of view, it is disappointing that the DSM-V people seem to be distancing themeselves from the intense philosophically informed discussion over DSM that has been doing good work for that last couple of decades. None of the major names in the philosophy of psychiatry seems to have been included in the DSM-V Task Force or Work Groups. Very few of the people in these groups has even entered any dialog with philosophers -- Ken Kendler on the Mood Disorders Work Group) being a notable exception. Of course, the DSM people might be able to put together a rationally coherent manual without the help of philosophers, but they would have benefitted from more philosophical input. Kendler et al argued that there should be a Conceptual Issues Work Group, but so far, it seems that their advice has been ignored.

1 comment:

Rob said...

Sadly, this is absolutely *not* the way to begin building bridges with science, philosophy, antipsychiatry, the survivors movement, or, well, anybody!

The architects of DSM-V do have a tough job, to be sure, but I've never found the toughness of a job to be anything like an adequate excuse for doing it poorly. Making that job easier via non-disclosure and non-openness is a terrible idea.

What's next, a puff of white smoke if a new disorder is canonized, and a puff of black if not?

I'd had significant hopes for a major conceptual overhaul with DSM-V, particularly using dimensional definitions rather than categorical definitions of disorder. That may well end up happening, but I'll be suspicious of anything dressed up as science voted on by a gagged committee in camera.