Laws, Sausages, and Psychiatric Nosology

Laws are like sausages. It’s better not to see them being made.
Otto von Bismarck
German Prussian politician (1815 – 1898)
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published periodically by the American Psychiatric Association (APA), aims to catalog all recognized mental disorders.  As the name implies, it is used both for clinical diagnosis and for various statistical (population) uses.  I previously posted how social judgments are inevitable in such a catalog; little wonder DSM has long served as a lightning rod for social debates over what is normal versus abnormal.

The fourth edition (DSM-IV) was published in 1994, followed by a minor “text revision” (DSM-IV-TR) in 2000.  Groups of psychiatrists are now drafting sections of DSM-V, due out in 2012.

It would be nice to imagine that the process of creating and updating DSM is scientific and unbiased.  However, like laws and sausages, psychiatric nosology (disease classification) is more palatable the less one notices how it is made.  As reported in today’s New York Times, putative disorders such as compulsive shopping, sexual fetishes, and binge eating have their advocates and detractors.  Transgender people have a personal stake in whether “strong and persistent cross-gender identification” remains a mental disorder.  (Interestingly, the stigma of this diagnosis is offset by its utility in obtaining insurance coverage for gender-reassignment surgery and other treatment.)  This recalls debates over the inclusion of homosexuality as a mental disorder in earlier editions of DSM.  Homosexuality was dropped as a diagnosis in 1973. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before those, too, were dropped in 1987.

Anyone who imagines that these debates are coolly scientific is dreaming.  As social norms change, our notions of mental illness change with them.  The long-term trend has been an expansion of DSM, both in terms of dividing syndromes more finely, and also widening the scope of behaviors considered disordered.  Stakeholders include the APA itself, sole publisher of the 800,000+ copies of this essential tome; pharmaceutical companies who stand to gain or lose fortunes based on whether a particular human deviance is treatable with medication; insurers who cover treatment for disorders but not non-disorders; patients who either have a mental illness or don’t; and scientists trying to collect data and make sense of the whole thing.

It is good to bear in mind that some disorders in DSM-IV-TR, like “nicotine dependence,” do not seem very much like mental disorders — and that one is bound to stay.  Meanwhile, other maladies of the human spirit, like living a life devoid of meaning or purpose, are not listed in the current DSM, and are not likely to appear anytime soon.  In my next post, I’ll discuss one aspect of psychiatric nosology, categorical versus dimensional ratings, that may improve DSM-V.  However, the inclusion of messy social judgments in DSM is with us for the duration, obscured in the finished product by careful prose, numerical labels for disorders, and a little quantitative data.  Laws and sausages aren’t bad either — if you don’t think about them too much.

4 comments to Laws, Sausages, and Psychiatric Nosology

  • Brian Malchy

    Your term “messy social judgements” is highly relevant and, at the sametime, unfairly biased against psychiatry. Philosphical examination of all medical diagnoses has revealed that the same illusion of “cool science” is at the heart of all medical diagnoses. It is only that psychiatry, because of the ‘public’ nature of the subject, is most vulnerable to that revelation becoming ‘public’and artificially controversial

    it is therefore our duty to avoid unfairly stigmatizing the practice of psychiatry as lacking a scientific basis. All medicine is a social enterprise at heart with all of its attendant “messiness” and vested interference from biased interests. It is only that illusions of scientific orthodoxy are able to persist longer in technical and therefore obscure fields such as those thought of as “physical”.

    • Hello, and thanks for writing. I agree there are social, non-scientific factors at play in non-psychiatric medical diagnosis as well, and indeed in all science as it is pursued in the real world. However, I disagree that psychiatry is singled out merely owing to the “public nature of the subject.” Determinations of what is behaviorally healthy or unhealthy — how much gambling constitutes a disorder, how much sexuality is healthy, how much opposition an adolescent is expected to show — are inherently more socially defined than analogous judgments in the physical and biomedical sciences.

      I also don’t believe that admitting this stigmatizes psychiatry. Indeed, I am proud that my field acknowledges and grapples with this “messiness” when so many others do not. I would never claim that psychiatry “lacks a scientific basis,” only that we should be humble about what we know (a little) and what we don’t (a lot), and that we should embrace the complexity of working in an area where science and humanity explicitly intersect.

  • Brian Chaze

    I value this discussion, and I wonder if I might be able to clarify what seems to be at issue here. I agree with Dr Reidbord that the social judgments underpinning psychiatric diagnoses are more “messy” compared to the ones underpinning many other medical diagnoses. I would take an example like “normal hemoglobin levels” to point out that we don’t merely use statistics to determine what is normal in medicine, but make the collective (and rather uncontroversial) judgment that falling far outside the normal curve USUALLY entails “bad things” for that organism. It so happens that “bad things” amounts to a social judgment (eg. It’s bad to lack energy so as not to be capable of working or playing). However, any hematologist will tell of you of the folks who function well with “abnormal” hemoglobin levels. I mention this example only to point out that social judgments become “messy” BECAUSE there is wider disagreement about them, and this is the reason that psychiatric diagnoses are sometimes viewed as less scientific. I agree with Mr. Malchy that mental health professionals run the risk of misrepresenting their field as “less scientific” if they do not grasp the important fact that all science is actually value-based, and not value-neutral. Moreover, it is not the values themselves that are messy, but rather the conflict between people that arises out of their implementation.

    • I believe there are (at least) two kinds of messiness at play here, something I didn’t think to distinguish in my original post five years ago. One concerns the data itself, the other our appraisals, e.g., diagnosis, based on the data. Determining the hemoglobin level in a particular patient is a qualitatively different process than determining whether a particular patient has “inappropriate affect” (a diagnostic criterion for certain disorders). The inevitable imprecision in hematological measurement is not due to social judgment; scientists can strive to make such measurement more precise. In contrast, “reasonable people can disagree” whether an affect is inappropriate or not, and indeed, there are systematic differences depending on the observer’s culture, personal history, and so forth. These are social judgments I colloquially called “messy.”

      An entirely separate matter is what we conclude from our data. Value-laden social judgments influence both hematology and psychiatry. The same hemoglobin level may be “within normal limits” in one era and abnormal in another (better examples are blood pressure and cholesterol level, both of which are more narrowly defined as normal than they used to be). In psychiatry, more of the general population is diagnosed with PTSD and ADHD as criteria for those disorders are loosened, while less of the population was diagnosed with sexual perversion when homosexuality was no longer considered a disorder. I agree that this kind of “messiness” is a feature of all science — and that psychiatry grapples with wider disagreement from within and without than many other fields. Thank you for writing.

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