I’ve just spent the last six months researching and writing the second edition of my Psychopathology text book – and I’ll probably be doing this for the next six months as well. I’ve included DSM-5 diagnostic criteria in the book – if I didn’t then it almost certainly wouldn’t be in the slightest bit competitive in the “Abnormal Psychology” textbook market. But I’ve attempted to be critically evaluative of DSM-5 wherever I can, and included a section specifically devoted to criticisms of the DSM developmental processes itself.
However, this led me to thinking about the value of current psychiatric diagnostic criteria. I got my copy of DSM-5 within days of it being published (all £88-11p of it). I was struck immediately by how similar it looked to DSM-IV-TR – except for the fact that they’d used an Arabic instead of a Roman suffix – very contemporary, and highly likely to be attractive to the youngsters. First, I couldn’t help but be impressed by how easily I could mistakenly pick up DSM-IV-TR and believe it to be DSM-5. How long did DSM-5 take to develop, and how much money did it cost?
Anyway, that’s not the point of this piece. It’s about whether research on diagnostic criteria are converging or diverging. That’s important because there is currently a desire to prioritize harmonization of ICD-11 and DSM-5. Let’s not forget that DSM-5 as published is still very much an arbitrary set of diagnostic criteria only very loosely based on biological and psychological evidence – that is clearly reflected in the move in DSM-5 to spectrum-based disorders. Writing an “abnormal psych” textbook is very instructive, because you’re not only writing about diagnostic criteria you’re also reviewing all the evidence on etiology as well – and very often the two just don’t match up!
Almost all Abnormal Psychology textbooks have etiology sections that cover biological, psychology and, sometimes, sociological explanations of almost every psychopathology. Yet trying to reconcile these different etiological approaches with the simplistic diagnostic criteria in DSM-5 is almost impossible. Given the (supposedly) lucrative market for Abnormal Psychology textbooks, there has been a frenzy to align these books with DSM-5. The 12th edition of Wiley’s Kring et al. Abnormal Psychology textbook even preceded DSM-5 and attempted to predict what the new diagnostic criteria would be!
But the more I research the etiology of individual psychopathologies for the second edition of Psychopathology, the more I realize that DSM-5 is a fabrication that is entirely remote from the diverse research being undertaken on all psychological disorders. Schizophrenia spectrum disorders is a good example. There is a growing wealth of knowledge about the neuropsychology of schizophrenia as a diagnostic category. There is also a growing wealth of knowledge about the psychological processes that give rise to cognitive biases contributing to psychotic symptoms. None of this is apparent in any of the words I read in DSM-5. I would hesitate to say this, but I think I would have a better idea of being able to spot and understand a “schizophrenia”-related disability from reading the literature on schizophrenia etiology research than I would ever have from reading the DSM-5 diagnostic criteria.
There is no doubt that DSM-5 is a poor guide to “understanding” psychiatric disorders – anyone who reads it will get very little insight into what it is like to experience a mental health problem and even less insight into what causes that problem. So is DSM-5 simply a load of very eminent psychiatrists exercising their intellectual muscle to force us all to fit into rather simplistic mental health boxes (and also an attempt by them to impress their more traditional medical compatriots)? And for who’s benefit? Well, as I understand it, much of this is for the benefit of the US health insurance market. So is this why we should have a deliberate convergence of diagnostic mental health criteria when such criteria are currently sketchy and arbitrary?
Don’t get me wrong. It’s important that researchers and practitioners collaborate to further knowledge and diagnostic criteria. But to believe that we are already at a point where we can begin to converge different worldwide diagnostic criteria is frighteningly premature. The development of diagnostic criteria for mental health problems has been a process that has been overseen by medics for far too long – not just in the APA but also in the World Health Organization. Mental health problems are not simply medical problems, many of them are problems stemming as much from ways of thinking and from socio-economic status as they are from medical dysfunction. Yet there is an alarming desire to align DSM with neuroscience – and not with psychology and nor with the socio-economic factors that give rise to many common mental health problems. Wouldn’t it be interesting at this stage in our knowledge development to see different attempts to consolidate diagnostic criteria take their own independent routes rather than deliberately converge as a matter of international medical policy?
However, this led me to thinking about the value of current psychiatric diagnostic criteria. I got my copy of DSM-5 within days of it being published (all £88-11p of it). I was struck immediately by how similar it looked to DSM-IV-TR – except for the fact that they’d used an Arabic instead of a Roman suffix – very contemporary, and highly likely to be attractive to the youngsters. First, I couldn’t help but be impressed by how easily I could mistakenly pick up DSM-IV-TR and believe it to be DSM-5. How long did DSM-5 take to develop, and how much money did it cost?
Anyway, that’s not the point of this piece. It’s about whether research on diagnostic criteria are converging or diverging. That’s important because there is currently a desire to prioritize harmonization of ICD-11 and DSM-5. Let’s not forget that DSM-5 as published is still very much an arbitrary set of diagnostic criteria only very loosely based on biological and psychological evidence – that is clearly reflected in the move in DSM-5 to spectrum-based disorders. Writing an “abnormal psych” textbook is very instructive, because you’re not only writing about diagnostic criteria you’re also reviewing all the evidence on etiology as well – and very often the two just don’t match up!
Almost all Abnormal Psychology textbooks have etiology sections that cover biological, psychology and, sometimes, sociological explanations of almost every psychopathology. Yet trying to reconcile these different etiological approaches with the simplistic diagnostic criteria in DSM-5 is almost impossible. Given the (supposedly) lucrative market for Abnormal Psychology textbooks, there has been a frenzy to align these books with DSM-5. The 12th edition of Wiley’s Kring et al. Abnormal Psychology textbook even preceded DSM-5 and attempted to predict what the new diagnostic criteria would be!
But the more I research the etiology of individual psychopathologies for the second edition of Psychopathology, the more I realize that DSM-5 is a fabrication that is entirely remote from the diverse research being undertaken on all psychological disorders. Schizophrenia spectrum disorders is a good example. There is a growing wealth of knowledge about the neuropsychology of schizophrenia as a diagnostic category. There is also a growing wealth of knowledge about the psychological processes that give rise to cognitive biases contributing to psychotic symptoms. None of this is apparent in any of the words I read in DSM-5. I would hesitate to say this, but I think I would have a better idea of being able to spot and understand a “schizophrenia”-related disability from reading the literature on schizophrenia etiology research than I would ever have from reading the DSM-5 diagnostic criteria.
There is no doubt that DSM-5 is a poor guide to “understanding” psychiatric disorders – anyone who reads it will get very little insight into what it is like to experience a mental health problem and even less insight into what causes that problem. So is DSM-5 simply a load of very eminent psychiatrists exercising their intellectual muscle to force us all to fit into rather simplistic mental health boxes (and also an attempt by them to impress their more traditional medical compatriots)? And for who’s benefit? Well, as I understand it, much of this is for the benefit of the US health insurance market. So is this why we should have a deliberate convergence of diagnostic mental health criteria when such criteria are currently sketchy and arbitrary?
Don’t get me wrong. It’s important that researchers and practitioners collaborate to further knowledge and diagnostic criteria. But to believe that we are already at a point where we can begin to converge different worldwide diagnostic criteria is frighteningly premature. The development of diagnostic criteria for mental health problems has been a process that has been overseen by medics for far too long – not just in the APA but also in the World Health Organization. Mental health problems are not simply medical problems, many of them are problems stemming as much from ways of thinking and from socio-economic status as they are from medical dysfunction. Yet there is an alarming desire to align DSM with neuroscience – and not with psychology and nor with the socio-economic factors that give rise to many common mental health problems. Wouldn’t it be interesting at this stage in our knowledge development to see different attempts to consolidate diagnostic criteria take their own independent routes rather than deliberately converge as a matter of international medical policy?
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