Diagnostic and Statistical Manual of Mental Disorders - Case Study Example

Evaluating DSM: Its Origins and Contemporary Role Every aspect of man is a complex matter to understand, because man is a complex being; not only because every man is unique but also because varied external factors such as cultural beliefs, social environment, economic base, etc. undeniably affect man. Similarly, to define what is normal and abnormal in man is a matter of difficulty, yet of importance, as “mental illness is [believed to be] as old as the human condition” (Shorter, 1997, p. 1). Through the years, there have been three contending approaches as to how this phenomenon is being dealt with: supernatural, biological, and psychological (Barlow & Durand, 2008, p. 7). And until today, the question as to what defines normality from abnormality, remains debatable. But it was also in defining and categorically classifying mental disorders that psychiatry – which was under a decade severe attack in the 70’s – won its bid for professional legitimacy and authority in this field, as brought about by the third edition of the American Psychiatric Association’s diagnostically based Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as DSM-III (Mayes & Horwitz, 2005, p. 249; Kirk & Kutchins, 1994, p. 71). As Robert Spitzer, the primary force in the development of DSM-III, stated “[W]hether we like it or not, the issue of defining the boundaries of mental and medical disorder cannot be ignored. Increasingly there is pressure for the medical profession and psychiatry in particular to define its area of prime responsibility” (cited in Healy, 1997, p. 233). However, although DSM-III had given so much influence to psychiatry, it did not actually resolve old-age questions regarding mental health, especially so that “Psychiatric diagnosis provides the fundamental rubric for discourse about mental illness” (Kirk & Kutchins, 1992, p.10). Additionally, although it is now widely used as a biblical text not only by psychiatrists but even by lawyers, federal agents, insurance agents, pharmaceuticals, it is on the other hand criticised in different fronts, which when analysed, such criticisms essentially attack DSM’s integrity as to its true intention, as to its scientific claims, and as to its usefulness. Whether such criticisms hold water could be scrutinised from critically evaluating DSMs origin and contemporary role. Origin of DSM The development of DSM from its very beginning to its latest version has consistently compromised with other political and financial interests shrouding its validity as a scientific, diagnostic instrument for treating mental disorder – an old-age condition that human society has been trying to cope with in varied ways. Contrary to what should be the motive force in developing DSM – to provide a scientific diagnosis of mental disorder – the development of DSM into a paradigm shift of symptom-based diagnoses resulting to the standardization of psychiatric diagnoses was neither an accident nor a result of pure scientific endeavour to give enlightenment on vague areas of mental disorder, but was the cunning product of converging factors that were in fact, not essential to scientific findings: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases. (Mayes & Horwitz, 2005, p. 249) In fact, by 1980, the criteria for a treatment that is “safe and effective on the basis of controlled clinical studies which are conducted and evaluated under generally accepted principles of scientific research” (Marshall, 1980, p. 35) was proposed as basis for government support to mental treatment. These support Kutchins and Kirk’s (1999) exposition that DSM is being used by the status quo as a tool to defend and perpetuate its political, economic and cultural interest, at the expense of the general interest especially of the weak and the powerless. Given the process by which Spitzer’s committee that developed DSM-III – which claim reliability and validity compared with DSM-I and II and from which DSM- IV was revised – was selected, where its chosen members were those “committed primarily to medically oriented, diagnostic research and not to clinical practice” (Millon, 1986, cited in Mayes & Horwitz, 2005, p. 259), immediately reflect bias against psychoanalysis in favour of psychopharmacology. This would mean greater benefit to pharmaceutical companies. In fact, it is not surprising to note that one study found a “strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness... especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders” (Cosgrove, Krimsky, Vijayaraghavan, & Schneider, 2006, p. 154). Furthermore, with the committee comprised mainly of those advocates of diagnostic research, led by Spitzer – an advocate of Kraepelin’s Theory which belief states that “mental disorders are a subset of medical disorders” (Spitzer, Sheehy, & Endicott, 1977, p. 4), it is not surprising or coincidental that DSM-III classified disorders on the basis of their symptoms. As Wilson (1993) commented: “The sense of the committee is that mental disorder should be defined narrowly rather than broadly, that a definition which permits false negatives is preferable to one that encourages false positives” (p. 405). Furthermore, it is highly inconceivable, yet it is what has happened that arbitrary inclusion and exclusion of what DSM termed as mental disorders depend on how powerful the lobbyist would be in rejecting or accepting such classification. As Shorter (1997) observes, “what had been considered for a century or more a grave psychiatric disorder ceased to exist” (p. 303). In fact, even Spitzer and his company acknowledge the difficulty of totally getting away with social and political pressures in defining mental disorders (Mayes & Horwitz, 2005, p. 259), especially so that funding for scientific researchers come mainly from influential powerful interest groups. An example of which was the transformation of homosexuality from its classification as ‘Personality Disorder’ to ‘Sexual Orientation Disorder’ until it was totally expunged from the list, as the psychiatrists could not justify it amidst the growing protests of gay movements. Also, seeing that neurosis has no empirical basis and that it has already outlasted its utility (Millon, 1983), Spitzer’s committee had intended to delete it from the list, yet threatened that DSM-III would not be approved by APA, a compromised was reached by not deleting neurosis from the list but it should be combined with the word ‘disorder (Bayer & Spitzer, 1985). Actually, these were only two of the known incidences by which political compromise define the direction and content of DSM. Moreover, Klerman, 1987 noted: “It appeared in response to some of the ideological and theoretical tensions within the profession of psychiatry. It also has been caught up in the rivalries and tensions among the various mental health professions—psychiatrists, social work, psychology” (p. 3). As a result, with the rise of DSM-III as the dominant approach in diagnosing mental disorders, psychiatry has finally taken its prestigious and influential place in medical history. And with the DSM-III becoming an authoritative text in mental health, as it was endorsed by key institutions, the APA has gained much in selling it. Contemporary Role Criticisms of DSM, specifically DSM-III, regarded by its advocates as the revolutionary version, centres on the way it treated mental disorder. That instead of dealing with the causes of mental disorder, it simply classified mental disorders according to its symptoms. And observably these are psychopharmacologically treatment-biased. From this, other related criticism could be gleaned, specifically: the method by which such mental disorders were identified and classified. Based on the insufficiency of DSM’s categorical system, for example its ambivalent treatment on the study of comorbidity (McGlashan, 1987, p. 473), as APA (1994) recognises the fact that not all cases may meet all criteria but only a required threshold, it is regarded that patients of similar diagnosis "are likely to be heterogeneous even in regard to the defining features of the diagnosis" (APA 1994, p. xxii), and based on its susceptibility to pressure, it shows unreliability, which is dangerous as it is being used today as the biblical texts of the medical society in treating mental disorder. One danger being posed is the possibility that it could be used by abusive clinicians against patients complaining of sexual abuse. Given the patient’s mental condition as defined by DSM, the clinician could easily argue that the patient is merely hallucinating or fabricating things, thus, DSM is used to cover-up the clinician. However, despite these criticisms and seen shortfalls of DSM, it could not be denied that it is in fact doing a great role in improving psychiatry. As has been evaluated, the strengths posed by DSM, specifically DSM-III, in dealing with mental disorders, have given society some hope that indeed abnormality can be categorically defined and can be treated. This alone, has human society greater hope that medicine has come a long way in uplifting the conditions of those affected with mental disorder, unlike before that even differentiating it could not be confidently drawn; worst, once afflicted by it, was almost tantamount to banishment. An evaluation of its strengths claimed by its advocate would substantiate the important role DSM is currently playing in human society. Fist, according to its advocates, DSM has been able to present an objective, true and reasonable classifications of mental disorder calling it a “victory for science” (Klerman, Vaillant, Spitzer, & Michels, 1984, p. 539). Although it was criticised to be “covertly committed to a biological approach to explaining psychiatric disturbance” (Spitzer, 2001, p. 351), it undeniably was able to standardise the classification of mental disorder, which is of great help not only to the medical society but even to the human society as a whole. As Mayes & Horwitz (2005) acknowledge, “for the first time, psychiatrists, psychologists, social workers, and counselors had one common language to define mental disorders” (p. 263). But aside from this, which when taken of its implication would appear both encouraging yet disturbing, “DSM-III created enormous professional and financial incentives for both researchers and pharmaceutical companies. As, [i]t gave them specific diagnoses to target their research and development efforts for prospective treatments.” (Ibid). On the other hand, it did also give pharmaceutical companies more leverage to expand its operation and gain greater profits. What made this disturbing is the fact that the categorisation of mental disorder in DSM was primarily aimed at clinical utility (Clark, Watson & Reynolds, 1995, p. 128). Second, the claim that DSM, specifically DSM-III simplified the approach to mental disorder, although contradicted by the trend that in a short time, “the number of officially recognized diagnostic categories has increased from 106 diagnostic categories in DSM-I to 182 in DSM-II, 265 in DSM-III, and 292 in DSM-III-R” (Ibid, p. 135), it could not be denied the fact that categorically classifying mental disorders with their proposed pharmacological treatment is easier to recognise and thus, simplifies the clinicians work, making it a simple selection process as to where the mental disorder of the patient falls. However, it is here where the danger of simplifying the diagnosis of mental disorder lies. Because as earlier stated, man is so complex. Furthermore, here also comes the validity of DSM’s critics that what is of primordial importance in treating mental disorder is no other than is aetiology, as ailment could not be treated without knowing its root cause. Thus, it could be argued that what DSM classified are in fact observable indications only of assumed mental disorder. As what the Task Force, specifically of DSM-IV explicitly emphasised that DSM’s specific criteria in classifying mental disorder are simply “meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion" (APA 1994, p. xxiii). Furthermore, Frances et al. (1991) noted that the leaderships of DSM themselves recognised that "the descriptive system is only a temporary way station to be replaced...with more incisive pathogenetic and etiologic models of classification" (p. 411). This therefore implies that treating DSM as a biblical text in treating mental disorder is too much of what DSM actually could offer; as it was made clear that it is here only to serve as guideline. Meaning to say, the greater role lies on the hands of the clinicians as to how they could improve more their field and contribute in clearing out the gray areas surrounding mental disorder. Conclusion The DSM is both a testament of the continuous search of medical science in understanding and treating mental disorders in man and to the pervasiveness of the influence of the power that be in determining the course of human society. Although it is not as reliable as it claims to be in terms of its process, composition of its task force – found to be psychopharmacologically biased, with strong links to pharmaceutical industries, methodology used in setting the criteria in classifying mental disorders, bound to [political pressures, etc., it nevertheless currently is serving its purpose. It has standardised the language of mental disorders among medical workers. It has provided specific guidelines that many ways have helped clinicians simplify their jobs. It has encouraged further researches with the power-group interest, all too willing to support. Therefore, despite its many shortfalls, and problematic aspects, the DSM remains a fruitful effort in enhancing psychiatry. Taken responsibly, DSM could still be used to its full advantage. References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th edn). APA: Washington, DC. Barlow, David H., and Durand, Vincent Mark. (2008). Abnormal Psychology: An Integrative Approach, (5th Edn). Wadsworth Cengage Learning: USA. Bayer, R., & Spitzer, R. (1985). “Neurosis, psychodynamics, and DSM-III.” Archives of General Psychiatry, 42, 187–196. Clark, L.A., Watson, D., and Reynolds, S. (1995). “Diagnosis and Classification of Psychopathology: Challenges to the Current System and Future Directions.” Annual Review of Psychology, 46, 121-149. Cosgrove, Lisa, Krimsky, Sheldon, Vijayaraghavan, Manisha and Schneider, Lisa. (2006). “Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry.” Psychotherapy Psychosomatics, 75, 154–160 Frances AJ, First MB, Widiger TA, Miele GM, Tilly SM, et al. (1991). “An A to Z guide to DSM-IV conundrums.” Journal of Abnormal Psychology, 100, 407-12. Healy, D. (1997). The Antidepressant Era. Harvard University Press: Cambridge, MA. Kirk, Stuart. A, and Kutchins, Herb. (1992). The Selling of the DSM. Aldine De Gruyter : Hawthorne, NY --- (1994). “The Myth of the Reliability of DSM.” Mind and Behaviour, 15 (1&2), 71-86. Klerman, G., Vaillant, G., Spitzer, R., & Michels, R. (1984). “A debate on DSM-III: The advantages of DSM-III.” American Journal of Psychiatry, 141, 539–553. Kutchins, Herb & Kirk, Stuart. (1999). Making us crazy: DSM: the psychiatric bible and the creation of mental disorders. Constable: London. McGlashan, T. ( 1987 ). "Borderline personality disorder and unipolar affective disorder. Long-term effects of comorbidity". 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