Good ole DSM may not be all is cracked up to be

 Psychology, the study of human thought and behavior, is touted as a science from within its ranks and attacked as a non-science by those outside the discipline.  As such psychology often relies upon the seemingly valid diagnostics of the DSM.  Yet is the DSM worthy of its influence?  Is it even worth the cover price?   The science of psychology, even if it is deemed a ‘soft science’ should have its basis in science, that is, the hypothetico-deductive model of epistemology.  By maintaining its atheoretical approach, the DSM lends no support to psychology as a science and adds to the criticisms of psychology being considered a science at all.  Because of the lack of theory, that is, criteria for falsifiability among others, there is no way to know if the DSM is getting it right.  The only course of action is to add more descriptors to the growing list.  How did the DSM get into this predicament?

The three articles assigned for this paper all give account of the history of the DSM as well as the social and political factors leading to its current form.  Psychoanalysis was attacked by many in the psychological community for its lack of effectiveness in treating the mental disorders of the day.  It was/is often referred to a ‘rubber-band theory’, a loose term attempting to describe the ‘theory’s’ way of explaining away any criticisms directed toward it.  Serious contention to Psychoanalysis came from the Behaviorists and their much stricter models of investigation and the emphasis placed on testing and refuting of the null hypothesis.  After eventually doing away with Psychoanalysis the DSM fell back on its medical model roots.  Psychologists, however, stressed the importance of other factors on human behavior, such as environment, volition, and so forth and threatened to create their own model of classification of disorders.  Had they done so, it could have been that the American Psychiatric Association would have eventually gone the way of the dodo.  We will not know, for in a brilliant move they published their classification system as atheoretical. 

At the same time the doors for studying Psychoanalysis were thrown open to nonmedical doctors and psychologists, looking for more theories to practice their therapy in, filled the ranks.  Psychology was booming as many disciplines began to sprout out and grow, community psychology, cognitive psychology, developmental psychology, interpersonal psychology, personality psychology, and so on.  This helped to make the opinion of psychology, already viewed as a ‘soft science’ to become even softer still.  What could be more welcomed to a discipline seeking validity and justification than the classification system set up by doctors, who have gone to medical school and who understood biology, itself a hard science?

And yet the medical community revised the DSM to appease their enemies and to stop a turf war between them and psychologists.  The DSM was written as atheoretical and offered no guidelines as to its assumptions on why things were the way they were.  This has the same affect of a country with many religious holidays but of which nobody can celebrate any of them in public office.  All are correct and yet none are correct.  We can all agree to disagree.  This is bad sociology and even worse science (if it can be called that).  There are theories about what PTSD is and how it operates (and even if it exists), but these theories operate within the confines of the atheoretical description of a category that may/may not have boundaries and whose members may/may not share criteria.  An article that investigated why Finnish WW2 veterans had lower rates of PTSD did not ask an important question, relevant here.  Is it that PTSD is a disease and shares common categorical definitions and can be empirically validated across cultures, as would small pox or HIV, or is it that the Finns have a different notion of what it means to experience war and the after affects of such.  Would an American researcher find PTSD among the Finnish vets where they themselves did not?  The medical model approach, implicitly asserted in the DSM, should, if theoretically elaborated, be pressed to better define or scrap the notion of PTSD.  Yet the DSM, in being atheoretical is able to be not only dogmatic and authoritative, but also relativistic and open in that it also makes reason for cultural differences as evidenced by hearing voices, clearly a mental hallucination, is not viewed as symptomatic if in context of a society that accepts such ideas as valid.  How on Earth can we have any criteria for gaining knowledge about the human condition with such openness?  This is worse than relativism and subjectivism!

 But what of the categories that are so important and defining? A category is defined as “when members of a diagnostic class are homogenous, when there are clear boundaries between classes, and when the different classes are mutually exclusive” and then the manual goes on to say “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder.  There is also no assumption that all individuals described as having the same mental disorder are alike in all important ways” and further that the “individuals sharing a diagnoses are likely to be heterogeneous even in regard to the defining features of the diagnoses” (p. xxxi DSM).  So the DSM, then, asserts that we have definite categories of ‘mental illness’ that may not have the properties of a category, that those who are diagnosed into a category may not have the important aspects of that category, and members of this category are likely (as opposed to not likely) to be heterogeneous.  What is created is a grab-bag of ‘what ails you’ where one can find the diagnostic to suit the needs.  How then are we to know when a person, who does not share the defining features of a category, is to be diagnosed as such?   Page xxxii has the answer under the heading of ‘Use of Clinical Judgment’ in that while it is a hodgepodge of categories where no real boundaries exist, an individual may be assessed as belonging to a category even if the requirements of that category as stated in the DSM dot exist or the individual does not belong to a category even though the requirements do exist as stated in the DSM, the individual “assessments that rely solely on psychological testing not covering the criteria content cannot be validly used s the primary source of diagnostic information”(p xxxii DSM).  The DSM makes it quite clear that the only individuals qualified to make the final judgment on diagnosis of an individual with appropriate clinical training.   How is one to know if ADHD is real?  If one cannot answer this question, the question of what is the use of the book pales in comparison to what use is psychiatry in general as well as the pharmaceutical companies that push drugs onto us and the majority of psychology that tries to fit itself under these mysterious and occult guidelines.

 Because the DSM is atheoretical and only descriptive, it will continue to increase in size and complexity as our descriptors of various human thoughts/actions are teased out from each other.  If there can be a caffeine induced mood disorder surely there can be a video game induced mania.  Why not?  What criteria does the DSM have for including a diagnosis within its covers?  Statistics may be in the title of the book, yet where are the statistics for Acculturation Problem (p. 741)?  I could question this, wondering if this not a normal phase to go through, using a theoretical perspective that such uncomfortableness motivates the individual to accommodate social rules of the new group as pertaining to my evolutionary theory.  Yet the DSM does not make any claims, it is atheoretical, and any true understanding of what this disorder means is beyond my, and any other’s,  grasp that is not a trained clinician (doctor).  Not only is this atheoretical but it is also not science as no theory of how disorders are classified or noted can be challenged by any outside the church of psychiatry.  This is religion wrapped up on scientific sounding garb.  It reminds me of medieval philosophy that argued about angels dancing on pin’s heads.

 Yet all is not lost, for the manual was created by teams of people, highly skilled and knowledgeable in testing and psychology and the human condition and for such a manual, particularly one with ‘statistics’ in the name of such one would expect to see statisticians in the Task Force.  In fact it states “We selected Work Group members who represented a wide range of perspectives and experiences” (p. xxiii DSM).  Yet, looking through the lists of names shows doctors.  The occasional Ph.D. is given, but mostly, by and large, it is all doctors who, in the end, had a consensus view of what to include or not include.  It has the same effect if they had tried to come up with a catalogue of the greatest music ever recorded.  Instead of criteria of using sales or radio air-time, or number of copies made, or languages the song was translated, instead it is akin to personal taste and agreement that we simply must include ABBA in the list of great bands.

 Surely, then, one of the most heavily diagnosed disorders out there, Attention Deficit Hyperactivity Disorder, given out so often, and not only that but also a methamphetamine drug prescribed to our children in alarming numbers, has just such criteria… or any criteria that it does exist as a disorder, as a sickness, as something to be cured.  Page 88 tells the sad story: “there are no laboratory tests, neurological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of ADHD.  Test that [have shown what appears to be suggesting the existence of this disorder] are not of demonstrative utility when one is trying to determine whether a particular individual has the disorder.  It is not yet known what cognitive deficits are responsible for such group differences.”  I’ve taken an Abnormal Psychology class and we looked at all of the DSM and this was not raised.  Instead we were given the feeling that by learning more of the DSM we were improving our standing as psychologists by leaning on science.  But, pray tell, where is the science in a disorder that has no findings or known assessments of such and the small tests that do seem to show some sort of diagnostic are not viewed as having any utility in diagnosing?  I must ask the question, of what use at all is the DSM?
 
 

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