What Is the “Bible of Psychiatry” Supposed to Do? The Peculiar Challenges of an Uncertain Science

By Vaughan Bell | May 22, 2012 8:45 am

The American Psychiatric Association have just published the latest update of the draft DSM-5 psychiatric diagnosis manual, which is due to be completed in 2013. The changes have provoked much comment, criticism, and heated debate, and many have used the opportunity to attack psychiatric diagnosis and the perceived failure to find “biological tests” to replace descriptions of mental phenomena. But to understand the strengths and weaknesses of psychiatric diagnosis, it’s important to know where the challenges lie.

Think of classifying mental illness like classifying literature. For the purposes of research and for the purposes of helping people with their reading, I want to be able to say whether a book falls within a certain genre—perhaps supernatural horror, romantic fiction, or historical biography. The problem is similar because both mental disorder and literature are largely defined at the level of meaning, which inevitably involves our subjective perceptions. For example, there is no objective way of defining whether a book is a love story or whether a person has a low mood. This fact is used by some to suggest that the diagnosis of mental illness is just “made up” or “purely subjective,” but this is clearly rubbish. Although the experience is partly subjective, we can often agree on classifications.

Speaking the same language
How well people can agree on a classification is known as inter-rater reliability and to have a diagnosis accepted, you should ideally demonstrate that different people can use the same definition to classify different cases in the same way. In other words, we want to be sure that we’re all speaking the same language—when one doctor says a patient has “depression,” another should agree. To do this, it’s important to have definitions that are easy to interpret and apply, and that rely on widely recognised features.

To return to our literature example, it’s possible to define romantic fiction in different ways, but if I want to make sure that other people can use my definition it’s important to choose criteria that are clear, concise, and easily applicable. It’s easier to decide whether the book has “a romantic relationship between two of the main characters” than whether the book involves “an exploration of love, loss and the yearning of the heart.” Similarly, “low mood” is easier to detect than a “melancholic temperament.”

Accordingly, reliable diagnoses consist of a clear list of symptoms that are easy to define and evaluate. This can be evaluated with statistical test called Cohen’s kappa, and results from the DSM-5 field tests have just hit the headlines. Science journalist Ferris Jabr, writing on the latest results of field tests, reported that inter-rater reliability for the new “autism spectrum disorder” diagnosis was excellent, but for two of the most common diagnoses, generalized anxiety disorder and major depressive disorder, it was so bad as to make them unusable.

Talking sense
Good inter-rater reliability is key, but the usefulness or “validity” of the description is equally as important. I could decide on a genre of literature called “Robots or Food.” It’s easy to agree on—any story that includes robots or food is a member of the genre—so it would have a high level of inter-rater reliability. But how useful is it? Do people who like one book in the genre tend to like the others? Do the books in the genre touch on similar political themes? Were they inspired by similar early writers? We classify literature not so much because it’s fun but because it helps us understand the vast sea of writing out there.

Psychiatric diagnosis are judged in the same way. It’s easy to think up reliable ways of classifying mental states, but diagnoses must also be useful. They must describe genuine impairment that can be treated by mental health professionals.

What do we mean by an illness?
In addition to the question about scientific usefulness, psychiatric definitions also involve a philosophical side. The philosophical aspect is common to all medicine and involves the question, “What should we define as an illness?” For example, everyone has a different level of body fat and glucose tolerance. Where should we draw the line to define who has obesity or diabetes? Similarly, we all experience mood changes. When should we say someone has depression? It’s easy to say, “when it has a negative impact,” but we still have to choose the extent of the negative impact, as we can’t define every harmful difference or behaviour as an illness—otherwise we’d all be considered sick.

In other words, what we define as a “negative impact” and “increased risk,” and where we draw the line between normality, free agency, and morality depends on how we value certain aspects of life and well-being. Once we’ve decided on what characterises an illness we can then use science to see if a particular diagnosis is a good fit. Just as in the rest of medicine, there are some clear-cut cases (e.g., dementia, chronic psychosis) but most of the debate happens around the middle ground, where what’s at stake is quality of life and the extent of the impairment, rather than total disability or impending death.

Notice that I’ve not discussed mental illnesses as if they were genuinely distinct pathologies that we are trying to “discover.” This is because these cases are the minority in medicine (largely infections or discrete genetic disorders) and the majority of illnesses of any type are not like this. For example, cancer, heart disease, stroke, emphysema and the majority of non-infectious diseases involve at least some arbitrary cut-off points. Good diagnoses are human creations that help us better capture a group of related symptoms that respond to a similar treatment plan. They are tools, by and large—not inherent truths.

You can see this thinking in action with the DSM-5. One proposal was to include a diagnosis of “attenuated psychosis syndrome” based on the fact that people diagnosed with schizophrenia often go through an initial “prodrome” episode of low-intensity unusual experiences. The idea was to include this diagnosis to catch cases early. But when you look at everyone who has one of these episodes, about 60–80% of them do not go on to develop full-blown psychosis. This proposed diagnosis has now been rejected, as it received a lot of criticism for potentially pathologizing too many people and hurtling them toward inappropriate treatments. It was not considered a useful clinical tool.

Will there ever be “biological tests” for mental illness?
Despite the fact that many psychiatric diagnoses can be made reliably, there is constant pressure to find objective biological tests to replace these descriptive diagnosis. This is in part due to a healthy desire to improve accuracy, but in part due to a fear of being seen as “unscientific,” something which psychiatry is particularly sensitive about due to years of criticism.

The trouble is, biological tests for mental illness may not be possible in many cases. The reason is that there is not always consistent relationship between the conscious mental experiences and low-level biological processes. This is related to the mind-body problem, which says that even though the mind clearly arises from the brain, it doesn’t necessarily follow that the concepts we use to describe the mind can be cleanly mapped onto neurological processes. In short, you can’t talk about one without losing meaning in the other.

Let’s get back to our analogy. No one would deny that a novel comes from the author’s words, but imagine if you tried to classify literature not by reading the book but by doing statistics on the text. You might find some differences—maybe romantic fiction has, on average, longer sentences than cowboy novels, or maybe there are more commas per line in current affairs books than in ones with poetry, but you couldn’t define poetry as a type of text with a small number of commas—it just misses the point. It is hoped that some underlying property will correlate sufficiently with your meaning-level classification to allow it to be used in its place, but it’s not clear that it would be possible to completely replace definitions based on meaning with definitions based on numbers. This applies equally to literature and mental illness.

There is also the issue of whether a particular diagnosis is a good starting point for a biological investigation, as many current diagnoses probably do not describe the result of single discrete disorder—making talk of the “gene for schizophrenia” or a “brain scan for bipolar” probably futile. Think how weirdly you’d look at someone if they said they were trying to find the single thing that had inspired all detective novels—but people do the same thing with mental illness all the time. Often, though, scientists encourage this because it makes their work easier to explain and occasionally because they share a naive belief that the diagnosis perfectly captures something with a discrete cause. This is not entirely ridiculous—in 1913 a mental illness known as general paresis of the insane was confirmed as being caused by syphilis—but the history of modern medicine and psychiatry has taught us that these examples are the exception rather than the rule.

A final compromise
On top of the unsteady foundations of diagnosis are pressures from drug companies (who want diagnoses to sell treatments for, rather than the other way round), insurance companies (who want to change or discard diagnoses because they are costing them too much money), professional organisations (who want to widen the range of problems they can charge for), and researchers (who want to make their name championing a specific disorder). So with all this in mind, you can see why the DSM is so contentious and, some would say, a mess. The irony is that when the DSM-5 comes out, not a lot will change. Most professionals will still use the same handful of core diagnoses and 90% of the manual will be ignored.

It’s also ironic that modern psychiatry has become fixated on classification. The idea is that better classification will lead to better treatment but the majority of treatments are not diagnosis specific and never have been. That’s not to say that diagnosis isn’t a useful tool, but it’s important to make sure that we don’t confuse our tools with actual solutions. If we genuinely want to improve treatment for mental illness, it’s the solutions that matter.


Drawing brain and  abstract brain images via Shutterstock

  • ben cooper

    I certainly agree “to make sure that we don’t confuse our tools with actual solutions” but I am confident that terms like “Schizophrenia” and “psychosis” are damaging tools that make solutions less possible due to stigma and self-stigma. When diagnosis manuals like DSM decrease the likelihood of full recovery as they are built on a 100 year old myth then we need a dimensional model of mental distress rather than another outdated and tired version of a conceptualisation built when we had barely learnt to fly

  • Pingback: What is the DSM supposed to do? « Mind Hacks()

  • Shawn

    The mind-body problem is cop out. It is not a problem anymore. If the tools of the trade (electrophysiology, fMRI, TMS) have taught us anything, it is that speaking about these two constructs in differing terms is futile and a waste of time. Time that could be spent working out the true nature of individual dysfunction. The majority of the DSM describes deviations from the norm. What is so hard for clinicians to agree on? They don’t know what normal is? Go back to college, watch a ball game, ride the bus… find out what normal is before trying to solve abnormalities.

  • Pingback: Talking to Each Other | Humanities and Health()

  • Robert

    Pharmaceutical treatments for mental disorders (excluding placebo effects) do work directly at the biochemical level, so invoking the mind-body problem is merely an excuse for psychiatrists to make themselves feel better about their ignorance of what is going on in their patients’ brains to cause their unwanted symptoms.

    From this electronic engineers point of view, large amounts of modern psychiatry are only a few steps removed from humorism.

  • http://dsm5.blogspot.com/ DS Arrowsmith

    “This is not entirely ridiculous—in 1913 a mental illness known as general paresis of the insane was confirmed as being caused by syphilis—but the history of modern medicine and psychiatry has taught us that these examples are the exception rather than the rule.”

    Not so fast. DSM IV defines mental illnesses as those disorders of cognition, mood, etc. with no known etiology. An illness with mental symptoms is a mental illness until it’s not, until some etiology is uncovered: tumors of the brain or the endocrine system, infections of the nervous system, epilepsy, metabolic disorders (pernicious anemia, porphyria), multiple sclerosis, lupus, Sydenham’s chorea, the list is endless.

    It is reasonable to expect that today’s mental illnesses–schizophrenia, bipolar disorder, etc.– will give up their secrets eventually and join the rest of the medical illnesses.

  • http://1boringoldman.com John M. Nardo MD

    A beautifully crafted piece in a time of cholera. Thanks…

  • Jotaf

    DS Arrowsmith, it’s never lupus.

    This was a very interesting read, and an example of what makes a great article — the use of analogies was spot on!

  • Rozelle

    A diagnosis is necessary for special education. A child must have a label to access resources.

  • Ron Shaver

    The original DSM was short and to the point, acting as a common language so that mental health professionals could agree on what they were seeing as problems with their clients. Now, as you note, it has developed a life of its own and is now an enormous and, even for those of us familiar with it, oftentimes confusing reference. I fear that by DSM VI we will be looking at multiple volumes that serve little or no purpose. A new DSM V diagnosis for children with fluctuating moods has been developed when they can simply be diagnosed with “mood disorder NOS” because Bipolar Disorder doesn’t really fit. Remember that the pejorative terms “idiot” and “moron” were once used to describe levels of intelligence. The American Psychiatric Association has created a monster but this time when the villagers appear with torches and pitchforks they might very well be diagnosed with Intermittent Explosive Disorder!

  • Dan Thompson

    First doing no harm requires the elimination of that word “mental”. It, as much or more than anything, is a huge barrier between many who need help with brain function and receiving the help they need. “Brain” relates to a body part. “Mental” is considered a reflection on the person, usually negative. Get rid of MENTAL. It use does harm, great harm.

  • Pippa

    I think the article has missed the main point of the DSM – it is there so that we can ensure psychiatrists, psychologists and others working in mental health are using a common language. That way we can learn from each other and, yes, do meaningful research. I have been practising psychiatry for about three decades now and have seen the difference in our ability to treat mental illness and restore people to functioning and enjoyable lives. This is why we practice. The DSM has allowed us to do this, sharing results and observations from one practice to another, knowing that what I describe as autism or psychosis is roughly the same as another psychiatrist’s patients with the same label given to their disorder. It is not only drug companies that do research. We have been involved in establishing manualised therapy for children with pain or behavioural disturbance, for moms with post partum depression etc – all done via the web or over the phone so that people who are more isolated can still access non-drug treatment. We have also been involved in school based programs to help children with ADHD and learning problems that lead to behavioural disturbance. Without the common terminology of the DSM we would not have been able to do the literature search that led us to set up an evidence based program that could then, in it’s turn, be researched. The DSM is an imperfect tool – but, a bit like democracy, it is the best that we have.

  • http://none Max

    In the course I had in the psychology of rheab I had both PhD Psychologist and a MD Psychiatrist, (no joke) names were Dr. Winer & Dr. Winer. I will never forget this statement
    “Normal is a narrow line and we all walk on either side of that line.”
    I say to physicians and my students ” Anyone can tell a compound fracture it is the variations less that that which are the hardest.”
    I regret that so many have attacked this aspect of our health care at a time when I see more and more that are on the side of the rope that create problems for themselves and their families.
    How about you use those analogies on heart disease, chronic pain etc.
    You might want to expose your self to the SF-36+D and see where you are.

  • Theresa Meuse

    A presentation by a doctor talking about DSM-5 sayed that it does not include Executive Function disorders. How can this be? Many in the autism spectrum present themselves with EF disfuncion comorbidity. Not having seen the draft myself, I cannot comment further, but if does not metion EF, it makes me wonder what other things it might neglect as well.

  • Tom Parmenter

    All this talk about the purpose of the DSM without mentioning one of the most common uses, coding the condition of the patient for the insurance companies. That is, you can charge for working on conditions named and numbered in the DSM. No other use is so important.

  • Pingback: 3×5: Culture, Neuroscience, and Psychiatry Roundup | thefpr.org blog()

  • http://N/A Stanley Tolle

    One of the big mistakes that appears to be being made in the new diagnostic manual is the elimination of the Aspergers Diagnoses and its placement in the Autistic Spectrum category. As an adult who has been diagnosed with Aspergers I can attest that Aspergers is quite separate from Autism. In my case the little professor syndrome and the inability to socially connect was quite apparent. One of the things that is going on, though, is that conditions such as mine appear to be a developmental disorder. The brain is not quite wiring itself together properly ofter in the higher function part of the brain. Like in my case in areas of language communication and facial recognition, coordination there were extreme deficits. In other areas I appeared quite normal so an Autistic diagnose would not make sense.

    What I do agree with is that the Developmental disorders appear to be related. While I have a Diagnosis of Aspergers this is not the only issue involved. I also have learning disabilities in the form of Dyslexia and ADD but excellent mechanical abilities. I also know of another individual who is Aspergic who has excellent writing skills but is completely befuddled by any thing mechanical. Both of us though have very similar social difficulties.

    There is also the problem of the degree of impairment where the symptoms can vary from mild to extreme. I think this is where the diagnostic manual is having its problem with Aspergers. Since most people with Aspergers are relatively functional there is some thinking that these people are not sick but just a little out of the normal range. This I think is quite wrong since the people that I know that have this milder form of impairment are having real problems and that category such as Aspergers truly helps in obtaining assistance and understanding.

  • http://canardtheduck.blogspot.com/ canardtheduck

    Great summary of the challenges of devising a system of classification of psychiatric disorders. You do however fail to answer the most important question which is how valid are these disorders? Validity extends far beyond dysfunction and is not the same as utility Instead it speaks to the existence of these disorders in external nature. Psychiatric diagnoses for the most part are not valid. We assume the same process underlies what we see in patients with a similar diagnosis such as schizophrenia but this seems unlikely to be the case. That so much is invested in these diagnoses as valid constructs, guiding treatment, suggesting an etiology, identifying risk factors and so, suggests that DSM is more than just a framework or set of diagnostic guidelines that can be easily discarded.

  • Korthone

    Some of this I don’t agree with. Why is there a problem in defining “illness”/”disease”? It is very clear, really, that these terms should be used only when someone is disabled (unable to provide for oneself and fulfill basic social obligations) or when someone is seeking help with some condition (which may involve pain, etc.). Trying to define anything else as “illness” is a marketing ploy, which is particularly disgusting coming from among psychiatrists.

    In reality, there can be a positive spin to medicine as a whole: instead of illness, doctors would encourage people to look for ways to increase one’s well-being. That is not to treat attention deficit, but to increase one’s attention. The difference is semantic but critical. Perhaps, in this way, our culture will become less sick.

  • Lilgirlblue

    What a superb analogy – particularly the bit about analysing literature by the letter and character to come up with a definition that doesn’t necessarily map onto the genre really at all.

    Through my psych studies I’ve started thinking about a great many things in terms of distance from a mean, and thinking of classification and categorisation in this manner has saved me a lot of mental wrangling when it comes to “is it X or is it not-X dammit” questions.

    In this respect, this article reminded me of Eleanor Rosch’s work in categorisation. Technically, a chair and a fishtank are both furniture, and a sparrow and a penguin are both birds, but we tend to see the first as a more prototypical example, and the second as further from central definition of what we consider furniture. Or birds. Depending what you’re talking about. (Wow, writing this torturous paragraph has left me with even more respect for Mr. Mindhacks’ lucidity above!)

    I think articles like this are tremendously important in ensuring that we think critically about what it is the DSM represents and what is designed to do. An understanding of its limitations is essential in order to exploit its strengths.

    Additionally, Mindhacks rocks and I completely adore it!

  • susurruss

    You fail to acknowledge the reason so many are calling for biological testing for mental illnesses. It is because of the phrase invented by psychiatrists: “chemical imbalance.” This catchphrase has been used so widely and for so many years, it is generally accepted to exist. It does not. Problem is, there is no known NORMAL brain chemical balance related to mental functionality, and no working test on living subjects has ever been devised. The vast majority of psychiatric drugs are marketed to ‘correct’ a ‘chemical imbalance’ that has never been proven to exist. This is what the true fight over the generalities in the DSM is about.

  • Pingback: Zero Degrees Of Empathy by Simon Baron-Cohen « unfebuckinglievable()

  • DietrichB

    I agree about the huge harm of stigma from the mental death profession with its bogus, life destroying degradation ceremonies via the DSM or BOOK OF INSULTS to serve the most powerful in society while destroying their victims just like any fascist country a la Soviet Russia in the guise of mental health. See books like MADNESS CONTESTED, THE MYTH OF MENTAL ILLNESS, PSEUDOSCIENCE IN BIOLOGICAL PSYCHIATRY, THE MYTH OF THE CHEMICAL CURE, AMERICA FOOLED, RETHINKING PSYCHIATRIC DRUGS, ADHD FRAUD, TRAUMA AND RECOVERY, DE-MEDICALIZING MISERYTHEY SAY YOU’RE CRAZY, MAD SCIENCE, THE SELLING OF THE DSM, MAKING US CRAZY and many others exposing this fraud and the worst medical crimes ever perpetrated against humanity per Dr. Fred Baughman, Neurologist. As Dr. Joanna Moncrieff exposes in her great essay, “PSYCHIATRIC IMPERIALISM,” psychiatry exists for the sole, soulless purpose of social control by which once one gets one of their bogus, life destroying stigmas, a preset abusive set of power rituals comes into place whereby the victim becomes a patient, discredited, disempowered, harmed with lethal, brain damaging drugs and ECT (this barbarity making a horrific comeback with the bogus lie it works for so called melancholia), silenced and ultimately destroyed.
    So, those self serving people practicing this BIG PHARMA funded enterprise of biopsychiatry have much to lose by having the truth exposed while their so called patients don’t have so much to lose since they have lost just about everything thanks to the mental death profession!
    The fact that Robert Spitzer, the malignant narcissist who created the horrific monstrosity now called the DSM III+ by treating people like rock specimens as he did in his own arrogant life, admitted that if any real causes of people’s stress and suffering such as abuse, bullying, predation and oppression by the power elite; domestic/work abuse/violence, job loss, divorce, poverty, humiliation, racism, sexism, homophobia and the millions of other harms done to humans by other humans (especially by psychopaths and narcissists ignored by psychiatry since it hits too close to home and/or they don’t want to deal with these nasties themselves per book, STALKING THE SOUL, so they prey on and stigmatize their victims as easier marks) the whole bogus house of cards of the DSM would come tumbling down. Plus, this great switch by psychiatry unbeknownst to many older people allowed them to trap many unsuspecting victims into their death trap or TOXIC PSYCHIATRY per Dr. Peter Breggin when people thought they were going for validation, support, advice, counseling!!! The fact that psychiatry is still portrayed in movies and the media as counseling when the NEW YORK TIMES writes about the horrific psychiatrist seeing about 40 people a day for med checks to maintain his high income is monstrous indeed since so many have been misled by this scam and TV shows like IN TREATMENT and even THE SOPRANOS about what psychiatry is and does now.

    So, sure, the mental death profession may be able to describe some of the outer stress symptoms of these gross injustices due to increasing injustice, oppression, enslavement, exploitation and theft by the 1% power elite that psychiatry really serves to push their lethal drugs and cover up all the damage done to other humans.
    A great book, MANIPULATION, talks about the power of repetition to perpetrate an evil lie, so it is interesting that the mental death profession keeps repeating its bogus DSM lies and fraud more and more vociferously the more they get exposed for being total junk science, lies and fraud!
    So, finding biological tests for this evil, massive coverup of gross inhumane social injustices is just another bogus farce perpetrated by biopsychiatry given that the new bogus lies and junk science are now being funded by the chief biopsychiatry fraud, Thomas Insel. They may be able to point to certain biological evidence of the stress and trauma suffered by the mental death profession’s many victims they only revictimize and retraumatize by aiding and abetting their fellow abusers, misogynists and other perpetrators in power, but they will never admit the real cause of their victims suffering and stress since their real job is to cover it up, hide it and lie and deny it!!


Discover's Newsletter

Sign up to get the latest science news delivered weekly right to your inbox!


See More

Collapse bottom bar