How to Critique the DSM

I've just finished reading Rachel Cooper's excellent, and remarkably unsung new book "Diagnosing The Diagnostic And Statistical Manual of Mental Disorders". It came out in May and it's hard to believe I hadn't run across it until now. In a debate that becomes polarised and heated with alarming speed, Rachel Cooper is a calm and insightful voice. Her book (replete with a brilliantly irreverent cover, which makes you wonder at first if it's part of the "official" series of companion texts published by APA) is only 60 pages, but it packs more substance into that space than many of the books on psychiatry I have read recently.

Given the book's relatively low profile (at least, apparently, in clinical circles), here is a summary of the its arguments:

- Cooper is unsure about what to call those protagonists in her story who receive diagnoses. She finds "survivor" "too angry" (something I like about a certain strain of philosopher is that they openly admit the role of personal temperament in their thought) and makes the point that "client" can be disingenuous. The nature of mental health care is such that, in many instances, it simply isn't the case that an individual is paying, in the manner of client, for a service that they straightforwardly want to receive. She opts for "patient".

-Cooper is skeptical about the APA's own attempts to manage the financial relationship between the DSM and the pharmaceutical industry. Limiting the present pharmaceutical interests of clinicians involved in the DSM is simply inadequate when the relationship between doctors and drugs companies is ongoing over the course of a career. Such relationships are more like what anthropologists call a gift relationship where "gifts are given and received over time, and thereby create real but non-explicit obligations for reciprocation in the future" (p. 15). Cooper suggests that only complete independence from the pharmaceutical industry can save the DSM from this sort of malign influence, but that this sort of step would require "nothing less than a revolution" in the way research is funded.

-The APA invited patient involvement for the creation of DSM-5, but this was, in Cooper's view, largely tokenistic. How informative can it really be for the working groups to hear information in the random, bitty way invited by the online-comment feedback structure it provided? Drawing on the sociology of science Cooper points out that the questions that get researched, and the conclusions that are drawn are partly a function of who does the asking. She advocates for the presence of "patient researchers" who are trained to do research but also happen to be patients. This seems a sound proposal, though it is hard to imagine some critical mass of patient-researchers being reached without an extraordinary recruitment drive. Perhaps the best model is Hearing The Voice, which tries to amalgamate the tools of researchers with the priorities and subjective experience of people with first hand encounters. Charles Fernyhough describes the project in this Lancet article.

-It is not just big pharma that drives the inclusion of new diagnoses. Hoarding Disorder is new in DSM-5 and was, Cooper argues, the result of a combination of public awareness (Hoarding has become quite popular on Channel 4 in recent years) and of the development, by Randy Frost, of a specific CBT protocol, replete with inclusion criteria. Cooper suspects Hoarding Disorder is a bad thing, and suggests that it is more analogous to an "unwise" habit like eating unhealthily than a psychiatric disorder. As such, it might be better suited to interventions which bear a resemblance to Weight Watchers than to the ministrations of health professionals.

-Fascinatingly, the standards for reliability seem to have shifted quite a lot between DSM-III and DSM-5. In 1980, Spitzer and his colleagues set a kappa (a metric for estimating reliability) of 0.7 as the "acceptable" threshold. In the field trials for the latest edition, the goalposts have shifted and kappas in the order of 0.5 and 0.6 are now regarded as acceptable (the issue is handled more extensively in this post by 1 Boring Old Man, which Cooper herself cites). Cooper suggests this may be the result of greater attempted precision in the latest manual, but her main concern is how to make sense of the question of reliability. In her survey of the changes in the definition of "acceptable" reliability, Cooper brings out the sense of how little agreement there is over how to use this metric. More work is needed on what, for a psychiatric diagnosis, constitutes reliable enough.

-Ultimately Cooper concludes that the DSM's days are numbered; not because an anti-psychiatric tide will wash away psychiatric diagnosis for good (Cooper explicitly distances herself from anti-psychiatric positions), but because of the likely rise of other classification systems in research (like the RDoC) and of other psychiatric jurisdictions in which mental health care is expanding (such as in China). She advocates not the abolition of diagnosis, but a more flexible thinking along the lines of philosopher John Dupre's "promiscuous realism". Interestingly Richard Bentall has recently advocated this in the case of psychosis.

This is a refreshing and constructive book. One approach to the DSM is to reject diagnosis altogether, but this sets up a seemingly unbridgeable divide between those who do and those who don't reject diagnosis. Cooper's approach is more painstaking. There is plenty wrong with the DSM and Cooper has thought hard about it. Not content with critique, she also tries to envision remedies.