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Skinner, B.F. (1953) Science and human behavior, New York: Macmillan.
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Chapter 4 Diagnosis, classification and the expansion of the therapeutic realm
David Harper
Contents
Introduction 103
1 The first two editions of the DSM 106
2 Challenges to psychiatry’s legitimacy: the road to DSM-III 1082.1 Empirical challenges: the validity and reliability of diagnosis 1082.2 Campaigning and diagnosis: the fall of one category and the rise of another 109
3 DSM-III and DSM-III-R: Spitzer’s revolut 111
4 DSM-IV to DSM-5: the end of an era? 1134.1 DSM-IV and DSM-IV-TR 1134.2 DSM-5: the end of Spitzer’s revolution? 113
5 Debates about DSM-5 and psychiatric diagnosis 1165.1 Reliability and validity redux: the appropriateness of a medical lens and the role of social norms 1165.2 Medicalisation and the expansion of the therapeutic realm 1195.3 The continuing impact of the DSM 122
Conclusion 123
Further reading 124
References 125
Introduction
‘Blue’ by Nevova Zdravka
As you saw in the preceding chapters, a medical framework is one of the dominant ways of understanding the kinds of psychological distress and behaviours that are collectively referred to as ‘mental health problems’, ‘mental disorders’ and ‘mental illnesses’. This chapter will focus on the assessment and categorisation of mental health problems via the medical practice of diagnosis, using the sets of categories and criteria found in diagnostic manuals. In the UK, service users are given a psychiatric diagnosis from the International classification of diseases (ICD), currently in its eleventh revision (ICD-11; World Health Organization (WHO), 2018). This international manual covers both mental and physical health. Another manual, published by the American Psychiatric Association (APA), is also extensively used internationally: the Diagnostic and statistical manual of mental disorders (DSM), currently in its fifth edition (DSM-5; APA, 2013). This chapter will focus on the latter manual because it has a significant international impact (e.g. on research and on other manuals, such as the ICD) and because it has been the focus of significant scholarship and research.
In medicine, a diagnosis is used to:
categorise the type of problem a person has
identify treatment options and their likely outcome
provide access to other kinds of support
inform research
inform the planning of health services.
The following quotations are from two people who received a psychiatric diagnosis. The first, Mike Shooter, is a psychiatrist who chose to speak openly about his experiences of depression, while the second is a mental health service user.
When I was told that I was depressed it gave me a framework of understanding and a first grip on what was happening, not just for me but for my wife and children who had been equally frightened by my behaviour.
(Shooter, 2010, p. 366)
You only have to look at the definitions given in ICD 10 and DSM IV and read comments such as ‘limited capacity to express feelings … callous unconcern for others … threatening or untrustworthy’ … [o]ne thing that these comments have in common is that they are not helpful in any way.
(Castillo, 2003, p. 128)
This chapter explores why such opposing opinions exist, outlining why some service users find diagnosis helpful and why others find it unhelpful.
This chapter aims to:
provide a basic explanation of psychiatric diagnosis and the systems of psychiatric classification found in diagnostic manuals
explain what medicalisation is and understand its role in the categorisation of certain problems in living as ‘illnesses’ and ‘disorders’
understand the ways in which diagnoses have changed over time and some of the reasons for these changes
evaluate some of the conceptual, ethical and practical problems involved with diagnosis.
1 The first two editions of the DSM
The DSM is based on the premise that mental health concerns can be medicalised. Prior to the first edition of the DSM, a number of different diagnostic systems were in use. Often these were focused on gathering basic statistics about patients in asylums and concentrated predominantly on psychoses. In 1946 the US War Department published a classification system called Medical 203 (War Department Technical Bulletin, Medical 203, 1946) organised around a categorical system of diagnosis. This was a broad system that focused on two ‘types’ of problems: those seen as primarily organic in origin and those seen as more psychological in origin. The term ‘disorder’ was used to refer to major categories but, for subcategories, the term ‘reaction’ was used. This reflected a broadly psychodynamic tradition in US psychiatry that saw problems arising from a dynamic interaction of biology, personality and social circumstances.
Medicalise To treat mental health concerns as though they are medical conditions that can therefore be diagnosed and treated.
Categorical system of diagnosis A system of organising diagnoses that assumes that mental health problems are distinct – that they have clear boundaries – and can, therefore, be differentiated from each other using diagnostic criteria.
Published in 1952, the first edition of the DSM (APA, 1952) was designed to be consistent with the ICD-6 (WHO, 1949) – the term ‘reaction’ was used both in the DSM and ICD. The DSM was heavily influenced by Medical 203 and was essentially a nine-page list of categories and codes followed by a longer section providing definitions and symptom descriptions. The categories were organised based on presumed causes. Sections with presumed organic and biological causes, such as ‘mental deficiency’, were differentiated from disorders seen as having psychological origins, including ‘psychotic disorders’, ‘psychoneurotic reactions’ and ‘personality disorders’ (which had been included
