Diagnosing the Diagnostic and Statistical Manual of Mental Disorders

Martyn Pickersgill, PhD
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Rachel Cooper (2014) Diagnosing the Diagnostic and Statistical Manual of Mental Disorders. London: Karnac. 

What can we say about the DSM that hasn’t already been said? Quite a lot, actually. The manual (full title: the Diagnostic and Statistical Manual of Mental Disorders), produced by the American Psychiatric Association, is incredibly powerful. It shapes research agendas, clinical practices, social care, economic decision-making and individual experiences internationally. As Rachel Cooper notes in her excellent new book, Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, changes to it impact ‘the lives of as many people as changes in the policies of most countries’ (p. 2). The DSM needs to be talked about.

With the new fifth edition of the DSM released last summer, we shouldn’t be too surprised about the fact that a large number of people are talking a great deal about this manual. Clinicians, scientists, care workers, patients and activists are reflecting upon (and arguing about) their hopes, fears, expectations, and disappointments with the DSM-5, and the place it will have within societies. What’s gone in, and what’s been taken out, are big issues. After all, each time a new edition comes out ‘diagnoses can be included or excluded, expanded or restricted. Interested groups must thus maintain pressure to ensure that their interests are protected, and lobbying activities can go on for decades: to get a single edition of the DSM as one desires is only to win a battle – winning the war requires longer-term effort’ (p. xii).

These issues – the inclusion and exclusion of diagnoses – form part of the focus of Cooper’s monograph. She examines the introduction of hoarding disorder, and attends to the removal of Asperger’s disorder. The former case allows her to reflect on the apparently expanding remit of psychiatric concern, whilst the latter enables a useful exploration of the role that lobby groups can and do play in shaping diagnostic constructs. Such issues speak to the ways in which wider scientific and social conversations and debates contour the terrain of psychiatry.

Noting how ‘individuals’ lives are radically affected by whether they receive, or lose, a DSM diagnosis’ (p. 47), Cooper is nevertheless careful to (quite rightly) point out that ‘one can’t predict in advance of an edition having been used for some years which changes to the DSM will turn out to matter: while some changes will come to affect the lives of millions, others will pass largely unnoticed’ (p. 12). After all, the ‘rates with which diagnoses are made depend not only on the contents of the DSM, but also on the economic, cultural, and bureaucratic contexts within which diagnoses are made’ (p. 12). Simply introducing a new diagnosis is not sufficient to give it life within the clinic and wider society: at the very least, many psychiatrists have to want to use it, and a certain number of patients have to be willing to accept it. These are important points which are confirmed by some existing social scientific research into psychiatry, and which should also direct future sociological and anthropological engagements.

One of the refreshing aspects of Diagnosing the Diagnostic and Statistical Manual of Mental Disorders is its tendency to be critical, without falling into the trap of simply rehearsing already well-worn criticisms of diagnostic systems per se and psychiatry more broadly. Cooper seeks to ‘distance [herself] from any generalised “anti-psychiatry” critique’ of the DSM” (p. 39), and is resistant to presenting a reductionist account of the American Psychiatric Association (APA) as simply an agent of pharmaceuticalisation. As she puts it, some members of the APA ‘always seek to “do the right thing”, and will support moves that they believe to be in the interests of patients even if these go against the narrow interests of organised psychiatry’ (p. 22). At the same time, Cooper is far from shy about interrogating the considerable vested industry interests that have shaped the DSM, and interrogating claims to transparency and democracy regarding the writing of the text. Further she writes compellingly and carefully about the notion of ‘reliability’, and argues for the importance of considering context of use when praising or castigating the diagnostic categories contained within the DSM for being ‘reliable’ (or not).

Cooper, it’s fair to say, is one of my favourite philosophers of mental health. I opened her new book looking forward to a clear, cogent and grounded articulation of some of the conceptual and practical issues associated with the writing of DSM-5. I wasn’t disappointed. Diagnosing the Diagnostic and Statistical Manual of Mental Disorders deserves a wide – and a wide-ranging – readership. No doubt it will get it.

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