Questioning the Underpinnings of Psychiatric Classification Systems

A new review of psychiatric nosology by Aftab and Ryznar highlights how diagnoses emerge from particular conceptual frameworks.

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Psychiatric classification systems only make sense within particular conceptual frameworks. Moreover, these frameworks make certain assumptions about knowledge-making, the origin of disease, and principles of diagnosis – principles that dictate, for example, whether we classify disease based upon symptoms or causes.

New scholarship by psychiatrists Awais Aftab and Elizabeth Ryznar provides a comprehensive review of the conceptual and historical evolution of psychiatric nosology, which refers to the branch of medical science dealing with the classification of diseases.

While the model of diagnosing psychiatric illness based on collections of symptoms, enshrined in the DSM-V, is a recent invention, the practice of looking to symptoms instead of causes to categorize disease is not new. As Aftab and Ryznar write:

“The tension between symptom-based (i.e., descriptive) versus causation-based (i.e., aetiological) classification systems was … present in the 18th century, and it continues to this day.”

Many, including former NIMH head Thomas Insel, have criticized the DSM’s symptom-based approach to classifying mental challenges. Indeed, the DSM has been assessed as “scientifically meaningless,” enshrining diagnostic categories that are contradictory, subjective, and heterogenous to the point of being unusable. Further, DSM panelist members have documented ties to the pharmaceutical industry, presenting egregious conflicts of interest. Others have pointed out that the DSM’s classification of mental disorders is also based on culturally and historically contingent symptom profiles.

Critics of psychiatric diagnosis in general point to the physical, mental, and epistemic violence that is enabled and legitimated via appeals to psychiatric categories. In addition, institutional acts of categorization can themselves be iatrogenic, racially-biased, enact epistemic violence, and justify harmful practices such as forced treatment that violate international principles of human rights and exacerbates problems of racial justice.

In their previous work, both Aftab and Ryznar have advocated for the reform of psychiatric training and practice through increased engagement with the philosophical assumptions of the field, critiques made by critical psychiatrists and service-users, the history of psychiatry, and approaches that avoid biological reductionism.

In their new article, Aftab and Ryznar place the ascendancy of the DSM, and the ultimate move toward symptom-based diagnostic systems, within the historical context of new demands for statistics emerging in the arena of public health throughout the 19th and 20th centuries.

In the mid-19th century, they write, that “the field of medical statistics experienced burgeoning growth driven by the need for accurate reporting of hospitalizations and causes of death.”

Thus, they argue that the DSM was born under increased pressure to quantify and report on health statistics for use in public planning. Although all classification systems have been subject to criticism for various gaps and issues, the DSM helped further the goals of medical statisticians.

The history of psychiatric nosology thus emerges as complex and divergent, pushed in one direction by biopolitical projects of classification and statistical analysis, and on the other by attempts to locate and treat underlying causes of mental abnormality and suffering.

Yet, despite its practical value, the DSM’s failure to meet the standards of medical science could point to a more enduring revelation about the nature of the subject of psychiatry itself.

“The difficulties and uncertainties that psychiatric nosology faces do not necessarily represent a ‘failure’ of the psychiatric project,” Aftab and Ryznar write, “but could also represent a ‘discovery’ of sorts of the limitations of the project of scientific classification itself.”
“Such a realization could conceivably help improve strained relationships between psychiatry and other stakeholders, facilitate pluralism in practice, and enhance clinical care.”

This nuanced, pluralist approach to the tenets of mainstream psychiatry would be a welcome change for those who have suffered under the DSM’s classificatory regime.

 

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Aftab, A., and Ryznar, E. (2021). Conceptual and historical evolution of psychiatric nosology. International Review of Psychiatry, 33(5), pp. 486-499. (Link)

11 COMMENTS

  1. The DSM is nothing more than slapping people with labels which will stay with them lifelong, resulting in becoming persecuted and abused by the very systems that labeled them.

    Every person should be warned about seeking help, because what most people want is support, the right supports and that is the last thing you will find in psychiatry or many therapies.

    You are better off being your own guide, much better. It could save your life, or make it a better quality.

  2. This would be the same Dr. Aftab often called out at MIA for defending psychiatry in the guise of critiquing it (e.g., https://www.madinamerica.com/2020/11/dr-aftab-interviews-dr-pies/).

    Three quick points. First, the authors conveniently ignore that the ascendancy of the DSM is a result of psychiatry marketing the DSM-III and the biomedical model, in partnership with pharma, to rebrand itself as a legitimate branch of medicine.

    Second, the authors ignore the single most important conceptual framework of the DSM: the notion that any thought, feeling, or behavior in its symptom checklists are abnormal “symptoms” regardless of the context in which they occur and represent a “manifestation of a pathological condition” (quoting DSM-5). Feel depressed or down 2 weeks after a loved one dies? That is a “symptom” – in other words, not an understandable response given the circumstances but a pathological and deviant expression of a medical illness located within the individual that has nothing to do with that individual’s history and context. That, by far, is the most fundamental conceptual framework embedded in the DSM. This framework is inherently dehumanizing and stigmatizing, transparently ridiculous, and is the core philosophical assumption of the profession of psychiatry without which the profession would have no rationale for existence. No wonder the authors, including the duplicitous Dr. Aftab, didn’t mention this in their “critical analysis” of conceptual frameworks related to psychiatric classification.

    Third, the authors write, “The difficulties and uncertainties that psychiatric nosology faces do not necessarily represent a ‘failure’ of the psychiatric project,” Aftab and Ryznar write, “but could also represent a ‘discovery’ of sorts of the limitations of the project of scientific classification itself.” Bullshit. As Thomas Szasz observed, real medical diseases exist and are easily and objectively proven. Psychiatric “diseases” are difficult to classify scientifically because they only exist in the minds of people who create and use them.

    • I concur with Steve, you’ve captured the fundamental bankruptcy of psychiatry as (I think) I’ve ever read in so few words. Not to put too fine a point on it, if I may, but far too often, after an initial diagnosis and subsequent drugging-from the very flawed and doomed premise you so clearly framed, further damage ensues through revised diagnosis and drugs viz the ‘very same’ premise. (the ADD diagnosis to bi-polar in zero flat an easy example) I understand this falls under the iatrogenic category. But I bring it up to point out that there is a critical distinction between incidental harm and structural harm, and I don’t think its a stretch to suggest that the iatrogenic harm from psychiatry is almost entirely, at this point, structural harm (reckless-intentional and imminent). But, even from this glaring failure point, not to mention the tragic personal and social cost, is yet deeper levels of passive structural failure/harm. No need to jump into that now, suffice to say that macro structures and their moral moorings have consequences beyond their institutions PR campaigns.

  3. “We argue that a multi-dimensional, multi-level extended evolutionary meta-model (EEMM) provides consilience and a common language for process-based diagnosis. The EEMM applies the evolutionary concepts of context-appropriate variation, selection, and retention to key biopsychosocial dimensions and levels related to human suffering, problems, and positive functioning. The EEMM is a meta-model of diagnostic and intervention approaches that can accommodate any set of evidence-based change processes, regardless of the specific therapy orientation. In a preliminary way, it offers an idiographic, functional analytic, and clinically useful alternative to contemporary psychiatric nosological systems.”
    Steven C. Hayes, Stefan G. Hofmann, Joseph Ciarrochi,
    A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model, Clinical Psychology Review, 2020
    https://www.sciencedirect.com/science/article/abs/pii/S0272735820300969

  4. “This nuanced, pluralist approach to the tenets of mainstream psychiatry would be a welcome change for those who have suffered under the DSM’s classificatory regime.”

    Realistically, it may be too late for many of the people who have suffered under this regime for any new approach to make any difference.

  5. The DSM reminds me of a Medieval Witch Hunters Manual.
    The Witch Hunters Manual was a Concoction..The Witch Hunters were always evil and sometimes deluded.
    https://en.m.wikipedia.org/wiki/Malleus_Maleficarum

    The first thing I noticed on my introduction to Psychiatry was the amount of normal young people that were claiming to be seriously mentally ill.

    I considered myself to be unwell when I was completely incapable of coming off “medication”. But I was lucky to be able to gain some insight into what was happening, and once I had this I was on my way to independence.

    I have also witnessed people in peer groups recover very quickly from lives of complete desperation, with the help of their friends.

  6. I should not comment….I peeked when I should not have…I’m sorry…but before I wash my coffee cup I feel I need to be a clever clogs.

    Someone should do a cartoon book…100 things you can do with a DSM book.
    Doorstop.
    Flower press.
    Yoga block.
    Apocalyptic prepper’s bunker kindling.
    Workplace Secret Santa gift.
    Gardening kneeler.
    High cupboard step.

    How many DSMs does it take to change a light bulb?
    One.
    Because its so tall now either all lightbulbs are within touching distance or if read half way up it may convince you there never was a lightbulb and the darkness is entirely yours.

    Jokes aside. I, myself, do not want diagnosis phobia. Civilization will always rush to diagnose me as a woman and that is enough for my brain to be called into question any time I submit a little poem to a magazine. There are still hardly any famous female poets. Nobody asks why.
    People will always find ways to call out differences. Positively or negatively.
    Bad treatment is what I think people should focus on ceasing, whatever profession or non profession metes it out.

    A DSM has been a way to…
    Call out difference.
    Excuse bad treatment.

    Those are two different things. A person can be different without that asking for bad treatment.
    Certain groups of people have been historically persecuted because they were deemed to have an unpopular sort of difference. Such as women in Afghanistan. Women in that country could petition for books that describe women as being “a difference” to be rewritten. I think that way of thinking allows persecution to persecute even further by requiring language to be made safe. It is not neutral language that needs to be made safe. A child can say any words, any words at all, without such words actually hurting anyone in any serious way. Words are empty air and sound vibrations. It is not language that should change and accomodate for the fact there are oppressors but oppressors themselves who should accomodate for the fact that using neutral language to oppress anyone is not alright.

    As for diagnosis. I just would say that “pain” is a sensation that can come from bodily disease of a known cause. But “pain” can come from mental anguish also. I am not in agreement that “pain” is always normal and healthy. Grief is a normal part of life and it causes pain, but to some grief causes such overwhelming pain that there comes a concrete wish to join the departed. That person in such colossal pain, perhaps through the loss of three children in a house fire, is probably at that moment feeling “ill”, as in out of sorts. That pain may riddle their brain and body with hormonal imbalance at least. By that point their brain and body is involved since these are interwoven. You could say that it is all just normal for someone who has had to bury three children to feel terrible and leave it at that, maybe send them to chat with an expensive grief counsellor once a long lonely week to talk it all through. If the bereft one says it does not work and they still want to jump off a bridge maybe the counseller will just tell them not to worry since there are no illnesses anymore and what they feel is “normal”.

    What feels “normal” to each unique individual is for each unique individual to say. That means that if an individual feels they are feeling abnormal to themselves and to their own understanding of who they are, that too should be respected.

    A society should resist calling perfect strangers normal or not nomal but rather listen to how the stranger feels about themselves.

    Some of the DSM has been an attempt to hear what some people have felt was distressing for themselves. But the DSM did so in brisk medicalese and whilst medical language is as neutral as any language, it ushered an air of chilly detachment in “dealing with” vast numbers of people with distress. This chill encouraged the advent of defining “difference” from the professional spectating point of view, not the sufferers own point of view, a sufferer who still needs to talk about feeling different and feeling distressed or ill according to themselves, and not some oppressive societal standard.

    To recap…
    Bad treatment should be banned.
    Seeing language as the cauldron of hatred is a ruse. Words alone are not the problem. Hatred is the problem.
    Sometimes a person is in too much anguish for themselves and they themselves may want to call that abnormal pain “feeling ill”. That “feeling ill” is the main thing to recognize and respect and not whatever faffy names the person chooses to asign to that “feeling ill” experience. To get endlessly stuck on fussing about what consitutes “feeling ill” and what we all now “must” or “must not” call our own unique understanding of our own illness, is to stick irritating sequins on other peoples ballgowns.

    Some people want to believe their feeling ill is from a classy DSM classification. Others want to believe their feeling ill is because their astrological birth chart has Jupiter in opposition to Pluto. And others want to believe it is because a workplace ploy is determined to hypnotize them into thinking they feel ill. Everyone is “different”.

    The drive to pulp the DSM merely because it points out the fact that there is “difference” could wind up as everyone not allowed to say they “feel different” or even in “pain”.

    (please don’t reply, this is just my hurried kitchen sink, observational comment regards the stellar article).

  7. Let’s See… The psychiatrist along with their little helper, the “trained LCSW therapist” “diagnoses” them with some “mental illness” description as listed in the DSM; which is actually more like a horoscope personality description (each one can fit anyone at any one time or all at the same time due to their vagueness and nebulousness) and from that highly scientific decision, they prescribe these psych drugs which affect the brain and body alongside “psychotherapy” which is just a perpetual reduncy to reinforce the psych drugs in both body and brain— and then what happens— the brain and body become the alleged sickness— the symptoms magically appear and reappear— but worse, the body and especially the brain become damaged— some of it may be irreversible. But, no matter what, the psych drugs and the therapy have done their damage. And, although when the person frees him or herself from psychiatry’s evil world, the person now must deal with the brain damage and other “side effects” from the drugs that never ever end.— Oh, did I forget to mention the withdrawal from these drugs, that almost everyone who has taken them must endure. You see, there is absolutely no justification to do this to people. And they do this irregardless of age or maturity of the body and brain. So, I again there is no justification. The entire psychiatric system is corrupt and criminal. The only thing that psychiatry can be do now is to repent of the evil. And those who have been abused by this evil— flee, leave, pay attention to what has been done to you and live your life accordingly but in such a manner that you win and they (psychiatry) lose. Even if it’s in your own mind or by the way you conduct your life and yourself each moment of your life and always be thankful that you have been saved from this evil and are now forever free. Thank you.

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