Monday, 7 July 2014

DSM-5 and the future of psychiatric diagnosis

I am in Geneva at a Brocher Symposium on DSM-5 organised by Matthew Smith. It is an interdisciplinary session with philosophers, historians, anthropologists and clinicians. My own contribution was to be a discussant for a paper by Vicky Long on the history of the the diagnosis of occupationally caused mental illnesses. Playing that role reminded me of the difficulty of commenting on one discipline from within another: the worry that one is simply missing the point. For example, if a paper charts the history of actual happenings, is it at all relevant to ask normative questions about whether something else would be or have been better? At its best, I guess that philosophy might be able to tease out some of the concepts both as deployed by historical 'actors' but also by historian analysts. (I lingered on the difference between work's tedium and the ennui and alienation it rationally prompts, on the one hand, and, on the other, it causing illness and then further how stable that distinction was.)

So far I am mainly chewing over a paper by Rachel Cooper, a precursor to which I heard last year. What was familiar was the idea that, just as the qwerty keyboard has become stuck because of the inertia of its beurocratic connections long after its initial rationale has ceased to apply, so the multiple uses of the DSM means that it is practically impossible to change (I can imagine Bruno Latour providing actual economic costings for changing it). That thought connected into a comment about the continuity, despite earlier talk of paradigm changes, of the actual content, the categories etc, of DSM-IV and DSM-5. What was new, however, was the fact that some framing comments about DSM have changed. The concept of disorder is no longer necessarily value-laden (it just usually is). DSM-5 is no longer supposed to be atheoretical but is grouped with the hope of spotting underlying theoretical uniformities. And... From this, Rachel drew two conclusions: there is no close connection between the theoretical frame of DSM and its content. And second, there is no reason to assume that the DSM has any single underlying broader conception of illness and healthcare. Afterall, it is written by several quasi autonomous subgroups and is read selectively and differently by its different readers. So the frame serves a less than obvious purpose. This prompted Gavin Miller to suggest, among other things, a kind of religious text analogy for the rhetorical purpose of the frame.

I am not sure about that. But there does seem to me to be an interesting question what the purpose of general definitions of disorder, or general comments on culture (discussed later by Stefan Ecks), is. Surely not, for example, to offer genuine guidance on whether a particular condition is a disorder (for the sorts of reasons Neil Pickering stresses). But to address that question would require some decision about the ground rules for answering it, for example, the role of the authors' intentions.