When Ronald Reagan was elected president, the world of psychiatry changed forever. In the political compromise that was DSM-III, psychoanalytic theories that were the basis of DSM-II were abandoned in favor of the biological overtones of Kraepelinian nosology. But in 1980 there had to be a biopsychosocial compromise; one could not overtly say that anything was purely biological or psychological or social. Enough ambiguity had to be allowed so that any condition could be taken in any of the three directions by the two clinical camps of psychopharmacologists and psychoanalysts. The term "disorder" was suitably vague and eclectic enough to serve the purpose. To underscore the point, the writers of DSM-III explicitly emphasized that the nosology was now "atheoretical" or "agnostic" about etiology.
This ideology of etiology was, in retrospect, an exercise in self-deception. It is now a truism in modern philosophy of science that there are no facts without hypotheses; there is always a theory behind everything we say or do; even the claim of absence of theory is itself a theory.
In fact, this wish to avoid theory lead to its predictable contradiction: many comment on the "reification" of DSM categories. Once a diagnosis makes it into the DSM lexicon, the "disorder" is typically translated, quickly and unconsciously in the minds of clinicians and the public, into disease concepts. All disorders are seen as diseases, hence the pathologization which has become the bête-noire of postmodernist critics of psychiatry. This is not the direct fault of the makers of DSM-III and DSM-IV; but it is the indirect consequence of their self-deception about trying to be atheoretical.
So the question is not whether DSM should remain atheoretical, but rather to identify what theory lies behind our current claims of agnosticism, whether it is valid, and what might be better. As discussed in previous posts, the predominant theory of DSM-IV is increasingly clear: an extreme postmodernist pragmatism. This approach lives in tension with a underlying current of biological realism that is part of the Kraepelinian substratum of DSM-III.
I think in future DSMs we need to be clear what our theories of nosology are. We need to have the courage of our science, both in expressing what we know, but, more importantly, in proudly announcing and avowing our ignorance, while we continue to engage in that scientific work that is the only way to turn the latter into the former.
The best way to do this is to jettison the universal Rohrschach of a term - "disorder" - and replace it with "disease" when biological disease is present, as defined above. Non-disease conditions should either be entirely removed from future DSMs, or they should be labeled with a completely different word - perhaps the generic term "condition" or the metaphorical term "clinical picture" would do - so as to emphasize their lack of disease-hood. In this process, burgeoning DSM disorder definitions (nosologomania) would be arrested, and a surgical process of excision could begin. Instead of the growth from about 100 "reactions" in DSM-II to about 200 "disorders" in DSM-III and almost 400 in DSM-IV, I would prefer, personally, if DSM could be reduced to about 10-20 disease entities (perhaps the classic Kraepelinian nosology text by Goodwin and Guze, Psychiatric Diagnosis, could be a model, though it would need updating based on our best science). I believe that research to date provides enough evidence for including only a few current psychiatric diagnoses as diseases. In that short list, I would include schizophrenia, manic-depressive illness, melancholic depression (in the traditional definition, not as a temperament), and obsessive-compulsive disorder. Other psychiatric diagnoses are clinical pictures, some of which may turn out to be diseases with further research, but many of which will prove to be non-diseases, but either problems of living in biologically normal persons, or the result of the interaction of environment with biologically abnormal personality traits. One approach would be to add about 50 other such common non-disease clinical conditions. All other problems with psychological symptoms, most of which probably represent problems of living rather than diseases, could be left out of any diagnostic definitions.
Mental "disorders", as we now label them, did not exist since time immemorial; they began with Ronald Reagan, and the Reagan era is over.
Be sure to read the following responses to this post by our bloggers: