{"id":57746,"date":"2015-06-09T21:19:43","date_gmt":"2015-06-10T01:19:43","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=57746"},"modified":"2015-06-09T21:42:22","modified_gmt":"2015-06-10T01:42:22","slug":"a-curious-inertia","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/06\/09\/a-curious-inertia\/","title":{"rendered":"a curious inertia…"},"content":{"rendered":"
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Why is the Diagnostic and Statistical Manual of Mental Disorders so hard to revise? Path-dependence and "lock-in" in classification.<\/font><\/a><\/div>\n
by Cooper R<\/div>\n
Studies in History and Philosophy of Biological and Biomedical Sciences<\/font><\/strong>. 2015 51:1-10.<\/div>\n

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, was published in May 2013. In the lead up to publication, radical changes to the classification were anticipated; there was widespread dissatisfaction with the previous edition and it was accepted that a "paradigm shift" might be required. In the end, however, and despite huge efforts at revision, the published DSM-5 differs far less than originally envisaged from its predecessor. This paper considers why it is that revising the DSM has become so difficult. The DSM is such an important classification that this question is worth asking in its own right. The case of the DSM can also serve as a study for considering stasis in classification more broadly; why and how can classifications become resistant to change? I suggest that classifications like the DSM can be thought of as forming part of the infrastructure of science, and have much in common with material infrastructure. In particular, as with material technologies, it is possible for "path dependent" development to cause a sub-optimal classification to become "locked in" and hard to replace.<\/font><\/strong><\/p>\n

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The abstract actually covers the central thesis of this paper. However, if you are a nosologist, I’d suggest getting hold of a full copy, where a wealth of wisdom waits within.<\/em><\/sup><\/div>\n

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So many things to so many people, the DSM-III set out to deal with a lot of problems. By sticking to descriptions, it skirted the theory-wars about the etiology or essential nature of the conditions known as mental illness. And since there are no absolute markers for these disorders, "The descriptive syndromes  of the DSM-III were selected primarily to ensure reliability [i.e. agreement between diagnosing clinicians] rather than validity [i.e fit with the natural structure of mental disorders]."<\/font><\/em> But it did so much more. It placed a firewall between psychiatry and psychoanalysis, part of the goal of becoming atheoretical. It created a "code book<\/font><\/em>" of diagnoses widely used for determining third party reimbursement by all mental health specialties. It gave the FDA and PHARMA a system to approve drugs for specific uses and to conduct Clinical Trials of presumably homogeneous groupings. It lent an air of "legitimacy<\/font>" and "medicality<\/font><\/em>" to the mental health specialties, and while expressly touted as atheoretical, it became a rallying point for the "biologification<\/font><\/em>" or "medicalization<\/font><\/em>" of psychiatry. Rarely mentioned, one of the outcomes was the elevation of "expert opinion<\/font><\/em>" as a decision making tool: in diagnosis, in guidelines, in algorithms. Another consequence of the DSM-III was to place the American Psychiatric Association, a guild organization, in a position of scientific and administrative centrality that has had any number of wide-ranging ramifications.  So what had started life as a tentative diagnostic manual built on a template constructed by psychiatry resident, John Feighner<\/a> the DSM-III soon became the "infrastructure<\/font><\/em>" for almost everything that had to do with mental health and mental illness world-wide. And each of the categories had meanings and implications that far exceeded the original goal of an accurate classification of psychiatric conditions:<\/font><\/div>\n
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"The DSM provides a common language for mental health research, policy and care. Almost all papers published in psychiatric journals refer to the DSM; the use of DSM categories to select subject populations for study is near universal. Worldwide, textbooks for mental health professionals, and treatment guidelines, tend to be structured around DSM categories. In the US, the DSM also plays an important bureaucratic and economic role; in particular, the DSM contains the codes that insurers commonly require before paying for mental health treatment." <\/div>\n<\/blockquote>\n
It is unlikely that many of us have subscriptions to Studies in History and Philosophy of Biological and Biomedical Sciences<\/font><\/strong>, or will run across it in a waiting room somewhere, but I think it adds a perspective to the endless deliberations about the DSMs that would be helpful to anyone interested in the topic. I hope that it will find its way to the Internet in full at some point. It’s one of the few things I’ve run across that actually made me feel some sympathy for the dilemmas faced by the Task Force that was asked to revise it. No, I haven’t gone over to the dark side. It didn’t make me feel that<\/u> sympathetic. But it did help me at least understand how the DSM has developed such a curious inertia, keeping it from iterating into something more useful…<\/div>\n","protected":false},"excerpt":{"rendered":"

Why is the Diagnostic and Statistical Manual of Mental Disorders so hard to revise? Path-dependence and "lock-in" in classification. by Cooper R Studies in History and Philosophy of Biological and Biomedical Sciences. 2015 51:1-10. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, was published in May 2013. In the […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-57746","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/57746","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=57746"}],"version-history":[{"count":32,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/57746\/revisions"}],"predecessor-version":[{"id":57778,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/57746\/revisions\/57778"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=57746"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=57746"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=57746"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}