
The Paradox of  Atheoretical Classification [pdf] - tokai
http://static-curis.ku.dk/portal/files/162415301/Proof_Paradox_of_atheoreticsl_cl.pdf
======
jmde
This paper is interesting to read, but confusing in my opinion and sort of
misled.

I'm not sure what point the author seems to be making about the DSM. They seem
to be stating something along the lines of "The DSM isn't successful because
it's atheoretical, it's successful because it adopted a biological theory, and
because its emphasis on reliability facilitated sociopolitical control by the
psychiatric profession." But later they recognize that the DSM isn't
successful, seeming to contradict themselves.

The theory of the DSM goes far beyond biology, being explicitly neo-
Kraepelinian and to some extent psychodynamic in nature, although that would
probably not be acknowledged by any of the DSM's authors unless you pressed
them on it. The success and failure of the DSM has everything to do with
sociopolitical factors and the biological and nonbiological tenets of neo-
Kraepelinian classification, and not on "atheoretical versus natural" or
"scientific versus nonscientific" or "ontological versus nonontological" or
"descriptive versus theoretical" or "ontological versus epistemological" or
any of those sorts of distinctions.

The DSM adopted Kraepelinian categories and assumptions, shoehorning
psychodynamic theories into this framework in some cases, and then further
elaborating the system with very biological criteria. It essentially asserts
that the major Kraepelinian categories are valid, that mental illness is
discretely distinguished from normality or wellness, and that its categories
reflect disruptions of biological systems that can be determined by certain
patterns of biological observations. It further asserts that reliability is a
central feature of classification and assessment. Some of these assumptions
have been accepted, cementing its success, but some assumptions have been
rejected by the community, leading to the current crisis that the author
recognizes. Underlying all of this are sociopolitical factors, such as
professional practice conventions, boundaries, and laws, and popular
perception, that have both augmented the DSM, but also undermined it by
highlighting the political processes underling its continued use.

The question is not whether a classification system is atheoretical or
natural, or descriptive versus natural, or ontological versus epistemological,
it's what criteria or theoretical principles are used to derive the system. In
the case of psychiatric classification, the tension historically, even with
the DSM itself, has not been about "atheoretical" versus "natural" systems, it
has been about whether classification systems are at the level of behavior,
which is proximate to the phenomena of interest and relatively tractable, or
biology, which is proximate to the causes of those phenomena, but relatively
intractable due to those causes being unknown. It's a bit like trying to
classify species, genera, etc. without knowledge of genetics. You can proceed
with a biology-based classification system under the assumption that your
understanding is close enough, or you can acknowledge that you don't
understand it and rigorously classify lifeforms based on what you do
understand. Or you can try to do something intermediate. None of these are
"natural" or "atheoretical," they're just at different levels of analysis.
Another analogy might be found in computer science: do you derive
document/file ontologies based on biology, or something like unsupervised AI
classification? People like to assume that going down to a lower level of
scientific analysis is always better, and it might be, but it might also not
be, depending on your goals.

~~~
jrapdx3
Having quite a bit of experience with the DSM since DSM-II, the article gives
a fairly coherent history of the document, and is correct that the advent of
DSM-III signaled a radical departure from the earlier, and much less useful
versions.

The theoretical underpinnings have been an issue in hot debate since the DSM-
III was in preparation. The deliberately descriptive nature of the
classification has been opposed by many critics who favor a more "casual"
medical classification or proponents of other theoretical systems.

Stakeholders in the recent and very prolonged gestation of DSM-5 fell into two
main groups, let's call them researchers vs. clinicians, or splitters vs
lumpers. The splitters were groups interested in having very specific criteria
that sharply distinguished diagnostic categories which of course suits
research agendas. OTOH clinicians, aka lumpers, were more interested in the
intermediate cases, like typical patients, that don't fit into highly distinct
categories at all well.

An alternative scheme was dimensional classification, which runs orthogonally
to the standard descriptive schema, inasmuch as behavioral dimensions such as
low mood are frequently encountered among many existing disorders. To
clinicians this idea had much appeal since it would most usefully reflect
symptom-oriented treatment modalities.

Whatever scheme is chosen it will have shortcomings. There is really
insufficient information at present to form a basis for any given theoretical
approach. It is quite apparent that there are biological, social, physical,
political and other phenomena that contribute to development of illness of all
kinds, including psychiatric disorders.

In this brief comment it's barely possible to scratch the surface of the
concepts and assumptions underlying the idea of "mental illness", however I
think the article is discussing issues tangential to those confronting
psychiatrists who grapple with management of the very disorderly nature of
psychiatric disorders.

The present diagnostic scheme is a practical compromise of many points of view
about disorders in general and specific disorders in detail. The DSM is the
field's attempt to find a language to discuss the great challenges in
understanding and healing very complex situations about which science has only
fragments of information.

IMO the relevance of the thousands of "theories" concerning human behavior is
yet to be determined. We need to have a great deal more knowledge about the
functional connections of the human organism in consideration of the near-
infinite range of neural, endocrine and immune system signaling and
interaction before it's appropriate to establish meaningful theories in the
human behavioral domain.

~~~
jahsjahs
Whenever discussion of the DSM arises, I tend to revert to Ian Hacking's
critique of the guide ([http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-
forest](http://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest)).

I'm a big fan of his contributions in the philosophy of science, which perhaps
gives his opinion more weight than it should on psychiatric matters (Rewriting
the Soul, and Mad Travellers are excellent books).

Is this criticism mistaken though?

~~~
jrapdx3
Unfortunately I'm not familiar with Hacking's piece, and I'll be very
interested in reading it. On a first run-through many of the expressed doubts
and concerns have been aired extensively in the 19 years between publishing
DSM-IV and DSM-5.

As I said a repeating theme is the tension between what researchers want and
what's useful in clinical practice. With a foot in both camps, I have
sympathies with both points of view. Perhaps no one set of criteria is
universally suitable.

As an non-psychiatric example I've been interested in the body's regulation of
calcium balance. When it's negative calcium is lost and results in thinning
bones, in full form it's osteoporosis, a disabling condition to be sure. One
aspect is calcium loss through the kidneys. The measure is 24hr calcium
excretion in the urine. The point is for clinical purposes 200mg/24hr is
significant, but researchers studying the problem would probably select 250 or
300mg/24hr because it defines a more homogeneous group.

IOW the cutoff point for having or not having a disorder is soft, indistinct
and somewhat arbitrary. If a person loses 199mg/24 hours does that not count
as a potential problem?

As Hacking says, the DSM is a work in progress. There are many messy issues in
real world practice of medicine including psychiatry. The DSM is a composite
of a hundred philosophies, I too have high regard for some philosophers, but
the DSM is a philosophical nightmare by any measure.

I've long since memorized parts of the DSM, and I can recite those in my
sleep, but always take it, like all science literature with ample quantities
of salt.

The saying goes if you like sausage, don't watch how they make it. The DSM is
like sausage, and politics, a very messy production. But for all its quirks,
and there are many, there is really nothing better for its main purposes. As
long as it's not always taken literally, and with healthy doses of clear
thinking, it is sometimes very useful, and sometimes not.

Thanks for bringing up your excellent question. I don't think I've answered it
very well. A thousand different criticisms would be easy to conjure, but kind
of a bottom is that for all the pot shots no one has come up with with
anything that is even close to being as applicable in so many different
settings.

