Book Review: Values and Psychiatric Diagnosis
| DOI | https://doi.org/10.1108/13619322200600009 |
| Published date | 01 March 2006 |
| Date | 01 March 2006 |
| Pages | 38-39 |
| Author | David Kingdon |
| Subject Matter | Health & social care |
Book Review
Values and Psychiatric Diagnosis
By John Z Sadler
Oxford: Oxford University Press, 2004
‘Any discipline that would dare to address, in the
aggregate, the politically oppressed, the socially marginal,
the sexually deviant, the worried well, the intimately
abused, the morally dubious, the unpredictably rational
and the emotionally labile must be controversial.’
Such a beginning – filled with value statements –
draws the reader into a book which raises issues of
such importance that it deserves to be read by anyone
with any interest in the ways we conceptualise mental
health. And it is very timely. The revision of the
American Psychiatric Association’s Diagnostic and
Statistical Manual (DSM) and the International
Classification of Diseases (ICD) has begun and the
leaders of that process have stated that developing
validity needs to be central to that process. If that
really is the case, we may end up with a system which
at last has credibility. If they read this book, the
chances of that happening will increase considerably.
It is fascinating, providing a blow-by-blow account of
the development of the DSM and commentary on
ICD. It seems that the DSM’s original basis was
psychodynamic theory – or at least Meyer’s
psychobiology, which used terms like ‘schizophrenic
reaction’ or ‘depressive reaction’ and seemed to
approximate to modern vulnerability-stress models,
but which also included pejorative terms like
‘inadequate personality’. DSMIII marked a turning
point with the explicit decision to focus on descriptive
categories as opposed to those assuming some
aetiological basis (although the assumption was that
such categories would emerge in time). It was at this
point, 1973, that homosexuality was voted out by the
APAmembership – just, by a relatively small
percentage.
The self-proclaimed goals in developing DSMIII
aredescribed. They are utilitarian but hardly idealistic
or values-based and certainly not user-centred: clinical
usefulness, reliability, acceptability to clinicians and
researchers, usefulness for educating health
professionals, compatibility with ICD, avoidance of
new terms and categories, aiming for consensus, and
for consistency with data. In describing the limitations
to this in terms of the values set out, the author notes
that these do not include those concepts central to
most classificatory systems – that they are valid,
comprehensive, accurate and precise. Relevance to
users and carers is not considered. Future involvement
of users and carers in these processes is advocated and
seems self-evident but, sadly,was recently rejected in
an article by Spitzer, one of the latter DSM’s
architects.
The development of the original terms used – for
example, schizophrenia and manic depression –
occurred long before current ways of determining
validity wereestablished and, by implication, would
never have survived if they had been in place. But the
challenge of establishing valid concepts seems to be
far too potentially disruptive and avoidance of such
disruption is, astonishingly, included as a criterion for
developing a scientific classification system. It leaves
the system as a mish-mash of descriptive categories
and ancient conglomerations of symptoms which have
been assumed to have a biological basis, such as
schizophrenia, and the now renamed bipolar disorder.
Depression and anxiety are included yet these are not
usually mental disorders at all but reactions to stress.
Severity of the experience is not necessarily a
determining factor; for example, severedepression as
part of bereavement or distress following severe
trauma need not be disordered or requireintervention
and the individual will usually choose self-help and
social support. Similarly many symptoms described as
partof syndromes, such as hearing voices or being
paranoid, can be responses to deprivation states, for
example, or spiritual experiences.
The major criticism of this excellent book is that
the most fundamental objection to current systems
follows from the above but is placed in a footnote: the
concept of mental disorder is acknowledged to be a
38 The Mental Health Review Volume 11 Issue 1 March 2006 ©Pavilion Publishing (Brighton) 2006
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