Whither DSM and ICD, Chapter V?
| Published date | 01 December 2008 |
| Date | 01 December 2008 |
| Pages | 4-15 |
| DOI | https://doi.org/10.1108/13619322200800023 |
| Author | Hugh Middleton |
Hugh Middleton
Associate Professor, School of Sociology and Social Policy, University of Nottingham
Honorary Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust
Whither DSM and ICD, Chapter V?
Abstract
Consideration is given to the extent to which the DSM and ICD approach to psychiatric case definition and treatment
supports clinical activity. Their validity as a way of defining ‘mental illness’ is found wanting and they do not, in
themselves, usefully guide treatment. These conclusions are set in a critical realist approach to ‘mental illness’, which
draws attention to the legitimacy of several differing perspectives, each reflecting their own sets of interests and
allegiances. DSM-V and ICD-11 are due to be published in 2012 and 2014 respectively, and their architects are called
upon to be clear about which of these constituencies they are representing.
Key words
Classification, DSM, ICD, mental illness
Columbo; 2004, Pilgrim & Rogers,2005; Stickley,
2006; McEvoy & Richards, 2007; Middleton & Shaw,
2007). The purpose of this paper is to consider the
'DSM project’ and its sister 'ICD project’ (World
Health Organization (WHO), 1992) from that
perspective. It reflects upon their contributions to
ordinary clinical practice.Clearly DSM and ICD have
other constituencies but these differ from the
clinician’s, and vary among themselves. A critical
approach accepts that all are legitimate expressions
of differing purposes and interests, and each may be
examined in its own right.
From a clinical viewpoint it is reasonable to expect
a scheme of diagnostic classification to determine
whether or not a particular set of symptoms reflects
'mental illness’ (case definition), provides an effective
way of improving public health by detecting 'hidden’
cases for treatment (case detection),and identifies
indications for particular forms of treatment (guide
treatment). This paper examines how well DSM and
ICD achieve these.
Case definition
The years leading up to DSM-III heard calls for more
reliable approaches to psychiatric case definition.
Academic psychiatrists were criticised for a lack of
rigour,funding organisations sought clearer definition
of their liabilities, the pharmaceutical industry sought
diagnostic criteria to support clinical trials and
Rosenhan’s vivid illustration of the unreliability of
psychiatric diagnosis (Rosenhan 1973) threatened
It is widely argued that a significant proportion of
the population suffers from mental illness, that this
amounts to a significant economic burden, and that
there is a strong case for investing in improved
mechanisms of detection and treatment (Layard,
2006). Not everyone is in full agreement (Moncrieff,
1999; Healy,2000; Middleton & Shaw,2001;
Double, 2002; Horowitz & Wakefield,2007; Pilgrim,
2007; Shaw & Taplin,2007; Bolton, 2008).
Contemporary approaches to detection and
classification reflect the American Psychiatric
Association’s third diagnostic and statistical manual,
DSM-III, published in 1980 and revised in 1987
(American Psychiatric Association,1987). Less
systematic manuals, DSM-I and DSM-II,had been
published in 1952 and 1968 and the current version,
DSM-IV was published in 1992. Work is under way
to release a finally approved DSM-V in 2012
(American Psychiatric Association,2008).
Mental health difficulties can be considered from
several viewpoints, including their lived experience,
neuroscience, public policy, professional practice,
commerce and the media. Attempts to authoritatively
define 'mental illness’ from any one of them all
prove wanting in one way or another (Zachar &
Kendler,2007; Bolton, 2008).An alternative is to
accept the independent legitimacy of each and
acknowledge multiple purposive definitions. This is a
critical realist (Bhaskar,1975) approach,and it is
proving to be popular (Ellis, 1992; Pilgrim & Bentall,
1999; Houston, 2001; Littlejohn,2003; Fulford &
Mental Health Review Journal Volume 13 Issue 4 December 2008 © Pavilion Journals (Brighton) Ltd
4
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