A Role for Philosophers, Sociologists and Bioethicists in Revising the DSM: A Philosophical Case Conference
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A Role for Philosophers, Sociologists and Bioethicists in Revising the DSM
A Philosophical Case Conference
Abstract

The recent publication of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was accompanied by heated debate. I argue that part of the reason for these recent controversies is that the process of DSM revision involves making certain value judgments, yet requires a better means for explicitly and expertly addressing these issues. It is important to do so because a) there are certain value-laden questions that science cannot answer but nevertheless need to be addressed in psychiatric classification, and b) the effects of psychiatric classification stretch far and wide. I suggest a means by which the value judgments involved in psychiatric classification can be more systematically and comprehensively examined—by including an independent ethics review panel in the revision process. An ethics review panel could include bioethicists, sociologists, and philosophers of psychiatry who would be in a better position to address these issues.

Keywords

Psychiatric classification, nosology, DSM, bioethics, philosophy of psychiatry, values, judgments

The creation of the latest version of psychiatry's 'bible' (the Diagnostic and Statistical Manual of Mental Disorders [DSM]) has been surrounded by a great deal of controversy (Andreason, 2007; Hyman, 2010; Regier, Narrow, Kuhl, & Kupfer, 2009; Widiger & Clark, 1999). The latest revision, the DSM-5, contains several controversial diagnoses that have been the subject of much debate. One of the central criticisms of DSM-5 is that it pathologizes some behaviors that were previously considered simply problematic, or variations of normal behavior—for example, fidgetiness, noisiness, abundance of energy, shyness, anxiety, and bereavement. Diagnoses such as Binge Eating Disorder, Disruptive Mood Dysregulation Disorder, Minor Neurocognitive Disorder, and the introduction of Behavioral Addictions have been met with controversy, as has the lowering of thresholds for Generalized Anxiety Disorder and Attention Deficit Hyperactivity Disorder. To reduce the chances that the DSM will come under such criticism in the future and to [End Page 187] strengthen the manual, it seems prudent to require those responsible for revising the DSM to ensure that the value judgments inherent in psychiatric classification have been examined explicitly and comprehensively.

Some criticism has been levelled at the membership of the Task Force and Work Groups, stating that, although those involved are experts in relevant fields of science and clinical practice, their background does not adequately equip them to make judgments on moral issues (Frances & Widiger, 2012). Gary Gutting (2013), in a short opinion piece in The New York Times, suggested that bioethics and philosophy of psychiatry should be included in the DSM revision process to aid in the analysis of the value judgments in psychiatric nosology.

Kendler et al. (2008) suggested the inclusion of a Conceptual Issues Work Group in the process of DSM revisions, a proposal that was not adopted by the DSM-5 Task Force. Although their proposal would address some of the issues I discuss in this paper, such a work group may be overly broad. In contrast, this paper focuses on specific conceptual issues—namely, those concerned with value judgments in psychiatric classification. I make a case for the importance of addressing these issues in particular as well as outlining a different means by which they could be addressed.

In this paper, I support the suggestion that bioethics and philosophy of psychiatry would help to inform psychiatric classification, and add that sociologists would also be helpful. I suggest that part of the reason for the recent controversies surrounding the DSM is that the process of psychiatric classification necessarily involves making certain value judgments that should be explicitly and expertly addressed. I argue that it is important to do so because a) there are certain questions that science cannot answer authoritatively where there may be clashes between different scientific groups and decisions made for non-scientific reasons, and b) the consequences of psychiatric nosology stretch far and wide. Because the DSM is influential in clinical diagnosis, research, funding, treatment, public policy, and forensics, classifying certain behaviors as mental disorder can have repercussions in all these sectors.

This paper also suggests a means by which philosophers of psychiatry, sociologists, and bioethicists...