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C H A P T E R 1 2 A Theory of DSM-IV Ideal Types Kraepelin’s manic-depressive insanity and dementia praecox are very important groups of cases, which do not, however, exhaust the material that presents itself to us. His types had best be used as paradigms. —ADOLF MEYER, 1906 1. The DSM system in psychiatry is a convenient straw man for all sides of the diagnostic discussion. Even by its name, DSM-IV seems like the kind of arid cookbook approach to human beings that produces shudders in our collective humanistic spines. Why should we categorize the richness of humanity into these labels? And on what basis? On the face of it, the whole enterprise appears questionable to many. A committee of psychiatrists, bureaucrats, and academics who belong to a guild (the American Psychiatric Association) get together behind closed doors and decide which symptoms, and how many, are to define the various diagnoses. Schizophrenia is a label given to someone with a certain number of psychotic symptoms ; depression is the diagnosis for a person who displays four out of eight mood symptoms for two weeks; it is mania if the patient has three out of seven symptoms for one week. Why those numbers of symptoms? Why those durations ? Why those specific symptoms? The suspicion exists among some critics that the process is arbitrary. The thought is that these members of an elite are defining illness for their own social , economic, or political purposes. This all seems a far cry from “real” medicine , where a scalpel and a microscope are expected to define a disease, rather than a committee of a medical society. These suspicions are unfounded, as I discussed in the previous chapter, insofar as they commit the essentialist fallacy in psychiatric nosology. Diagnoses in medicine are not really different from diagnoses in psychiatry. Hence, although there are some ways in which the DSM system is indefensible, I will defend it as necessary, largely accurate, and basically scientific. And I will do so knowing that it is ridden with limitations and imperfections. Its strident critics seem to misinterpret its whole purpose and its underlying logic. At the outset, it is important to clarify what the DSM system is not. 2. DSM is not a method of discovering or divining illnesses among psychiatric patients. The psychiatrist Manfred Spitzer has made this point in distinguishing between “contexts of discovery” and “contexts of justification.” As he points out, quoting the British scientist Peter Medawar, this is an old distinction in medicine: “First, there is a clear distinction between the acts of mind involved in discovery and in proof. The generative or elementary act in discovery is ‘having ideas’ or proposing a hypothesis. Although one can put oneself in the right frame of mind for having ideas and can abet the process, the process itself is outside logic and cannot be made the subject of logical rules” (1994, 174). Spitzer goes on: However, what is of interest in science is not the peculiar way in which a scientist arrived at a hypothesis but rather, very simply, whether this hypothesis is true. In other words, what is of interest is the justification of the hypothesis, not its discovery . . . . Diagnostic manuals are important when it comes to the question of why patient X suffers from disorder Y, that is to say, when it comes to the justification of a diagnosis. Sets of necessary and sufficient criteria provide a basis for answers to such questions and are indispensable as long as medicine is a science. Hence, a useful answer to the question of why patient Z suffers from, for example, schizophrenia, is not that the psychiatrist had that peculiar praecox feeling, but instead consists of a list of criteria met by the patient. It is equally as ridiculous to answer the question, “How did we get at the correct diagnosis of schizophrenia in this patient?” by stating, “We checked all criteria we found in the entire DSM-IIIR , and ended up with the ones for schizophrenia being met.” (174–75) I believe that this touches on one of the main misconceptions that leads to unjustified criticism of the DSM system of nosology. The DSM criteria are often seen as a cookbook; patients and clinicians are forced to simply run down this checklist, answer yes or no, and accept the resulting diagnosis. All of this oc176 Practice [3.128.79.88] Project MUSE (2024-04...

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