The fifth edition of the Diagnostic and Statistical Manual (DSM-5) has generated its fair share of critique (Francis Citation2013; Shorter Citation2015; Paris and Phillips Citation2013). Much of the controversy seems to be emanating from within the field of psychiatry itself, with divisive debates emerging around a myriad of issues ranging from the American Psychiatric Association’s (APA) financial dalliances with pharmaceutical industries to the manual’s apparent blurring of clear-cut categories of ‘normal’ and ‘abnormal’. Such internal debates tend to understand any problems or limitations that are identified with the manual to be empirical problems, best resolved through adjustments/improvements to research practices and methods (e.g. stricter ethical regulations, better research methods and/or more suitable conceptual frameworks, etc.). By contrast, in Diagnosing the Statistical Manual of Mental Disorders Rachel Cooper moves her critique of the DSM-5 outside the realm of the strictly empirical. Diagnosing the diagnostic manual as a socio-political artefact, Cooper shows us how diagnostic categories come to matter, in what ways and to whom.
Most importantly, Cooper situates the DSM-5 as a site of contestation. For Cooper, the manual is a text that is shaping and shaped by a multitude of historical, cultural, economic, bureaucratic and ideological contexts. It is also, and by extension, a text that inevitably generates a host of very real, very material effects. ‘The DSM matters’ (xii), writes Cooper, and this assertion fuels two key lines of questioning that seem to run throughout much of her book: how does DSM-5 come to matter (i.e. how is it that our social context shapes this text and vice versa); and how does the manual make matter an array of behavioural, mental and emotional states, as well as the people who come to embody these states?
Diagnosing the Diagnostic and Statistical Manual is divided into seven chapters, which are, according to the author, meant to be ‘self-standing’ and thus can be read in any order. Chapter 1 provides some general historical context about the emergence of the DSM, before delving into some more specific details regarding the fifth and most recent iteration of the manual. The DSM-5 has, of course, undergone some notable changes, and what I found to be most intriguing here is Cooper’s discussion of the shifts in DSM-5’s diagnostic frameworks: the manual’s subtle movements away from a strict categorical approach to diagnosis (i.e. whether one meets the diagnostic criteria or not) and towards a more dimensional approach (i.e. to what degree does one meet diagnostic criteria). Cooper is quick to assert her belief that the DSM-5 has not, as yet, undergone any kind of clear paradigm shift. Indeed, she goes on to argue that, with respect to the fifth edition revisions, conservatism has prevailed (3). Still, as Cooper goes on to demonstrate quite clearly in the chapters that follow, even the subtlest of changes to diagnostic frameworks and categories can catalyse seismic shifts in the social, political, economic and policy landscapes.
In Chapter 2, Cooper trains her gaze on the APA’s ongoing involvement with pharmaceutical corporations and interests. Such industry-ties range from the overt (e.g. tens of millions of dollars of the APA’s revenue can be traced back to drug industry sources or the fact that 69% of the members of the DSM-5 committee disclosed ties to the pharmaceutical industry) to the more covert (e.g. pharmaceutical funds that back certain kinds of research projects over and against others). Throughout this chapter, Cooper provides readers with plenty of supporting evidence that serves as an effective call for clinicians and laypeople alike to treat the manual not as an objective taxonomy of mental health and disorder, but instead as an historically-specific interpretive text.
Chapter 3 follows with an examination of the transparency of the manual’s research and revision process. Cooper shows us that while the APA has made concerted efforts to engage transnational perspectives as well as the perspectives of non-psychiatrists and other professional stakeholders, comparatively little effort has been made when it comes to genuinely engaging with those who are on the receiving end of a psychiatric diagnosis (i.e. those whom Cooper has chosen to name ‘patients’). While the DSM-5 committee chair has openly stated that patient perspectives are both welcome and necessary to the revision process, Cooper cites numerous cases (e.g. the case of UK-based patient advocate and blogger Suzy Chapman) that seem to indicate otherwise. Indeed, Cooper suggests that the inclusion of patient perspectives might be tokenistic at best. At worst, she argues, facile attempts at inclusion may in fact be covertly stifling discussion and dissent among those with lived experiences of the psychiatric system. Cooper goes on to assert the critical importance of the patient-researcher, stating that ‘it matters who does research […] how science is done, who gets a say, what issues are investigated, what results are valued – is always a political issue’ (28). I feel it necessary to briefly address Cooper’s choice of the word ‘patient’ when referring to those with lived experience of psychiatric systems. As Cooper herself admits, the act of choosing the terminology of ‘patient’ is not a neutral choice. Time and again throughout the book, she demonstrates that systems of classification matter: the ways we classify and order people and problems affect our understandings of these. However, I felt that Cooper offered comparatively little discussion on the political issues and implications of her own choice to classify (in this case, name) those with lived experience of psychiatric systems as ‘patients’. Of course, such terminology can work to produce psychiatric systems as value-neutral/apolitical systems of ‘care’. Cooper’s decision to adopt this terminology, therefore, seemed to me somewhat antithetical to the overarching critical aims of the book.
The next pair of chapters moves from looking at the controversies of process to exploring more specific content issues in the 2013 manual. In Chapter 4, Cooper raises concern over DSM-5’s inclusion of ‘hoarding’ as a new, diagnosable disorder. While, she writes, that ‘hoarding problems arise relationally – the combination of individual characteristics, living situation and broader material and social environment’, diagnosis locates the problem/pathology squarely with the individual (38). She argues that the move to medicalise an individual’s accumulation patterns not only suggests that it is possible to objectively classify what counts as ‘junk’, it frames ‘hoarders’ as potentially having a ‘lack of insight’ into the pathological nature of their choices. Such judgments are not and can never be made apolitically, says Cooper, nor can they be made without material consequence. In light of this, Cooper importantly expresses the worry that the addition of hoarding disorder to the DSM will ultimately lower the threshold for coercive treatment, risking harm in the name of ‘help’.
In Chapter 5, Cooper moves her examination from hoarding – perhaps the least controversial of the DSM-5 changes – to the most controversial of changes: the treatment of the diagnostic category of autism. The DSM-5 does away with the multiple sub-categories of autism diagnoses (Asperger’s, Rett’s syndrome, etc.) in favour of a singular wide-reaching diagnosis of ‘autism spectrum disorder’. One interesting element of Cooper’s analysis here lies in her discussion of how diagnosis rates, public awareness of autism and autism advocacy initiatives come together to influence DSM diagnostic criteria. Following considerable pressure from autism advocacy groups (both mainstream and self-advocate groups) that feared the removal of the DSM-IV categories of autism would translate into lost diagnoses and thus lost access to needed services and benefits, the DSM-5 was amended to include a note urging clinicians to grant those with well-documented DSM-IV autism diagnoses a new DSM-5 diagnosis of ‘autism spectrum’. As Cooper points out, what is remarkable about the addition of this note is in its overt demonstration of how special interest groups and policy concerns can and do impact the development of diagnostic criteria; criteria that are purportedly neutral and objective. The final two chapters are comparatively brief, with Chapter 6 highlighting some significant problems with reliability measures in the DSM-5 field trials. In the seventh and final chapter, Cooper offers her own speculations as to the future of the DSM – a future, she contends, that remains uncertain given some of the shifts currently underway in the field of mental health research.
Diagnosing the Diagnostic and Statistical Manual extends current critique of the DSM-5 by engaging the multiple ways in which the text is shaped via a network of contexts: cultural, historical, economic, bureaucratic and ideological. Most importantly, Cooper shows us a text that has been endowed with the power to adjudicate what and who comes to be regarded as ‘sick’ or ‘well’, normal or not. Such designations bear real consequences not only in terms of our understandings of self and other, but also in terms of our ability to gain access to material tools for survival, such as accommodations, services, insurance and so forth. Interestingly, throughout her book Cooper maintains that the DSM-5 does not represent a radical departure from previous iterations. Indeed, she writes in the book’s final chapter: ‘The most striking thing about the DSM-5 is how very similar it is to the DSM-IV’ (60). Still, as Cooper’s work demonstrates, time and again, even the most subtle or banal of adjustments to such a powerful text mitigates the way human affects and behaviours are interpreted and regulated, and conditions the ways people are treated. ‘When it comes to classification, the devil is in the details’, writes Cooper (3). Diagnosing the Statistical Manual of Mental Disorders emerges as a testament to the critical importance of attending to these details in order to enhance our understanding of the social.
University of Toronto, Toronto, ON, Canada
[email protected]
© 2015, Anne McGuire
http://dx.doi.org/10.1080/09687599.2015.1062233
References
- Francis, A. 2013. Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. New York: Harper Collins.
- Paris, J., and J. Phillips, eds. 2013. Making the DSM-5: Concepts and Controversies. New York: Springer.
- Shorter, E. 2015. What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today. New York: Taylor & Francis.