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Alternative Perspectives on Psychiatric Validation: DSM, ICD, RDoC, and Beyond

edited by Peter Zachar, PhD; Drozdstoj St. Stoyanov, MD, PhD, PGCert; Massimiliano Aragona, MD, BPhil; and Assen Jablensky, MD. In book series: International Perspectives in Philosophy and Psychiatry. Oxford University Press, New York, NY, 2015, 274 pages, $59.95 (paper).

The assumptions and aspirations of psychiatric nosology have been pushed to the fore by the National Institute of Mental Health Research Domain Criteria (RDoC) initiative and American Psychiatric Association’s release of the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These 2 systems for conceptualizing psychopathology hint at the diversity of possible systems. DSM-5 remains a tool for operationalizing symptomatically defined categories; it offers potential solutions to the problems of caseness and the enumeration of clinically relevant features. The RDoC approach defers the problem of caseness and instead focuses on biologically relevant features. Although it is tempting to frame the 2 systems as competitors, it is possible that validity in psychiatry demands multiple systems that coexist through explicit delineation of their goals.

Alternative Perspectives on Psychiatric Validation is well timed to help readers consider the strengths and weaknesses of candidate diagnostic systems. The book is an edited collection of chapters presented in 2 sections—“Matters More Philosophical” and “Matters (Slightly) More Clinical”—framed by a prologue and epilogue from the editors. The 13 chapters stand, nearly without exception, as independent works and can be perused based on the individual reader’s needs and interests. The Matters More Philosophical chapters outnumber the Matters (Slightly) More Clinical chapters by nearly 2 to 1. The shift to more clinical topics for the last third of the book is a subtle one both because the philosophical chapters have clinical applicability and because the clinical chapters are steeped in lawyerly distinctions.

Although the timing and title of this text link it to the NIMH and APA projects, its authors concern themselves with the largest possible notions of validity in psychiatry. The critiques and histories of the specific systems seem to be sources of salient examples rather than goals unto themselves. The book is evenhanded with respect to candidate nosologies, rather than building a philosophical case for one or another system.

The first chapters of Alternative Perspectives contain a history of the forces and epistemological stances that shaped the DSM. Chapter 2, by Aragona, reviews important history, and begins the text’s pattern of carefully dissecting received wisdom and objective evidence as it considers RDoC’s impact on the trajectory of the DSMs: “A shift in the direction of the RDoC project would be revolutionary in several aspects but largely continuous with the ideal of validation as grounding mental disorders in neurobiological processes” (p 43). Though billed as a “matter more philosophical,” this chapter offers valuable perspective on central problems in psychiatry—not just philosophically and scientifically, but clinically—as a medical specialty reliant on diagnosis.

Moving from history of general interest into the heart of the matter, Dominic Murphy’s chapter “Validity, Realism, and Normativity” opens by positing that “biologically based psychiatry does not make any needless metaphysical commitments, and if it is realist, it is realist in an entirely harmless way” (p 61). This does not mean that accumulating biological knowledge alone brings us closer to psychopathological omniscience. The section “Normativity” (pp 68–69) within this chapter takes on aspirational biomarkers and the realities of social construction more directly and accessibly than works entirely dedicated to those topics. This is an important chapter for anyone wanting to criticize, defend, or simply be thoughtful about psychiatric diagnosis and diagnosing.

Still, embracing Murphy’s ideas might cause anxiety that reliance on normativity to establish disorders is intractably problematic. In chapter 9, Loughlin and Miles grab the horns of this dilemma and acknowledge that “a diagnosis will be valid contingent upon the assumptions of a normative framework” (p 147) but go on to chart a course whereby adopting a position of “realism with respect to value” (p 153) might rescue psychiatry.

It is not a coincidence that these 2 samples of Alternative Perspectives’ contents were drawn from its Matters More Philosophical section. It is here that problems inherent to the psychiatric enterprise are laid bare. Thus, it is here that one finds the raw material to think through the complexities of our daily work. Among the Matters (Slightly) More Clinical are applications of that material to various “alternative” schemes for psychiatric classification/conceptualization. These are interesting in their own right, but few of us will, could, or should be forming idiosyncratic systems in the clinical domain. These chapters instead aim to show that our current state of diagnostic affairs is a matter of victory, not necessity.

There are a few points of caution for would-be readers. Although by no means inaccessible, the book uses many philosophical concepts without definition or introduction. Also, the volume’s use as a reference is slightly compromised by its bare-bones table of contents. Reading the chapters is the only way to find out if you wanted to read them in the first place. The 2 reviewers had the opportunity to review the book in paper and electronic formats. Those interested in reading electronically should be aware that while the book’s 12 figures reproduce well in reflowable e-reader format, its 3 tables translate awkwardly.

Given its strengths and weaknesses, this is not a book for every psychiatrist. It is a good book for those who accept the inherent uncertainties of our specialty and want to consider them rigorously. It is an even better book for those who plan to complain about diagnostic systems and wish to do so well. Alternative Perspectives on Psychiatric Validation provides a thoughtful review of the practical, epistemological, metaphysical, and even ethical nuances of classifying and identifying psychopathology. For those about to complain, we salute you.

Thomas H. McCoy, Jr, MD

Nicholas Kontos, MD

nkontos@partners.org

Author affiliation: Harvard Medical School, Boston, Massachusetts.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2016;77(1):e32

dx.doi.org/10.4088/JCP.15bk10263

© Copyright 2016 Physicians Postgraduate Press, Inc.