Abstract
Undoubtedly, psychiatric diagnoses are central to psychiatric research and clinical practice. The initial impetus for this book came from a symposium on psychiatric taxonomy in San Diego. Later additional contributors were invited to join the authors. The book borrows the title “extraordinary science” from Thomas Kuhn, 1 who coined this term for scientific research that is taking place during the paradigm change. The authors contributing to the volume explore the nature and sources of the present problems and possible ways out.
While the book is a must-read for psychiatric researchers, it also has much to offer to clinicians interested in the diagnostic process. The authors feel that the recent hot debates surrounding the DSM-5 2 indicate in particular that in psychiatry, there are now major tensions between clinical and research aims, as well as controversies over diagnoses and treatments. Many critics have found the DSM unusable for research and feel it is linked to the notable paucity of progress; some consider it also flawed for clinical practice.
The overriding concern is that the mental disorder constructs found in the DSM are not appropriate for scientific research. The DSM categories are seen as too general and too symptom based, leading to heterogeneity. They overlap and the boundaries are loose. There are problems with the validity and reliability of psychiatric diagnoses, heterogeneity of the resulting groupings, confusing comorbidities, inclusiveness of criteria, and overlap with normality.
The main goal of the book is to help reconcile the competing directions and to explore the ways that may lead out of this dilemma. Contributors include mental health researchers and philosophers of science. They discuss the origins of the current controversies, explore the weight of evidence in psychiatric research, and criticise the National Institute of Mental Health (NIMH) proposal to replace DSM diagnoses by their own research categories (RDoC).
For clinicians, of particular interest will be the chapters by Richard Bentall on schizophrenia and Harold Kincaid’s chapter on bipolar disorder. Bentall provides a brief history of the schizophrenia concept and demonstrates that the prevailing, widespread assumptions about the nature of schizophrenia do not incorporate all the available evidence. He offers an explanation that researchers may be blind to data that do not fit the expectations and end up protecting the existing paradigm. Kincaid centers his analysis on major depressive disorder and bipolar disorder as they have grounded substantial research findings. After reviewing the evidence, he finds in particular insufficient evidence for using bipolar classification in young children.
Several contributors point out that the probing of dominant thinking and the emergence of alternative initiatives suggest an epoch that Thomas Kuhn characterised as “extraordinary science.” It includes both intense attempts to defend the prevailing paradigm (as expressed particularly in the DSM) as well as probing research results that do not fit the present concepts and exploring alternative research frameworks.
The book contains multiple proposals on what would constitute an adequate response to this situation. Several approaches appear promising, but no consensus has been achieved. Let me mention a few examples: probing the problems exhibited by DSM categories, targeting various aspects of mental illness in novel ways, and integrating resources from a broader range of relevant sciences. Elsewhere, however, there are proponents of more revising and tinkering with DSM, an approach for which a new committee has already been set up. Others, as we know, pushed towards the rejection of the DSM project together. 3
Definitely, there is not yet accord about how to best deal with the multifaceted, multidimensional complexity of mental health–related issues embedded in sociocultural contexts. But the current situation certainly provides an important opportunity for a critical examination of the foundations of psychiatric research and diagnostic practices.