Psychiatrists make Diagnoses, but not in Circumstances of Their Own Choosing: Agency and Structure in the DSM1

Abstract

PSYCHIATRIC activity that CLASSIFICATION IS A PROFOUNDLY IMPORTANT directs subsequent treatment decisions, assumptions about etiology, and prognostic considerations. While the ideal classification scheme would be clear, concise, comprehensively inclusive of, and hospitable to, the en-tities under consideration, in practice, all classification systems reflect trade-offs and embody flawed structures. Accordingly, it is essential to be fully cognizant of the shortcomings, biases, and tacit assumptions of extant systemsso that classifications can be improved and so that misrepresenta-tions will not be blindly repeated or reproduced. Modern psychiatric clas-sification and diagnosis are almost exclusively defined within the context of the nomenclature and diagnostic categories of the American Psychiat-ric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). This article adapts Giddens’s (1984) theory of “structuration ” to explain how at least some of the consequences of relying on the DSMfor classifica-tion result in unexamined conditions of its use and unintentionally repro-duced its underlying assumptions. This article uses the DSMto explicate agency in structuration theory and structuration theory to illuminate the structure and use of the DSM. The discussion suggests that Mouzelis’s (1995) four-fold duality-dualism typology, by empowering the agent not only virtually but in actuality, is a necessary and salutary modification of structuration theory. Finally, it will be suggested that several prominent issues and concerns in psychiatric nosology resonate profoundlywith those that have concerned, and continue to interest, library classificationists