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PA R T I
DIAGNOSTIC PRINCIPLES
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1
Introduction
The year 2013 marked the publication of DSM-5, the fifth edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM),
published by the American Psychiatric Association (APA). This was
the first major revision in more than 30 years.
Prior to 1980, diagnostic classification of mental disorders
was an abstruse subject, of interest only to researchers and a few
experts. But if mental disorders are medical diagnoses, they require
a scientifically based classification. Moreover, since 1980, the DSM
system has had a profound influence on all the mental health professions. The public, some of whom have been on the receiving end
of a diagnostic process, also finds the subject fascinating, so revisions of psychiatry’s manual are front-page news.
This book is a guide to the main features of the latest version
of the manual. It will focus on three questions. First, what are the
most important changes? Second, what are the implications of
these changes for practice? Third, is DSM-5 better, worse, or equal
to its predecessors? This book, as a critical guide for the intelligent
clinician, will applaud the positive aspects of DSM-5 but underline
its limitations. It will be supportive of some changes but be critical
of others.
What DSM-5 Can and Cannot Do
The first two manuals published by APA, DSM-I (1952) and DSM-II
(1968), did not have a great impact on psychiatry. They were used
for statistical purposes, but they were not guides to clinical practice.
3
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4 | Part I Diagn ostic P ri n cip l e s
In contrast, the third edition of the manual, DSM-III, published
in 1980, was a major break with the past, as well as a best-selling
book. The ideas behind this edition reflected a new paradigm for
psychiatry, and the politics that made a radical revision possible are
a fascinating story in their own right (Decker, 2013). DSM-III moved
classification from clinical impressions to some degree of rigor. It
increased reliability by taking an “atheoretical” position—that is,
making diagnoses based on what clinicians can see and agree on
as opposed to the abstract theories used in DSM-I and DSM-II.
DSM-III, and its successors, found a place on the shelf of almost
every psychiatrist, psychologist, and mental health professional.
There were no major changes in the manual during the next
30 years. DSM-III-R, published in 1987, allowed a greater degree of
overlap between diagnoses, and DSM-IV, published in 1994, added
some important new diagnoses, including bipolar II disorder and
attention-deficit hyperactivity disorder in adults. In 2000, a slightly
edited version, DSM-IV-TR, appeared. The absence of major changes
for so long could be seen as suggesting a need for a new system that
could radically revise the diagnosis of mental disorders. This was the
mandate given to the editors of DSM-5 by the APA. The work lasted
10 years, with a result that was initially claimed to be a “paradigm
shift.”
Is the DSM-5 system an improvement over previous editions?
The answer has to be yes and no. One would like to believe so, but
there are reasons for doubt. Some problems derive from the concept
that psychopathology lies on a continuum with normality, making
it difficult to separate mental disorders from normal variations and
leading to a danger of overdiagnosis. Other issues derive from a
strong attachment to the principle that mental disorders are brain
disorders, even though knowledge is insufficient to develop a classification based on neuroscience. Although great progress has been
made in research on the brain, the origins of mental illness remain
a mystery.
When one does not know enough, one should not invest in
change for change’s sake. Sometimes it is better to keep a known system, however faulty, than make modifications with unpredictable
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1 I n t ro d u c t i o n | 5
consequences. Moreover, even the smallest changes to diagnostic
criteria can have profound effects on research and practice. Finally,
revisions with good intentions can still lack clinical utility. Revising
DSM is an enormous job, and each edition has grown larger, more
complicated, and thicker. Yet much of what is written in the manual
may never be applied in practice.
The Validity of Psychiatric Diagnosis
DSM-III aimed to make diagnosis more reliable, but reliability is
not validity. During the next 33 years, constant use of the manuals gave clinicians the impression that their categories were valid.
That was not true. The DSM system lacks the data to define mental
disorders in the way that physicians conceptualize medical illnesses.
Diagnoses in medicine can also be vague, but psychiatry is far behind
other specialties in grounding categories in measurements that are
independent of clinical observation.
Almost all DSM-5 diagnoses are based entirely on signs and
symptoms. Although some disorders have support for their validity, and although observation can be made more precise through
statistical evaluation and expert consensus, most other areas of
medicine use blood tests, imaging, or genetic markers to confirm impressions drawn from signs and symptoms. Psychiatry
is nowhere near that level of knowledge. No biological markers
or tests exist for any diagnosis in psychiatry. For this reason,
any claim that DSM-5 is more scientific than its predecessors is
unjustified.
In 1980, I was a strong supporter of the paradigm shift introduced by DSM-III. It was progressive to make diagnosis dependent
on observation rather than on theory. But this provisional stance
became frozen in time, and progress during the succeeding decades
has been slow. Radical changes in classification would require much
more knowledge about the causes of mental disorders. And that is
just what we do not have.
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6 | Part I Diagn ostic P ri n cip l e s
Psychiatry and Neuroscience
Psychiatry has bet on neuroscience as the best way to understand
mental disorders, to solve problems in diagnosis, and to plan
treatment interventions. Only time will tell how this wager will
pan out. Some psychiatrists claim that the field is on the verge of
a great breakthrough. If one were to believe the hype, a biological
explanation—and a biological cure—for mental illness lies just
around the corner. (Or as one wag put it, every few years we are told
that answers are just a few years away.)
Although progress in brain research has been rapid and impressive, its application to psychiatry has thus far been very limited.
Brain scans are impressive (even if one keeps in mind that the colors are artificial), but all they tell you is that activity is different at
different sites. The precise meaning of these changes is unclear, and
none are specific to any diagnosis.
We do not know enough about the brain, or about the mind, to
develop a truly scientific classification, and it could be 50–100 years
before we can even get close. It is understandable that psychiatry,
so long the Cinderella of medicine and desperate for respectability,
wanted to plant its flag on the terrain of neuroscience. But the promise of the 1990s (“the decade of the brain”) for research on mental
disorders has not been fulfilled. Neuroscience has shed much light
on how the brain functions, but we do not understand the etiology or
the pathogenesis of severe mental disorders. We know that most are
heritable, but we have no idea about which (or how many) genes are
involved. Although some disorders are associated with abnormalities
on brain imaging, the findings are neither specific nor explanatory.
Although psychopathology can be associated with changes in neurotransmitters, the theory that chemical imbalances cause mental
disorders is too simple or plain wrong. Ultimately, it may be impossible to fully explain mental disorders as brain disorders. The neuroscience model attempts to reduce every twisted thought to a twisted
molecule, but it devalues studying the mind on a mental level.
Considering that it will take many decades to unravel these mysteries, the current situation is nothing to be ashamed of. The DSM-5
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1 I n t ro d u c t i o n | 7
task force, as well as the leaders of the National Institute of Mental
Health, believe that psychiatry should give up its traditional mission, which was both scientific and humanistic, and redefine itself as
the clinical application of neuroscience. To paraphrase a famous line
from the Vietnam War, they want to destroy psychiatry in order to
save it. It is of course true that mental phenomena reflect the activity of the human brain. But the brain is the most complex structure
known in the universe. There are more synapses in the brain than
stars in the galaxy. This is a project for a century, not a decade, and
its results may never provide a full explanation of mental illness.
Unsolved Problems in Psychiatric Diagnosis
Lack of Knowledge About Mental Disorders: DSM-5 is not “the bible
of psychiatry” but, rather, a practical manual for everyday work.
Psychiatric diagnosis is primarily a way of communicating about
patients. This function is essential but pragmatic—categories of illness can be useful as heuristics without necessarily being “true.” The
DSM system is a rough-and-ready classification that brings a degree
of order to chaos. But it describes categories of disorder that are
poorly understood and that will be replaced with time. Moreover,
current diagnoses are syndromes, not true diseases. They are symptomatic variants of broader processes defined by arbitrary cutoff
points. Thus, although classifications serve a necessary function,
psychiatrists can only guess how “to carve nature at its joints.” That
phrase (attributed to Aristotle) describes an impossible task. We do
not know if it is possible to find joints to be carved. Even in medicine, diagnoses are not always cleanly defined or related to a specific
etiology. In contrast, mental disorders greatly overlap with each
other—and with normality.
The Need for Biological Markers: In the absence of a more fundamental understanding of disease processes, DSM-5, like its predecessors, had no choice but to continue basing diagnostic criteria on
signs and symptoms. But observation needs to be augmented by
biological markers, as has been done in other medical specialties.
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8 | Part I Diagn ostic P ri n cip l e s
In the absence of independent measures of this kind, we cannot be
sure that any category in the manual is valid. We should not therefore think of current psychiatric diagnoses as “real” in the same way
as medical diseases. Also, listing them in a manual does not make
them real. For example, broad categories such as “major depression”
in no way resemble diseases. Even the most “classical” concepts in
psychiatry, such as the separation of schizophrenia from bipolar disorder, have not fully stood up to scrutiny. In summary, psychiatrists
must make diagnoses, but they do not need to reify them. They are
best advised to stay humble and to avoid hubris.
Boundaries Between Mental Disorder and Normality: This is one
of the most nagging problems in psychiatric diagnosis. Every edition of DSM has expanded this frontier, taking on increasingly more
problems of living as diagnosable disorders. Psychiatric classification has become seriously overinclusive, and the manual grows ever
larger with each edition. DSM-5 also errs on the side of expanding boundaries—mainly out of fear of “missing something” or not
including problems that psychiatrists treat in practice. The result
is that people with normal variations in emotion, behavior, and
thought can receive a psychiatric diagnosis, leading to stigma and
inappropriate and/or unnecessary treatment.
Diagnostic Validity and Research: Because we have to live with a
diagnostic system that is provisional—and that will almost certainly
prove invalid in the long run—much of the research on mental disorders has to be taken with a grain of salt. For example, although
a massive amount of data has been collected on the epidemiology
of mental illness, almost all its findings are dependent on the current diagnostic system. Similarly, studies of treatment methods in
psychiatry that target specific disorders are sorely limited by the
problematic validity of categories. Most treatments, from antidepressants to cognitive behavioral therapy, have broad effects that
are not specific to any diagnosis.
Comorbidity: One of the most troubling problems with the DSM
system is that it yields multiple diagnoses in the same patient. That
is not the way medicine usually works. It is possible for patients to
suffer from more than one disease. But in psychiatry, if you follow
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1 I n t ro d u c t i o n | 9
the rules, the same symptoms can be used to support two or three
diagnoses. Thus, “comorbidity” is little but an artifact of an inexact system in which criteria overlap. The sicker a patient, the more
mental disorders will be identified. DSM-5 considered severity ratings and diagnostic spectra to address this problem, but these procedures could not resolve underlying questions about boundaries.
Algorithmic Diagnosis: Another source of uncertainty is that
diagnosis in psychiatry does not depend on “pathognomonic”
signs and symptoms that define specific diseases. The algorithmic
approach of the DSM system has been rightly popular: It uses “polythetic” criteria—making a list and then requiring a given number
to be present. These quantitative thresholds are superior to asking
clinicians to determine whether the patient’s condition resembles
a prototype. But if a typical DSM diagnosis requires, for example,
five out of nine criteria, nobody knows whether four or six criteria
would have been more or less valid. Few categories have absolute
requirements for any criterion, and no system of weighting takes
into account the most characteristic features. The DSM system has
been jocularly called a “Chinese menu” approach to diagnosis. But
most clinicians need to consult the menu, and they would be hard
put to remember all criteria for any category.
Dimensionalization: The editors of DSM-5 thought that the
solution to the comorbidity problem is to view disorders as
dimensions—spectra of pathology that can be scored in terms of
severity. All previous editions have classified mental disorders as
specific categories, much like general medicine. One of the main
ideas behind DSM-III was the revival of a model based on the work
of the German psychiatrist Emil Kraepelin (1856–1926). Categories
are consistent with the view that psychiatry concerns itself with
mental illness, not with unhappiness or life itself. They also imply
that psychopathology falls into a set of categories or natural kinds,
much like tuberculosis or most forms of cancer. DSM-5 sought to
overthrow this “neo-Kraepelinian” approach and replace it with a
model in which normality and illness lie on a continuum. The rationale is that research suggests the underlying biology of mental
disorders is more dimensional than categorical. But measuring the
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10 | Part I Diagn ostic P ri n cip l e s
severity of depression is not like taking blood pressure. The definition of dimensions is based on observation rather than biological markers, and it can only be provisional. Dimensional diagnosis
also runs the risk of being overinclusive. Even normal people have
some symptoms of disorder but do not deserve a formal diagnosis.
Because differences in degree can become differences in kind, categories are necessary.
Expert Consensus: DSM-5 is not a scientific document but, rather,
a product of consensus by committees of experts. Sometimes the
outcome depends on who was put on these committees. Where
experts disagree, there is a way to “fix” results in advance—by ensuring that membership reflects a preexisting point of view. There are
many scientific disputes affecting diagnosis, but most reflect a lack
of basic knowledge. As the American physician Alvan Feinstein once
remarked, the consensus of experts is the source of most medical
errors.
In summary, DSM-5 was a noble attempt at a revision in line
with current research, and it can be considered as a draft for future
editions based on more data. What has to be kept in mind is that the
new manual only begins to develop a better framework for research
and practice. Psychiatry has to put off scientifically based definitions of mental disorders to a future time when it knows more.
The Constituencies of DSM-5
A diagnostic manual serves many purposes and has many potential
constituencies. Let us consider each of them.
Clinical Practice: The most important consumers of a diagnostic
manual are mental health clinicians: psychiatrists, psychologists,
social workers, and family physicians. Practitioners use the manual
on a daily basis but are strapped for time. Researchers do not mind
if procedures for reaching a diagnosis are complicated, but clinicians do. If the manual is not user-friendly, it will never be used as
intended—or not used at all.
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1 I n t ro d u c t i o n | 1 1
Clinicians do not have the time or the inclination to open a book
and count criteria. (They are even less likely to score symptoms on
rating scales.) That is why previous editions of DSM were never
applied in a systematic way. Many (if not most) users of DSM-5 may
prefer an electronic version that can be easily searched. Even so,
given that previous printed editions have not been used as intended,
it is unlikely that the text of DSM-5 will be regularly consulted, even
when available on mobile devices.
Clinicians need to reach conclusions rapidly. They rarely follow
algorithmic procedures, and they prefer to make diagnoses intuitively. Most have a prototype in their mind as to what any disorder
should look like. The more closely a patient fits this model, the more
likely it is that a diagnosis will be made. In this light, DSM-5 will not
make as much difference to real-world practice as one might imagine. Because the details of DSM-III and DSM-IV were complicated,
clinicians were happy to leave systematic diagnosis to researchers.
Previous editions of DSM were poor guides to therapy. To be
fair, the system was never intended to guide treatment. (This principle was explicitly stated in DSM-III, but clinicians did not seem
to believe it.) As mental health practice becomes increasingly
evidence-based, it could eventually develop specific treatments for
diagnoses based on research. Doing so is not possible now. Only a
few well-established links are known between any diagnostic category and specific therapeutic options.
Research: This is the area in which the DSM-5 manual will be followed most systematically. Diagnosis is an essential tool for clinical
investigation, and researchers need to establish that their studies
examine populations that correspond to accepted rules of classification. However, changing criteria for mental disorders leads to discontinuities, making it more difficult to compare older studies to
newer ones. The question is whether changes in DSM-5 can move
research forward or only create unnecessary confusion. Another
issue is whether the more complex procedures described in DSM-5
should be reserved for researchers if they are the people most likely
to apply these procedures.
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12 | Part I Diagn ostic P ri n cip l e s
The Pharmaceutical Industry: This constituency has a strong
interest in DSM-5. Companies are interested in maximizing their
profits; one way to do so is to get physicians to prescribe more drugs
for more people. Any change that encourages wider diagnosis of
mental disorders as a whole is in their interest. Specifically, the way
DSM defines schizophrenia, bipolar disorder, and major depression
could have an impact on industry profits. Some of the most problematic trends in modern psychiatry have resulted from attempts
to make patients fit into categories that justify the prescription
of drugs. But overinclusiveness tends to make the pharmaceutical
industry happy.
The Legal System: Lawyers and judges are also interested in
DSM-5. Psychiatric diagnoses have found their way into the
court system, affecting everything from criminal responsibility
to custody rights and insurance payments. Although the science
behind diagnosis does not justify any of these practices, they are
widespread.
The General Public: Finally, DSM-5 has and will continue to
influence the way everyone views mental illness. Patients (and
nonpatients) have access to published criteria and sometimes
diagnose themselves (or their relatives). This amplifies the danger
that too many people will receive psychiatric diagnoses. The way
consumers and families view mental problems will also have an
influence on practice, most likely in the direction of more aggressive treatment.
The one certain thing about DSM-5 was that it would be another
best-seller. What is less certain is whether it would lead to improved
mental health care.
Ten Highlights of DSM-5
Although many changes in the new manual are relatively minor,
I highlight areas in which major revisions have been made, particularly those that have aroused controversy. All will be discussed in
detail in this book.
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1 I n t ro d u c t i o n | 1 3
1. DSM-5 is reorganized into a new set of chapters that either
reflect common clinical features or fall within a spectrum.
Because most mental disorders begin early in development,
there is no separate section for disorders first apparent in
childhood.
2. The multiaxial system introduced in DSM-III has been eliminated. There is now no such thing as five axes, and personality
disorders are considered in the same way as other categories.
3. Functioning, previously coded on Axis V, is now rated by
scores on an instrument developed by the World Health
Organization.
4. The criteria for attention-deficit hyperactivity disorder in
adults have been expanded somewhat (by changing the
requirements for a childhood onset).
5. Personality disorders are defined in the same way as in
DSM-IV, but an alternative system based on trait dimensions
can be found in a separate section of the manual.
6. Substance use disorders now describe cases using the term
addiction, no longer distinguishing between dependence
and abuse.
7. Highly moody and aggressive children can be given a new
diagnosis—disruptive mood regulation disorder with dysphoria.
8. Autism spectrum disorders consider classical autism and
Asperger’s syndrome as being on the same spectrum.
9. Dementias are classified as neurocognitive disorders, rated by
severity on a spectrum.
10. Somatic symptom disorders replace somatoform disorders and
are classified differently.
Some of the most controversial changes that were proposed
earlier in the DSM-5 project were either dropped or greatly diluted.
Thus, attenuated psychosis syndrome (which might have led clinicians to treat people who have mild symptoms but never develop
schizophrenia) was moved to a section of conditions requiring further study. A proposal to reduce the length required for a hypomanic
episode from 4 days to 1 or 2 days was not adopted. The potential
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14 | Part I Diagn ostic P ri n cip l e s
impact of dropping the grief exclusion in diagnosing depression was
diluted—by warning clinicians to avoid making a diagnosis when
the course of mourning appears relatively normal. The range of
autism spectrum disorder has been kept limited. A radically different system for classifying personality disorders was not accepted.
Although it is assumed that most mental disorders lie on a spectrum
with normality and have subclinical forms, dimensionalization was
not consistently applied. Formal severity ratings for diagnoses, too
complex for clinical use, were considered to require further study.
The Structure of This Book
The first part of this book is devoted to broader issues. Chapter 2
reviews the history of psychiatric diagnosis, Chapter 3 how diagnostic manuals are prepared, Chapter 4 how diagnoses are validated,
Chapter 5 how mental disorder can be separated from normality, and Chapter 6 how dimensional assessment could be used.
Chapter 7 examines clinical utility.
The second part examines the major diagnostic groups in DSM-5.
Chapters 8–14 present separate discussions of the most frequently
used diagnoses: psychoses, bipolar disorder, depressive disorders,
anxiety disorders, obsessive–compulsive disorder, neurodevelopmental disorders, impulse control and conduct disorders, eating
disorders, sexual disorders, and personality disorders. Chapter 15
takes a briefer look at neurocognitive disorders, somatic symptom
disorders, dissociative disorders, sleep–wake disorders, elimination
disorders, and adjustment disorders.
In Part III, Chapter 16 examines responses to DSM-5 from the
scientific and clinical communities, and it comments on an alternative system proposed by the National Institute of Mental Health.
Chapter 17 discusses how clinicians can use the manual in practice.
Chapter 18 examines the future of psychiatric diagnosis, suggesting
guidelines for the practical use of DSM-5 in clinical work and underlining issues that need to be resolved for the next edition—DSM-6.
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2
The History of Diagnosis in Psychiatry
Why Is Diagnosis Important?
Since the dawn of medicine, diagnosis has been essential to practice.
Physicians need to organize the chaos of clinical symptoms into
meaningful categories of disease. They also need to make a diagnosis before prescribing treatment. Ideally, valid medical diagnoses
should be rooted in an understanding of disease processes. They
should be based on a specific cause (etiology) and on a specific pathway to illness (pathogenesis). Yet many categories in medicine have
been little but descriptions of signs and symptoms.
Patients come to clinical attention with physical changes
(signs) and subjective complaints (symptoms). But these are only
the apparent manifestations of pathology. The great advances of
medicine over the course of the nineteenth and twentieth centuries
depended on understanding underlying mechanisms. Some of the
most important discoveries showed that apparent symptoms (pain,
fever, swelling, anemia, and jaundice) can be due to entirely different
pathological processes.
Differential diagnosis is a “game” that every medical student is
expected to learn how to play. Every set of symptoms, even the most
common, can be explained by a variety of causes, and it is the job of
the physician to sort these possibilities out. Differential diagnosis is
much like detective work. Every detail of history, physical examination, and laboratory findings can be a clue. Sir Arthur Conan Doyle
based the character of Sherlock Holmes on one of his medical school
teachers, Joseph Bell (1837–1911), who gave his name to Bell’s palsy
and could deduce a great deal from a small amount of information.
15
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16 | Part I Diagn ostic P ri n cip l e s
The discovery of a difficult diagnosis is the subject of an even
more complex game—the Clinical Pathological Conference (CPC).
An expert is asked to review all the records of a difficult case, and
the correct (but often missed) diagnosis is revealed by an autopsy.
(It has been said that pathologists are always right, but they are usually too late.) These exercises have long been carried out at top medical schools, and a series has been published for several decades in
the New England Journal of Medicine.
The detective work of diagnosis has also become the subject of popular columns in newspapers and magazines. The reader is given a clinical presentation (often from an emergency room), and the process by
which an astute physician reaches a correct diagnosis is described. The
main difference from a CPC is that the outcome is a good news story.
Despite the importance of diagnosis, physicians still spend much
of their efforts treating symptoms. The great Canadian physician
William Osler (1898) opposed the “shotgun” medicine of his time,
in which every symptom was managed with a different drug. (As we
will see, despite advances in medical science, that practice remains
common, especially in psychiatry.) But psychiatry is not the only
specialty in which etiology and pathogenesis are unknown. In some
areas of medicine (e.g., infectious diseases), valid diagnoses can be
based on an understanding of underlying pathological processes. In
others (most chronic diseases), that is not possible.
Yet even when knowledge of disease is limited, diagnosis performs a number of important functions. First and foremost, it allows
physicians to communicate with each other. When one informs a
colleague that a patient has a classical case of peptic ulcer—or paranoid schizophrenia—a vast amount of information is conveyed by a
single diagnostic term.
Second, diagnosis offers something important to patients: a validation that they are indeed sick, an explanation for why, as well as
what can be done for them and a prognosis. Even when prospects
for effective treatment are slim, most people feel better when they
receive a diagnosis. At the very minimum, suffering is no longer a
mystery, and one can expect to benefit from whatever knowledge
medical science has at hand.
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Third, diagnosis provides researchers with a tool for conducting investigations and for developing theoretical models of disease.
That is why cancer research uses coding of disease types and staging
and why clinical research in psychiatry makes use of standardized
interviews.
Fourth, diagnosis helps physicians to plan treatment and to
establish a prognosis. When research is available to determine outcome, planning can be more rational.
Fifth, diagnosis aims to provide categories specific enough to
guide the choice of treatment. Currently, only a few treatments,
such as antibiotics, can claim that kind of specificity, and even then,
drugs are often prescribed without a clear idea as to what is wrong
with the patient. Yet medicine is slowly but inexorably moving in the
direction of specificity. Pharmacogenetics may be in its infancy, but
it is already being applied to a few diseases. In the future, psychiatry
might benefit from this approach.
Diseases, Disorders, and Syndromes
Valid medical diagnosis is a relatively recent phenomenon, but it is
based on more than a century of research (Balint et al., 2006). Over
most of the history of medicine, illnesses could be described only as
syndromes (a cluster of commonly associated signs and symptoms).
These syndromes could have a multiplicity of causes. For example,
the popular eighteenth-century category of “dropsy” (swelling of the
extremities) confused edema due to heart disease, kidney disease,
and a variety of other causes. In the nineteenth century, only a few
true illnesses could be properly diagnosed (mainly infectious diseases). Even so, causes were not well understood before the advent
of the germ theory of disease in the 1880s, and it took many years
before that theory resulted in effective treatment for infections.
The late nineteenth century was a time of rapid progress in medical research. The work of chemists such as Louis Pasteur (1822–1895)
and bacteriologists such as Robert Koch (1843–1910) led to the
identification of specific infectious agents behind many diseases.
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18 | Part I Diagn ostic P ri n cip l e s
The work of pathologists such as Rudolph Virchow (1821–1902)
allowed scientists to directly observe disease processes at the level
of the organ and of the cell. Despite these advances, physicians were
not yet able to help most of their patients.
By the early twentieth century, scientific medicine entered a
period of ascendancy. William Osler (1849–1919) was one of the
key figures. Over several decades, working at four universities
(McGill, Pennsylvania, Johns Hopkins, and Cambridge), he established many of the principles that still guide medical education and
practice (Osler, 1898). These include diagnosis based on detailed
observation of signs, careful listening to patients’ symptoms, and
laboratory tests to confirm the presence of a pathological process.
As long as physicians were limited in their ability to treat disease,
diagnosis did not necessarily lead to specific and effective therapy. But
later in the twentieth century, medical therapeutics greatly advanced.
The introduction of sulfa drugs in the 1930s and of antibiotics such
as penicillin after World War II was followed by a cornucopia of effective agents for many other conditions. Now accurate diagnosis really
began to make a difference. Again, the most dramatic example was
infectious diseases, where lives could be saved by culturing a specific
microorganism and by prescribing an antibiotic to which it was sensitive. Later, similar principles were applied to other diseases. To treat
syndromes such as anemia, hypertension, and congestive heart failure, physicians need to divide them into diagnostic categories based
on specific pathological mechanisms. Even in psychiatry, where mechanisms are rarely understood, bipolar disorders can be separated (at
least partially) from other conditions by a relatively specific response
to mood stabilizers (Goodwin & Jamison, 2007).
Principles of Nosology
“Nosology” refers to the science of diagnosis (Black et al., 2014).
This term gives the impression that diagnostic categories are scientific and based on empirical data. Yet all too often they are not.
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Although the problem is more severe in psychiatry, uncertainty
affects many medical diagnoses. Categories can change as knowledge
increases. For example, when I was a medical student, we studied a
disease called “viral hepatitis.” That entity has now been subdivided
into hepatitis A, hepatitis B, hepatitis C, and hepatitis D—with
more to come in the future as separate infectious agents, each with a
unique method of transmission, are identified. One can imagine the
same process occurring in other poorly understood diseases, each of
which could arise from a different pathological process.
Medicine need not worry about validity for diagnoses that are
based on known etiology and pathogenesis. It can also support
many categories using medical imaging, biological markers, and
cellular processes. Ideally, diagnosis evolves lockstep with research.
Even so, many—if not most—diseases remain mysterious. That is
particularly the case when it comes to mental disorders.
To be fair, medicine and psychiatry are not the only areas of science in which classification can be problematic. Biology offers an
illustrative example. There are more than 1 million types of multicellular organisms, and the number of single-celled species is
much larger. The taxonomy developed by the Swedish scientist Carl
Linnaeus (1707–1778) was a breakthrough in its time and is still
used. But as with diagnosis in medicine, classical taxonomy is based
almost entirely on appearances.
Although biologists have had no trouble understanding that
birds and bats belong to different groups, subtler distinctions have
not always been clear. The classification of organisms can be based
on evolutionary relationships, but the tools to carry out such analyses have only been available relatively recently, as the use of DNA
as a marker became practical. Using this tool allowed “the tree of
life” to be organized into three domains (Sapp, 2009; Archaea,
Bacteria, and Eukarya) divided into six kingdoms (Archaebacteria,
Eubacteria, Protista, Fungi, Plantae, and Animalia). Even so, there
are boundary problems—for example, the question of whether or
not viruses are living organisms.
Nuclear physics offers another example (Schumm, 2004).
Matters were relatively simple when the only known particles were
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20 | Part I Diagn ostic P ri n cip l e s
electrons, protons, and neutrons. As dozens of other “elementary
particles” were discovered, physics faced a crisis. The development
of quark theory resolved the problem by describing all these phenomena as combinations of much smaller entities—which seem, at
least for now, to be irreducible. Even so, this classification (as well
as the actual existence of some of the particles predicted by the
theory) remains controversial. Although some of these problems
may be resolved by experiments conducted in the Large Hadron
Collider, physics, like psychiatry, sometimes has to use a classification system with uncertain boundaries. If the “hard sciences” face
difficulties of the same kind, physicians and mental health professionals should feel a little better about their own problems in
classification.
Why Psychiatric Diagnosis Is Difficult
The categories used in psychiatric diagnosis are based on observation of signs and symptoms rather than on pathological processes.
One can make use of a few signs, such as facial expressions associated with depression, or the flight of ideas associated with mania.
But what clinicians mainly use for diagnosis are symptoms, the
subjective experiences reported by patients. Psychiatrists have little knowledge of the processes that lie behind these phenomena.
Thus, psychiatric diagnoses, with very few exceptions, are syndromes,
not diseases.
Many have hoped that advances in neuroscience would solve
these problems. After all, changes in thought, emotion, and behavior must ultimately reflect neural processes. Disorders of the mind
are also disorders of the brain. But the brain is not as easy to understand as the heart or the kidney. It may be the most complex structure in the entire universe. Thus, mental disorders cannot easily be
reduced to the biology of neurons. With billions of neurons, billions
more glia, and trillions of synapses connecting neurons to each
other, the brain does not lend itself to any simple explanation. To
add to the complexity, psychological phenomena are shaped by life
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experiences and by a sociocultural milieu. It is not surprising that
mental illness is so difficult to understand.
Moreover, although mind depends on the brain, mind cannot
be entirely reduced to the activity of neurons. Mental processes are
“emergent” phenomena that cannot be explained on the level of cellular activity or synapses (Gold, 2009). They require another level of
analysis, in which thoughts, feelings, and behaviors are studied in
and of themselves.
In summary, although research has provided some insight into
the localization and mechanism of brain function, psychiatry today
stands about where the rest of medicine was 100 years ago. It will
take many decades to answer even the most basic questions facing
neuroscience. It was an illusion to believe that we knew enough in
2013 to create a classification of mental illness based on biology.
The DSM System
The International Classification of Diseases (ICD), a system sponsored by the World Health Organization (WHO), is the most widely
recognized classification of medical illness. Even today, DSM codes
are “translated” for ICD, the official system worldwide. Originally
derived from a list of causes of death, the first version of ICD was
compiled in 1893. Mental disorders were first listed in ICD-6, published in 1949. Although mental illnesses took time to be recognized, the WHO system has become more sophisticated with each
revision; the current version, ICD-10 (World Health Organization,
1993), differs from DSM-IV only in detail. ICD-11 is planned to
appear in 2017 and to be more or less compatible with DSM-5. (It
remains unclear to what extent that will be the case.)
ICD has been eclipsed throughout the world by the more detailed
and systematic American system—the Diagnostic and Statistical
Manual of Mental Disorders. A preference for DSM reflects the dominance of research in the United States and the wish of clinicians and
investigators to use categories compatible with American science
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22 | Part I Diagn ostic P ri n cip l e s
that are used in most medical and psychological journals. However,
there is a more substantive reason for the greater influence of DSM.
That is due to the manual being algorithmic so that clinicians count
observed criteria and then follow an established logical sequence.
This approach is, in principle, more amenable to science. It is also
much easier to count criteria than to match detailed descriptions.
Instead, ICD describes prototypes for each of its categories, which
the clinician is asked to determine if a case approximates.
This algorithmic approach to diagnosis dates from the publication
of DSM-III in 1980. In 1952, the American Psychiatric Association published DSM-1, which was mainly intended to keep statistical records
and was not much of a scientific instrument. I learned DSM-I as a
medical student: The manual was thin, with 130 pages describing 106
disorders. It had nowhere near the impact of later editions. The most
important limitation of DSM-I was that it listed disorders, described
them briefly, but did not precisely define them. Without algorithms
for diagnosis, reliability was inevitably low. As a result, psychiatrists
could not even agree on their most basic diagnostic concepts.
For example, American psychiatrists of 50 years ago had an
overly broad concept of schizophrenia and were not in accord with
their British colleagues, who were more likely to diagnose psychotic
patients as having manic–depressive illness. The problem was documented by research in which videotapes of interviews were shown
to psychiatrists on both sides of the Atlantic Ocean (Cooper et al.,
1972). Later, American clinicians came to diagnose patients in much
the same way as their British cousins.
A second problem with DSM-I was that it adhered to theoretical models that were eventually found wanting. Under the influence of the Swiss–American psychiatrist Adolf Meyer (1866–1950),
who favored environmental models of etiology, almost all mental
illnesses were described as “reactions.” (There was even a category
called “schizophrenic reaction.”) Such turns of phrase implied that
all mental disorders are reactions to environmental stressors.
Although this idea contains a grain of truth, the concept is misleading. It entirely misses the essence of disease processes, which have
a trajectory of their own, even when environmental factors act as
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precipitants. In internal medicine, stressors—both physical and
psychological—can raise blood pressure, but no one would consider
making a diagnosis of “hypertensive reaction.”
DSM-I also reflected the strong influence of psychoanalytic
theory. At that time, many of the leaders of American psychiatry
were either trained analysts or sympathetic to the analytic movement. Several disorders (mild depression, anxiety, conversions,
phobias, and obsessive–compulsive symptoms) were classified as
“neuroses”—a term popularized by Freud. The manual specifically
stated that such symptoms were the result of “unconscious conflict.” How one might assess the presence of such a process was left
to the clinician. Clearly, the era of basing diagnosis on measurable
phenomena had not yet arrived. In the end, DSM-I was used for hospital records, but it never had a defining role in research or practice.
It was also not consistent with the ICD system, isolating American
psychiatry from the rest of the world.
DSM-II, introduced in 1968, was taught to me when I was a psychiatric resident. Its 134 pages described 182 disorders. All these
diagnoses were supposed to be compatible with ICD. The term “reaction” disappeared entirely—schizophrenia was now just “schizophrenia.” However, the psychoanalytic influence on the definition
of disease remained in place. Neuroses were still described as due to
unconscious conflict, as every good Freudian believed. Also, because
the definitions of each category were not algorithmic, the reliability
problem was in no way resolved.
Although all psychiatric residents had to learn DSM-II, we did
not take it very seriously. For one thing, it was written in descriptive paragraphs rather than algorithmic criteria. Thus, there was
too much latitude for clinicians to interpret phenomena in their
own way, with the result that DSM-II diagnoses were not particularly reliable. But at the time, diagnosis had few implications for
treatment. Psychotic patients were given antipsychotics, whereas
antidepressants were prescribed for depression. Everyone else got
psychotherapy, and diagnosis did not make that much difference in
choosing how to conduct it. The classification of mental disorders
only became a hot topic when DSM-III was published.
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24 | Part I Diagn ostic P ri n cip l e s
The DSM-III Revolution
In 1974, only 6 years after the publication of DSM-II, the American
Psychiatric Association (APA) realized that the problems of diagnosis in psychiatry were too severe to retain the second edition. This
was an era in which critics who refused to believe in the reality of
mental illness were vigorously attacking psychiatry. Many had a
political agenda. On the right, the American psychiatrist Thomas
Szasz (1961) was a libertarian who did not want to allow any role for
the state in determining personal conduct and rejected psychiatric
diagnosis because it can be used to support the involuntary commitment of psychotic patients. On the left, the British psychoanalyst Ronald Laing (1967) claimed that mental illness is a response
to an insane society—a point of view that fit the spirit of the 1960s.
Laing was against diagnosis for the same reason he was against
medication—he believed that psychosis could be a personal journey
that only required an expert guide.
Obviously, such critiques were well out of the mainstream of
medical thought. Yet they had a wide popular appeal at the time,
and psychiatry felt the pressure. Moreover, if, as research showed,
diagnosis was not reliable, no one could trust it. It was important
for the field to show that the classification of mental disorders had
some basis in science.
Perhaps the most important factor in the APA’s decision
to revise DSM was psychiatry’s need to overcome its isolation
from the rest of medicine (Spitzer, 1991). DSM-II was based on
unproven theories and had categories that looked nothing like
medical diagnoses. Thus, psychiatrists earned little respect from
their colleagues. Of course, inaccurate diagnosis is not the only
reason why physicians disrespected psychiatry. The stigma associated with mental illness was, and remains, the most important
factor (Corrigan, 2005). But the blatantly unscientific system used
in DSM-II did not help.
In the course of the 1970s, the APA—under the leadership of its
director, Melvin Sabshin (1902–1987)—began to prepare the next
edition of DSM. The APA chose Robert Spitzer (1932–), a professor
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from Columbia University, to lead the task force. This was a time
of change and ferment in psychiatry, and the selection of Spitzer
proved pivotal. A former analyst who had rejected Freud, Spitzer
focused his career on developing better methods of assessment for
mental illness.
Spitzer’s concept for the new edition was based on the research of a
group of psychiatrists at Washington University in St. Louis, led by Eli
Robins (1922–1995) and Samuel Guze (1924–2000). These men began
as renegades but became the leaders of a new psychiatry. Dismissing
psychoanalysis out of hand, they wanted to move American psychiatry
into consonance with traditions developed in Europe.
Spitzer was a natural ally for the Washington University group,
several of whom he brought into his DSM task force. Like many of
his contemporaries in academic psychiatry, Spitzer was disillusioned
with older paradigms and looking for something different. His interest in psychometrics was based on the principle that diagnosis, as well
as signs and symptoms on which categories are based, can be quantified. Spitzer was following a long-standing principle in science: The
only valid concepts are those that can be measured with numbers.
This point of view involved a return to principles developed
by the German professor Emil Kraepelin (1856–1926). Kraepelin,
a contemporary of Freud, was the leading psychiatrist on the
European continent in the early twentieth century and became
famous for his separation of psychoses into schizophrenia and
manic depression (Kraepelin, 1921). As Shorter (1997) observed,
Kraepelin turned out to be much more important for contemporary
psychiatry than Freud, whose star has rapidly faded. That is why
DSM-III was described as “neo-Kraepelinian” (Klerman, 1986).
Kraepelin understood that psychiatric diagnosis must eventually be based on biological processes. But while waiting for specific
markers to be discovered, categories can be provisionally based on
signs and symptoms, as well as on clinical course, prognosis, and
treatment response. That was precisely the view of Spitzer and of
the group at Washington University.
One of the assumptions of Kraepelinian psychiatry was that
categories of disease are real, even if they remain to be discovered.
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26 | Part I Diagn ostic P ri n cip l e s
This view is in accord with the approach of modern medicine. Yet
some view it as a form of “essentialism” that fails to acknowledge
that diagnostic categories inevitably have fuzzy edges (Livesley,
2011a). DSM-5 seeks to go beyond Kraepelin, accepting categories
as a temporary expedient but viewing illness as a point on a broad
continuum that shades into normality.
Whether or not this paradigm ultimately prevails, in the absence
of biological markers for disease, DSM-III and its successors were not
in a position to reach Kraepelin’s goals. But the neo-Kraepelinians
rightly insisted on observable, phenomenological criteria. One of
the main effects of this principle was to undermine the influence of
psychoanalysis on American psychiatry (Paris, 2005, 2008a) and to
replace that paradigm with a new perspective.
Some years earlier, Robins and Guze (1970) had developed a
set of criteria that could be used to define schizophrenia and other
major psychiatric disorders. The system focused on observable phenomena and was algorithmic (i.e., it had a defined pathway from
observation to diagnosis). This approach, often called the “Feighner
criteria” after the lead author of the seminal paper (Feighner et al.,
1972), was the germ of DSM-III. It was the model on which all diagnosis in the third edition was built (Kendler et al., 2010;).
The Washington University group also proposed that these
“research diagnostic criteria” could be used as a general benchmark for diagnostic validity (Robins & Guze, 1970). Their idea was
that all diagnoses should be based on (1) precise clinical description, (2) laboratory studies identifying biological markers, (3) clear
delineation from other disorders, (4) a characteristic outcome in
follow-up studies, and (5) a genetic pattern in family history studies. Although none of these criteria were directly based on etiology
or pathogenesis, they could be markers for disease processes. The
Robins–Guze criteria were similar to the way medical diagnoses
are validated. But these goals, however modest, have proven to be
beyond reach. Twenty years later, no major mental disorder had met
this benchmark (Blashfield & Livesley, 1999), and the situation has
not changed. Moreover, some of these assumptions have been challenged (Hyman, 2007). Mental disorders, if they do not correspond
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to strict categories, may not have the characteristic features suggested by such a paradigm.
The Impact of DSM-III
DSM-III was much larger than any previous edition: 494 pages
describing 265 categories. It was a true paradigm shift that threatened some, drew applause from others, and aroused great controversy. It may be difficult for a new generation, brought up on this
system, to understand the tumult that preceded and followed its
adoption. In particular, most psychoanalysts opposed DSM-III.
They rightly perceived that it contradicted their worldview and loosened their hold on the profession. Some thought the manual would
destroy psychiatry. For example, early drafts of DSM eliminated the
concept of neurosis entirely and made no mention whatsoever of an
unconscious. For a while, angry psychoanalysts threatened to secede
from APA as a group. Then, in a clever move, Spitzer fashioned a
compromise in which the term “neurosis” continued to appear, but
only in parentheses. (That term was dropped entirely in DSM-III-R.)
Another source of resistance was that DSM-III took, at least at
first, an unfamiliar approach. Diagnosis had long been considered
an art, based on clinical experience. Now, with specified criteria,
anyone could do it. If you could assess signs and symptoms, you just
had to open the book and count. Making diagnosis easy demystified
psychiatry in that its procedures could be used by family doctors
and by nonmedical professionals. Some thought DSM diagnosis was
too robotic, but this conclusion was mistaken. A final diagnosis may
depend on an algorithm, but it takes a fair amount of experience
to assess whether criteria are present or whether they are clinically
significant.
In the end, the momentum of DSM-III proved unstoppable.
Psychiatrists were no longer willing to stand outside of medicine
and be mocked and looked down on by their colleagues. Even if they
could not aspire to having a specialty fully grounded in empirical
data, they now had a diagnostic system that at least looked scientific.
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28 | Part I Diagn ostic P ri n cip l e s
DSM-III met a need, and almost everyone began to use it. Today,
hardly anyone can remember being against it.
One of the main criticisms of psychiatric diagnosis had been that
clinicians seeing the same patient might not make the same diagnosis. The absence of reliability was a potentially fatal problem. As every
psychology student knows, measurements cannot be valid without
first being reliable. Low reliability ultimately reflected the fact that
the criteria sets of earlier DSM manuals were vague. If one uses a “prototype”—that is, a description of a typical clinical presentation—one
expects the clinician to determine whether a patient’s signs and
symptoms approximate a written description (Berganza et al., 2005).
But doing so is not easy, and different raters may still come to different conclusions. That remains the main weakness of the ICD system.
Even if you do not have the data to determine diagnostic validity, you can prioritize reliability. That is precisely what DSM-III did.
The problem is that we can all agree—and all be wrong. Even so, it
was better to have categories that everyone can agree on. Diagnostic
validity would just have to wait.
Interestingly, although some psychiatrists resisted DSM-III,
clinical psychologists were generally positive. That was quite an
achievement, given the traditional competitiveness between these
two professions. What psychologists liked about the system was
that it looked like the criteria they learned in graduate school and
used for many other purposes: relatively precise definitions, with
algorithms leading to a conclusion.
In this respect, DSM-III diverged significantly from ICD. That is
why DSM took precedence—not only in the United States but also
throughout the world. It is now difficult to find a scientific paper
that does not use the DSM system or to find a group of clinicians for
whom the manual is entirely unfamiliar.
The DSM System Since 1980
The year 1980 was a watershed. The DSM system changed relatively
little during the next 30 years. It took time for practitioners to
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adapt to a radically new method of classification. Moreover, further
changes in diagnosis could be problematic for researchers. If it was
standard for all patient samples to be described according to DSM,
then changing the criteria could put a research paper out of date
even before it was published.
Moreover, there was some tinkering in DSM-III-R (APA, 1987).
The manual was now 567 pages long and described 292 diagnoses.
The most significant shift was that hierarchical rules (excluding a
diagnosis if another category explains the same clinical features) were
greatly restricted. That led to an even greater degree of “comorbidity”
(multiple diagnoses)—a problem that, as we will see, remains unresolved. Some psychiatrists believed that the changes in DSM-III-R
were not sufficient to justify a new manual. Murmurings were heard
that revisions were arbitrary and that they came out of informal
meetings in Spitzer’s basement. Suspicions were even raised about
the large profits that APA made every time a revision is published.
After revolution, people crave stability. The APA eventually
decided that stability in diagnosis was more important than Robert
Spitzer. To this end, it assigned a different leader—Allen Frances
(1942–), then a professor at Cornell University—to lead the
DSM-IV process. This revision (APA, 1994) made fewer changes than
DSM-III-R had made. It described 297 disorders in much greater
detail (the length was now 886 pages). The most major innovation
was a new section on sleep disorders. Another was the publication
of “source books,” summaries of the research findings on which the
manual was based.
At the time, Frances stated that the new manual should be
good for another 15 years. He was more than right—it lasted for
19 years. Only a few minor changes were introduced in a “text revision,” DSM-IV-TR (APA, 2000), which did not change the criteria for
disorders but discussed them slightly more thoroughly.
Plans for a major revision began soon after DSM-IV-TR was published. The authors of the new edition viewed it as an opportunity
to base the classification more firmly on neuroscience (Kupfer et al.,
2002; Regier et al., 2009). This book will offer a critical examination
of whether that goal has been reached.
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30 | Part I Diagn ostic P ri n cip l e s
Because research continues to make slow progress, we do not
know how many years it will take for the next major revision to be
prepared. The question is whether it is better to maintain stability or to introduce a system that allows for continuous update. The
reason why DSM-5 uses an Arabic (rather than a Roman) numeral
is that it is open to revisions, even prior to DSM-6. Like computer
programs that are updated on the Internet, a DSM-5.1 or -5.2
could appear. The upside is that if a great discovery is made, it can
be included. Also, it may be easier for clinicians to accept change
gradually. The downside is that changing criteria can be disruptive
for both research and practice.
How the DSM System Shaped Psychiatry
Every mental health clinician needs a copy of DSM-5 (or at least the
list of criteria in an inexpensive paperback edition)—even if they
do not read it cover to cover. And the way that patients are classified can have an effect on the treatment they receive—even though
diagnosis need not determine therapy. Every research project in the
coming years will have to take the new system into account. In 947
pages, it lists more diagnoses in total (541) than DSM-IV, although
because some are subtypes of broader categories, the number with
specific criteria is actually less. In any case, all diagnostic instruments based on DSM-III or DSM-IV will have to be revised. Within
a few years, all medical journals receiving submissions about clinical
populations will require a DSM-5 diagnosis. The residents I teach all
want to know if they have to master the new system to pass their
exams. Mental health professionals also need to use DSM-5 to write
reports on their patients.
Textbooks of psychiatry have been built around DSM diagnoses
for the past 35 years. Even doubtful categories are given their own
chapter—forcing editors to choose proponents of the most controversial diagnoses as authors. This implicit validation is one of the
reasons why it has been so difficult to remove any diagnoses from
the manual. Moreover, the bar for removal is as high as the bar for
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2 T he H i s tory of D i a gno si s i n P sy c h i a t r y | 3 1
inclusion. (Even in a hard science such as astronomy, the demotion
of Pluto to a “dwarf planet” in 2006 drew loud protests.)
There was a time when psychiatrists were known as deep thinkers, not classifiers of disease. All that changed in 1980. Today, the
field of psychiatry has come to be organized around the DSM system. It may not be, as the media sometimes claim, “psychiatry’s
bible.” But given the general public’s interest in psychiatry, each
revision has been front-page news.
Diagnosis and Treatment
DSM-III included a disclaimer that diagnoses based on the manual
should not necessarily lead to any specific mode of treatment. This
remains the case for DSM-5, but it has been impossible to resist the
linkage. Psychiatrists, as well as other physicians and clinical psychologists, are usually not interested in classification for the sake of
classification. When they have a hammer, they search for nails. This
can make them try to fit a patient into a category they think they
know how to treat. Although today the hammer is usually a drug,
diagnosis can also fit methods of psychotherapy, as shown by the
vast interest in posttraumatic stress disorder.
The pharmaceutical industry has not been shy to take advantage of these forces to encourage the use of more diagnoses. When
they market a new drug, they often need to create a market for it.
(These campaigns usually go under the rubric of providing “information” for practitioners.) For example, attention-deficit hyperactivity disorder is diagnosed much more often now, in adults as well
as in children, in part because of pharmaceutical promotion for new
agents (to replace the tried-and-true option of methylphenidate).
Similarly, one reason why major depression tends to be diagnosed is the large number of antidepressants on the market. Also,
bipolar disorder tends to be diagnosed because of the perceived
effectiveness of mood stabilizers and antipsychotics. In contrast, a
relative lack of interest in anxiety disorders reflects the absence of
newer and more effective pharmaceutical options.
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32 | Part I Diagn ostic P ri n cip l e s
There are exceptions to this principle. For example, there has
been an increase in the diagnosis of autism and autistic spectrum
disorders despite weak evidence for the efficacy of therapy. Here,
the driving force seems to have been fascination with the diagnostic
construct.
The claim that DSM-5 represents the latest in scientific knowledge is doubtful. Diagnosis is not necessarily a neutral and empirically based procedure. It is driven by a variety of social forces lying
outside of medicine (Horwitz, 2002). It can be influenced by academics promoting a theory or a favorite diagnosis. It can be influenced by practitioners’ desire for predictable clinical results. It can
be influenced by patient advocacy—most of the main diagnoses in
psychiatry now have their lobby group. It can also be influenced by
the media, which have the power to affect everyone’s opinion—even
experts. The authors of the DSM-5 may not acknowledge, or even be
fully aware of, all these influences. That does not make them any
less important.
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3
How Diagnostic Manuals Are Made
Producing a diagnostic manual is a complex process that resembles
a military operation. It requires a “general” and a hierarchy of command. The American Psychiatric Association (APA) has put the creation of each new manual in the hands of a “task force” chaired by
a prominent academician. For DSM-III and DSM-III-R, that person
was Robert Spitzer. For DSM-IV, it was Allen Frances. For DSM-5,
the role was shared between two research psychiatrists: David
Kupfer and Darrel Regier.
Kupfer and Regier are prominent leaders in their fields. Kupfer
is a mood disorder researcher who served for 26 years as Chair of
Psychiatry at the University of Pittsburgh. Regier is an epidemiologist, a research administrator at the National Institute of Mental
Health, and director of the APA’s Division of Research. Their point
of view on diagnosis is rooted in extensive academic and research
experience. But their clinical perspective is less clear. High-ranking
academics do not see a large number of patients—most live in a
rarified world that is protected from raw clinical reality. That is also
true of most of the psychiatrists and social scientists working on
DSM-5 committees. The experts involved in the process tend therefore to be influenced more by theory than by practice.
The result is a manual designed to make researchers happy.
Investigators have the luxury of taking all the time they need. They
do not have to make diagnoses rapidly while multitasking—as many
clinicians must. Insensitivity to the needs of busy practitioners
tends to make the manual unwieldy for practice. DSM-5 has worked
hard to inject more “science” into psychiatric classification, but the
result may be more useful for researchers than for practitioners.
33
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34 | Part I Diagn ostic P ri n cip l e s
The detailed writing of a DSM manual depends on many people. APA set up a group of task force members, most of whom were
either chairs of “workgroups” (each of which dealt with a major
group of disorders) or of “study groups” (each of which was asked
to examine broader conceptual issues). All groups were composed of
prominent researchers, and being a member was considered a great
honor. The chairs were asked to choose the experts they wanted,
and these decisions may have led to predetermined outcomes.
The task force consisted of 28 people. Each of the workgroups
had 6–12 members and conducted regular meetings, either in person or electronically. (Using e-mail, they had to travel only a couple
of times a year to meet face to face.) Their mandate was to review
the existing literature, prepare new sets of criteria, and field test
them. They were assigned to examine the following groups of disorders: attention-deficit hyperactivity disorder (ADHD), anxiety,
childhood and adolescence, eating, mood, neurocognitive, neurodevelopmental, personality, psychosis, sexual, sleep, somatic, and
substance use.
The study groups were assigned broader questions. One focused
on spectra that cross diagnostic boundaries, recommendations for
structuring categories, and developing better overall criteria for
psychiatric diagnosis. A second was assigned to examine how developmental processes influence diagnosis. A third studied the influence of gender and culture. A fourth examined interfaces between
psychiatry and medicine, with a mandate to develop a new definition of disability (to replace Axis V, the scoring system introduced
in DSM-III). A fifth was assigned the task of reviewing the measurement of dimensions within categorical diagnoses.
DSM-5 conducted a series of field trials in 2011 to determine whether the system was reliable and user-friendly. This was
intended to allow for fine-tuning. However, the field trials suffered
from a serious lack of time (Jones, 2012). Also, given the lack of
comparisons with DSM-IV, it was difficult to determine whether the
new system actually works better in practice.
There was considerable debate in the literature about the wisdom and validity of making radical changes in DSM-5. However, it
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3 H ow D i a gnos ti c M a n u a l s A re M a d e | 3 5
was decided to begin with a new team, excluding most of the experts
who worked on DSM-IV. Although the editors backed away from
their initial hope of a “paradigm shift,” workgroups were encouraged
to be innovative. However, all decisions received scientific review
by a separate committee led by an eminent academic psychiatrist,
Kenneth Kendler of Virginia Commonwealth University. At the end
of this complex process, all reports were submitted to the task force
for approval. The final document of DSM-5 then had to be approved
by the APA Board of Trustees and by an assembly of APA delegates
from across the United States.
Keeping Industry Out
When DSM-III and DSM-IV were published, some critics expressed
concern that the text had been subject to undue influence by the
pharmaceutical industry (Kutchins & Kirk, 1997). Actually, drug
companies had no direct input into the DSM process. But industry benefits financially from diagnoses that lead to a wider use of
products that can obtain indications from the U.S. Food and Drug
Administration. Also, experts in psychiatry, many of whom receive
money from industry, can be biased in favor of expanding diagnostic categories. No one claims that industry can tell organized psychiatry how to write its diagnostic manual. But when so many of its
key opinion leaders are in the pay of industry, diagnoses that lead to
specific pharmaceutical indications could be more likely to get into
DSM. That possibility is worrying.
Thus, experts who take money from drug companies are likely to
be biased, often without realizing that they are being so. They live
in a climate of opinion that consistently favors new diagnoses and
new drugs. That was a good reason to keep them out of the process
of preparing DSM-5. But it was not possible to exclude everyone
because almost every professor of psychiatry has been supported
in some way by industry. Cosgrove and Krimsky (2012) have documented how the rules were stretched in a way that reduced, but in
no way eliminated, conflict of interest. The best one can say is that
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36 | Part I Diagn ostic P ri n cip l e s
those who served took less money. Most of them will probably go
back to industry for further support once the process is over.
The APA has had a history of overly close relations with “Big
Pharma.” Until recently, industry sponsored many events at its
annual meeting, creating profits used to support the organization
as a whole. This supported the suspicion that drug companies could
somehow shape DSM-5. Actually, most industry funding is not used
to support research but, rather, pays for pharmaceutical representatives and offers payment to experts who promote sales. Academics
in the pay of Big Pharma often give talks that directly or indirectly
support new drugs. They may also be paid to be “consultants” for
industry or serve on “advisory boards,” which usually involves little
real work but allows for attendance at conferences in interesting
or exotic locales. The funds that professors of psychiatry take from
pharmaceutical companies have made a few of them into millionaires. The latest drugs, few of which are very different from agents
already on the market, are strongly promoted by these opinion leaders, who get paid for giving talks advising clinicians to use them.
In short, it is possible for academic psychiatrists to be “bought”
by the pharmaceutical industry (Healy & Thase, 2003). Even one of
the chairs of DSM-5, David Kupfer, had provided services for several
companies, although he stopped when he took on his position. In
any case, there is little doubt that new diagnoses in psychiatry are
good for business. For example, the relatively new category of social
phobia generated billions in sales for the makers of antidepressants
(Lane, 2007). The more categories there are in DSM-5, the better for
industry.
These concerns have led to a backlash against organized medicine for its overinvolvement with Big Pharma (Angell, 2000).
Despite its weak position within medicine as a whole, psychiatrists
take more money from industry than any other group of specialists.
These conflicts of interest have the potential to corrupt both clinical practice and research. In 2008, Senator Charles Grassley of Iowa
brought these issues to public attention. The spotlight was placed
on academic psychiatrists who take millions of dollars from industry in “consultant fees” for promoting products in lecture tours. As
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3 H ow D i a gnos ti c M a n u a l s A re M a d e | 3 7
reported in The New York Times (June 8, 2008), the chair of psychiatry at Emory University lost his job when these facts came out and
when it became clear that he had not informed his university or
the National Institute of Mental Health (NIMH) about how much
money he had been paid. (Due to his fame and a close relationship
to the leaders of NIMH, this psychiatrist had no trouble getting
another chairmanship.)
New guidelines governing the relationship between industry
and professional organizations in medicine have been proposed to
deal with these problems (Rothman et al., 2009). The DSM-5 process required that all task force and workgroup members be vetted
and that only minimal involvement with pharmaceutical companies
would be allowed from the time of participation. This rule slowed
down the entire process (it took a full year to vet everyone). In the
end, all task force members were declared to be “clean” of major
involvement with industry. But if almost all of them have taken
money from pharmaceutical companies in the past, one cannot be
certain whether their objectivity was permanently compromised.
Transparency Versus Secrecy
The process of preparing DSM-5 was criticized for insufficient transparency (Frances, 2009a, 2009b, 2009c). A document with such an
enormous influence on practice cannot be prepared in secret, and it
needs to attain a degree of “buy-in” from potential users. Although
all proposals for change were eventually put on a website for commentary, the initial process by which the new manual was revised
was far from open.
The authors of earlier editions had taken greater pains to consult widely. For years before the publication of DSM-III, I remember
well-attended symposia at each annual meeting of APA in which all
changes were discussed and feedback was considered seriously. (I
even wrote Spitzer with a question and got a typed reply.) When
DSM-IV was being prepared, drafts were sent for comments to
experts who were not members of the workgroups. (I was one, even
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38 | Part I Diagn ostic P ri n cip l e s
if my comments had little effect on the outcome.) In contrast, the
DSM-5 process was, at least at first, closed. This created suspicion
that the task force wanted to avoid criticism and hoped to present
psychiatry with a fait accompli.
In a spirited exchange published in the newsletter Psychiatric
Times, Allen Frances (2009a, 2009b), joined by Robert Spitzer
(2009), criticized the confidentiality agreements signed by all workgroup members. Everyone had to promise to keep their discussions
under wraps. This rule threatened to close the whole process to feedback. Both Frances and Spitzer also suggested that because many of
the revisions under consideration were problematic, they needed to
be openly and intensively debated outside the task force.
A group representing DSM-5, led by a president of APA
(Schatzberg et al., 2009), wrote back to deny these claims. The group
argued that early drafts were too provisional to be up for general
discussion and noted that the most major changes were being presented at a number of scientific meetings. Unfortunately, this letter included a nasty counteraccusation, raising serious questions
about the judgment of those who wrote it. Schatzberg et al. claimed
that the authors of previous editions (i.e., Frances and Spitzer) were
motivated by a financial interest in books and assessment measures
they published after DSM-III and DSM-IV. This comment made no
sense because nobody would buy these books once DSM-5 was in
place. Schatzberg himself had been accused of conflict of interest
(by Senator Grassley) for promoting drugs in which he had a financial interest. The tone of his reply shows how badly APA was stung
by criticism.
The process of writing the manual should have been more open
from the beginning. When you are making changes that may or may
not be valid or user-friendly, you should circulate proposals widely
and open them up to scientific debate. The bigger the decision, the
more input from clinicians and researchers is needed. Although
everyone eventually had the opportunity to submit suggestions on
the Web, I doubt that they were taken seriously.
In the end, all proposed changes were published on the DSM-5
website in February 2010. Further revisions were posted in 2011
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3 H ow D i a gnos ti c M a n u a l s A re M a d e | 3 9
and 2012. One suspects that this happened as a result of the criticism as well as pressure from higher levels, which created a committee in 2009 (chaired by a former APA president, Carolyn Robinowitz)
to oversee the entire process.
Frances and Spitzer (2009) also complained that no one outside the committees had access to the data driving the revision. In
DSM-IV, the driving principle was that any changes must be justified by evidence. That evidence was summarized in a four-volume
“sourcebook” (Widiger et al., 1997), put out a few years after the
revision. There are no plans to publish a similar document for
DSM-5. Instead, one could have consulted the website, in which
changes were explained and justified with reference to the scientific literature. But when preliminary reports from the workgroups
were posted in February 2010, they offered only brief rationales,
not detailed literature reviews, data analyses, or critical comments
about criteria. This vagueness suggested that some of the revisions
were based on opinion rather than data, as happened in previous
editions (Lane, 2007). Being vague deflects comment and prevents
researchers not on the task forces from making informed critiques.
Moreover, proposals were not sent to potential opponents to avoid
bias—as had been the policy in DSM-IV (First, 2010). Moreover,
the document as a whole was not presented to experts entirely outside the DSM-5 process for independent assessment. Because peer
review is a basic principle in science, DSM-5 risks being less scientific than its predecessors.
Many academics had their first good look at the proposed
changes in February 2010. By the time the website opened, the
process was well advanced, and workgroups had been meeting for
2 years. Although some changes were made after that, the train had
already left the station. Moreover, all the rationales for changes
were removed from access when the website was shut down a few
months prior to the publication of DSM-5.
Perhaps the real problem lay not in the process but, rather, in the
fact that DSM-5 is more driven by ideology than previous manuals.
The guiding principles are that mental disorders are neurobiological
and dimensional and that they lack a cutoff from normality (Kupfer
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40 | Part I Diagn ostic P ri n cip l e s
& Regier, 2011). The agenda was to overthrow the neo-Kraepelinian
paradigm. But although changes could be rationalized by empirical
findings, the data were not sufficient to support these ideas. DSM-5
could not be a paradigm shift, and those who originally thought it
could be were guilty of hubris.
A more serious objection was that DSM-5 lacks clinical utility.
The academics who wrote it may not have slaved away, like most of
us, in a clinic or emergency room for years but, rather, spent much of
their careers in front of computer screens. That is why they have not
given the proper weight to clinical practice. This circle might have
been squared if DSM-5 had been published in two versions—one for
daily clinical use and one for research. That idea has been supported
by some commentators (McNally, 2011) and seems sensible. But for
the APA, dividing DSM-5 in two has no traction because it would be
seen as compromising scientific cachet.
In the end, DSM-5 made the same mistake one sees in many
decisions made by governments or corporations. Without criticism from outsiders, “groupthink” takes over (Janis, 1972). We
have often seen this happen in political decision-making, ranging
from the Bay of Pigs to the invasion of Iraq. From my own knowledge of colleagues who served on the workgroups, I think some of
them signed on to changes they did not really believe in to achieve
a consensus.
A Cautionary Tale
One of the most serious omissions in the process of creating a new
manual is the absence of any direct comparisons between DSM-IV
and DSM-5, accompanied by an assessment of the clinical and
research impact of changes. The omission was deliberate because
the editors viewed DSM-IV as invalid and did not see any value in
head-to-head comparisons. Moreover, the task force made a point of
not consulting either Allen Frances, the editor of DSM-IV, or Robert
Spitzer, the editor of DSM-III. Many other senior figures in psychiatry were left out of the loop. Leaving experts out of a process, and
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3 H ow D i a gnos ti c M a n u a l s A re M a d e | 4 1
not even asking their opinion, was unwise. It led in some cases to
open opposition (through both the scientific literature and the public media). The belief of the leadership was that the time had come
for radical change and that although outsiders might disagree with
changes, they would eventually have to come around—as they did
after DSM-III. But there was a price to be paid.
The DSM-5 process downplayed continuity (First, 2010). The
most radical revision proposed was for personality disorders, a
diagnostic group viewed as a poster child for dimensionalization
(see Chapter 14). Although some degree of change was warranted,
the proposed revision was unwieldy and problematic. It was openly
criticized by a member of the workgroup (Livesley, 2010) who went
on to resign in protest. The new criteria were certainly contentious.
Every time they were presented at conferences, researchers who
were not on the task force attacked these proposals. The response
to these critiques was almost always along the lines of “you don’t
really want to keep DSM-IV, do you?” Anyone who suggested leaving
things more or less as they were until more evidence became available could be written off as a dinosaur.
I was one of those left out of the process, but my criticism was
not based on personal pique. After all, the opinion of most senior
investigators in my area was never formally solicited. Anyone with
opinions that might have contradicted the agenda was simply not
heard. The result was that experts who were not included turned
against the proposals, albeit for different reasons. Opponents, even
as their suggestions were rejected, were forced to write articles in
journals and/or letters of protest to the APA. The only way to exert
any influence on the process was informal, through personal relationships with workgroup members. I wrote some workgroup members and even organized colleagues for a conference call with the
chair of the personality disorder task force. A few minor changes
we lobbied for did find their way into the final document. But in the
end, the final proposal remained deficient in scientific support and
in clinical utility, leading ultimately to its rejection. This is not the
best way to prepare a diagnostic manual that would shape clinical
work and research for many years to come.
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