In a recent Psychiatric Times blog, Allen Frances engaged a debate with Andrew Hinderliter over the question of change in the diagnostic categories of DSM-5.1 Frances has argued in recent blogs and in the pages of the Bulletin of the Association for the Advancement of Philosophy and Psychiatry2 for a conservative attitude toward change in the new manual. In response, as cited in Frances’ blog, Hinderliter has argued that the conservative approach has allowed unwarranted, over-medicalized conditions, such as the paraphilias, to be grandfathered in from one DSM to the next, with no process in place for eliminating them when indicated.
Defending the conservative approach Frances responded: “To keep the diagnostic system from expanding wildly, we established extremely high thresholds for change in DSM-IV. Substantial scientific evidence was required for changes in either direction - - those that would add to the reach of the system, but also those that would subtract from it. The rationale was that without clear and high scientific thresholds, changes would be arbitrary, destabilizing, and subject to personal whim. This requirement did indeed permit the grandfathering of decisions made previously that would not have met the standards for new suggestions.”1
To summarize this argument, we have two conflicting positions. One position, that of Frances, states that we should only make changes in the DSM-5 diagnoses when there is strong scientific evidence to support the change. And he adds that unwarranted, unscientifically-based changes will destabilize the system. The opposing argument, that of Hinderliter, states that the Frances approach provides no mechanism for removing diagnoses that are not supported scientifically and don’t belong in the DSM. How might we resolve this dispute?
I propose a rather simple resolution. The first step is to recognize that science won’t tell us what is a disease or disorder and what is not. We can expect further genetic and neuroscientific understanding of both schizophrenia and optimistic temperament, but that scientific understanding won’t carry tags that label one as a disease and the other as a normal variant. Judgments as to what qualifies as a disease depend on other factors such as suffering and disability.
When Frances argues that our scientific genetic and neuroscientific understanding of the major psychiatric disorders is quite a mess -- and thus warrants a conservative attitude toward changes in the DSM-5 manual -- he is making valid point; but his argument applies only to genuine psychiatric disorders. When Frances writes about DSM-IV, for instance, that “...it was wiser to settle for the less ambitious goal of reducing additional puffery (by introducing high thresholds for change in DSM-IV),”2, p. 31 he is referring to conditions that belong in the manual. If we have in fact stuck conditions into the DSM that don’t belong there, there is no science to wait for. We can make the decision right now to throw them out.
So the resolution of the debate between Frances and Hinderliter is fairly simple. For the conditions that we all agree are genuine psychiatric disorders, we should follow Frances’ advice and proceed cautiously with manual changes until we have cleared up the murky waters of current genetics and neuroscience. On the other hand, for those conditions whose very disease status is in dispute, we should forget the neuroscience, have the debate, and throw out the losers. Deciding, for instance, whether pedophilia should be considered a psychiatric disorder or simply a socially unacceptable behavior will make for a very contentious debate, but waiting for more science won’t make it an easier debate to settle.