The DSMs: Useful for Whom?

The first paragraph of the Introduction to DSM-IV contains the following statements: “The utility and credibility of DSM-IV require that it focus on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers”^1,p.xv The question I’d like to raise is “Whose utility is being prioritized? Clinicians’ or researchers’?”

Let’s begin with the primary achievement of DSM-III and DSM-IV—namely, the establishment of reliability through the use of diagnostic criteria. The criteria help to assure that different psychiatrists will diagnose the same patient with the same disorder(s). Now the paradox of the DSMs (since DSM-III) is that while the authors insisted on the utility of the manuals for practitioners, what they produced were manuals that improved reliability (and thus utility) for researchers. Does this mean that practitioners are not interested in reliability? Certainly not. But clinicians tend to rely on prototypes, general gestalts of the disorders, rather than diagnostic criteria; and they learn these quickly through the manual descriptions or glances at the criteria.²

Clinicians are after all focused on treatment, not on obsessing over whether a patient meets two, three, or four of the diagnostic criteria. To summarize this distinction, while researchers check criteria carefully to assure a uniform research population, experienced clinicians use prototypal, syndromal diagnoses, often a pragmatic mix of the currently ascendant biomedical categories with a varying admixture of psychodynamic considerations. The simpler and more informal use of prototypes serves them quite well. I would guess that in ordinary practice an experienced psychiatrist uses the manual only for such tasks as formal coding or a reminder about an uncommon disorder.

Is there any real evidence for this claim I am making, other than my anecdotal, personal impressions? The limited empirical research evidence^2-4 supports the impression that practitioners, if they use the manuals at all, use them in a loose, informal manner and are comfortable ignoring diagnostic criteria and making their diagnoses following an informal prototypal pattern.⁵ With the huge amount of work going into the DSM-5, it would surely be of use to have more information on how these overweight screeds are actually used by the psychiatrist on the street. In keeping with the stated intent of the existing and previous manuals, Michael First and colleagues argue that any change in the existing manual should use clinical utility as a criterion of change.⁶

What might we expect from DSM-5? At this point we only have hints, and here is one: “The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-5 will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-5 will be the more prominent use of dimensional measures in DSM-5.”⁷ Whatever the merits of dimensions, it’s hard to disagree with Michael First, writing in another article,⁸ that they will wreak havoc with clinical utility.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association; 2000.
2. Jampala VC, Sierles FS, Taylor MA. Consumers’ views of DSM-III: Attitudes and practices of U.S. psychiatrists and 1984 graduating psychiatric residents. Am J Psychiatry. 1986;143:148-153.
3. Jampala VC, Sierles FS, Taylor MA. The use of DSM-III in the United States: A case of not going by the book. Compr Psychiatry. 1988;29:39-47.
4. Jampala, VC, Zimmerman M, Sierles FS, Taylor, MA.. Consumers’ attitudes toward DSM-III and DSM-III-R: A 1989 survey of psychiatric educators, researchers, practitioners, and senior residents. Compr Psychiatry. 1992;33:180-185.
5. Cantor N, Smith E, French R, Mezzich J. Psychiatric diagnosis as prototype categorization. J Abnormal Psychology. 1980;89:181-193.
6. First MB, Pincus HA, Levine JB, et al.. Clinical utility as a criterion for revising psychiatric diagnoses. Am J Psychiatry. 2004;161:946-954.
7. Regier DA, Narrow WE, Kuhl EA, Kupfer D. The conceptual development of DSM-V. Am J Psychiatry. 2009;166:645-650.
8. First M.. Clinical utility: A prerequisite for the adoption of a dimensional approach in DSM. J Abnorm Psychol. 2005;114:560-564.