The DSM: Not Perfect, but Better Than the Alternative
By Michael First, M.D., and Robert L. Spitzer, M.D.
April 1, 2003
Dr. First is associate professor of clinical psychiatry in the department of psychiatry at Columbia University and research psychiatrist at the New York State Psychiatric Institute. He was co-chair and editor of DSM-IV-TR.
Dr. Spitzer is professor of psychiatry in the department of psychiatry at Columbia University and director of the biometrics research department of the New York State Psychiatric Institute. He chaired the work groups that developed DSM-III and DSM-III-R.
We are the first to acknowledge that the DSM categories do not always jibe with the ever-evolving body of scientific research and that they sometimes conflict with clinical reality. For example, findings that suggest a common genetic basis for major depressive disorder and generalized anxiety disorder (Kendler, 1996) and for BD and schizophrenia (Berrettini, 2000) run counter to the DSM convention of having these conditions classified in separate sections. Furthermore, the fact that psychiatric symptoms occur on a continuum, without hard boundaries separating disorder from normality (and between various disorders), suggests that the DSM categorical approach has significant limitations that may be addressed by adopting a dimensional approach, especially for the diagnosis of personality disorders (First et al., 2002). It is precisely for these reasons that the DSM is periodically revised after conducting a comprehensive review of the literature, in order to ensure that DSM stays in step with the research base and that the initial work on DSM-V consists of establishing a research agenda (Kupfer et al., 2002) that stimulates the research needed for future changes. However, does the fact that the DSM has flaws mean that the DSM should be "dumped"? Certainly not!
The author of the point article wisely acknowledges that he is "better at tearing down" than proposing an alternative. But he does propose an alternative: the mental disorders section of ICD-9 or ICD-10. There are several reasons why this suggested alternative makes no sense. First, the ICD-9 does not have diagnostic criteria. Users are obligated to use their own idiosyncratic definition(s) of the terms--setting psychiatry back 30 years. In recommending ICD-10, the author ignores the fact that it closely resembles--both in structure and diagnostic criteria--DSM-III-R. This is further evidence that, rather than being ridiculed, the DSM principles have been embraced by world psychiatry. Furthermore, the developers of ICD-10 did not have the resources that enabled the DSM-IV work groups to conduct comprehensive literature reviews. They had to rely exclusively on expert consensus in developing diagnostic criteria.
To paraphrase what Sir Winston Churchill said about democracy, DSM may not be such a wonderful system, but it is better than any other existing alternative.
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