A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences

We should begin with full disclosure. As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data. Please keep this history in mind as you read my numerous criticisms of the current DSM-V process. It is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby. I feel sure that I am identifying grave problems in the DSM-V goals, methods, and products, but it is for the reader to judge my objectivity.

Much of our effort in developing DSM-IV centered on avoiding possible misuses of the system. We established a rigorous 3-stage procedure of empirical documentation to filter out mistakes. This consisted of systematic and extensive literature reviews, data reanalyses, and field testing conducted under well-controlled conditions and in a wide variety of settings.^1-3 The null position was always to keep things stable: any change had to meet a high burden of empirical proof and risk-benefit analysis.

The work on DSM-IV was transparent and widely inclusive.⁴ We knew how important it was to get as many critical comments as possible to assist us in spotting pitfalls and blind spots. To this end, we enlisted the help of more than 1000 advisors, seeking particularly those opinions most opposed to the changes being considered. To recruit as many comments as possible from users at large, we also prepared a regular and widely distributed newsletter and journal column.⁵

There was explicit accountability for decision making on all changes. We published many articles to establish the methodology of the DSM-IV empirical review, to indicate ways of judging the value and risks of “innovations,”⁵ and to determine the pluses and minuses of the particular diagnostic changes that were under review.^1,2,6-9 In midstream, we published a widely distributed DSM-IV Options Book: Work in Progress10 that contained the alternative criteria sets proposed for every disorder. This gave everyone a chance to join us in evaluating each decision for change in DSM-IV.

After DSM-IV was completed, we published 4 sourcebooks, laying out in great detail the process and rationale for all the decisions that had been made, as well as their empirical support.^11-14 Our goal throughout was to ensure that everyone would understand precisely what we were doing and how we were going about it. There was explicit accountability for decision making on all changes.

Why did we go to all this trouble in preparing DSM-IV and why should DSM-V undergo a sharp midterm correction to provide equivalent safeguards by becoming far more transparent, explicit, and conservative? I believe that the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology. First we will explore the excessive ambition, because it has encouraged an excessive tolerance for risk taking.

The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V.

Fortunately, the NIMH is now embarked on a fascinating effort to effect the real paradigm shift of basing diagnosis on biological findings. Unfortunately, this is years (if not decades) from fruition.

So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality.

Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system.^15,16 With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities.

Part of the exaggerated claim of a paradigm shift in DSM-V is based on the suggestion that it will be introducing dimensional ratings and that this will increase the precision of diagnosis. I am a big fan of dimensional diagnosis and wrote a paper promoting its use as early as 1982.¹⁷ Naturally, I had hoped to expand the role of dimensional diagnosis in DSM-IV but came to realize that busy clinicians do not have the time, training, or inclination to use dimensional ratings. Indeed, the dimensional components already built into the DSM system (ie, severity ratings of mild, moderate, and severe for every disorder and the Axis V Global Assessment of Functioning scale) are very often ignored. Including an ad hoc, untested, and complex dimensional system in an official nomenclature is premature and will likely lead to similar neglect and confusion.¹⁸