Future DSM Plans Overlook Core Problem of Validity

CONCEPTS IN PSYCHIATRY

The Future DSM Strategic Committee laid out planned changes to the diagnostic manual in a series of articles in the American Journal of Psychiatry.¹ The committee described 4 organizational adjustments: (1) revisions to architecture, (2) attention to biomarkers, (3) contextual factors, and (4) measurement of functioning and quality of life. Yet despite these promising areas of focus, the committee largely overlooks DSM’s core scientific problem: its lack of validity. Before reliability, before the debate over categories vs dimensions, and before we add biomarkers or social determinants, the central question remains: Are the diagnoses real? DSM‑III acknowledged that most diagnoses lacked validation; DSM‑IV repeated the structure; DSM‑5 avoided the question; and the future DSM appears poised to do the same.

If the diagnostic system is valid, psychiatry can advance scientifically. If it is invalid, everything that depends on it—such as biomarkers, epidemiology, therapeutics, reimbursement, and research—rests on an uncertain foundation. One of us (S.N.G.) raised these concerns directly with leaders of the Future DSM Strategic Committee, but they received little weight. This article explains why the DSM remains scientifically weak, why the new proposals do not address the underlying issue, and why the field of psychiatry must adopt a scientific model based on empirical data rather than consensus.

Repeating Past Mistakes

We have been repeating essentially the same DSM system since 1980 (Figure). We now live in an era in which, for the first time, the leaders of the DSM Task Force are no longer members of the baby boomer generation, but of the next cohort, Generation X. DSM-III and its successors were created by a generation that came of age in the 1960s and 1970s, and that group retained substantial influence over each revision through DSM-5 in 2013. Many of those figures have since retired or passed away. Leadership of the next DSM Task Force has now shifted to a new generation, those who came of age in the 1980s and 1990s. This generational transition might have been expected to bring meaningful change, consistent with Max Planck’s² observation that scientific progress often occurs not by persuading individuals but through generational replacement, with younger cohorts more open to new ideas.

One of us (S.N.G.) has met with members of the future DSM leadership, whom he personally knows as peers through his professional career, unlike prior DSM-5 leaders, with whom his acquaintance was more remote. Yet despite this shift, the central problem that has limited progress in psychiatric diagnosis remains unchanged: The diagnostic system is not grounded primarily in validity—that is, in the reality or truthfulness of its definitions. In this article, we review this problem, explain why it matters, and argue that the only viable solution is to adopt the standard approach used in other areas of medicine: Diagnostic definitions should be determined by scientific experts on the basis of empirical research, rather than by consensus or preference.

Back in the 1970s, the original precursor to DSM-III was the Research Diagnostic Criteria (RDC), which argued that psychiatric diagnosis should be based on validity and reliability (in that order); 14 valid diagnoses were identified.³ Diagnostic validators were proposed, based on the fact that an external validator is always needed for symptoms. Symptoms are nonspecific: Different symptoms can occur in the same disease, and the same symptom can occur in different diseases. General medicine solved this problem in the 19th century with the advent of pathology and the rise of autopsy. Psychiatrists such as Theodor Meynert, Emil Kraepelin, and others tried to apply pathology to psychiatric diagnoses, mostly unsuccessfully. They then turned to other independent lines of evidence to be able to correctly evaluate symptoms and identify valid diagnoses: They emphasized the long-term course of illness and heredity (genetics). The RDC group formalized this approach, which later evolved into 4 basic diagnostic validators: symptoms, genetics, course of illness, and biological markers.⁴

Diagnostic Validators

• Symptoms
• Genetics
• Course of illness
• Biological markers

No single validator is sufficient to make a diagnosis valid. The more validators point in the same direction, identifying a clinical condition that is distinguishable from other conditions and from normality, the more valid the diagnosis.

The RDC group was subsumed into the DSM-III Task Force, and in 2 years, 14 valid diagnoses were expanded to 292 diagnoses, which means that 278 (95.2% of the total) were invalid. They were invented, created out of thin air, based on the wishes and beliefs of clinical leaders in psychiatry. The DSM-III leadership admitted this fact⁵ and argued that if the 95% invalid diagnoses could be defined well (reliability), then future studies could change them to make them more valid. That did not happen, of course, because the leaders of DSM-IV in 1994 refused to make major changes to DSM-III, and the leaders of DSM-5 in 2013 refused to make major changes to DSM-IV. Reliability has not led to validity, and yet the future DSM leadership continues to claim that reliability matters more than validity. A dictionary is useful if the definitions in it are true (valid).⁶ A false dictionary is worse than useless; it is misleading.

One possible path forward, advanced by one of us (M.L.R.), is for the future DSM to establish a validity-based hierarchy in which diagnoses are ranked according to their empirical support.⁷ Diagnoses with robust validity would be listed at or near the top of the hierarchy, whereas diagnoses with limited or poor validity would be listed at the bottom of the hierarchy, encouraging clinicians to utilize more valid diagnoses. Another path, advocated by one of us (S.N.G.), is to replace the DSM system with a new clinical research diagnostic criteria,⁸ using the 4 diagnostic validators to identify and define diagnoses, as with the RDC of the 1970s. A third alternative, perhaps the best, is to simply eliminate DSM altogether and for clinicians to rely on textbooks and scientific research to guide diagnosis, as is done in every other branch of medicine. Insurance reimbursement, as with the rest of medicine, would depend on ICD-10 or ICD-11 codes; there is no need for a DSM coding at all for anything.

All 3 approaches differ in practical details, but they share a common premise: Psychiatric diagnosis should be governed by validity rather than consensus, preference, or institutional convenience. As one of the RDC leaders, Samuel B. Guze, MD, observed, “Validity is the gold standard for judging any diagnostic category and comparing different diagnostic approaches. Esthetic and political consideration and a priori assumptions must give way to it.”⁹

DSM-III was a social construction; it was not a scientific document.¹⁰ It was created for the social and political purposes of the American psychiatric profession. That remains the case. DSM revisions happen when the American Psychiatric Association needs to renew its main source of income—sales of DSM. The economic motivation for continuing the DSM enterprise is hard to ignore.

Instead, psychiatry should reconsider the continued centrality of DSM to clinical practice and research. The current system remains heavily shaped by administrative, economic, and legal considerations, particularly insurance reimbursement, rather than by the scientific question of diagnostic validity. Yet diagnostic concepts should be determined primarily by empirical evidence concerning the nature of psychiatric illness, not by professional consensus or institutional convenience. If psychiatric diagnoses are to advance scientifically, they must be grounded in reality rather than maintained for pragmatic or bureaucratic reasons. Biology and nature do not care what we want; they won’t adjust to our DSM wishes. We need to adjust to reality, not the other way around, and find out which psychiatric illnesses really exist. The DSM approach is abetted by a widespread antiscientific postmodernist attitude that we will never know how to reach validity, and thus we can make things up as we like. Our patients deserve better.

Dr Ghaemi is a lecturer on psychiatry at Harvard Medical School, Cambridge Health Alliance, and is employed by Bristol Myers Squibb.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando, where he is director of psychotherapy training in the adult psychiatry residency program. He is also an adjunct assistant professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts, and on the faculty of The New Jersey Institute for Training in Psychoanalysis in Teaneck, New Jersey.

The views expressed in this article are solely those of the authors and do not necessarily reflect the official policy or position of their employers.

References

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