Regretfully, if we are to judge the progress of DSM-5 by the incoherence of a recent commentary by the Chair and Vice-chair of the DSM-5 Task Force, we have a lot to worry about.
In a commentary in the July, 2011 issue of the American Journal of Psychiatry1 David Kupfer and Darrel Regier, Chair and Vice-chair of the DSM-5 Task Force, have provided us with a current status report on DSM-5, now in field-trial phase and scheduled for publication in 2013. We can certainly thank them for their effort to bring us up to date; but regretfully, if we are to judge the progress of DSM-5 by the incoherence of their commentary, we have a lot to worry about.
I am of course aware that in labeling the commentary as incoherent, I am using a strong and unflattering adjective. I hope to demonstrate that the commentary warrants that adjective.
In most general terms, the incoherence involves the authors’ account of DSM history. They informed us in A Research Agendafor DSM-V2 in 2002 that the diagnostic constructs of DSM-III and DSM-IV had reached a crisis of validity and that to meet that challenge, DSM-5 would require a “paradigm shift.” In the intervening years, however, the paradigm shift in the DSM-5 work was not accomplished, and the authors have now shifted to a “Whiggish” narrative of a steady march forward (without paradigm shift) from Robins and Guze to DSM-5 and beyond. Let me spell this out in some detail.
In A Research Agenda,2 after detailing the failure of ongoing research to meet the Robins and Guze validation requirements for DSM-IV diagnostic categories, the authors wrote:
All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes beyond our current ways of thinking to attempt to integrate information from a wide variety of sources and technologies.2,p19
In the July commentary they write:
In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder.
In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred. This optimism was not wasted, however.1,p.1
The authors support their optimism with recent neuroscientific work on a “stress-induced and fear circuitry spectrum” that groups a number of phenotypically heterogeneous anxiety disorders with a common circuitry disruption, the proposal of 11 external validators to aid in grouping disorders, and further expected finding from the NIMH Research Domain Criteria (RDoC) project.
So we have reason to be optimistic because neuroscience and genetics are making progress (although it is not clear what that has to do with DSM-5). Toward the end of the Commentary the authors summarize that “[i]t is important to emphasize that DSM-5 does not represent a radical departure from the past, nor does it represent a radical separation from the goals of the RDoC. As we gradually build on our knowledge of mental disorders, we begin bridging the gap between what lies behind us (presumed etiologies based on phenomenology) and what we hope lies ahead (identifiable pathophysiologic etiologies)”1,p.2
So, what is confusing or incoherent in this picture? First, how are we supposed to understand the just quoted sentence? From all available evidence the distance between DSM-III and the post-RDoC DSM will be profound - indeed, it will be the paradigm shift adumbrated in A Research Agenda, just not realized in DSM-5. We know that the Robins/Guze criteria for validation will not be realized. And we have very little idea how diagnostic categories of the future will be defined and grouped, what will be left of the DSM-III and DSM-IV categories, or how neuroscientific and genetic findings will match up with the older phenomenological, descriptive categories. Kendler has warned us not to expect anything simple and straightforward from genetics.3 In the face of all this uncertainty the authors wish to place DSM-5 comfortably between DSM-III/IV and the post-RDoC DSM, with no significant break in either direction. What could that possibly mean?
Second, we can look at what the authors actually propose for DSM-5. They mention two categorical changes: the proposal for a single “autism spectrum disorder” and the proposal for an “attenuated psychosis syndrome.” They do not mention the controversies surrounding these diagnostic categories, involving the question of creating populations of false-positive patients who would be subjected both to diagnostic mislabeling and unwarranted, potent medications.
Also, in addition to not mentioning the many other proposed categorical changes in DSM-5-some controversial (eg, the low sexual interest disorders for men and women), others not-the authors do not mention what in their 2009 commentary/update they called the major innovation of DSM-5. In that piece they wrote that “The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-V 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-V will be the more prominent use of dimensional measures in DSM-V.”4,p649
Where have these dimensions gone? Oddly, they seem to have disappeared from the DSM-5 Web site. In earlier versions the dimensional measured figured prominently, prompting me to write a blog expressing my own skepticism toward them.5 But in the current Web site, I could only find a trace of them as a topic of the Diagnostic Assessment Instruments Study Group. I am left wondering whether the “major change” is alive but not being talked about, or whether it is a victim of an unannounced euthanasia.
The above changes relate only minimally to the anticipated findings from neuroscience and genetics. The authors bring in this science of the future in the following manner: “...our recognition of the significance of neuroscience and genetics in psychiatric diagnosis has supported DSM-5's novel integration of neurobiological findings, such as inclusion within the text that accompanies diagnostic criteria sets the potential role of these factors in shaping risk and prognosis. While not central to the criteria themselves, this information is nonetheless useful and informative for helping DSM provide a more precise picture of the clinical realities of psychiatric diagnosis.”1,p1 For an idea that the authors call “novel,” I can think of a couple other words. One would be “wild.” The other would be “desperate” - to link DSM-5 to the coming science. To take them at their word, they are actually proposing to incorporate what we presume to be inchoate, untested findings from the new neuroscience into DSM criteria text (as opposed to, say, letting those findings simmer in the oven for a few years to see if they’re worth anything). To take the example of the “stress-induced and fear circuitry spectrum,” this is an early finding, and we have no idea whatsoever what role it will play in diagnosis and treatment. Do we really want to include it in the diagnostic criteria text?
How can we summarize the authors’ Commentary? Although by their account (in A Research Agenda), the DSM-III/IV diagnostic constructs haven’t and won’t achieve the Robins/Guze standards of validity, and although the hoped-for answers from the RDoC project are too distant to play a significant role in DSM-5, they describe a course of unbroken progress from DSM-III/IV, through DSM-5, to whatever lies ahead, for our nosology. For DSM-5's role they mention a couple changes, leave out the formerly touted dimensional measures, and provide the link to the post-RDoC DSM by incorporating early neuroscientific findings into the DSM-5 diagnostic criteria text. They have replaced the image of a paradigm shift in DSM-5 with a narrative of DSM-5’s providing a smooth (however unexplained and incoherent) transition to the neuroscience of the future. I would submit that this Commentary does not inspire confidence in DSM-5.
So what should we do? In the semi-official publication from this year, The Conceptual Evolution of DSM-5, DSM-5 Task Force member Steven Hyman writes (after discussing the warrant for including a criterion of cognitive deficits into the criteria set for schizophrenia): “This example notwithstanding, the DSM revision process should be extremely conservative with respect to existing categorical disorders, because even small changes in wording could produce significant disruptions to epidemiology, clinical trials inclusion criteria, and laboratory research; such disruptions would militate against tinkering without very strong justification.”6,pp10-11 Hyman goes on to argue for “structural alterations that will facilitate discoveries that hasten the development of usefully valid diagnoses, new treatment approaches, and a sounder basis for clinical and translational research.” In the latter vein he mentions adding the dimensional measures, using the 11 “external validators,” and reclustering the diagnostic categories. He is thus conservative regarding small changes in the existing categories, but quite bold in proposing large-scale changes. Aside from this puzzling mixture of conservative and boldly assertive gestures, we should note that all the large-scale changes are proposed to promote research. Like everyone else in the DSM hierarchy, Hyman is reluctant to distinguish the clinical and research goals of a diagnostic manual. Every change he proposes belongs in a manual for the researcher, not the clinician.
For another response to the question, how to proceed, I turn to DSM-IV Task Force chief Allen Frances, who has argued consistently over many months for a conservative approach to change in DSM-5. His argument has been that, caught as we are in this transition between the validity failure of DSM-III/IV and the barely started work of RDoC, we should mostly hold the line with DSM-IV, which we are at least familiar with, and accept that making significant changes in DSM-5 without the new science in place will do more mischief than good.7-10 The Commentary that is the subject of this posting will do nothing to dispel Frances’ concerns.
References1. Kupfer DJ, Regier DA. Neuroscience, clinical evidence, and the future of psychiatric classification in dsm-5`.Am J Psychiatry. 2011;168:1-3.
2. Kupfer DJ, First MB, Regier DA, eds. A Research Agenda for DSM-V. Arlington, VA: American Psychiatric Association Press; 2002.
3. Kendler K. Reflections on the relationship between psychiatric genetics and psychiatric nosology.Am J Psychiatry. 2006;163:1138-1146.
4. Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V.Am J Psychiatry. 2009;166:645-650.
5. Phillips J. DSM is a many-dimensioned thing.Psychiatr Times. Available at: http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1696725.
6. Regier DA, Narrow WE, Kuhl EA, Ph.D, Kupfer DJ, eds. The Conceptual Evolution of DSM-5. Arlington, VA: American Psychiatric Association Press; 2011.
7. Frances A. DSM-5 badly off track.Psychiatr Times. Available at: http://www.psychiatrictimes.com/display/article/10168/1425383.
8. Frances A. Advice to DSM-5: Change deadlines and text, keep criteria stable.Psychiatr Times. Available at: http://www.psychiatrictimes.com/display/article/10168/1444633.
9. Frances A. Opening pandora’s box: The 19 worst suggestions for dsm-5.Psychiatr Times. Available at: http://www.psychiatrictimes.com/dsm/content/article/10168/1522341.
10. Frances A. DSM in philosophyland: Curiouser and curiouser.Bulletin of the Association for the Advancement of Philosophy and Psychiatry. 2010;17:21-25.