Are the revisions of current diagnostic criteria contemplated by the
DSM-V Task Force necessary, or even possible?
Robert Spitzer, M.D., who led the development of DSM-III, argues
that a true breakthrough in psychiatric diagnoses will occur when biological
markers for mental illness are discovered. Until then, he says, the developers
of the revised manual are seeking a refinement of diagnosis that oversteps the
science, using dimensional criteria for which clinicians are unprepared.
Spitzer told Psychiatric News that he believes DSM-V Task
Force leaders are "promising more than they can deliver."
But the task force leaders, in turn, say 30 years of experience has shown
that the patients treated by psychiatrists in their offices do not fit the
rigid diagnoses of DSM-III or DSM-IV.
"Comorbidity is a fact of life in clinical psychiatry," said
Renato Alarçon, M.D., a member of the Personality Disorders Work Group."
A psychotic patient may have obsessive symptoms, a depressed patient
may have definite characteristics of borderline personality disorder, and an
anxious patient may impulsively attempt to commit suicide. Are these patients
only psychotic, depressed, or anxious? Probably not."
This point was made in a lengthy article by Darrel Regier, M.D., and
colleagues in the June American Journal of Psychiatry. Regier is
executive director of the American Psychiatric Institute for Research and
Education (APIRE), director of APA's Office of Research, and vice chair of the
DSM-V Task Force.
In that article, "The Conceptual Development of
DSM-V," the authors outlined the history of research on
psychiatric diagnosis and the deficiencies in the now 30-year-old categorical
diagnoses of DSM-III: the substantial overlap in symptoms from
condition to condition; the failure to distinguish disease presentation at
different developmental periods, and among different racial, cultural, and
gender groups; and the overuse of "not otherwise specified" (NOS)
to categorize patients who do not wholly fit any other category.
Broadly summarizing the article's points in an interview with
Psychiatric News, Regier noted that in 1980 Spitzer guided a"
wholesale rewrite" of the preexisting DSM (prior to
DSM-III, it had been dominated largely by psychoanalytic constructs)
using criteria developed by John Feighner, M.D., Eli Robins, M.D., and Samuel
Guze, M.D., at Washington University in 1972. The Washington University group
expected that clinical and research experience would prove each syndrome"
valid" by its separation from other disorders, common clinical
course, genetic aggregation in families, differentiation by future laboratory
tests, and differential response to treatment.
"After 30 years, there are now many validity tests of the
DSM-III to DSM-IV criteria that have not lived up to the
expectations of Robins and Guze," Regier said. "In fact, the
criteria have in many respects become reified and have begun to limit
scientific and clinical advances."
So a new approach adding "dimensions" of severity to the
existing explicit criteria is being contemplated for DSM-V to add
depth and nuance to diagnosis. "This will allow clinicians to precisely
and quantitatively describe the severity of their patients' diagnoses and also
to describe the full range of their patients' clinically significant problems
beyond the 'yes/no' diagnostic categories," Regier said. "These
dimensional ratings will also help researchers, who in the past have been
unduly constrained by the reification of the DSM categorical system
in the research enterprise.
"We are aiming to develop a diagnostic system that is usable and
useful to clinicians. Investigators at APIRE and other institutions have been
developing new assessment methods that have been shown to be highly acceptable
to clinicians in routine practice, useful, and maintained over