The Diagnostic Dilemma: Is Revising the Official Manual of Mental Disorders a Prescription for Confusion?

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The Diagnostic Dilemma

The God of the Old Testament advised, "Be fruitful and multiply." Developers of the "psychiatric bible" setting forth the guidelines for diagnosing mental disorders -- known secularly as the Diagnositc and Statistical Manual of Mental Disorders, or DSM -- have taken His counsel to heart. The 1980s have seen a rapid revision and expansion for all manner of mental ailments in the DSM, from schizophrenia to social phobia to sexual sadism.

There are, however, rumblings of discontent from researchers and clinicians faced with these "biblical" rewrites every half dozen years.

The DSM, published by the American Psychiatric Association in Washington, D.C., serves as the standard reference guide to psychiatric diagnoses in the United States. DSM-I, published in 1952 as a pamphlet, described nearly 60 mental disorders, and an expanded version, DSM-II, came out in 1968. These two editions contain fairly general descriptions of mental problems based on Sigmund Freud's concepts of psychoses (severe mental disorders such as schizophrenia) and neuroses (less severe forms of psychological conflict and anxiety).

The release of DSM-III in 1980 brought major changes. It largely dropped Freudian terminology and instead listed specific criteria for more than 150 disorders, based on statistical analyses of standardized interviews with thousands of psychiatric patients. Seven years later a revision, DSM-III-R, incorporated more than 250 disorders into the psychiatric fold. DSM-IV is slated to appear by the end of 1992.

The DSM has assumed increased importance in the 1980s because its diagnoses are often required by government and private insurers who pay for psychotherapy and other mental health services. It has also become the reference of choice for scientists studying mental disorders, although there is concern that the rapid appearance of new DSMs will muddy the research waters.

Some psychiatrists hail the impending arrival of the third diagnostic manual in 12 years, but other mental health workers, both in and out of psychiatry, question how fruitful it is for DSMs to multiply so rapidly. They say the flurry of new and changing diagnoses is based on inadequate data, confuses research on mental ailments and may be ignored by many clinicians who are comfortable with the diagnostic guides they originally trained with.

A number of reservations about the current and future diagnostic manuals are set out in the December 1988 ARCHIVES OF GENERAL PSYCHIATRY in an article titled "Why Are We Rushing to Publish DSM-IV?" Its author, Mark Zimmerman, a psychiatric resident at Chicago Medical School in North Chicago, has published numerous scientific studies in collaboration with psychiatrists at the University of Iowa School of Medicine in Iowa City.

"I think psychiatry will get itself into a lot of trouble by changing diagnostic criteria too quickly," Zimmerman says.

To begin with, he notes, the five-year span between DSM-III-R and DSM-IV guarantees that only limited data on the usefulness of current diagnoses will be available to guide revisers. In late 1987, Zimmerman points out, research began on the validity of DSM-III-R criteria, aimed at determining whether a diagnosis such as schizophrenia accurately predicts how a person will respond to specific treatments and functions several years down the road. Initial results will not be ready until 1990, about the same time as the first draft of DSM-IV appears.

Although early validity data no doubt will inform the final version, there will be no time to replicate results suggesting diagnostic changes are needed. Zimmerman asserts. And if past experience serves as a guide, he adds, members of DSM-IV committees in charge of reviewing diagnostic guidelines will tailor many changes to their own clinical judgments.

Zimmerman, a member of the DSM-III-R committee that revised the definition of melancholia, a form of severe depression, saya consensus based on individuals' clinical experiences -- not on empirical data -- governed the committee's thinking. …