The DSM-IV Sourcebook, Volume 2
is the second of a projected four volume series aimed at presenting the
empirical bases and rationales underlying the recommendations and decisions
that informed the development of DSM-IV (The Diagnostic and Statistical
Manual of Mental Disorders, 4th Edition, developed and published by the
American Psychiatric Association 1994.) 
(Note that the fourth volume is out of print.) Given the central role of the DSM in
clinical practice and scientific research bearing on mental illness and given
the considerable controversy that has traditionally accompanied psychiatric
classification and has surrounded DSM based classification in particular, it
was deemed important by the DSM developers to lay bare the empirical basis for
the decisions leading to the production of the most recent DSM. In so doing,
the scientific credibility of the classification system and of the practices
based upon it would be affirmed. The DSM Sourcebook is a massive record of the
results of literature reviews, data re-analyses, and field trials and of the
deliberations based upon them.

In a prior review of the DSM-IV
Sourcebook, Volume 1 (Metapsychology April 2001), I provided a general
outline of the process by which the DSM-IV was developed and the various guidelines
and standards that were supposed to inform that process. In addition, I
outlined a number of lines of criticism of the DSM approach to classification.
The main thrust of that review was to examine Volume 1 of the Sourcebook with
an eye to determining how well the work recorded in that volume lived up to the
standards of the developers and how well it responded to the concerns of the
critics. In the present review, I will continue pursuing those objectives with
respect to Volume 2.

As with Volume 1, this volume
consists of a series of papers authored by members of the various work groups
charged with identifying critical issues to be addressed in the development
process, conducting literature reviews designed to collect relevant evidence,
conducting data re-analyses and field trials to gather further evidence,
framing development options for consideration, and eventually making
recommendations for development of DSM-IV. The volume is divided into sections
concerning five broad categories of mental disorder (Mood Disorders, Anxiety
Disorders, Personality Disorders, Psychiatric System Interface Disorders,
Sexual Disorders), and each of these sections is broken down into an
introductory chapter (providing an “executive summary”) followed by a series of
chapters summarizing the results of literature reviews relevant to issues
related to specific disorders and presenting options and recommendations
concerning those issues. A sixth section of the volume is devoted to Late
Luteal Phase Dysphoric Disorder (LLPDD), and this section consists of a single
long chapter with the same purposes as the other five sections. The existence
of a separate section devoted to LLPDD is perhaps best explained in terms of
the considerable controversy surrounding that category since its initial
proposal in the mid 1980’s.

The papers collected in this volume
exhibit a number of shortcomings that lead one to conclude that the development
process did not live up to its own standards and has not achieved some of its
most important stated objectives. To begin, it does not seem likely that the
DSM development process, as reflected in Volume 2 of the Sourcebook, has
succeeded in effectively breaking with the long tradition (re-affirmed in both
DSM-III and DSM-III-R) of basing decisions regarding the existence and nature
of diagnostic categories on consensus among practitioners rather than on sound
science, either in the form of carefully collected empirical data or well
tested theories. There are at least three reasons for thinking this. First,
throughout the volume there are repeated affirmations of the lack of relevant
empirical research findings bearing on issues concerning the construct and
predictive validity of the categories (i.e., their scientific meaningfulness.)
Most of these issues could not be so much as seriously raised, let alone
resolved during the DSM-IV development process. Second, as a consequence of the
conservative approach to change (viz., to make changes only when there is a
“solid basis” for doing so) and the lack of relevant empirical research, the
inertia supplied by past editions of the DSM dominated this most recent effort.
Since it is generally agreed that DSM-III and DSM-III-R were developed on the
basis of a politically derived consensus (sometimes not even among “experts”;
cf., p. 647) and without being informed by any serious research bearing on the
validity of the categories, it can only be concluded that DSM-IV consists
largely of categories which have been introduced and retained, not on the basis
of science, but on the basis of political consensus unconstrained by empirical
research. Third, the explicitly articulated guideline of making decisions that
increased the consistency of DSM-IV with the ICD-10 (The International
Classification of Diseases, 10th Edition), means that recommendations for
change were made, not on the basis of empirical data addressing validity, but
with an eye to enhancing agreement with a different system which, at least with
respect to mental disorders, is also based on consensus largely uninformed by
science.

A further shortfall with respect to
the stated standards and objectives of the development process concerns the
ideal of making significant changes only when there was a “solid basis” for
doing so. Throughout this volume, the widespread lack of relevant and good
quality research made the process quite vulnerable to loose, sometimes rambling
and barely coherent, speculation. A frequent refrain throughout the volume
involved vague appeals to “ease of use” and “clinical utility” without any
clarification or justification. More serious problems perhaps are the
imposition of dubious ideas onto the reasoning process (e.g., the idea that it
is important to minimize differences between children, adolescents, and adults,
p. 4-5) and pursuit of lines of reasoning which are barely relevant to an issue
under discussion or barely coherent (e.g., discussions of whether pain is a
mental disorder, p. 923-4). It is one thing to call for changes for which a
solid basis exists, it is quite another to have and adhere to a serious
standard of what counts as a solid basis.

Two specific sorts of change
recommended for introduction into DSM-IV are especially noteworthy in both
their significance and their lack of a solid basis. The first concerns the widespread
introduction of a criterion of “clinical significance” (e.g., clinically
significant distress or impairment in social, occupational or other important
area of functioning) for most if not all categories. None of the work groups
identified any relevant data to support such an introduction as improving the
construct or predictive validity of the categories they considered. Apparently,
the introduction of this criterion was mandated by the Task Force overseeing
the work groups (e.g., p. 1082) perhaps because of some belief that raising the
bar on distress and impairment (“clinical significance”) might have the effect
of reducing false positives, creating more homogeneous categories, or reducing
inflated prevalence rates. However, there is no reason to believe that a
criterion of clinical significance will achieve either greater categorical
homogeneity or fewer false positive diagnoses; and the proposal, as it bears on
prevalence, seems quite arbitrary in the absence of an independent measure of
the presence or absence of a disorder. Such a change clearly is significant
insofar as it bears on who is diagnosed with a mental disorder for either
clinical or research purposes; but it is far from solidly based.

The second sort of change, which is
significant but lacking in a solid basis, concerns the indirect introduction
into the official nomenclature for mental disorders of categories which were
not deemed to have a sufficient basis for direct inclusion. This is typically
accomplished by citing a category as an example of a residual category of
mental disorder (e.g., Depressive Disorder Not Otherwise Specified.) Such
categories exist so that someone who does not satisfy the criteria for any
listed category can still be diagnosed as suffering from a mental disorder. At
east two categories discussed in Volume 2 of the Sourcebook were determined not
to have a sufficient basis to be included as an official diagnostic category,
but were nonetheless included as examples of mental disorders which can fall
under a residual label (i.e., they are real mental disorders that just don’t
happen to satisfy one of the listed categories.) One example of this,
“Telephone Scatalogia” (i.e., the making of obscene phone calls) demonstrates
how something which certain clinicians believe “in their bones” is a sign of
mental pathology can make it into the official classification system of mental
disorders (under the heading, “Paraphilias Not Otherwise Specified”) despite
there being no empirical or theoretical basis for believing this represents a
legitimate mental disorder. A second example, “Premenstrual Dysphoric Disorder”
(the new label for what was previously called “Late Luteal Phase Dysphoric
Disorder”), is a clear case of the introduction into the diagnostic system
through the backdoor of a category that was heatedly debated and found to lack
a sufficient basis for direct inclusion. PMDD is now listed as an example of a
mental disorder that qualifies one for a diagnosis of Depressive Disorder NOS.

Yet a third reason for questioning
whether the DSM-IV development process, as reflected in Volume 2 of the
Sourcebook, lived up to the stated ideals and objectives of the developers
concerns its conformity to ideals of scientific objectivity frequently
rehearsed throughout the volume. One such ideal concerns the openness of the
development process: it is pointed out by the developers that the DSM
development process involves many stages with ample opportunity for critical
review and discussion of evidence, options, deliberations, and recommendations
by the substantial number of consultants and the psychiatric community at large
(e.g., by circulation of interim drafts, presentations at conferences,
publications). In this way, the ideals of peer review and open critical
discussion in the relevant scientific community are supposed to be realized.
But, there is reason to be skeptical about just how open the process was. In
particular, with respect to Late Luteal Phase Dysphoric Disorder (or, PMDD),
there are grounds for concern that the process involved significant
marginalization of critical perspectives and the stifling of dissent. Although
the chapter concerning LLPDD mentions the controversy and provides a limited
discussion of some of the concerns of critics, there is no very sophisticated discussion
of the issues involved. Rather, the chapter is for the most part devoted to a
long hashing over of a largely inconclusive research record and a clarification
of just how little empirical support there is for direct inclusion of the
category in the DSM. But, then, PMDD was included in the DSM nonetheless and
despite the controversy surrounding the legitimacy of the category, a
controversy which, if properly engaged, might have produced a solid basis for
exclusion of the category entirely from the DSM. See Caplan 1995 for an
alternative perspective on the process from that reflected in the Sourcebook.
There it is suggested that, far from being open, the process ignored
criticisms, stifled dissent, and marginalized dissenters. The importance of
this episode is that it suggests that those controlling the DSM development
process may not be very willing or able to grapple with issues that challenge
implicit or explicit interests or presuppositions. Controversy may be
permitted, but only within rigid assumptions to which many participants may
well be blind and only subject to politically influenced procedural practices.
At the least, this is something requiring closer scrutiny given the broad
impact of the DSM system of classification.

Let us turn now to the question of
how well the papers in Volume 2 of the Sourcebook, either individually or
collectively, provide effective rejoinders to the critics of the DSM approach
to classification of mental disorder. There are at least three areas of
concern: foundational issues, validity of the categories, impact of the inertia
of the system.

First, as with Volume 1, there was
in Volume 2 a notable lack of serious attention to foundational issues and a
serious mishandling of those that were discussed. There was frequent confusion
about the nature of the entities being included in or excluded from the
taxonomy (e.g., Are they empirically defined syndromes?, Are they disorders
involving a core dysfunction?), and hence there was lack of clarity regarding
the sorts of considerations relevant to making key decisions (e.g., p 5.)
Further, discussions regarding the distinction between disorder and no disorder
(normality and abnormality) were marred by a lack of understanding of and
attention to conceptual issues raised by such questions. Hence, there was again
an evident lack of clear understanding of what needs to be shown in order to
effectively address important questions (e.g., p. 955-6.) And, as noted above,
the broad incorporation of a clinical significance criterion was made without
any serious attention to the issues raised by the problems of categorical
heterogeneity, inflated prevalence rates, and false positives. Finally, an
extended discussion regarding whether a categorical approach to classification
should be replaced by a dimensional approach is found in the section concerning
the personality disorders. The somewhat dismaying conclusion of the discussion
was that, even though there is a broad consensus that the categorical approach
needs to be replaced because it is riddled with problems and is not promoting
either clinical or research purposes very effectively, the categorical approach
will be retained in DSM-IV because it is the standard for research and clinical
purposes and because changes would be too confusing and disruptive (cf., p.
647-650.) The deep problems with changing the DSM come into full view here:
even when a solid basis for change exists, change proves impossible because of
the powerful inertia of the interests and the tradition that supports the current
form of the classification system. Never was there a more patent need for
clarity about the foundations of a discipline than is evident here; and yet,
the DSM development process, to date, has given no serious attention to such
issues.

Second, the evident lack of
empirical research bearing on the most critical issues concerning the
development of a categorical system of classification, viz., the validity of
the categories, meant that these issues could not so much as be meaningfully
framed, let alone addressed by the Work Groups represented in Volume 2. As a
consequence of both this lack of evidence and the conservative approach of the
development process, the discussions represented in Volume 2 (as in Volume 1)
displayed a very powerful bias to retention of categories (the vast majority of
categories) which had been introduced in DSM-III and retained in DSM-III-R on
the basis of no sound scientific evidence of validity. As a consequence,
beginning in 1994 (the publication date of DSM-IV), we have had eight more
years (and counting) of powerful influence on clinical and research practice of
a system of classification containing categories with no demonstrated validity.
Critics of the DSM approach to classification have contended for two decades
that this approach (as initiated in DSM-III) is not a sound way to develop a
system of classification that exhibits appropriate levels of validity, and the
deliberations in Volume 2 of the Sourcebook provide nothing to encourage a more
optimistic view.

Finally, since the deliberations
and recommendations made in Volume 2 were rarely based on sound scientific
considerations, they were inevitably made on the basis of considerations that
tend to corrupt future scientific research. Thus, deliberations and recommendations
based on consistency with ICD-10, clinical utility (“ease of use”), empirically
unconstrained speculation, and the imposition of ideas and criteria with no
empirical basis introduce arbitrary and unjustified factors that directly
influence diagnostic practices in research settings and hence that influence
the nature of the samples that are collected and studied. The failure of the
DSM developers to appreciate this sort of impact has led to a continued
endorsement of a flawed model of the relation between science and the clinic, a
model that undermines research. The seemingly bankrupt research programs
associated with the various categories discussed in Volume 2 are not likely to
be revived given the way that diagnostic criteria are developed.

What is the significance of these
shortcomings in the DSM development process as reflected in Volume 2 of the
Sourcebook? The result of laying bare the nature of the scientific evidence and
the deliberations supporting the decisions leading to the publication of DSM-IV
is to bring into sharper relief just how deep the problems with the DSM system
of classification go. The developers of DSM-IV appear to have been massively
uninformed by sound scientific research and to have been deeply confused about
a number of important foundational issues. Both of these shortcomings impact
upon the coherence and credibility of the process, as well as upon its capacity
to clarify and effectively cope with important problems as they arise. The
result is that powerful inertial forces direct the development process and lead
to retention of categories that have never had a scientific justification.
These problems are compounded by concerns about the objectivity and scientific
integrity of the DSM development process and about the potential for future
research based upon DSM categories to be productive. Volume 2 of the Sourcebook
has done nothing to allay such concerns, and has provided additional grounds
for thinking it is time for some profound changes in how we conceptualize,
investigate, and respond to mental illness, and in how a highly influential
system of classification gets developed.

 

©
2002 Jeffrey Poland

 

Jeffrey Poland, Ph.D., University of Nebraska-Lincoln

 

 

References

Caplan, Paula (1995). They
Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s
Normal (New York: Addison-Wesley).

Categories: Philosophical

Tags: Psychiatry, Mental Health Policy and Advocacy