Advancing DSM: Dilemmas in Psychiatric Diagnosis

Of all medical diagnoses, psychiatric diagnoses have the broadest impact, important to all medical specialties, to the courts, to the schools, to public policies, even to the arts. Within the house of medicine, however, psychiatric diagnosing has little respect. The authors’ delineation of the dilemmas of DSM-IV provides clear directions as to how to increase the respect for future DSMs.

A fundamental dilemma is the distinction between normal and abnormal. To set hurdles high enough to avoid inclusion of ordinary problems of daily living, DSM-IV placed “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” in many criteria sets. This book asks if “harmful dysfunction” would be a more satisfactory hurdle.

There are dilemmas about the organization of DSM-IV disorders. Would patients be better served, for example, if obsessive-compulsive disorder, Tourette’s disorder, body dysmorphic disorder, hypochondriasis, and trichotillomania were placed together in DSM’s organization? One of the chapter authors suggests that it would be a conceptual advance to organize around “schizotaxia,” which includes schizophrenia and schizotypal personality disorder, as well as healthy people who are genetically similar to people with those two disorders. These suggestions, however, imply that DSM’s entities are valid, probably DSM-IV’s major dilemma.

DSM-III and subsequent DSMs vastly improved reliability, but there is no reason to believe that the results are valid as to pathogenesis. Even when we have an etiology, we sometimes lack an identified pathogenesis. Stress, for example, can lead to nine DSM-IV disorders (as well as precipitating many other disorders in which stress is not a required finding), but none of the nine criteria sets implies pathogenesis. DSM-IV has a dozen cocaine-related disorders, but DSM-IV ties none to pathogenesis. On the other side of the coin, a major depressive episode can be the result of eight nonetiological diagnoses, none of which has an identified pathogenesis.

Even when pathogenesis has yet to be developed, other parts of medicine sometimes have a diagnostic test, but DSM-IV’s only test within the criteria sets is IQ testing for mental retardation. Are we ready, the authors ask, to introduce sleep laboratory studies, apolipoprotein E genotype measures, or functional magnetic resonance imaging to some criteria sets, especially when that would lead to refinements in treatment and prognosis?

Psychiatry’s challenge in uncovering pathogenesis includes clarifying the role of relationships. DSM-IV, for example, says that attention deficit hyperactivity disorder is not diagnosed if inattention, impulsivity, and hyperactivity are observed in the classroom but not observed at home or on the playground. This book explores the pros and cons of a far greater role for relationships.

One topic comes up frequently—DSM-IV’s multiaxial system. Some authors want to abolish the multiaxial system, some want to retain it as is, and some want to expand it by making it richer in describing patients and their circumstances.

This book is recommended for those willing to look critically at the DSM-IV foundation on which they are standing.