Dr. First and Dr. Pincus Reply

The article by Dr. Pope et al. contains a serious misconception about the standards for adding new diagnoses to DSM-IV and about the placement of the disorders in appendix B (“Criteria Sets and Axes Provided for Further Study”). A new diagnosis was added to DSM-IV only after a comprehensive review of the literature (and often data reanalysis and field trials) determined that there was sufficient empirical evidence to justify its inclusion (1). The reason that premenstrual dysphoric disorder and binge eating disorder were not added as official categories to DSM-IV was not because they “[did] not meet DSM-IV standards for consensus” (p. 321). The empirical evidence supporting their inclusion was simply insufficient. Dissociative disorders that had already been included in earlier versions of DSM (e.g., dissociative amnesia and dissociative identity disorder) were retained in keeping with the conservative approach to DSM-IV, which “opposes the removal of existing categories in the absence of strong evidence recommending either action. The burden of proof generally rests on providing convincing data for either the removal or the addition of categories in preference to keeping the status quo” (1). However, when there are sufficient data indicating a lack of validity, a disorder can be eliminated, as was done with DSM-III-R’s idiosyncratic alcohol intoxication criteria. Most problematic is the assumption that a simple vote should be the basis for the inclusion of a new DSM category.

The authors provided no information on the basis for each respondent’s vote nor on the extent to which the psychiatrists were fully informed as to the full array of empirical information available on the conditions about which respondents were queried. Nor did the authors note whether the framing of these questions elicited such questions as the extent of evidence needed, whether existing disorders should be held to the same standard as proposed conditions, and the impact of changes in DSM on education and research efforts. In other words, these kinds of clinical or scientific questions should have been answered only through a systematic, evidence-based process.