DSM-V Needs Mid-Course Correction

An article titled“ Expert Appointments Key Step On Road to DSM-V” in the September 19 issue identifies the DSM-V Task Force members and the work group chairs and indicates that national and international researchers and clinicians will review and collaborate to produce the next DSM.

But, I hear a familiar refrain:

DSM-III was a revolutionary departure from its predecessor in that it introduced specifically defined symptom-based criteria sets for each diagnosis. The intent was to make DSM-III “more scientific.”

The inadvertent consequences of our “new” symptom-based diagnostic system are that our new DSM system is perfectly suited to the symptom-relief approach of the pharmaceutical industry, which has essentially captured psychiatric treatment with its “scientific studies” and “double-blind statistics” that have become the primary source for evidence-based treatment in psychiatry.

“Revisions” of DSM-III, namely DSM-III-R and DSM-IV, have resulted in criteria changes, but the diagnostic system remains a decision-tree approach that becomes a “shortcut” questionnaire primarily designed to get to the “criteria sets” that define each diagnosis. What has been sacrificed are almost all of the elements of the traditional basic psychiatric evaluation and mental status exam.

We now emphasize the chief complaint and present illness as we scrutinize the words of the patient to ascertain if the criteria sets have been fulfilled. The flaw in the scientific DSM-III “diagnostic system” was not in the establishment of specifically defined criteria sets for each diagnosis, but the deemphasis and essential elimination of traditional aspects of the basic psychiatric history taking and the examination of the psychiatric history, medical history, substance abuse history, family history of mental illness, and developmental, educational, and social history of the patient—that is, fundamental psychiatry.

This unrecognized flaw in the DSM diagnostic system has not been addressed in previous revisions of DSM, and we now appear poised to repeat it. The flawed diagnostic system needs to be revised, rather than the criteria sets for specific diagnoses.

I propose that DSM-V include a mid-course correction by creating a new multiaxial diagnostic scale that corresponds to the existing, well-established sections of the psychiatric examination. This would include the chief complaint and present illness sections, which are already being emphasized as we continue to examine for the presence of symptom criteria.

However, the currently neglected information and data obtained from the examination of the psychiatric history; family history of mental illness; developmental, educational, and social history; medical history; substance abuse history; legal history; and the patient's responses to the mental status examination will now all be entered on separate scales, to be added to the information obtained from the chief complaint and history of present illness so that each category of information is now included and used as part of the complete diagnostic profile. In addition, there should be added an informant reliability axis and scale to prompt the examiner to ascertain the reliability and validity of information obtained from all patients.

I do not believe that the mere addition of a multiaxial diagnostic scale to the symptom-based criteria will by itself bring about a change in the direction that psychiatry has taken as an unintended consequence of the introduction of the symptom-based criteria sets, the questionnaire-type evaluations, and decision-tree approach that has replaced clinical thinking and judgment in psychiatry over the past three decades. I do not know a remedy for this problem, but I believe that this proposal is, at least, a beginning and a mid-course correction for our DSM system.

This is too important an issue to allow this to be decided only by elected officials or a group of selected experts. If you agree, please contact me with your recommendations and/or criticisms at [email protected]. (This article is an abbreviated version of a lengthier one on the same subject, which is available via e-mail upon request.) ▪