- Open Access
The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis
- James Phillips1Email author,
- Allen Frances2,
- Michael A Cerullo3,
- John Chardavoyne1,
- Hannah S Decker4,
- Michael B First5,
- Nassir Ghaemi6,
- Gary Greenberg7,
- Andrew C Hinderliter8,
- Warren A Kinghorn2, 9,
- Steven G LoBello10,
- Elliott B Martin1,
- Aaron L Mishara11,
- Joel Paris12,
- Joseph M Pierre13, 14,
- Ronald W Pies6, 15,
- Harold A Pincus5, 16, 17, 18,
- Douglas Porter19,
- Claire Pouncey20,
- Michael A Schwartz21,
- Thomas Szasz15,
- Jerome C Wakefield22, 23,
- G Scott Waterman24,
- Owen Whooley25 and
- Peter Zachar10
© Phillips and Frances; licensee BioMed Central Ltd. 2012
- Received: 30 April 2012
- Accepted: 23 May 2012
- Published: 23 May 2012
In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.
- Psychiatric Diagnosis
- Dimensional Measure
- Research Diagnostic Criterion
- Etiologic Research
- Research Domain Criterion
For the full text of the General Introduction to the entire article, the reader is referred to Part 1 . The General Introduction reviewed the history of the article, which originated in a controversy initiated by Robert Spitzer and Allen Frances, Chairmen respectively of the DSM-III and DSM-IV Task Forces, over the ongoing work of the DSM-5 Task Force and Work Groups. In a series of articles and blog postings in Psychiatric Times, Frances (at times with Spitzer) carried out a sustained critique of the DSM-5 work in which he focused both on issues of transparency and issues of process and content [2–15].
In the course of this debate over DSM-5 I proposed to Allen in early 2010 that we use the pages of the Bulletin of the Association for the Advancement of Philosophy and Psychiatry (of which I am Editor) to expand and bring more voices into the discussion. This led to two issues of the Bulletin in 2010 devoted to conceptual issues in DSM-5 [16, 17]. (Vol 17, No 1 of the AAPP Bulletin will be referred to as Bulletin 1, and Vol 17, No 2 will be referred to as Bulletin 2. Both are available at http://alien.dowling.edu/~cperring/aapp/bulletin.htm.) Interest in this topic is reflected in the fact that the second Bulletin issue, with commentaries on Frances’ extended response in the first issue, and his responses to the commentaries, reached over 70,000 words.
With the success of the Bulletin symposium, we approached the editor of PEHM, James Giordano, about using the pages of PEHM to continue the DSM-5 discussion under a different format, and with the goal of reaching a broader audience. The new format would be a series of “essential questions” for DSM-5, commentaries by a series of individuals (some of them commentators from the Bulletin issues, others making a first appearance in this article), and responses to the commentaries by Frances. Such is the origin of this article. (The general introduction, individual introductions, and conclusion are written by this author (JP), the responses by Allen Frances.
For this exercise we have distilled the wide-ranging discussions from the Bulletin issues into six questions: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1  of this article covered the first two questions, and Part 2  the second two questions. This text, Part 3, covers the fifth and six questions. The final Part 4 of the article will contain the general conclusion.
Question #5: How compatible are all the purposes of DSM?
Is there a conflict over utility in the DSMs? The authors of DSM-III, DSM-IV, and DSM-5 intend the manuals to be useful for both clinicians and researchers. Is there a conflict between what is useful for clinicians and what is useful for researchers? Which group is served better by DSM-III and DSM-IV, and by the prospective changes in DSM-5?
Any discussion of the utility question in DSM-5 should begin with the way in which the previous manuals dealt with this question. The first paragraph of the Introduction to DSM-IV contains the following statements: “The utility and credibility of DSM-IV require that it focus on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers” (, p. xv).
The primary achievement of DSM-III and DSM-IV was the establishment of reliability through the use of diagnostic criteria. The criteria worked to assure consistency of diagnosis across settings. Psychiatrists using the same diagnosis had the comfort of knowing that they were talking about the same patients - or that two psychiatrists evaluating the same patient would make the same diagnosis. As sensible as this rationale is, it leaves questions open - who in fact actually uses the diagnostic criteria, and for whom are they really important?
In discussing these questions, we should not forget that the DSM manuals also provide thorough descriptions of the respective disorders, what we may call descriptive, phenomenological, or prototypal accounts. Among the various user groups - clinicians, students, and researchers, to name the three cited in the above quotation from the DSM-IV Introduction - who uses what? The available research  supports one’s anecdotal impression that experienced clinicians use the descriptive prototypes, calling on the criteria for the occasional infrequently used diagnosis, and that students and researchers are the main users of the criteria. This is hardly surprising. Clinicians are focused on treating their patients, not checking criteria, and are usually working with a mental grasp of the prototype; students are focused on learning the diagnoses; and researchers are required to be careful that their research subjects meet the criteria.
It is difficult to avoid the conclusion that the diagnostic criteria are mainly useful for researchers, who are obligated to insure a uniform research population. In this regard, it is an ironic side effect of the diagnostic criteria that they may impede research by confining research efforts to criteria-determined questions .
The introduction of dimensional measures into DSM-5 adds a further wrinkle to this discussion. Regier and colleagues have written: “The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-5 will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-5 will be the more prominent use of dimensional measures in DSM-5”  (see also ). These authors assure us once again that these dimensions will provide clinical as well as scientific utility. The proposed dimensional measures raise two questions: should they even be in the manual, and who will use them. The questions raised above about who will use them are apposite here. Given their undemonstrated scientific status, Frances challenged their introduction into DSM-5 in Bulletin 2, and Paris and Whooley challenge it below. First and colleagues have argued that any change in the existing manual should use clinical utility as a criterion of change , and First has expressed concern over the dubious clinical utility of the proposed measures .
Commentary: Useful for whom? clinicians, researchers, and DSM’s many-sided nature
Owen Whooley, Ph.D.
Institute for Health, Health Care Policy, and Aging Research
The DSM serves many interests and performs many tasks. It provides a common language of mental disorders for clinicians, standardized categories for researchers, diagnostic codes for insurance companies, and valid diagnoses of mental illness for legal and juridical purposes. Task Forces of DSMs, past and present, have treated these tasks as complimentary, but their diversity belies the inherent tensions in the complex negotiation of these interests.
There is no tension more challenging than that between psychiatric clinicians and researchers. The introductions to each edition of the DSM state that the “highest priority” of the manual is “to provide a helpful guide to clinical practice,” (, p. xxiii). Yet, the manual is produced by psychiatric researchers, who are attuned to different goals (e.g. reliability, standardization, robust research designs, and statistical analyses) than the average clinician. Indeed clinicians are often portrayed as obstacles to these goals as evident in the discussion around DSM-5. Framed as an issue of “clinical utility”, this discussion focuses on the mundane, practical limitations to reforming the clinical practice - the extra paperwork, the pressing lack of time, the need for computer access, and the unmanageability of 38-point personality scales. Clinicians, according to this view, need to be accommodated by the Task Force, which is charged with the impossible task of achieving a paradigm shift with as little disruption as possible.
While these technical problems are real, the Task Force reads them incorrectly. Misconstrued as a technical problem, the tension between researchers and clinicians in psychiatry has deep roots that no clever construction of new dimensional scales can solve. Rather than the specific exigencies of clinical practice, the salient issue is epistemological in nature. Quite simply, the divergent roles that clinicians and researchers serve in the profession lead to different orientations toward knowledge and competing models of what constitutes useful psychiatric knowledge. It is these differences that underwrite the debates over clinical utility.
The epistemological tensions between researchers and clinicians reflect a classic distinction, noted by Aristotle, between episteme and phronesis. Episteme is what we now understand as scientific reasoning; its goal is to illuminate universal and general rules, to uncover timeless Truth. This is how psychiatric researchers understand the purpose of psychiatric knowledge. Since DSM-III, each edition of the DSM – including and especially DSM-5 - has aimed for the standardization of psychiatric knowledge. The continual push for more reliability in diagnosis is animated by a concurrent desire to reign in idiosyncratic, subjective interpretations of clinicians, so that researchers can accumulate objective data and achieve generalizable knowledge on mental disorders. Or in the words of DSM-III (, p. 7), researchers promote a standardized classification system “with the lowest order of inference necessary”.
Clinicians, on the other, understand relevant psychiatric knowledge differently, adopting a more practical posture toward knowing. Practical wisdom, or what Aristotle calls phronesis, addresses particular cases and specific quandaries, employing, not maxims or rules, but a network of considerations to be tested by trial and error. It operates in the realm of the concrete, the temporal and the presumptive. The goal is not universal knowledge for its own sake, but practical intervention through case-based reasoning. In the phronesis of psychiatric practice, clinicians are not interested in identifying a universal truth but a particular one – what will work for a specific patient.
Phronesis and episteme are not inherently opposed. In other branches of medicine this divide is bridged by concrete diagnostic tests and treatment protocols, backed by research, which then inform – but do not dictate – clinical practice. But, as of now, psychiatry lacks these bridges, and simply reforming a nosological manual will not provide one, as it skewed toward standardization at the expense of clinical intuition.
The recommendation of the DSM-5 Task Force to add dimensional measurements to the current focus on diagnostic categories is likely to widen the divide between clinicians and researchers. In pivoting toward a more dimensional model of mental illness, the Task Force has embraced a project of quantification by introducing numerical scales. These scales value information of a specific kind, namely statistical, quantitative data. They aim to transform the complex suffering of individual patients into numerical values. In quantification, researchers shoot for more standardization via quantification in the interest of obtaining information on aggregate populations of patient.
This is at odds with the practical motives of clinicians. Clinicians are oriented toward individual patients. Statistical aggregates are of little use or relevance to them. The patient can never be just a number. For clinicians, the trade-off for this marginally useful statistical knowledge is not only more bureaucratic headaches; it is an attack on clinical discretion– an attempt to standardize the patient/psychiatrist intervention that devalues the nuance and particularistic thinking required for treating patients. Dimensionalization carries with it great implications for identity of clinicians as knowers. It threatens to alter the role of psychiatrists from interpreters to measurers, as the dimensional revisions currently being field tested (i.e. cross-cutting dimensional scales and severity scales for each diagnosis) will, in effect, bookend the clinical interaction with the production of numerical data. The goal of reigning in discretion is evident in a major justification for dimensionalization - to reduce the need for clinical judgment in diagnosis so as to assist non-psychiatrists (, p. 21). Such diagnosis by numbers threatens the hermeneutic tradition of the psychiatric practice, by promoting episteme at the expense of phronesis.
The effort to standardize clinical practice through the DSM fosters ambivalence (at best) and/or resentment (at worst) in clinicians. It is perhaps unsurprising then that many clinicians resist DSM reforms. In fact, this epistemological divide probably underlies clinicians’ long-standing refusal to follow DSM protocols lock-step. DSM reformers lament clinicians’ rejection of the GAF, their refusal to adopt the multiaxial system, and the prevalent use of vague, “garbage can” diagnoses like NOS category. Often viewed as technical deficiencies with the DSM itself (i.e. Regier et al. ), these practices might be better conceived of as ways in which clinicians resist the imposition of the DSM. These “workarounds” are assertions of phronesis, an attempt to carve out a space of autonomy from the DSM in practice .
Thus, on the eve of DSM-5, clinicians find themselves in a complicated relationship with the DSM that dimensionality is poised to worsen. On one hand, as members of a profession, clinicians gain credibility from their association with science and research. The DSM has played an essential role in linking psychiatry to science for the last thirty years. On the other hand, the more the needs of researchers dictate the DSM and impinge on clinical practice, the more clinical intuition is devalued in those contexts. Scales may obtain more advanced statistical analyses and knowledge but devalue clinical nuance in the process.
Researchers and clinicians do not see eye-to-eye on dimensionality because their gazes are directed at different targets, aggregate collectives and individual patients, respectively. Rather than a bridge, dimensionality erects a barrier between the episteme of researchers and the phronesis of clinicians. The existence of this epistemological divide raises a question: can the DSM center hold? Instead of hitching together to epistemologically divergent interests, should psychiatry decouple the efforts of researchers and clinicians so that a bridge may arise, not by fiat, but more organically?
Given the problems in DSM-III, DSM-IV, and (likely) in DSM-5, would you argue for an alternative, more rational diagnostic system than the DSM? Could you describe it? Would your alternative system simply replace the DSM or restructure it in a major way?
Should the activist stance toward change proposed by some commentators in question 3 be carried to another level – that of replacing the manual with an alternative, more rational one? Or, if not replacing the manual, of restructuring it substantially?
We can sort the possible responses to this question into three groups: alternative systems already in development, alternative nosological systems developed by the commentators themselves, and major restructuring proposals for the DSM. For a representative of the first group we have First’s presentation of the NIMH Research Domain Criteria Project (RDoC). In the second group belongs Pies’ proposal (along with those of Hayes, Mender, Mishara and Schwartz, Peled, and Pies in Bulletin 2). And to represent the third group we have Paris’ discussion of the thrust toward dimensional measures in DSM-5 (also covered by Whooley in the preceding question).
As with the previous four questions, commentaries and responses on the final two offer a mix of opinion, with both agreement and occasional disagreement. Regarding the fifth question, utility, Frances agrees with the specific critique of the proposed DSM-5 dimensional measures as offending clinical utility, but not with the more general critique of DSM-III & IV as embodying unresolved conflicts between clinical and research utility. He is, after all, responsible for the DSM-IV statement:
The utility and credibility of DSM-IV require that it focus on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers. (, p. xv).
Let’s first recognize that the fifth question, “Is there a conflict over utility in the DSMs?,” contains in fact three questions: is there a conflict among the various goals?, what goal or purpose is served best?, and would we have been better off with more than one manual? Frances tends to acknowledge the first, ignore the second, and center his argument around responding to the third question in favor of a single manual. He concludes that “[h]owever imperfect, DSM's special value is as a common denominator that avoids a Babel and is good enough (if admittedly not best) at each of its jobs.” Unlike the pluralogue in the other questions, where some or most of the commentators were on Frances’ side of the argument, in the question of utility we have all three commentators lined up against him: all recognizing the clinical/research conflict, all agreeing that DSM-IV is prejudiced toward research, and two of the three opting for separating clinical and research diagnostic documents.
With their agreement that there is a conflict between the clinical and research goals of the DSM, the three commentators offer different perspectives on this conflict. Adopting Aristotle’s distinction between theoretical and practical knowledge (episteme and phronesis), Owen Whooley argues that there is a rather deep, metaphysical divide between the research and clinical goals of DSM-III/IV: the search for universal laws versus individualized care of the particular patient. He illustrates this vividly with the proposed dimensional measures for DSM-5. Aside from the practical matters such as that clinicians will find them cumbersome, of no practical use, and won’t use them, they also represent, philosophically, an effort to treat human beings and human suffering as quantifiable entities who can be evaluated with quantitative measures as opposed to interpretation and judgment.
Joseph Pierre focuses on what he might call the DSM architects’ own confusion regarding the goal and use of the manual. While they subject the clinician to the diagnostic criteria in the service of promoting research, the categories with their criteria impede research as much as they facilitate it. Citing the RDoC, Pierre points out that the most significant research may be done outside the confines of the DSM categories. Finally, Aaron Mishara and Michael Schwartz point to the clinical/research conflict as a consequence of basing DSM-III on a Hempelian scientific model; they argue that a DSM designed with the ideal-type structure they advocate would eliminate the clinician/researcher split and would in fact serve the two groups equally well.
Finally this six-question exercise ends appropriately with a grand question (related to the earlier question regarding attitudes toward change): do the problems of the DSMs warrant a major overhaul? Consistent with his previous response arguing for a conservative attitude toward change, Frances argues that the state of psychiatric science dictates minimal change, not the “paradigm shift” proposed by the DSM-5 architects, and not any other form of major overhaul. He invokes the NIMH Research Domain Criteria project (RDoC) that promises to change the scientific landscape of psychiatry in the future. Pending findings from that endeavor, which may indeed warrant a significant refashioning of the DSM, we should hold tight and await the return of the RDoC jury.
The first commentary flows neatly from Frances’ closing remark. Michael First provides a clear description of the NIMH project, clarifying that this is research project, not an alternative diagnostic manual. But it is a research project whose findings may significantly affect all DSMs that follow in its wake. In a second commentary Ronald Pies reviews his effort at imagining an alternative diagnostic system, described more thoroughly in Bulletin 2. His proposal involves two innovations: basing the system on prototypal diagnostic constructs, and dramatically reducing the number of diagnoses from several hundred to a large handful. Finally, Joel Paris tackles the major innovation of DSM-5, the introduction of a variety of dimensional measures. His critique overlaps with some of the discussion in the previous question on utility – for the obvious reason that the introduction of such measures involves both questions, utility and alternate systems. He is in agreement with previous discussion of this topic – indeed, we have not had a positive response, either from Frances or any of the commentators, toward the proposed dimensional measures. Paris also expresses an agreement with commentators of Question 5, that the manual might work better by being split into two: a shorter version for clinicians and a more detailed version for researchers. Such a split would certainly work for Pies’ proposed alternative system, and it again touches on the issue of utility.
It is around question 5, utility, that Allen Frances and I have been in most disagreement. He certainly recognizes that DSM-IV will be dissatisfying to each of its users in its own way; but committed as he is to a single manual, he is probably right that DSM-IV does a reasonable job of reconciling the diverse goals of its different interest groups. I do remain convinced that for their work clinicians only need prototypal descriptions (which are in fact included in DSM-III/IV), although I can also agree that the criteria have played a role in reinforcing the prototypes. For me the diagnostic criteria have had a complicated course. They certainly play a role in reinforcing reliability across clinical and research settings. That accomplished and the prototypes in place, they lose their usefulness for clinicians. With regard to the research community, the diagnostic criteria have played an ambiguous role: on the one hand assuring reliability across research settings, on the other hand restricting research by forcing research to work within the criterial boundaries. I agree with Owen Whooley that the manual with its diagnostic criteria and its proposed dimensional measures does expose a deep discord between conflicting visions of people and psychopathology. I also agree with Joseph Pierre regarding a core contradiction in the DSM structure: that it is designed to support research but in the end imposes strictures that force researchers to work outside the manual. Finally, I am sympathetic to the way in which Aaron Mishara and Michael Schwartz’s analysis converges with Pies’ in the next section, the restructuring of the manual around a small group of superordinate diagnostic categories. This is of course the lumping strategy; I am not convinced that the DSM approach of splitting into hundreds of diagnoses has accomplished much.
With question 6 I can in some fashion agree with everyone. Allen Frances makes a convincing case that, pending more definitive science than currently available, we should stick with the DSM that we have, and, in agreement with Joel Paris, without the dimensional measures currently planned. But if there is to be a more definitive science, the NIMH Research Domain Criteria project as described by Michael First seems like the best prospect. What we all agree about – Frances, the commentators, and myself – is the uncertainty as to whether the RDoC project will succeed in becoming the real paradigm shift it promises to be.
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