A DSM critic, Andrew Hinderliter sent this perceptive email questioning the wisdom of the most fundamental decision we made in preparing DSM IV- ie, our goal of keeping the system stable. "A problem with your conservative approach to psychiatric nosology is that it grandfathers in the good and the bad alike and provides no way of changing really bad parts of the system. Unquestionably, there are things in DSM that couldn't pass a risk-benefit analysis (the Paraphilia section is one example).
In a previous email to me, you gave the following explanation for its continued presence in DSM IV : 'I think they are there only because of history and inertia, but these are powerful forces'. Quite possibly, the single most powerful force of diagnostic inertia in psychiatric nosology in the past half century was the strongly conservative approach to diagnostic change that you yourself chose to implement in DSM-IV.
A conservative approach to diagnostic change has much to be said for it, but in all the arguments back and forth about it, I feel like there is an elephant in the room regarding the much-harder-to-justify diagnoses. I have no doubt that you've thought about this before, but I was just curious as to your thoughts on the matter".
Indeed I have thought and blogged about this before. My fullest previous answer to the question can be accessed at http://alien.dowling.edu/~cperring/aapp/bulletin.htm (see particularly commentaries by Pierre, Piasecki, Kinghorn, Waterman, Cerullo, and Porter, and Ghaemi -and my responses to them). But Andrew Hinderliter has raised the issue most pointedly and is quite right in identifying this important paradox and weakness in my arguments for a conservative approach to psychiatric diagnosis.
To keep the diagnostic system from expanding wildly, we established extremely high thresholds for change in DSM IV. Substantial scientific evidence was required for changes in either direction- those that would add to the reach of the system, but also those would subtract from it. The rationale was that without clear and high scientific thresholds, changes would be arbitrary, de stabilizing, and subject to personal whim.
This requirement did indeed permit the grandfathering of decisions made previously that would not have met the standards for new suggestions. Many of the conditions in DSM 4 have been subjected to too little research study to justify sunsetting, given our high threshold for change in either direction.
We could have taken a different approach- denying tenure to the already included DSM IIIR conditions unless they could prove themselves using the new, more stringent, rules. The advantages of having a slim but solid diagnostic system had to be balanced against the unknowable risks and inconveniences of making such a radical break with longstanding diagnostic traditions.
You could argue the case either way. We decided to play it safe and conservative. This left some problematic conditions in DSM IV- especially the Paraphilia section. But disrupting the system by drastic trimming probably would have caused other disturbing consequences. Our attitude was when in doubt, stand pat and do least harm. However, a plausible case can be made that the system needed more pruning and that we were too timid.
