Pragmatism In Psychiatric Diagnosis
A reply to Dr. Nassir Ghaemi.
Posted January 11, 2013
Here is part of Dr Ghaemi's challenge: "A member of the DSM-IV task force told me that the leader of DSM-IV ... said that in addition to their scientific evaluation of the material there, they should keep in mind three overriding principles:
1. To make no changes unless the scientific evidence was extremely strong (ie., DSM conservatism).
2. To make no changes that would lead to radical changes in the document (DSM conservatism again), and
3. To make no changes that would harm insurance reimbursement to clinicians (economics).
Perhaps the former leader of DSM-IV can confirm publicly if these were his instructions."
Dr Ghaemi has my first two instructions to the DSM IV Task Force completely right. No change in the diagnostic system should ever be made unless it is supported by strong science and vetted for its possible risks as well as its hoped for benefits.
His alleged third instruction is inaccurate. When we began work on DSM IV in 1987, I laid out the following hierarchy- DSM IV's clinical purpose came first and was paramount; followed, at considerable distance, by its uses in research, education, forensics; and then, much further back, that we shouldn't be dumb about DSM's impact on administrative decisions (disability, VA benefits, insurance reimbursement, school services etc)- but that these were hard to predict and wouldn't be determining.
Dr Ghaemi ignores the two reasons why pragmatics must necessarily play a large role in making DSM decisions:
•The science is always incomplete and never clear cut. Data doesn't jump up, grab you by the throat, and tell you what to do. The science is always subject to different interpretations.
•DSM has become far too important in people's lives to ignore its practical impact. Seemingly small changes can result in the mislabeling of millions of 'patients' who are then subjected to unnecessary and often harmful treatments, stigma, costs.
Dr Ghaemi goes on: "This means making practical judgments about what is best for the psychiatric profession, first of all, and then for social, economic, or other reasons. We should change criteria, said my colleague explicitly, so that clinicians should be induced to use more or less of some medications (such as antipsychotics, less, versus antidepressants, more) based on the beliefs of the leadership of the DSM task forces about the risks and benefits of those medications."
Dr Ghaemi has it wrong again. The practical judgments must not be based on what is best for psychiatry- rather, they are based on what is likely to be best for potential patients and for the public health. And yes, we should not be introducing poorly tested and overly inclusive new diagnoses (or reducing the thresholds for existing ones) when this will give an opening to the misleading and aggressive drug company marketing that already has one in five Americans taking an often unnecessary psychotropic drug.
Our country has a very real practical problem that Dr Ghaemi seems oblivious to. We are currently over diagnosing and over treating many people who would be better off left alone and shamefully neglecting the really ill who desperately need and can benefit from our help. DSM IV tried (with only partial success) to stem the tide. DSM 5 has opened the floodgates to much more mislabeling and to drug company misleading marketing.
Dr Ghaemi also somehow fails to understand the quite obvious differences in the goals, methods, and values of DSM iV and DSM 5. Their diametrically opposite goals- DSM IV to be safe; DSM 5 to be innovative. Their opposite methods- DSM IV was boringly meticulous; DSM 5 was recklessly disorganized. Their values- DSM IV embraced pragmatism; DSM 5 explicitly renounced it, making the fallacious claim that is decisions were science based.
When we completed DSM IV, I felt we had done a careful and good job. But we failed to predict or prevent subsequent huge increases in the diagnosis of ADD, autism, and adult bipolar disorder. DSM 5 has been oblivious to its practical impact and to the practical risks of harmful unintended consequences.
If anything, our diagnostic system needs shrinking- instead DSM 5 is recklessly expanding the definition of mental disorder and making it. The following problems of DSM 5 are due to utter its lack of pragmatism, not any presumed excess. dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes