Is Psychiatric Accuracy a Challenge?
Producing accurate psychiatric diagnoses.
Posted Apr 09, 2012
With the upcoming publication of DSM-5 very much in mind, the editors of The Journal of Child Psychology and Psychiatry published a special issue last week on the “challenges and potential of DSM-5 and ICD-11 revisions.” To this, they also attached an intriguing, unusually candid editorial (h/t: Suzy Chapman’s Diagnosis Revision Watch).
“This year,” write editors James F. Leckman and Daniel S. Pine, “we focus on the challenges, complexities, controversies, and clinical necessity of diagnostic schema as they impact our field. This is a timely endeavor,” they add, “given that a year from now the long-anticipated fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be released and the eleventh revision of the International Classification of Diseases (ICD-11) is well underway.”
Whether the new edition is “long-anticipated” or “long-dreaded” depends greatly on whom one asks, but in either case it’s notable that the editorial concludes with the following unusual (because unusually frank) admission:
As we reflect on current and future nosologies, we are reminded of the blind man who confronts an elephant and is not sure if he has discovered a rare form of snake, some unique variety of animate wall, four warm tree trunks, or some other very large and highly unusual organism.
“As with many complex entities,” the editors continue,
particularly when they are viewed up close in “dim lighting,” it is often difficult to grasp the enormity of the entity. Only with distance, as might come from many more years of research, might we understand the enormity of current nosological questions and the associated changes that sit before the field in 2012. …While we know much more about pathophysiology than we did 20 or even 10 years ago, we have not progressed far enough to implement radical changes in our nosology. Nevertheless, perhaps as we look back at the current state of affairs 20 years from now, we will recognize the seeds of such a radical transformation, as delineated in these deeply thought-provoking reviews.
Trying rather obviously to end on an upnote, with the “seeds of…radical transformation” replacing the earlier, much-less flattering metaphor of the blind man groping his way, the editors' paragraph strikes me as refreshingly candid about the enormous challenges that still beset and confound psychiatric nosology—which is to say, the question of its classificatory and diagnostic accuracy. While a professional might read Leckman and Pine’s analogy of the blind man with a nod of recognition, even as a sign of professional humility, the general reader is likely to feel concern, even some alarm, over such discrepancies in judgment (“a rare form of snake”? “some unique variety of animate wall”? “four warm tree trunks”? “some other very large and highly unusual organism”?), given how dramatically those judgments can impact his or her life.
Despite years of promised rigor and accuracy, including forthright assertions in 1984, during a major debate about DSM-III, that “the problem of [diagnostic] reliability had been solved” (Klerman 541), the “dim lighting” (as the editors of The Journal of Child Psychology and Psychiatry put it) clearly remains. And since they’re talking centrally about psychiatric nosology, including “the challenges, complexities, controversies, and clinical necessity of diagnostic schema” that await DSM-5 and ICD-11, it’s hardly a stretch to argue that the same analogy necessarily holds for the task forces overseeing both editions. Neither is detached from or unaffected by the same difficulties.
Nor is the general reader likely to find much reassurance in learning that, despite multiple assertions that psychiatry finally alighted in the 1980s on “truth and reliability in diagnosis,” similar problems have in fact vexed—and similar analogies have since tried to console—every DSM task force since 1968. That was the year when one man, Sir Aubrey Lewis at the Maudsley Institute of Psychiatry, London, assumed the onerous responsibility of single-handedly updating DSM-I, making dramatic, questionable revisions without any oversight at all.
As I document at length in Shyness: How Normal Behavior Became a Sickness, a detailed account of the DSM-III, -IIIR, and -IV revisions, each edition set out to correct such mistakes by defining mental disorders in “descriptive, explicit, and rule-driven” ways (Wilson 404). Indeed, throughout the DSM-III correspondence that I researched and reproduced at length in the book, there were repeated attempts to standardize the traits and boundaries given each disorder, in theory stamping out awkward disparities in judgment. Yet each edition repeatedly ran aground on the issue of nosological accuracy and reliability. As DSM-III and -IIIR editor Robert Spitzer acknowledged to me in a 2006 interview, Klerman’s boast about solving both was “regretful, because the problem of reliability hasn’t been solved at all” (qtd. in Shyness 63). George Vaillant was less diplomatic, calling DSM-III “a bold series of choices based on guess, taste, prejudice, and hope” (Vaillant 545). Other commentators, equally doubtful of the edition’s nosological progress, warned that DSM-III “promulgates a pseudo-objectivity which simply substitutes the subjectivity of the observer for the subjectivity of the patient” (qtd. in Shyness 66).
With the DSM-5 task force apparently set to approve such contentious, hotly disputed conditions as “attenuated psychosis syndrome,” "disruptive mood dysregulation disorder," "premenstrual dysphoric disorder," and "complicated grief disorder," among others, it’s far-from reassuring to learn via Leckman and Pine that Spitzer’s concern still stands. As the editors implied only last week, in matters of nosology psychiatry is still too much like a blind man declaring an elephant to be a snake, “some unique variety of animate wall,” or a warm set of tree trunks. Apply such homely metaphors to the controversy surrounding “disruptive mood dysregulation disorder,” to take just one subject of dispute, and one grasps very quickly why DSM-5 is generating so much public and professional concern.
Klerman, Gerald L. “The Advantages of DSM-III.” American Journal of Psychiatry 141.4 (April 1984): 541.
Lane, Christopher. Shyness: How Normal Behavior Became a Sickness. New Haven: Yale University Press, 2007.
Leckman, James F., and Daniel S. Pine. “Editorial Commentary: Challenges and Potential of DSM-5 and ICD-11 Revisions.” The Journal of Child Psychology and Psychiatry 53.5 (April 4, 2012): 449-54: http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2012.02548.x/full
Vaillant, George E. “The Disadvantages of DSM-III Outweigh Its Advantages.” American Journal of Psychiatry 141.4 (April 1984): 542-45.
Wilson, Mitchell. “DSM-III and the Transformation of American Psychiatry: A History.” American Journal of Psychiatry 150.3 (March 1993): 399-410.