Philos Ethics Humanit Med. 2012; 7: 9.
©2012 Phillips and Frances; licensee BioMed Central Ltd.
The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis
1Department of Psychiatry, Yale School of Medicine, 300 George St, Suite 901, New Haven, CT, 06511, USA
2Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 508 Fulton St, Durham, NC, 27710, USA
3Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 260 Stetson Street, Suite 3200, Cincinnati, OH, 45219, USA
4Department of History, University of Houston, 524 Agnes Arnold, Houston, 77204, USA
5Department of Psychiatry, Columbia University College of Physicians and Surgeons, Division of Clinical Phenomenology, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
6Department of Psychiatry, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
7Human Relations Counseling Service, 400 Bayonet Street Suite 202, New London, CT, 06320, USA
8Department of Linguistics, University of Illinois, Urbana-Champaign, 4080 Foreign Languages Building, 707S Mathews Ave, Urbana, IL, 61801, USA
9Duke Divinity School, Box 90968, Durham, NC, 27708, USA
10Department of Psychology, Auburn University Montgomery, 7061 Senators Drive, Montgomery, AL, 36117, USA
11Department of Clinical Psychology, The Chicago School of Professional Psychology, 325 North Wells Street, Chicago, IL, 60654, USA
12Institute of Community and Family Psychiatry, SMBD-Jewish General Hospital, Department of Psychiatry, McGill University, 4333 cote Ste. Catherine, Montreal, H3T1E4, QC, Canada
13Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Los Angeles, CA, 90095, USA
14VA West Los Angeles Healthcare Center, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
15Department of Psychiatry, SUNY Upstate Medical University, 750 East Adams St, #343CWB, Syracuse, NY, 13210, USA
16Irving Institute for Clinical and Translational Research, Columbia University Medical Center, 630 West 168th Street, New York, NY, 10032, USA
17New York Presbyterian Hospital, 1051 Riverside Drive, Unit 09, New York, NY, 10032, USA
18Rand Corporation, 1776 Main St Santa Monica, California, 90401, USA
19Central City Behavioral Health Center, 2221 Philip Street, New Orleans, LA, 70113, USA
20Center for Bioethics, University of Pennsylvania, 3401 Market Street, Suite 320, Philadelphia, PA, 19104, USA
21Department of Psychiatry, Texas A & M College of Medicine, 4110 Guadalupe Street, Austin, Texas, 78751, USA
22Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA
23Department of Psychiatry, NYU Langone Medical Center, 550 First Ave, New York, NY, 10016, USA
24Department of Psychiatry, University of Vermont College of Medicine, 89 Beaumont Avenue, Given Courtyard N104, Burlington, Vermont, 05405, USA
25Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
Received April 30, 2012; Accepted May 23, 2012.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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. ([33
], 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.