Nassir Ghaemi, MD, MPH


May 18, 2013

Thoughts on a New DSM

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is here. We might as well pretend that Ronald Reagan is still president. Radical changes were made, with limited scientific evidence, when DSM-III was published in 1980 (the year Reagan was elected); even the tiniest changes, with great scientific evidence, are now the subject of outrage.

For me, DSM-5 is a disappointment. I take no pleasure in making this judgment. I wish I could say that DSM revisions are increasingly scientific and getting us closer to truths. But this simply hasn't happened.

DSM-5 is a disappointment for me not because it is much different from DSM-IV, but because it is so similar. Almost 2 decades after the fourth revision in 1994, despite thousands of research studies on psychiatric conditions, our profession hardly can bring itself to change anything of importance. The radical bipolar/major depressive disorder (MDD) dichotomy is unchanged and untouchable -- the third rail of US psychiatry -- despite numerous studies casting doubt on the validity of the MDD definition and providing support for broader definitions of bipolar disorder.

The personality disorder concept was nothing but the description of psychoanalytic speculations in 1980. It has remained basically unchanged, despite little research evidence of validity. Personality traits, one of the most well-proven facts in psychology, were recommended by the DSM-5 task force but vetoed by the American Psychiatric Association Board of Trustees. Science was rejected; psychoanalytic tradition was not.

Clinicians may have assumed that we have scientific validity for most of the approximately 400 diagnoses in DSM-5; we have hardly any validity data for the vast majority of those diagnoses, and we have notable validity evidence for numerous concepts that are excluded.

The claim in the Reagan presidency was that DSM would provide reliability; we could agree on definitions. Then, we would do more research so that definitions would evolve toward better validity. Reliability would lead to validity.

When Bill Clinton was president and DSM-IV was published in 1994, a change happened: DSM became an end in itself. The DSM-IV leadership explicitly stated that unless a very high bar of scientific evidence was reached, no changes were allowed. The bar kept being moved higher and higher for science, and lower and lower for politics. The DSM-IV leadership called it "pragmatism": DSM changes were made on the basis of what that leadership thought was best for patients, they said, and for the profession.

Reliability had become an end in itself; validity no longer mattered because, in a species of extreme social constructionism, the DSM-IV leadership saw the nosology as a way to influence practice, not as a way to discover causes of and treatments for mental illnesses. (They didn't bother with the question of how you could practice well if you didn't find out the causes and treatments of illnesses.)

There were hopes that DSM-5 would be different, with scientifically based changes. But a major backlash came: The DSM-IV leadership opposed changes on "pragmatic" grounds, and many in the larger public criticized DSM on social constructionist grounds, as just a means for psychiatrists to make money and influence people. Major changes became minor, and even the minor ones were often dropped to an appendix for further research, which is likely to be ignored.

After 2 decades of being a loyal follower of DSM, the debates of recent years led me to make a sad but definite conclusion: DSM has caused stagnation in psychiatry. If DSM categories are devised primarily because professional leaders want to achieve some clinical or even economic goals, there is no reason why nature should play along. By being "pragmatic" and not scientific, DSM has doomed biological and pharmacologic research in psychiatry to failure for 2 generations.

Now I see a generational change. The leaders of the DSM-III, -IV, and -5 workgroups are often literally the same people, representatives of the 1970s/1980s generation in psychiatry. Some of us in later generations do not venerate DSM as the bible of psychiatry, as it's often called; we instead question it as theology instead of science. Recently, the leadership of the National Institute of Mental Health (NIMH) reached the same conclusion and stated it forcefully: DSM criteria are not scientifically valid, and patients deserve better.

DSM-5 is out, and clinicians will use it, but unfortunately it represents a failed past. Those of us who grew up in that past, and have seen how it has led us to stand still, are inclined to agree with the NIMH that our future deserves to be different.