Science and “Pragmatism” in DSM: A Question of Priorities

Response to Decker’sCan Validity and Pragmatism Go Hand in Hand?

In my reference to Prof. Decker’s excellent history of DSM-III, I don’t mean to imply that Prof. Decker herself agrees with my interpretation of her exposition. Readers can judge for themselves if the facts she uncovers agree with my interpretations or hers. To adapt an old saying: the facts are the facts; interpretations can differ. Besides her book, readers should also consult the work of the historian Edward Shorter (Beyond Prozac).

The main problem here is not that past DSM leaders were derelict or purely political. The problem is that they now say that they would place science below pragmatism, meaning whatever they think is best, as the core criterion for revising DSM. This is a clear statement that DSM is unscientific; it doesn’t require much interpretation. Furthermore, I maintain that any science, whether physics or psychology, has certain basic standards, the first of which is actually believing that there are right answers, and seeking to get them right. The pragmatic approach of these DSM leaders is to try to reach consensus on what the profession wants, irrespective of whether it is right (meaning proven scientifically whatever extent that might be considered acceptable; I’ve provided numerous examples in my own interactions with the DSM-IV leadership on this point). Prof. Decker shows that DSM-III started with scientific intentions, and she also shows how far away it went from those intentions. The fact that she herself is not willing to draw that conclusion reflects her own interpretation of psychiatry as a profession. My view is that we should try to be as scientific as possible, and not settle for as little science as has been allowed into the DSM process. This doesn’t mean that I’m setting the standard at astrophysics. I just think, as she noted, that if a huge scientific literature supports a concept like personality dimensions, then the APA Board of Trustees should not have the power to veto it.

I would like to clarify a few matters of detail:

(1) Of the 10 personality disorders in DSM-III, there still are basically no studies proving scientific validity (using the 4 Robins/Guze validators) for 7 of them. This is the case now; it was the case in 1980. Hence, MOST personality disorders were included by Spitzer in 1980 without any evidence of scientific validity, and this remains the case. Even for the other 3, borderline PD being one of them, there was hardly any evidence of scientific validity for that condition in 1980. The fact that Spitzer was meticulous in defining it doesn’t mean that he had the scientific evidence that it was a valid diagnosis. Prof. Decker seems to conflate reliability and validity here.

(2) She may be correct that Dr Spitzer did not directly seek to mollify the psychoanalytic community on the issue of personality disorders. Her book makes it clear, though, that the psychoanalytic community was a hugely powerful constituency that needed to be won over before DSM-III could be ratified. Personality disorders were one aspect of that process (as was the axis II concept in general, and other matters: the unscientific broadening of “major depressive disorder” to include concepts of neurosis, as Edward Shorter so well documented from the APA archives.)

(3) The issue of schizoaffective disorder is well-described. I was in communication with some members of the schizoaffective committee for DSM-5. There has been a large amount of research in the past 3 decades on this topic, supporting a major revision in the concept. It seems to have little evidence as a legitimate scientifically valid diagnosis. The schizoaffective researchers I spoke with agreed, but one member of the committee ended further discussion of attempting to influence the DSM-5 task force on this matter, with the comment: “They are clear they will not make any major changes.” No science, of any variety, works this way. If some in our profession are fine with this approach, so well documented by Prof. Decker, they are entitled to that view. But I think we should have a higher standard, as is the case in most other medical disciplines, and give science a higher priority than the pragmatic preferences of a profession from 33 years ago.