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by David J. Kupfer, Michael B. First, and Darrel A. Regier
American Psychiatric Publishing, 2002
Review by Rachel Cooper, Ph.D. on Oct 7th 2003

A Research Agenda for DSM-V

The Diagnostic and Statistical Manual of Mental Disorders (known to its friends and enemies as the DSM) is a classification of mental disorders published by the American Psychiatric Association. The current edition of the DSM, DSM-IV, was published in 1994 (although a text revision, DSM-IV-TR, containing minor textual revisions, followed in 2000). The DSM seeks to describe and classify all mental disorders. Within its pages can be found descriptions for hundreds of mental disorders -- types of schizophrenia, depression, anxiety disorders and so on -- and also less well-known conditions -- nicotine dependence, nightmare disorder, and mathematics disorder, for example. A new edition, DSM-V, is due to in 2010, and A Research Agenda for DSM-V seeks to stimulate research and discussion prior to work on DSM-V commencing.

A Research Agenda for DSM-V is a dull though worthy read, but an extraordinary document. The book doesn't consist of plans for DSM-V but rather of plans for plans -- a series of "white papers" outlining research priorities in various areas relevant to psychiatric classification. It is a testament to the extraordinary success of the DSM that such a book should be published, and not only published but published in paperback. Scientific research papers on most topics get read, it is said, by an average of somewhere between zero and one readers, and yet research proposals related to psychiatric classification now find a mass readership. The very term "white paper", used by the editors to describe the chapters, is more normally associated with plans produced by the offices of nation states. Though partly bluster, such self-importance is basically justified. The DSM is an exceptionally important classification system. Psychiatric patients in the U.S., but also increasingly around the world, receive a DSM diagnosis, and the diagnosis they receive may well determine the kind of treatment they are given, and indeed, in many health care systems, whether they are considered worthy of treatment at all. Given that millions of people world-wide suffer from mental disorders, changes to the DSM can potentially effect the lives of as many people as changes in the policies of most nation states.

The six "white papers" that make up A Research Agenda for DSM-V are intended to stimulate research and discussion prior to the start of the official revision process that will culminate in the publication of DSM-V. The six chapters concern fundamental methodological issues (how to define "disorder", the meaning of "validity", the differences between the DSM and the ICD), the possible contributions of neuroscience, and of developmental science, problems with personality disorders and relational disorders, the relations between mental disorder and disability, and cross-cultural issues. The chapters on basic methodological issues, personality disorders, and disability, are more concrete in their suggestions than the others, and for this reason both more readable and more useful. In contrast the chapters on neuroscience, developmental science, and cross-cultural issues basically say "these areas will be important in the future, but we don't quite know how yet".

In many cases the problems now faced by the DSM are rooted in its success. Because the DSM has come to be used extensively outside the United States issues to do with cross-cultural diagnosis have become especially pressing. The chapter on culture and psychiatric disorder is one of the longest in the book, and experts on cross-cultural issues were also assigned to the groups writing all the other chapters. Although this concern is admirable, much of the discussion remains strangely parochial. Pressures arising from the oddities of the financing of U.S. health-care are evident (see, for example, the discussion on pages 102-103, concerning problems with getting reimbursement for routine monitoring of the emotional and mental development of children). Even from a European perspective, the discussion of Relational Disorders seems quaint. Families are assumed to consist of a married couple caring for a couple of children, and the aim of marital therapy is considered to be the prevention of divorce. Such examples highlight the difficulties of achieving cross-cultural relevance, and bring into sharp focus the oddity of the American Psychiatric Association controlling a classification that is now of global importance.

The DSM-III, published in 1980, sought to be a purely descriptive classification that made no use of unproven etiological assumptions. It was hoped that this would render the DSM acceptable to mental health professionals working within different theoretical frameworks. An ongoing theme of A Research Agenda for DSM-V is that the descriptive syndromes included in the DSM have become so embedded in psychiatric research as to be potentially problematic. Most studies use DSM criteria to select subject populations. If it turns out that the syndromes included in the DSM map onto genuine disorders this will cause no problems -- all cases with a particular DSM label will be fundamentally alike and psychiatric research will eventually discover how. Unfortunately, it increasingly seems likely that some theoretically interesting populations do not map on to DSM categories, and such groups are currently under-researched. If, for example, some sub-group of those with a particular DSM diagnosis share a genetic abnormality, or a drug can help a population that cuts across current categories, this is likely to be missed by researchers. Unfortunately, while there is some consensus that research based on DSM categories may make little progress, it is less clear what researchers should do instead. The introduction to the collection states that "research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies" and adds that some "as yet unknown paradigm shift may need to occur." (p. xix) Ironically, it is at the very point that the DSM has achieved global dominance, that such doubts in the way forward have become mainstream.

To sum up, the DSM is currently of such great importance that books providing some indication as to how the DSM might evolve, such as A Research Agenda for DSM-V, are also important. Like government white papers the white papers included in A Research Agenda for DSM-V carry the hallmarks of having been written by committee -- at their best they are authoritative and comprehensive, at their worst they are bitty and over-long. Although an important book, A Research Agenda for DSM-V is tough going. Despite being aimed at all mental health professionals, only the diligent will reach the end. Even the less than diligent, however, will benefit from flicking through its pages.

 

© 2003 Rachel Cooper

 

Note that this book is available free as an Adobe Acrobat download from American Psychiatric Publishing.  Click here.

 

 

Rachel Cooper, Ph.D., Lecturer in Philosophy, Institute for Environment, Philosophy and Public Policy, Furness College, Lancaster University, UK




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