Arguments Opposing the DSM-IV

Janet Greider

The quick turnaround between the DSM-III, III-R, IV, and IV-TR (6-7 years between each) was a source of concern for many. There were four arguments against proceeding with publication of the DSM-IV, and later the DSM-IV-TR update (Blashfield, Sprock & Fuller, 1986; Zimmerman, 1989):

  1. Revision would disrupt researchers studies, and confuse clinicians
  2.  A revision may create unnecessary controversy regarding diagnoses
  3. Attention devoted to specific definitions might result in excessive and trivial changes
  4. The DSM-III and DSM-III-R already demonstrate significant changes, and there may not be a need to alter them so quickly.

Why was the DSM-IV Published Anyway?

These arguments were overruled by the simple fact that the United States is under a treaty obligation to maintain coding and terminology consistent with the ICD-10, which was projected to be published in the same year as the DSM-IV.

The primary purpose of this treaty is to achieve international cooperation by providing formal channels of communication, and influence between workers of two nomenclatures.  The construction of the DSM-IV was much more rigid than the development of the DSM-III.  There was an increasing focus on documentation, to reduce the risk of whimsical or random shifts in nomenclature. (Frances, Widiger & Pincus, 1989)

Pincus, H.A., Frances, A., Davis, W.W., First, M.B., Widiger, T.a. (1992). DSM-IV and new diagnostic categories; holding the line on proliferation.The American Journal of Psychiatry, 149, 112-117.

Malik, M.L., Beutler, L.E. (2002). The emergence of dissatisfaction with the DSM. In M.Malik & L. Beutler (eds.) Rethinking the DSM: A psychological perspective, Decade of behavior (3-15). Washington, DC, US: American Psychological Association

Zimmerman, Mark. (1988). Why are we rushing to publish the DSM-IV. Arch Gen Psychiatry, 45(12), 1135-1138.













Mark Zimmerman published an article questioning the usefulness of manuals that are being updated every 7 years. Between the DSM-III and the DSM-III-R, he argues, there were sufficient changes made that the DSM-III-R could be called the DSM-IV. However, it was not the DSM-IV to maintain  the similarity with the ICD-9.  At the same time,  work on the DSM-IV began only 1 year after the publication of the DSM-III-R.

Zimmerman points out that with the lengthy process of validation and replication of studies in the DSM-III-R, the replication studies will be published around the same time as the first draft of the DSM-IV is submitted (which was 1990). While this still allows time for the editors to apply the new knowledge to the DSM-IV, the previous studies will have been working from the valid and replicated studies of the DSM-III. Zimmerman makes the convincing case that publishing a new or updated revision of the DSM every 6-7 years negates the usefulness of the Manual by allowing studies to leap-frog each other in validity and replication. It is likely that the changes made to every other Manual will not be data-based, because the data will be obsolete.

To exemplify this potential undermining of the DSM-IV, Zimmerman points out what happened with the criteria for ‘melancholia’ in the DSM-III-R. He points out that despite the fact that research had been conducted on the subject for more than 50 years, there were such significant gaps in the updated empirical database that the Committee  (which would be a Work Group in the DSM-IV) would frequently rely on clinical judgment (personal judgment) and was strongly influenced by group consensus.
The issues that Zimmerman identifies due the quick publication turnaround between the DSM-III and DSM-III-R are equally applicable to the DSM-III-R and DSM-IV.  He points out that although Dr. Allen Frances (the Chair of the DSM-IV Task Force) stresses the importance of beginning the revision process early so the DSM-IV can influence the ICD-10, the editors of the ICD-10 have put more years into refining the diagnostic criteria and are unlikely to change them just because an American version came out first. Instead, Zimmerman stresses the need for high-quality, valid and reliable, scientific research. Without science driving the mechanisms behind the modifications to the DSM-IV, the validity of the APA itself will fall.

Zimmerman, M. (1986). Why are we rushing to publish DSM-IV?. Arch Gen Psychiatry, 45, 1135-1138

Janet Greider

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