Abstract

In lieu of an abstract, here is a brief excerpt of the content:The Impact of Clinicians on the Diagnostic ManualThomas A. Widiger (bio)Keywordsdiagnosis, classification, DSM, taxonomy, clinical judgmentSurveys of clinicians’ opinions can be very informative. There is a long tradition within medicine that new disorders are discovered within clinical practice. The original edition of the American Psychiatric Association’s (APA) diagnostic manual (DSM) was based in large part on clinical experience. The recent editions have been governed more heavily by more systematic research (Widiger and Clark 2000), but many of the new additions are still said to come from clinical practice. As described for the development of DSM-III (APA 1980), “if there is general agreement among clinicians, who would be expected to encounter the condition, that there are a significant number of patients who have it and that its identification is important in their clinical work, it is included in the classification” (Spitzer, Sheehy, and Endicott 1977, 3).Clinicians can also be surveyed with regard to their opinions concerning a proposed revision. The ultimate consumers of a diagnostic manual are practicing clinicians and any effort to develop an official nomenclature should consider the opinions of the persons who must use the classification within their clinical practice (First et al. 2004; Sadler 2005). Clinicians can also be surveyed (or studied) with respect to how the diagnostic manual is being implemented. Much of this research has demonstrated that clinicians might be failing to apply the diagnostic manual in a reliable or valid manner (Garb 2005; Kutchins and Kirk 1997).It is perhaps obvious, however, that a diagnostic manual should not be governed primarily by clinical opinion or current clinical practice. The authors of DSM-III (APA 1980) and DSM-III-R (APA 1987) indicated that they would include a new diagnosis within the official nomenclature if a group of clinicians indicated that it was important to their clinical practice (Spitzer et al. 1977). This liberal threshold led to the decision of the DSM-III-R Task Force to include such diagnoses as paraphiliac rapism, self-defeating personality disorder, and sadistic personality disorder despite the lack of systematic research supporting their validity and the likelihood that these new diagnoses would have harmful social and forensic applications (Widiger 1995). These diagnoses no longer even appear within the appendix of DSM-IV-TR (APA 2000) for proposed diagnoses needing further study.The authors of DSM-III avoided opinion surveys because “no one wanted to repeat the scene of the general membership voting on a presumably ‘scientific’ issue, as was done in 1973 on the [End Page 277] issue of the elimination of homosexuality from the DSM-II classification” (Spitzer, Williams, and Skodol 1980, 152). Matters of construct validity should probably be addressed through systematic research rather than through opinion polls. Decisions should be informed by a fair hearing of the diversity of perspectives, and these viewpoints and perspectives should be systematically and enthusiastically solicited. Nevertheless, the most scientifically valid decision may at times be “politically incorrect.” The authors of the diagnostic manual should have the authority to make innovative decisions that are scientifically justified even when they are contrary to general clinical consensus (Widiger and Clark 2000).Some persons, though, do suggest that the diagnostic manual should be modeled on how disorders are being diagnosed within clinical practice. This is perhaps most readily evident in the proposals of Westen and Shedler (2000) to diagnose mental disorders via prototypal matching. They eschew the provision of specific and explicit criterion sets in favor of simply matching the patient to a global (e.g., paragraph description) of a prototypic case. A purported strength of this approach is that it is said to “conform to the way clinicians think about psychiatric diagnoses” (First and Westen 2007, 473).There are, however, concerns with respect to prototypal matching. First, it is not really clear that clinicians actually provide diagnoses in this manner. There are data to suggest that clinicians instead reach a diagnostic decision on the basis of just one or two individual diagnostic criteria rather than matching to a global prototype (Herkov and Blashfield 1995).More important, it is unclear whether the diagnostic manual should in fact emulate what is occurring within clinical practice. There is a...