(3 of 4)
"For some of these, there is an issue of grandfathering," admits Dr. Michael First, editor of DSM IV. "The onus is on the person who wants to change it to prove that we should do so." First also acknowledges that the A.P.A. does not subject every criterion to rigorous scientific testing, "for practical reasons of continuity." Which may be another way of saying some old-timers still bill sessions for "transvestic fetishists," and they don't want to lose the DSM stamp of approval needed for insurance reimbursement.
To be sure, a few disorders are dropped from each edition. First notes that a supposed childhood condition called identity disorder was excluded from DSM IV even though many child psychologists wanted to keep it. Kids could qualify for that disorder if they were "uncertain" about long-term goals, career choice and friendship patterns. "We said, 'Wait a minute. This looks like normal adolescence,'" says First, "and so we eliminated it."
The DSM's critics say this sit-around-the-table-and-jawbone method isn't really science. Jerome Wakefield, a Rutgers professor of social work, says that while the DSM's authors do try to eliminate errors so that normal emotional reactions aren't diagnosed as disorders, "there's no systematic process here. Changes are made on a very ad hoc basis, where people say, 'Oh, my god, we forgot X.'" Others have even harsher criticism. Dr. Paul McHugh, who chairs the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, says the DSM has lost its usefulness partly because it has "permitted groups of 'experts' with a bias to propose the existence of conditions without anything more than a definition and a checklist of symptoms. This is just how witches used to be identified." He cites multiple-personality disorder as an example of an "imagined diagnosis"; while much of the evidence supporting its existence has been debunked, multiple-personality disorder is still listed in the DSM, though today it's called "dissociative identity disorder."
New controversies have already erupted over what to put in DSM V. For instance, the A.P.A. is considering adding "relational disorders"--severe problems between spouses or siblings--to the fifth edition. Relational-disorder sufferers are completely sane except when they are around, say, their spouse. Skeptics contend that marital spats shouldn't be considered mental illnesses. A group of Stanford researchers wants to put "compulsive shopping disorder" into DSM V, but First doesn't seem to like the idea. While a number of studies have shown that pathological gambling exists and can be measured, he says, compulsive shopping "has received virtually no research attention to date." (The same goes for sex addiction, according to other psychiatrists: it's just Clinton-era pop psychology thus far, not a documentable illness.)