How Reliable is the DSM-5?

Rachel Cooper, PhD
19
3596

More than a year on from the release of DSM-5, a Medscape survey found that just under half of clinicians had switched to using the new manual (Stetka & Ghaemi, 2014). Most non-users cited practical reasons, typically explaining that the health care system where they work has not yet changed over to the DSM-5. Many, however, said that they had concerns about the reliability of the DSM, which at least partially accounted for their non-use. Throughout the controversies that surrounded the development and launch of the DSM-5 reliability has been a contested issue: the APA has insisted that the DSM-5 is very reliable, others have expressed doubts. Here I reconsider the issues: What is reliability? Does it matter? What did the DSM-5 field trials show?

The basic idea behind reliability tests is that the diagnosis that a patient receives should depend on their symptoms, rather than on who does the diagnosing. Suppose I go and see a clinical social worker in the United States and am judged to have schizophrenia. If a reliable classification system is used then it should enable, say, a psychiatrist in Kenya, to decide on the same diagnosis.

When the DSM-III was published in 1980, it was presented as solving the problem of ensuring diagnostic reliability (A.P.A., 1980, pp.467-472). The story told was that while in the dark days of psychoanalytic dominance a patient judged neurotic by one therapist might well appear psychotic or normal to another, with the employment of the DSM-III patients could expect to be given the same diagnosis by all clinicians.  Proof of improvement was taken to be shown by a statistical measure, Cohen’s kappa, which assesses the chances that two clinicians will agree on a diagnostic label. As DSM-III, and its successors, demonstrated “acceptable” values of kappa, the reliability problem was widely taken to have been solved.

But then with reliability tests in the field trials of DSM-5 diagnostic criteria, something odd happened. In reports of the DSM-5 field trials, results that found kappas at values which for thirty-five years would have been judged “poor” or “unacceptable” suddenly became “good.” Commentators with long memories pointed out the inconsistency (for example, 1 Boring Old Man, 2012; Frances 2012; Spitzer, Williams & Endicott, 2012; Vanheule et al 2014).

What had happened? Is the reliability of the DSM-5 really no better than that of classifications fifty years ago? What is truly a good value for kappa? And how much does the reliability of psychiatric diagnosis matter anyway? Let’s go back and look at the debates in more detail to answer these questions.

The reliability of psychiatric diagnosis started to be a matter of some concern in the 1960s and 1970s. A number of studies sought to investigate the issue of reliability. Comparing the results of the different studies was difficult, as different studies employed different statistics and it was unclear what level of agreement one might reasonably expect (for a review of the debates see Kirk & Kutchins, 1992). Those who produced these early studies were unsure what to make of their results, but Robert Spitzer, who would later become the chairman for DSM-III, thought he knew both how to understand the problem of reliability, and, once he’d demonstrated a “crisis”, also how to fix it. The statistical measure, Cohen’s kappa, was key to Spitzer’s argument (Spitzer, Cohen, Fleiss & Endicott, 1967).

Cohen’s kappa provides a measure of agreement that seeks to take into account that some level of agreement could be expected by chance. Cohen’s kappa is defined as being (po – pc) /(1 – pc) where po is the observed proportion of agreement andpc the proportion expected by chance. A value of 0 indicates chance agreement; 1 indicates perfect agreement. At this point many readers’ eyes will have glazed over. This, glazing, Kirk and Kutchins (1992) point out in their history of the DSM-III, is important to understanding the evolution of debates about reliability in psychiatry. Cohen’s kappa is a statistical innovation, but its utilisation complicated discussion of reliability to the extent where lay people and average clinicians could no longer contribute. While everyone may have a view as to whether it seems acceptable that a patient judged schizophrenic by one clinician should have only a fifty per cent of being similarly diagnosed on a second opinion, who knows whether a kappa of 0.6 is acceptable?

Having introduced Cohen’s kappa to psychiatrists, Spitzer (with co-author Joseph Fleiss 1974) used it to reanalyse the existing reliability studies and to argue that the agreement achieved by clinicians using DSM-I and II was unacceptable. In their meta-analysis, Spitzer and Fleiss judged a kappa of over 0.7 to be “only satisfactory” (a level achieved only by diagnoses of mental deficiency, organic brain syndrome, and alcoholism), and condemned the kappas of less than 0.5 that were achieved by many of the diagnoses studied “poor.” They conclude that “The reliability of psychiatric diagnosis as it has been practised since at least the late 1950s is not good” (Spitzer & Fleiss, 1974, p.345). This judgment was echoed by later commentators. A key point for us is that in this paper Spitzer and Fleiss judged only values of Cohen’s kappas greater than 0.7 to be satisfactory. Where had this threshold come from? No reference for this threshold is provided in the paper. Kappa had not previously been employed in psychiatry and no conventional values for an acceptable kappa had been established. Spitzer and Fleiss were free to pick a threshold at their discretion.

When Spitzer became the chairman of the taskforce to develop DSM-III he continued to be concerned about the reliability of diagnosis. Field trials for the DSM-III included reliability tests. In these a Cohen’s kappa of 0.7 continued to be the threshold for “good agreement” (A.P.A., 1980, p.468). For the most common diagnoses in adults –  substance use disorders, schizophrenic disorders, and affective disorders – Cohen’s  kappas of 0.8 plus were reported. Spitzer and his colleagues were pleased, and concluded “For adult patients, the reliability for most of the classes … is quite good, and in general higher than that previously achieved with DSM-I and DSM-II” (A.P.A., 1980, p.468). Kirk and Kutchins provide a critique of the DSM-III field trials and provide a more modest assessment of their achievements. For us, however, the key question isn’t whether the DSM-III truly was reliable, but that it was claimed to be – with reported kappas of 0.7 plus taken to be the proof.

When it came to the DSM-5, however, the goal posts seemed to shift. Prior to the results being available, members of the DSM-5 taskforce declared that a kappa of over 0.8 would “be almost miraculous,” a kappa between 0.6 and 0.8 would be “cause for celebration,” values between 0.4 and 0.6 were a “realistic goal”, and those between 0.2 and 0.4 would be acceptable (Kraemer, Kupfer, Clarke, Narrow, & Regier 2012a).  Data from a motley assortment of other reliability studies in medicine was cited to support the claim that such thresholds would be reasonable. These benchmarks were much lower than those employed in the DSM-III trials. Many commentators viewed these new standards as an attempt to soften up readers prior to the announcement of reliability results that, by historical standards, appeared shockingly poor (1 Boring Old Man, 2012; Frances 2012; Spitzer, Williams & Endicott, 2012). Schizophrenia, which achieved a kappa of 0.81 in the DSM-III trial, had a kappa of 0.46 in the DSM-5 trial (Regier et al 2013). Major affective disorders had a kappa of 0.8 with DSM-III and 0.28 with the DSM-5. Mixed anxiety-depressive disorder achieved a negative kappa – meaning that in this case clinicians would have been better off putting their diagnostic criteria in the bin and simply guessing. Of the twenty diagnoses studied in the DSM-5 field trial only three obtained kappas of over 0.6. Although commentators found the DSM-5 reliability results distinctly unimpressive, using their new thresholds for an acceptable kappa, the DSM-5 task force looked at their results and found  that “most diagnoses adequately tested had good to very good reliability” (Regier et al, 2013, p.59)

What should one make of these field trials? Were the results appalling, or good? Why were lower kappa scores obtained in the DSM-5 trials than in the DSM-III trials? And, what threshold should one adopt for “acceptable” reliability?

First we can note that the methodology of the reliability studies had shifted, such that seeking to directly compare the DSM-III and DSM-5 studies is unfair. Many of the diagnoses studied in the DSM-5 field trial were new diagnoses, and were generally at a “finer-grained level of resolution” than the diagnoses studied in the DSM-III study – for example, while the DSM-III study examined the reliability of “eating disorder” the DSM-5 trial looked at “binge eating.” In the DSM-5 study, clinicians independently interviewed the patients, at time intervals that ranged from four hours to two weeks. In the DSM-III trial, clinicians either jointly interviewed patients (but recorded their diagnoses separately) or interviewed them separately but as soon as possible. Such differences might partly account for the differing results.

Now for the shifting thresholds: While many psychiatrists have become used to thinking of Spitzer’s threshold of 0.7 as the cut-off point for a “good” kappa, there are precedents for employing lower benchmarks in the statistical literature. Influentially, Landis and Koch (1977) count 0.21-0.4 fair, 0.41-0.6 moderate, 0.61-0.8 substantial, and 0.81 – almost perfect. Altman (1991), condemns only kappas of less than 0.2 poor, and considers anything above 0.61 as good. Fleiss, Levin and Cho Paik (2003) counts kappas below 0.4 poor, those between 0.4 and 0.75 fair to good, and those above 0.75 excellent. Clearly there are no universally agreed standards for what would count as a “good” Cohen’s kappa.

In any case, I suggest that seeking some threshold for “acceptable” reliability to be applied across all contexts and all diagnoses is a mistake. Sometimes it is important for diagnosis to be very reliable; sometimes disagreements can be tolerated. In a research setting, it may matter a very great deal that the subject groups employed in different studies should be comparable. For research that depends on all subjects having the same disorder, the values of kappa that should be sought should be high. Sometimes the diagnosis that a patient receives is important because it makes a difference to the treatment that will be given.

In many contexts, however, exacting standards of reliability need not be required. Suppose I am a marriage counsellor. My clients receive a DSM diagnosis which I place on their insurance forms, but I don’t prescribe drugs; all my clients, regardless of diagnosis, receive exactly the same sort of talk-based therapy. In such a context, what does it matter if I diagnose a client as having a major depressive disorder while my colleague would have diagnosed them with an anxiety disorder? Even in drug-based therapy the link between diagnosis and drug type may not be tight. Many psychoactive medications are approved for the treatment of broad swathes of disorders and in such cases so long as a wrong diagnosis makes no difference to treatment little harm will be done.

The importance of achieving reliability varies with the diagnosis in question and with the context of use. When it makes little difference whether a particular diagnosis or those it is likely to be confused with gets made, “acceptable” kappas may be quite low. When there is a real risk that unreliable diagnosis will lead to harm, standards must be higher – either a higher value of kappa should be demanded, or, if diagnostic criteria can’t themselves be made reliable, then mechanisms for dealing with uncertainty in practice may need to be employed (e.g., the routine use of second, or even third, opinions).

As we conclude, we are left with a puzzle: The point of the reliability tests was to demonstrate that the diagnostic criteria are reliable, but now that the results are in it remains unclear whether the levels of reliability achieved are acceptable. This is because there are no generally accepted standards for what counts as reliable enough against which the DSM criteria can be judged.

With a different trial design, it might have been possible to at least show that progress had been made, and that the DSM-5 revisions produced criteria that could be applied more reliably than those in the DSM-IV. However, the shifts in methodology and statistics mean that the results of the DSM-5 field trial could never be directly compared with those of field trials for earlier DSMs. Changes in trial design were defended on the basis that methodology had improved; the DSM-III trials used the bad old ways, while the DSM-5 studies would use the new, good ways (e.g., Clarke et al 2013; Kraemer, Kupfer, Clarke, Narrow, & Regier 2012a).  Fair enough. But then why was no head-to-head comparison of DSM-5 and DSM-IV criteria incorporated into the tests? (a possibility discussed by Ledford, 2012). The task force said head-to-head comparisons would make the trials too cumbersome, but in the absence of such tests, now that the DSM-5 field trial results are in, it is unclear whether or not the new system is more reliable than its predecessors.

* * * * *

References

1 Boring Old Man (2012). To take us seriously. Posted 22 May 2012.  [last accessed 28 August 2014].

Altman, D. (1991). Practical Statistics for Medical Research. London: Chapman and Hall.

American Psychiatric Association (1980). Diagnostic and Statistical Manual of Mental Disorders. (3rd edition). Washington, DC: American Psychiatric Association.

Clarke, D., W. Narrow, D. Regier, S. Kuramoto, D. Kupfer, E. Kuhl, L. Greiner, H. Kraemer (2013) DSM-5 field trials in the United States and in Canada, Part 1: Study Design, Sampling strategy, implementation, and analytic approaches. American Journal of Psychiatry: 170: 43-58

Fleiss, J., Levin, B. & Cho Paik, M. (2003). Statistical Methods for Rates and Proportions. Third edition. New York: John Wiley.

Frances, A. (2012). DSM-5 field trials discredit the American Psychiatric Association. Huffington Post Science. The Blog. Posted 31 October 2012.  [Last accessed 28 August 2014].

Kirk, S. and H. Kutchins (1992) The Selling of DSM: The rhetoric of science in psychiatry. New York: Aldine de Gruyter.

Kraemer, H., D. Kupfer, D. Clarke, W. Narrow, D. Regier (2012a) DSM-5: How reliable is reliable enough? American Journal of Psychiatry. 169: 13-15

Landis, J. & Koch, G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33: 159-174.

Ledford, H. (2012). DSM field trials inflame debate over psychiatric testing. Nature News Blog. Posted 5 November. [Last accessed 28 August 2014].

Regier, D., W. Narrow, D. Clarke, H. Kraemer, S. Kuramoto, E. Kuhl, D. Kupfer (2013) DSM-5 Field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry: 170: 59-70

Spitzer, R., J. Cohen, J. Fleiss, J. Endicott (1967) Quantification of agreement in psychiatric diagnosis. Archives of General Psychiatry. 17: 83-87

Spitzer, R. and J. Fleiss (1974) A Re-analysis of the reliability of psychiatric diagnosis. British Journal of Psychiatry. 125: 341-347.

Spitzer, R., J. Williams. J. Endicott (2012) Standards for DSM-5 reliability. Letters to the editor. American Journal of Psychiatry. 169: 537

Stetka, B. & N Ghaemi (2014) DSM-5 a year later: clinicians speak up.  [Last accessed 28 August 2014].

Vanheule S, Desmet M, Meganck R, Inslegers R, Willemsen J, De Schryver M, Devisch I.(2014) Reliability in Psychiatric Diagnosis with the DSM: Old Wine in New Barrels. Psychotherapy and Psychosomatics. 83:313-314.

* * * * *

This is an edited extract from Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, by Rachel Cooper (published by Karnac Books in 2014), and is reprinted with kind permission of Karnac Books.

 

 

Support MIA

Enjoyed what you just read? Consider a donation to help us continue to produce content, provide up-to-date research news, offer continuing education courses, and continue building a community for exploring alternatives to the current paradigm of mental health. All donations are tax deductible.

$
Select Payment Method
Loading...
Personal Info

Credit Card Info
This is a secure SSL encrypted payment.

Donation Total: $20.00

19 COMMENTS

  1. Wonderful article Rachel.

    I am reminded of the debate around liguistic relativity.

    In innuit culture the number of words for snow are many, and the differences in the types of snow can have serious consequences for people. Reliability between those in the culture as to what constitutes the different types can be vital to survival. When there is no agreement about what constitues the different types, then seperate terms are redundant.

    It seems that the DSM 5 is at the point where diagnostic categories are of little use to clinicians, and can only lead to confusion. The consequences of this confusion may have negative effects for patients.

    I feel sure that the reluctance to take up the new manual is based on a recognition of this.

    • “… diagnostic categories are of little use to clinicians, and can only lead to confusion. The consequences of this confusion may have negative effects for patients.”

      It does have negative effects for patients. I haven’t been able to get health insurance for my children and I since my husband passed away, due to diagnostic confusion. And this diagnostic confusion problem has confused and embarrassed subsequent doctors, too.

      Diagnostic confusion issues:

      The adverse withdrawal symptoms of a “safe smoking cessation med” / “antidepressant” were misdiagnosed as “bipolar.”

      The “cure” for this, Risperdal, resulted in a “Foul up” medical confession due to an extremely adverse reaction to that drug.

      The “cure” for this, anticholinergic intoxication poisoning, was also claimed to be “bipolar.”

      Possible withdrawal induced super sensitivity mania (a sleep walking / talking problem once ever in my life), which was treated with “snowing” (willy nilly forced drug cocktails of at least seven differing drugs each day for ten straight days) was diagnosed as “bipolar” with “schizoaffective symptoms.”

      Follow up care resulted in an “atypical bipolar” diagnosis (this diagnosis is not even in the DSM).

      Possible withdrawal induced super sensitivity mania (lying in a park looking at clouds) / or shock and feelings of betrayal at finding the medical proof we have a medical community that misdiagnoses and poisons people for profit was diagnosed as “adjustment disorder.”

      I pray for the day the psychiatric industry learns that defaming people with unprovable and invalid diagnoses and coercing and forcing brain damaging, mind altering psychotropics onto innocent people so doctors may cover up a medically confessed “bad fix” on a broken bone, a “Foul up” with improperly given Risperdal, and medical evidence of child abuse is known as the “dirty little secret of the two original educated professions” because it’s morally and ethically unacceptable behavior.

      Thank you for pointing out that lack of validity of the DSM diagnoses. I don’t want my children defamed with the supposedly “life long, incurable, genetic” bipolar disorder, merely because I suffered from easily recognized, complex, and controversial iatrogenesis. I’m quite certain medical care would improve significantly if we got rid of the stigmatization “bible.”

  2. I have a major issue here. You state that reliability should be allowed to be flexible across diagnostic categories. Nothing could be further from the truth. The fact is that reliability sets the UPPER limit on validity, something that many seem to forget. A diagnostic category can be no more valid than it is reliable. Thus, by loosing standards of reliability you automatically detract from the validity of a diagnostic category. Would you state the validity of certain diagnostic categories should be allowed to fluctuate? I would hope not. Moreover, the values for Kappa used by the DSM reflect research thresholds and these values can be flexible depending on the aims and design of research, but in a clinical situation where the life and future of a person is at stake it is important to be as precise and accurate as possible. The DSM does not concentrate on validity studies, which is a major problem.

  3. Hi Rachel,

    Thanks for your article. It’s really useful to have the history of the DSM reliability drama described like this. I’m a big fan of the work of Kirk and Kutchins.

    Unfortunately, I think it’s easy to get beguiled by all of the reliability statistics and the judgements about whether they are “good”, “acceptable”, or some other term denoting an apparent standard. I’m not meaning to imply that you have been beguiled – the clarity of your writing would certainly argue against that – I think, for me, there is a broader conceptual issue that is fundamental to the reliability issue. I’ve written about this on another website (http://dxsummit.org/archives/608) where I talk about the “red herring of reliability”.

    Even if the developers of the DSM could achieve perfect reliability for all of their diagnostic categories it would still be the wrong way to understand psychological distress and problems of living. In fact, in some respects, it’s trivially simple to achieve good reliability. With nothing than a date of birth and a few minutes of training, “diagnosers” could routinely achieve perfect reliability in assigning people to various star signs (Sagittarius, Gemini, and so on). The impressive reliability in this case does not add legitimacy to the system of horoscopes as a way of understanding human functioning.

    While in principle I agree with your statement that “The basic idea behind reliability tests is that the diagnosis that a patient receives should depend on their symptoms, rather than on who does the diagnosing.” this doesn’t apply to diagnosis in psychiatry. Because there is no independent means for determining if someone has “really” “got” Borderline Personality Disorder or Generalised Anxiety Disorder the only thing that DSM reliability tells us is how much two people agree on the presence of certain symptom categories. What we learn from DSM reliability is the extent to which two independent raters can see the same disorder in a set of symptoms – and, apparently, the extent is “not great”! What DSM reliability does not tell us is whether or not a DSM disorder is “really” present. DSM reliability can’t tell us that because DSM disorders are never “really” present or absent – they are just assigned and either believed or refuted.

    The DSM system is simply the wrong way to understand psychological problems of human functioning and no amount of attention to Kappas or field trials will correct that. We need to be devoting our best scientific efforts to something other than the improvement of DSM reliability.

    Tim

    • Tim, I agree. And now that we have HIPPA laws, where medical practitioners can automatically see all a patient’s prior diagnoses, “reliability” should theoretically be near perfection. Signing HIPPA papers is what allowed all my doctors at a point in time, who all also wanted to cover up easily recognized iatrogenesis and other sins, to collectively claim that a person who’d never suffered from either mania or depression, and had no personal or family history of “mental illness,” had “bipolar.”

      We need a system other than defaming patients with unprovable “mental illnesses” and tranquilizing people, to deal with justifiable distress and bad reactions to psychotropic drugs and other iatrogenesis.

      • Someone Else. Interesting that you mention that psychiatrists can access prior diagnosis. When I asked for my psych records i only received them from the most recent agency I was assigned to.However it was apparent when I talked to the psychiatrist that she had access to records that the agency was denying me. It seems that she was pigging backing on a previous diagnosis, rather than using medical evidence to come to her own conclusion like a real medical doctor. Is there such a thing as a second opinion in psychiatry as in real medicine? Or is it rather the case, that the word of psychiatrist is the holy rite, even if someone high up as Thomas Insel admits that there is no biological markers for mental illness.

        • Actually Social Workers, Psychologists, and Psychiatrists and I am unsure about Nurse Practitioners but I will include that profession as well are all able to diagnosis from the DSM 5 . There is also another less well known code system called the ICD 9 ( at least there was when I was practicing).

          All diagnosis is subjective in the long run. We as patients can have several different diagnosis dependent on the practitioner and our personal stressors. There is an axis that is supposed to relay environmental stress as well as another global scaleeval.

          Once again, back in the old days we had a solid two weeks for assessment. This does not happen now and a diagnosis has to be made on the first visit or the practitioner will not get paid.
          This really began in earnest when Social Workers and Psychologists started doing private practice. The Insurance industry rules.

          Ultimately the whole diagnosis world is a game to get money from the insurance company or the government. Who and what you are is basically a paper construct.

          Everything is basically the best guess of a skilled or not so skilled Mental Health professional constricted by the need for monetary gain.
          Again back in the old days labeling was seen as a necessary evil to get people in need of help ,help. It was never meant to be part of a pride movement or anything just a way to get folks services.
          It was never meant to be handled the way that it is now

          . I blame the insurance industry and government bureaucrats. I also blame the APA the AMA NASW and other professional groups for standing idly by and letting this nightmare happen.

          It is hard for the decent professionals left working, it is hard for us those in need of help. and the families are left totally out in the cold without proper access to anything.

          A truly good practitioner would see the client without records so to be unbiased then actually spend time doing a c hart and historical overview. I am guessing this never happens today because it is not paid for.

          • It’s worth mentioning that these bs diagnosis can follow you for the rest of your life affecting job prospects, your ability to adopt children or keep custody of them, negatively affect you in court cases etc. Having a mentally ill label means that you’re for the rest of your life suspicious and a likely candidate for being seen as a criminal, abuser and what not.

        • chrisreed,
          My concern for years has been the availability of psychiatric diagnoses electronically. Ten years ago I went to a new family physician for excruciating pain and she had accessed my former records saying I had a serious mental illness. Within meeting me for 5 seconds she dismissed my physical problem by telling me to see my psychiatrist (who I stopped seeing). In The USA it’s hard to get your psych records but I did after I had an attorney ask for them. I have to wonder if I went to a psychiatrist with the purpose of having my mental state diagnosed as “normal” would this help? Carry this piece of paper around for my own protection? If I only knew the answer?? One psychiatrist poly drugging me till I was a vegetable then saying oh this woman’s mentally ill follows me around.

          • I had the same experience when I tried to diagnose the source of serious neck pain and associated paresthesias. The doctor looked up my records and suggested that I have depression. Everything these days is “somatoform”.

          • ” she had accessed my former records saying I had a serious mental illness. Within meeting me for 5 seconds she dismissed my physical problem by telling me to see my psychiatrist…” aria

            HIPAA Violations and Enforcement
            Failure to comply with HIPAA can result in civil and criminal penalties (42 USC § 1320d-5).
            Civil Penalties
            The “American Recovery and Reinvestment Act of 2009”(ARRA) that was signed into law on February 17, 2009, established a tiered civil penalty structure for HIPAA violations (see below). The Secretary of the Department of Health and Human Services (HHS) still has discretion in determining the amount of the penalty based on the nature and extent of the violation and the nature and extent of the harm resulting from the violation. The Secretary is still prohibited from imposing civil penalties (except in cases of willful neglect) if the violation is corrected within 30 days (this time period may be extended).
            HIPAA Violation
            Minimum Penalty
            Maximum Penalty
            Individual did not know (and by exercising reasonable diligence would not have known) that he/she violated HIPAA $100 per violation, with an annual maximum of $25,000 for repeat violations (Note: maximum that can be imposed by State Attorneys General regardless of the type of violation) $50,000 per violation, with an annual maximum of $1.5 million
            HIPAA violation due to reasonable cause and not due to willful neglect $1,000 per violation, with an annual maximum of $100,000 for repeat violations $50,000 per violation, with an annual maximum of $1.5 million

            aria, Had you signed a medical release authorization form? If not, that’s A LAWSUIT WAITING TO HAPPEN.
            Do you have his or her name and address?

  4. Reliability and validity are not the same thing, and I don’t understand the point of this article. As someone else pointed out, if you gave many raters the birth date of their patients, they would show one hundred per cent reliability in assigning the patients to the proper astrological sign. What would this tell you about the validity of astrology in explaining anything of importance? Of course, absolutely nothing.

    I noticed when DSM 5 came out, the APA talked of nothing but reliability For lay people without scientific training (of which I have a bit, at least enough to detect nonsense when I see it) this sounded very impressive, I’m sure. But as we readers of MIA all know, this doesn’t address the fact that the labels now being applied to people have almost no validity at all.

    I just don’t get the point of this article.

  5. Thank you for this article because it chips away at the edifice of psychiatry although I share Ted’s dismay that we need this level of scrutiny to expose the obvious….

    As one boring old man points out, “patients” don’t believe in this rubbish, physical doctors certainly don’t, psychiatrists hold their noses when they write these things down and increasingly the general public understands that these labels are essentially meaningless.

    It’s all to the good that people outside the mental health bubble are taking an interest in these issues….

  6. @ Ted , this doesn’t address the fact that the labels now being applied to people have almost no validity at all.

    The traditional argument is that reduced validity is worth it because the labels have some sort of utility value, but as the majority of the posting on this site demonstrate the utility value claim is very flimsy indeed…. of course thats something you and a lot of people here know already…. the trouble is getting to the attention of the public. One way is holding a placard in public another way is to get academics and journalists writing about the issues…. its all to the good and I believe will lead to the same end…..

  7. Rachel, I am planning to read your upcoming book. So far I have read only this post and your article against Hacking, discussing “weedy kinds”, which I keep on my desktop. I appreciate learning from your writing, and my favorite present philosopher of psychiatry is your colleague Dr. Hannah Pickard.

    What interests me is just what is getting referred to, and if it is a concept or physical entity, when we get diagnosed with “some” disorder. I can’t understand how the metaphysical status could be more subtantive for one of these non-medically approached disorders of psychiatry than is the existence of dents, wrinkles, or shadows. Even ineffable afterthoughts and guessing that you smelled something are more definitely there than “a disorder” with its own name, qualities, and age.

  8. I would like to know the kappa values of developmental trauma disorder. I believe it is an ABSOLUTE travesty to neglect child abuse and neglect. The DSM is truly a joke and it does hurt people. People who have attachment trauma and disorganized attachment and develop the natural consequences to such an event may not respond at all to talk therapy at least not until affect regulation is obtained. WE are harming millions of abused children and adults by giving them tons of psychiatric diagnoses which they do not have when what they do have is a history of severe child abuse and neglect. Children get to feel like they have some type of medical or biological illness (and are not left to know — If you swing an axe at my leg, the axe strikes my leg and I bleed that is normal — no it is not normal you need Sapharis or Abilify as the treatment of choice. People are being hurt. The DSM is harming lots of people.