Volume 37 · Number 9
SEPTEMBER 2007

Analysis: DSM Biases Evident in Clinical Training and Courtroom Testimony

By Abilash A. Gopal, AB; Harold J. Bursztajn, MD

The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), which was most recently revised in 2000 with DSM, fourth edition, text revision (DSM-IV-TR), has been helpful in promoting inter-rater reliability or agreement among clinicians. This reliability has been achieved by moving from a causation-heavy, narrative-rich system to a causation-free, narrative- and context-empty system of diagnostic categories. However, as helpful as an increased degree of agreement among clinicians may be, this measure of the reliability of a diagnosis does not indicate if the diagnosis is valid. A challenge for those involved in the construction of the DSM, fifth edition (DSM-V) is how to retain the strength of reliability and increase diagnostic validity.

ABOUT THE AUTHORS

Abilash A. Gopal, AB, is a Pasteur/Doris Duke Research Fellow of Harvard Medical School and a fourth-year student at Tufts University School of Medicine. Harold J. Bursztajn, MD, is co-Founder of the Program in Psychiatry and the Law at Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School.

Mr. Gopal and Dr. Bursztajn have disclosed no relevant financial relationships.

Address correspondence to: Harold J. Bursztajn, MD, 96 Larchwood Drive, Cambridge, MA 02138; e-mail: hbursztajn@hms.harvard.edu.

Acknowledgements: Thomas Gutheil, MD’s, insights into the dilemmas of clinical training and the courtroom initiated this analysis. Carol Nadelson, MD; Robert M. Hamm, PhD; and Bennett Simon’s insights have been vital to the authors’ understanding of the cognitive psychology of medical decision making. Lisa Cosgrove, PhD; Eric Drogin, JD, PhD; Ron Abramson; K. Ellen Lowenthal, JD; and Archie Brodsky, BA, have provided helpful commentary throughout the writing process. The authors also thank members of the Program for helpful discussions and Ellen Dubie, Jason Huffman, and Jennifer Maiona for assistance with the evolving manuscript.