Tsuang Harvard Rev Psychiatry

July/August 1993

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major depressive disorder in the community: a latent class analysis of data from the NIMH epidemiologic catchment area programme. Br J Psychiatry 1989;155:48-54. Thomsen PH, Jensen J. Latent class analysis of organic aspects of obsessive-compulsive disorder in children and adolescents. Acta Psychiatr Scand 1991;84:391-5. Begg CB, Metz CE. Commentary: consensus diagnosis and gold standards. Med Decis Making 1990;10:29-30. Uebersax JS. Modeling approaches for the analysis of observer agreement. Invest Radio1 1992;27:738-43.

Response: Further Reflections on the DSM-IV Process and Method

Allen J. Frances, MD*

In preparing DSM-IV we have relied heavily on empiric data gathered through a three-stage method of systematic liter- ature reviews, reanalysis of previously collected data sets, and focused field trials. The threshold for change in DSM-IV was set quite high to avoid the subjectivity that is of concern to Dr. Tsuang. The changes that have been suggested for DSM-IV were felt to be necessary because of the weight of empiric evidence, the need to increase clarity and clinical utility, and the desire to increase compatibility with ICD-10 (The International Classification of Disease, tenth edition). Our emphasis on empiric data resulted in a process that relied much less on the opinions of consensus panels of e ippts than did that of DSM-111, DSM-111-R, and ICD-10.

As noted by Tsuang, latent structure analysis is a prom-

Reprint requests: Allen J. Frances, MD, Department of Psychiatry, Duke University School of Medicine, PO Box 3005, Durham, NC 2771 0.

*Chair, DSM-N Task Force.

HARVARD REV PSYCHJATRY 1993;1:128.

Copyright 0 1993 by Harvard Medical School.

1067-3229/93/$1.00 + .10 3911148034

ising way of analyzing descriptive data in the absence of other, more fundamental, methods of establishing a diag- nostic gold standard. It is unfortunate that latent structure analyses have been reported only rarely in the literature and that the full potential of this powerful analytic technique has not yet been realized. Nonetheless, it must be recog- nized that the use of latent structure analyses based on descriptive data alone to provide a gold standard may have many of the limitations that are inherent in all descriptive approaches. Ultimately, whatever the analytic technique used, the development of a really meaningful gold standard for psychiatric diagnoses will require the availability of validity data that provide information beyond the descrip- tive level. We have been in the unfortunate position of having only a limited pool of such validating data to help us consider how best to define the disorders in DSM-IV.

As a field, however, we are fortunate in having available a reasonably reliable diagnostic system and an ever-increas- ing array of powerful research methods that will provide a much richer understanding of the pathogenesis of mental disorders and clearer standards for developing future diag- nostic systems. The current descriptive approach has many limitations but is a necessary tool in the development of a diagnostic system that is influenced by a fundamental un- derstanding of the causes of mental disorders.

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