Keeping an eye on clinical utility.

Fulford et al's efforts to raise awareness of the interplay between value judgments and scientific facts will undoubtedly be helpful in framing many of the discussions about how to define particular mental disorders during the next revision of the DSM. While consideration of value diversity was a factor in a number of the DSMIV discussions (for example, adjusting the criteria set for gender identity disorder so that it did not inappropriately capture tomboys), such considerations were not explicitly and systematically part of the DSM-IV process. Beyond that, it is difficult to comment on the practical aspects of Fulford et al's arguments since they neglect to explain with any clarity precisely what their proposal for values-based practice (or "values-based diagnostic assessment") actually entails. Fulford et al appear to be suggesting that patient values be given center stage in the clinical diagnostic assessment process itself. I see at least two problems with this suggestion, in terms of its potential for compromising the clinical utility of DSM-IV and the inevitable interaction of psychopathology with value-determination. The most important goal of the DSM diagnostic system is to facilitate clinical communication between mental health professionals and to help guide clinical practice. By employing operationalized, standardized, and descriptive criteria, DSM diagnoses allow the clinician to reliably summarize patients' patterns of psychopathology and make evidence-based treatment decisions. The success of this enterprise, however, depends on a reliable application of the diagnostic criteria. Idiosyncratic application of the diagnostic criteria can result in inaccurate diagnoses that can mislead other clinicians who may be part of the treatment team and invalidate the applicability of empirically based treatment guidelines. For example, consider a clinician evaluating a severely depressed patient who believes that having severe depressed mood is a normal fact of life, resulting in no diagnosis of major depressive disorder despite the fact that the full syndromal criteria are met. Consultants reviewing the diagnosis will be operating under the mistaken assumption that the patient's symptoms are much less severe than they actually are, resulting in clinical confusion rather than clinical communication. Furthermore, the clinician is likely to make inappropriate treatment decisions if he or she assumes that treatments that have been empirically demonstrated to be effective only for mild depressive symptoms (such as supportive psychotherapy) will also work for this severely depressed patient. A second problem concerns Fulford et al's proposal for having the patient's values about what is pathological "be on an equal footing with the professionals". For many mental disorders, the psychopathology itself may involve distortions in the patient's value system. Take, for example, the diagnosis of pedophilia. Many pedophiles believe that there is nothing pathological about having sex with children. Should the diagnosis of pedophilia depend on an equal consideration of the patient's value system? If it did, it would be impossible to make a diagnosis of pedophilia for most individuals whose arousal patterns involve having sex with children. Although pedophilia might seem like an extreme example, in fact this problem applies to all disorders in which the symptoms are essentially ego-syntonic, i.e., those disorders in which the person does not appreciate his or her psychopathology as being symptomatic of a disorder. DSM-IV avoids this insight problem by having the clinician's value judgments supercede the patients' in such cases. Perhaps the best way to integrate values into psychiatric practice is to separate the process of making a diagnosis from the process of applying the diagnosis for the purposes of clinical management. I agree with Fulford et al's statement that "Symptom control... is often less important than professionals tend to assume. People often have other priorities (a home, a job, etc.) that may actually be prejudiced by over-enthusiastic efforts to control symptoms". It is crucial for clinicians to place their patient's values frontand- center when formulating a treatment plan - otherwise, treatment adherence will inevitably be compromised.