Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5

DSM-5 is not merely a revision of DSM-IV. It does something far more fundamental. Readers should view the publication of DSM-5 as the abandonment of the Disease-Centered Paradigm by the American Psychiatric Association (APA) for the study and treatment of mental illness. Starting with DSM-III (pub. 1980) the APA instituted a paradigm of mental illness based on the idea that various mental illnesses were caused by specific brain diseases, primarily chemical imbalances in the brain that were genetic in origin. This conception arose primarily because of the limited success obtained from treating patients with psychotropic medications that altered neurotransmitters in the brain. The underlying goal of DSM-III was to provide accurate classifications of mental disorders for laboratory researchers looking for discrete brain diseases. In the 1970s there was no existing proof that each of the hundreds of disorders in DSM-III was based in a separate brain disease. It was simply assumed that each of the disorders could first be defined along descriptive parameters. Then laboratory research could provide the empirical evidence to conclusively define the precise brain diseases involved. However, as DSM-5 states: "Not surprisingly, as the foundational science that ultimately led to DSM-III has approached a half-century in age, challenges have begun to emerge for clinicians and scientists alike that are inherent in the DSM structure rather than in the description of any single disorder. These challenges include high rates of comorbidity within and across DSM chapters, an excessive use of and need to rely on 'not otherwise specified' (NOS) criteria, and a growing inability to integrate DSM disorders with the results of genetic studies and other scientific findings" (DSM-5, p. 10). In other words, after thousands of studies and millions of dollars spent on research, the laboratory confirmation of specific brain diseases as the underlying causes of the hundreds of mental disorders in DSM-III and DSM-IV has not arrived as expected. Indeed, the most recent genetic studies and other recent laboratory findings do not support the idea established in DSM-III that there is a specific brain disease of genetic origin at the basis of each mental disorder. This is why the "Associated Laboratory Findings" section found in each disorder of DSM-IV (pub. 1994) has been eliminated in DSM-5. The APA is no longer assuming that there are laboratory findings that can scientifically validate a specific brain disease (genetic or otherwise) as the cause of each mental disorder in DSM-5. The mental disorders listed in DSM-5 are syndromes (each merely a collection of symptoms), not brain diseases, and the emphasis throughout DSM-5 is on reliability and clinical utility. The scientific validity of DSM-5 disorders as specific brain diseases is therefore nil. The APA has abandoned the Disease-Centered Paradigm.In DSM-5 the APA is establishing a new Client-Centered Paradigm (my term) of mental illness that favors a spectrum approach. "Although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors, and possibly shared neural substrates. In short, we have come to recognize that the boundaries between disorders are more porous than originally perceived" (DSM-5, p. 6). "Earlier editions of DSM focused on excluding false-positive results from diagnoses; thus its categories were overly narrow, as is apparent from the widespread need to use NOS diagnoses. Indeed the once plausible goal of identifying homogenous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like most common human ills, mental disorders are heterogeneous at many levels, ranging from genetic risk factors to symptoms" (DSM-5, p. 12). For example, it "no longer is sensible" to identify a homogenous population of people with Schizophrenia to research their supposed common brain disease simply because there is no such thing as a homogenous population of people with Schizophrenia. The disease category itself lacks vigorous scientific validity, therefore research based on this idea of a common brain disease is bound to fail. Similarly, treatment of patients based on the idea of a common brain disease becomes highly problematic and fraught with difficulties because of the heterogeneity of the population with the supposed disease of "Schizophrenia." For this reason, DSM-5 states, "It is also important to note that DSM-5 does not provide treatment guidelines for any given disorder" (DSM-5, p. 25).The new Client-Centered Paradigm in DSM-5 emphasizes cultural differences in mental illness and help seeking, including alternative health care. "Mental disorders are defined in relation to cultural, social, and familial norms and values. In Section III, 'Cultural Formulation' contains a detailed discussion of culture and diagnosis in DSM-5, including tools for in-depth cultural assessment. The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cultures, social settings, and families. Hence, the level at which an experience becomes problematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians. Awareness of the significance of culture may correct mistaken interpretations of psychopathology, but culture may also contribute to vulnerability and suffering. Cultural meanings, habits, and traditions can also contribute to either stigma or support in the social and familial response to mental illness. Culture may provide coping strategies that enhance resilience in response to illness, or suggest help seeking and options for accessing health care of various types, including alternative and complementary health systems. Culture may influence acceptance or rejection of a diagnosis and adherence to treatments, affecting the course of illness and recovery. Culture also affects the conduct of the clinical encounter; as a result, cultural differences between the clinician and the patient have implications for the accuracy and acceptance of diagnoses as well as treatment decisions, prognostic considerations, and clinical outcomes " (DSM-5, p. 14). Cultural differences in the meanings and experiences of mental illnesses are at the heart of the new Client-Centered Paradigm and DSM-5 provides a clinical interview tool for in-depth cultural assessment (DSM-5, pp. 749-759).DSM-5 specifically disallows the use of a simple checklist approach to diagnosis. "The case formulation for any given patient MUST (my emphasis) involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. It requires clinical training to recognize when the combination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges" (DSM-5, p. 19). In other words, a short diagnostic interview of simply counting symptoms from a DSM-IV checklist, and writing a prescription, is no longer considered an appropriate clinical practice according to DSM-5. The Client-Centered approach to diagnosis established in DSM-5 is more holistic, including psychological, social, and cultural factors in diagnosis, and development of a comprehensive treatment plan. "The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is informed by the individual's cultural and social context" (DSM-5, p. 19). The Client-Centered approach requires dealing with clients' cultural backgrounds, current life problems, and past traumas.DSM-5 includes in-depth discussions about psychological and social sources of stress and trauma that can be implicated in the development, exacerbation, and perpetuation of mental disorders including family relational problems; multiple forms of childhood physical and sexual abuse and neglect; spouse or partner violence, abuse, and neglect; educational and occupational problems; housing and economic problems; social environment problems (e.g., victim of crime); religious and spiritual problems; and lack of access to health care (DSM-5. pp. 715-727). These in-depth discussions of psychological and social stressors are a clear rejection of the simplistic Disease-Centered Paradigm, and an acceptance of the important role played by stress and trauma in the development, exacerbation, and perpetuation of mental disorders.DSM-5 also includes an in-depth discussion of the serious brain damage that can result from the long term use of psychiatric medications (DSM-5, pp. 709-714). This in-depth discussion is a clear recognition that treatment based on the Disease-Centered Paradigm in which patients are kept on psychiatric medications for years if not decades is dangerous for patients and should be discontinued. Psychiatric medications should be used only when necessary, and for the shortest amount of time possible. Mentally ill people do not have a chemical imbalance in the brain, and psychiatric medications do not normalize the chemistry of the brain. Psychiatric medications cause an abnormality in brain chemistry, and long term use can result in serious brain damage.I claim substantial credit for the new Client-Centered Paradigm in DSM-5, which the APA has essentially borrowed whole from my textbook Culture and Mental Illness: A Client-Centered Approach (pub. 1996). I predicted 17 years ago in Chapter 1 of this book (p. 11) that the APA would establish a new Client-Centered Paradigm in DSM-5, and presented such a paradigm in Chapter 15 of the book.Mental disorders need to be defined in a holistic manner that includes the interactions of the individual's sociocultural environment and effects of diagnosis and treatment on the individual's brain. I am somewhat surprised that it took so long to replace the Disease-Centered Paradigm established in DSM-III, and perpetuated in DSM-IV, but I am gratified that the change has finally been made. I am sure that this new paradigm will usher in a new era of holistic research on mental illness that will greatly benefit those suffering from mental illness.

Nearly all of the media criticisms of DSM-5 are fairly wide off the mark. The main critique is that psychiatry is trying to pathologize increasing amounts of normal human behavior with the DSM-5. The new diagnoses in DSM-5 are modest, evidence-based, and are ways of better describing the types of problems that people come into psychiatrists' and psychologists' offices asking for help with.For example, the diagnosis of Body Dysmorphic Disorder makes a distinction from "dysmorphic concern" (which is largely normative) and requires that the preoccupation interferes with social or occupational functioning, or causes clinically significant distress. That means: it is already a problem for the person, whether or not anyone makes it a diagnosis.The main problem with the manual is actually that the changes were not bold enough, not forward thinking enough, and have resulted in very few improvements considering the huge amount of effort put into the enterprise.There was a goal to improve certain diagnoses, and address problems such as the rampant overuse of bipolar diagnosis in youth. Certain problems are significant in the execution of the goal. First, the diagnosis of Disruptive Mood Dysregulation Disorder is actually very narrow, and contains to specifiers that make it not apply to many of the kids that have been incorrectly diagnosed "bipolar". It requires irritable or angry mood most of the day, nearly every day. Many of the kids, if not most, that are engaging in rages actually have a mood that is fine whenever you are giving them whatever they want, or things are going their way. The disturbance has to be in 2 settings, and sometimes kids are able to suppress rages outside the home. The disturbance must also be enduring for 3 months. So, what do you diagnose if they are the narrow criteria aren't met? Mood Disorder NOS is no longer available, so then do you do depression NOS? That hardly seems descriptive to what is occurring. Intermittent explosive disorder accurately describes the raging of these youth, but misses the mood reactivity that we commonly see, and the text asserts that IED (those are initials that should have been terrible/stigmatizing enough to cause a name change) is rare in youth. Data? The diagnosis of DMDD also moves in the opposite direction of the rest of the DSM, which is allowing coding of ADHD in Autism, etc., and not shooting for complete syndromes, but more "modules" of behavioral problems that can be put together to describe a person. For DMDD, ODD and Conduct Disorder are not allowed-- which leads me to the conclusion that what we see in the DMDD diagnosis is the result of an inter-committee turf war. The DMDD decision, and placing it within depressive disorders and suppressing clinically meaningful comorbidities of ODD and CD, suggests that the child mood people have a lot of sway in the APA. This disorder of mood regulation does have real relationships to depression, but it also is not dominated by the typical depressed mood, and is not episodic and tempermental. The construct of Severe Mood Dysregulation seems to be a lot more serviceable, and the rationale for preferring DMDD is not convincing. The Deficient Emotional Self-Regulation concept, that came-out of the Achenbach (I believe) also may be a better foundation. The syndrome does have validity, but it is not encompassing of all (or in narrow definition, most) of the kids with rages and mood reactivity/dysphoria. And... there is not a category like Mood NOS to capture them.Other problems with the DSM are indicative of some of the compromises it was trying to achieve, such as integration with ICD-10/11. For opioid withdrawal, it says that the disorder cannot be coded with a mildopioid use disorder, "refelcting the _fact_ that opioid withdrawal can occur only in teh presence of a moderate or severe opioid use disorder". This demonstrably false statement (opioid withdrawal can take place in pain patients that _don't even have a disorder) might have escaped my attention if it didn't say the word "fact". How this got past such a large committee reviewing for so many years is beyond me (the severity of the disorder is not based on the pharmacologic definition, but on the behavioral one) and it shows the committee may have been over-eager to pursue ICD-10 synthesis-- when they should have just focused on the already very difficult job of classifying reality. Cannabis-induced anxiety disorder is not allowed with onset during withdrawal, despite numerous case reports and data from the data on cannabis withdrawal. Although, cannabis-induced sleep disorders was appropriately added.Of course, much of the criticism has been placed on using the "judgmental" term addiction-- but the word addiction is not going to disappear for treatment centers because some people might get their feelings hurt-- and recovering from addiction requires facing-down some uncomfortable concepts.I think that the current substance use disorder classifications also miss a very important group-- that is adolescents who are using at _considerable_ risks to themselves, but may not be on an addiction continuum. The significant risks involve OD, DUI, and being victim of sexual assault-- and high-risk adolescent users may not be making significant progress on the addiction continuum, but might kill themselves before they ever get there. This is what they were going for with the Abuse/Dependence distinction, but it was found that most people progressed through all of the symptoms of both disorders on one dimensional line-- but high-risk use in adolescence may be a different class. This group may still have some concerning addiction pathology, but it is the amplification of adolescent risk-taking that is most concerning. The lumping of NMDA antagonists with other hallucinogens does not make a lot of sense, due to the mechanism of action being different, and calling verything phencyclidine without mentioning ketamine or dextromethorphan may confuse some. A better job was done separating nitrous from volatile hydrocarbon "inhalants". The manual was so slow in development, that there is no mention of synthetic cannabinoids. Finally, the use of "mild" as a descriptor of Substance Use Disorder pathology is not a wise choice in words for a disease that features rationalization and lack of insight as part of its phenomonology.Binge-eating disorder was also criticized, but if we are talking about 3000 calorie-binges once a week with a sense of lack of control, eating rapidly, alone, until uncomfortable, and when not hungry really seems like a problem to me. Criticism is sure to come that more people will be seen as having a psychiatric diagnosis because of this, but we are a culture whose availability of food and other changes may be leading to more people with disordered behavior. So, an increase in prevalence doesn't increase a power-grab by psychiatry, just as the rise in obesity doesn't mean that the rest of medicine is inappropriately expanding its range-- the problem is just increasing.The merger of Asperger's and Autism into Autism Spectrum really does go against some of the utility of having a diagnostic manual, in the first place. Studies have found the two to not be genetically distinguishable (most of the time), but that doesn't mean there is no distinction, because the data could just be noisy. The DSM committee admitted there were significant differences, but said these were mainly accounted for differences in IQ scores and subscores. Okay, that shows there is a difference-- so why lump them together? Possibly the answer is politics, and the pragmatics of getting FDA drug approval-- if you can lump the Aspergers and Autistic kids together in one group, then an FDA indication has broader reach. The politics comes-in with parents complaining their Aspeger kids have been denied services provided to autistic individuals, but that is probably did not sway the committee. One sad answer may be that they followed flawed data over the cliff of clinical significance. The distinction works for clinicians and parents-- and there are different treatments for Asperger's and even high-functioning autistic kids.The lack of a go-live on the bold classification of personality disorders is sad-- but was probably necessary due to the manual's biggest short-coming: the lack of progress in dimensional/biologically-based/empirical classification of the other Axis I disorders. This is what the NIMH director was complaining about. The idea that we should junk DSM in favor of Research Domain Criteria is almost as laughable for research as it is for clinical science, but I understand the impulse- as remarkably little has been done, despite the explosion of knowledge in neuroscience. Efforts were made to make the diagnoses more biological, and the ADHD work-group initially was looking at incorporating brain-imaging into the diagnosis of ADHD, but found they just could not make it work. The same problem will probably befall the Research Domain Criteria, as we may have difficulty finding all the endophenotypes that make-up the clinical reality of a disorder. Researchers frustration may not be due to DSM, but are probably due to the reality of psychiatric illnesses-- the complexity of the brain means that these are subtle disorders, affected by differential expressions and interactions between multiple genes, all of small effect-- leading to an large number of underlying conditions that do seem to lead to some final common pathways.The overuse of medications may be due to the fact that we do not have enough diagnoses in the manual, rather than too many. When you think everything is a nail, you are likely to use a lot of the hammer. The medication overuse is most likely related to the other problem of psychiatry-- the lack of evidence-based therapy-based interactions that are rewarded by government and insurers.The best thing about DSM-5 is that the use of Arabic numerals allows the easier modification of criteria-- that means many of the problems may be corrected in DSM 5.1. And, possibly the monumental size of this task lead to a compressed period of evaluation and synthesis of data-- and the future evolution of the manual will need to take place continuously, one module at a time, so there is continuous forward progress. This will keep psychiatry from getting 20 years out-of-date with its diagnostic systems, and allow the DSM to more strongly guide clinical care.

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