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DSM-5 two years later: facts, myths and some key open issues

1. Lasalvia, Guest Editor*

In May 2013, the American Psychiatric Association (APA) published the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The pro- cess that led to the release of the DSM-5 took nearly two decades, with working groups of experts asked to propose revisions based on the most recent research findings. Originally, the APA hoped to introduce a ‘paradigm shift’, in which psychiatric diagnosis would be in greater harmony with neuroscience (Regier et al. 2009). When it became clear the data sup- porting these changes were too fragmentary for radical changes, the APA backed off from major revisions (Paris & Phillips, 2013). In fact, to date, there is no knowledge on whether most conditions listed in the manual are true diseases. In the meantime, while wait- ing for genetics and neuroscience to elucidate the causes (and guide the treatment) of psychiatric disor- ders, we should simply acknowledge, ‘our classifica- tion of mental disorders is no more than a collection of fallible and limited constructs that seek, but never find, an elusive truth. Nevertheless, this is our best cur- rent way of defining and communicating about mental disorders’ (Frances & Widiger, 2012).

The main and most consistent criticism of the DSM-5 (actually it was criticised both before and after it was formally published) is that it included a number of new and untested psychiatric disorders without sufficient data on prevalence, reliability, valid- ity, treatment response and risk/benefit ratio (Frances, 2010, 2013). According to critics, all of the proposed new diagnoses, together with lowered thresholds for some existing diagnostic categories, would expand psychiatric diagnosis at its fuzzy and hard-to-define border with normality, leading to overdiagnosis, i.e., attributing diagnostic labels to responses to life situa- tions that should be considered to be within normal variation. This is both a major clinical and an ethical issue (Wakefield, 2010, 2013a). Such overdiagnosis could discredit psychiatry by claiming that there is no essential difference between mental disorder and normality, and by forcing clinicians to treat normally

functioning people with medications that they do not necessarily need (Paris & Phillips, 2013). Psychiatry has long been criticised for medicalising and patholo- gising normal variations and overdiagnosis means overtreatment, with all the existing side effects of psy- chopharmacological interventions.

However, as critics themselves acknowledge, ‘des- pite all its epistemological, scientific and even clinical failings, the DSM incorporates a great deal of practical knowledge in a convenient and useful format; it does its job reasonably well when it is applied properly and when its limitations are understood. One must strike a proper balance’ (Frances & Widiger, 2012). At its core, the DSM-5 should be simply regarded ‘as a guidebook to help clinicians describe and diagnose behaviours and symptoms of their patients; it provides clinicians with a common language to deliver the best patient care possible’ and aims to encourage future directions in research (Kupfer, 2013).

Two years after its publication, it is time to carefully weigh the pros and cons of the new diagnostic system and to explore the facts and the myths surrounding the DSM-5. For this purpose, we invited to comment in the ‘Editorial in this Issue’ of Epidemiology and Psychiatric Sciences, two eminent scholars who have leading roles in the DSM-5 debate taking place in the scientific literature, Jerome Wakefield (see e.g., Wakefield, 2010, 2013a, b) and Mario Maj (see e.g., Maj, 2012, 2013, 2014).

Wakefield (2015) highlights a number of critical issues with the DSM-5, considering this new diagnos- tic system flawed in process, goals and outcome. The revision process itself suffered from lack of adequate public record of the rationale for the changes, thus mis- leading the future scholarship. In fact, for scholars try- ing to understand and evaluate the validity of the DSM-5 task force’s decisions, the most important prob- lem with the revision process was its secrecy and lack of adequate documentation. Moreover, the declared goals of the revision process, such as dimensionalising diagnosis, incorporating biomarkers and separating impairment from diagnosis (Regier et al. 2009), were ill-considered and were eventually mostly abandoned. In Wakefield’s view, the major drawback of the DSM-5 is the worsening of the false-positive problem. This is a major problem: the DSM-5 has missed the opportunity

* Address for correspondence: Dr A. Lasalvia, Department of Psychiatry, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico “G.B. Rossi”, Piazzale L.A. Scuro, 37134 – Verona, Italy.

(Email: antonio.lasalvia@univr.it)

Epidemiology and Psychiatric Sciences (2015), 24, 185–187. © Cambridge University Press 2015 doi:10.1017/S2045796015000256

EDITORIALS IN THIS ISSUE, JUNE 2015

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to increase the conceptual validity of psychiatric diag- nosis by aggressively addressing false-positive issues; in squandering this opportunity, the DSM-5 placed the hard-won integrity of psychiatry as a medical dis- cipline at risk. According to Wakefield (2015), the wor- sening of the false positive problem specifically applies to: (1) substance use disorder (increasing the symptom options while decreasing the diagnostic threshold will pathologise mild conditions), (2) major depression (the elimination of the bereavement exclusion implies that bereaved individuals who manifest five general dis- tress symptoms for 2 weeks after a loss will now be classified as having a Major Depressive Disorder), (3) intermittent explosive disorder (allowing verbal argu- ments among diagnostic criteria will artificially inflate its prevalence rate) and (4) attention deficit hyperactiv- ity disorder (expanding diagnosis to adults before addressing its manifest false positive problems in chil- dren will perpetuate the same high false positive rate by encompassing normal variations within the umbrella of the disorder). On the other hand, Wakefield (2015) also acknowledges that the DSM-5 has made some progress in addressing the false posi- tive problem, such as the addition of a more stringent criterion for insomnia disorder, the exclusion of defiant behaviour directed only at a sibling for the diagnosis of oppositional defiant disorder, and the exclusion criter- ion of severe relationship distress for diagnosing sex- ual dysfunction. Moreover, the DSM-5 changes are likely to prevent some false positives, e.g., excluding ‘irritable mood’ from manic episode criteria (only ‘abnormally and persistently increased activity or energy’ is now required) will probably reduce mis- diagnoses of bipolar disorders.

Maj (2015) challenges some recurring critical com- ments in the media that have preceded and followed the publication of the DSM-5. These include statements such as (1) the DSM is ‘the bible of psychiatry’ (e.g., Horgan, 2013), (2) the DSM pathologises conditions that are in the range of normality (e.g., Cassels, 2013), (3) the unavailability of biological tests invali- dates psychiatric diagnoses (e.g., Insel, 2013), and (4) the Research Domain Criteria (RDoC) project recently launched by the NIMH in the USA (Cuthbert, 2014) is going to transform psychiatric diagnosis by replacing descriptive psychopathology with behav- ioural and neurobiological measures (e.g., Insel, 2013). Maj challenges these statements by applying rigorous reasoning and providing compelling evidence drawn from the scientific literature. Regarding the first issue, literature shows that only a minority of psychia- trists around the world use formal diagnostic systems in their ordinary practice and, when a diagnostics sys- tem is used, only one tenth of clinicians use the DSM. It therefore seems that the wide gap exists between

current diagnostic systems and ordinary diagnostic practice; the scientific community keeps revising diag- nostic systems, but the impact of these revisions on clinical practice is much lower than expected. With regard to the second statement, after having acknowl- edged that some conditions included in the DSM-5 may not qualify as psychiatric disorders and that the threshold for the diagnosis of some conditions that do qualify may be too low. Maj argues that a pragmat- ic set of inclusion and exclusion criteria needs to be developed in order to apply them explicitly and con- sistently when the introduction of a new condition in the diagnostic system is proposed (and if a balance between possible benefits of the inclusion and possible risks is involved in the decision, this should be made explicit). Moreover, non-validated thresholds should not be used in the name of reliability or to avoid chan- ging current assessment instruments; alternative thresholds should be formally studied, especially with respect to their clinical utility. As far as the third issue is concerned, Maj points out that the crucial element is not whether the threshold for the diagnosis of a disorder is based on a biological test or a set of clinical variables, but rather whether the threshold has sufficient predictive validity (therefore, in the absence of biological tests, an active search for clinical thresholds that are predictively valid should be per- formed). Finally, the notion that the RDoC approach will transform psychiatric diagnosis in the foreseeable future is also challenged; based on the current avail- able research evidence, the RDoC project is more likely to develop neurobiological measures that may help in subtyping rather than replacing current diagnostic cat- egories, with the aim of improving the predictions of outcomes and treatment responses.

In summary, a number of problems do exist in our current diagnostic systems (and the DSM-5 has probably even worsened the situation), and many lim- itations still affect the diagnostic process in psychiatry. However, trashing current diagnostic practices may be harmful for psychiatry’s image and, more importantly, for our patients. Throwing out the baby with the bathwater, so to speak, is always dangerous.

References

Cassels C (2013). DSM-5 officially launched, but controversy persists. Medscape Multispecialty, May 18.

Cuthbert BN (2014). The RDoC framework: facilitating transition from ICD/DSM to dimensional approaches that integrate neuroscience and psychopathology. World Psychiatry 13, 28–35.

Frances A (2010). The first draft of DSM-V if accepted will fan the flames of false positive diagnoses. BMJ 340, 492.

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Frances A (2013). Saving Normal: An Insider’s Revolt Against Out-of-control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. William Morrow & Co.: New York.

Frances AJ, Widiger T (2012). Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annual Review of Clinical Psychology 8, 109–130.

Horgan J (2013). Psychiatry in crisis! Mental health director rejects psychiatric “bible” and replaces with. . . nothing. Scientific American, May 4.

Insel T (2013). Director’s blog: Transforming diagnosis [Online] [cited 29 Apr 2013] http://www.nimh.nih.gov/ about/director/2013/transforming-diagnosis.shtml.

Kupfer D (2013). Statement by David Kupfer. Chair of DSM-5 Task Force Discusses Future of Mental Health Research. American Psychiatric Association: Arlington, VA; May 3, 2013 http://www.psych.org/FileLibrary/ AdvocacyandNewsroom/PressReleases/2013Releases/ 13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf.

Maj M (2012). Bereavement-related depression in the DSM-5 and ICD-11. World Psychiatry 11, 1–2.

Maj M (2013). The DSM-5 approach to psychotic disorders: is it possible to overcome the ‘inherent conservative bias’? Schizophrenia Research 150, 38–39.

Maj M (2014). DSM-5, ICD-11 and ‘pathologization of normal conditions’. Australian and New Zealand Journal of Psychiatry 48, 193–194.

Maj M (2015). The media campaign on the DSM-5: recurring commentsandlessonsforthefutureofdiagnosisinpsychiatric practice. Epidemiology and Psychiatric Sciences, this issue.

Paris J, Phillips J (eds) (2013). Making the DSM-5. Concepts and Controversies. Springer: New York, pp. 1–180.

Regier DA, Narrow WE, Kuhl EA, Kupfer DJ (2009). The conceptual development of DSM-5. American Journal of Psychiatry 166, 645–650.

Wakefield JC (2010). False positives in psychiatric diagnosis: implications for human freedom. Theoretical Medicine and Bioethics 31, 5–17.

Wakefield JC (2013a). DSM-5 and clinical social work: mental disorder and psychological justice as goals of clinical intervention. Clinical Social Work Journal 41, 131–138.

Wakefield JC (2013b). The DSM-5 debate over the bereavement exclusion: psychiatric diagnosis and the future of empirically supported treatment. Clinical Psychology Review 33, 825–845.

Wakefield JC (2015). DSM-5, psychiatric epidemiology, and the false positives problem. Epidemiology and Psychiatric Sciences, this issue.

DSM-5 two years later: facts, myths and some key open issues 187

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