Mental Disorders Classify and Diagnostic Manual for Professionals

Do you know, used by clinicians and researchers to diagnose and classify mental disorders, the new edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health.
Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research.

This manual, which creates a common language for clinicians involved in the diagnosis of mental disorders, includes concise and specific criteria intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings inpatient, outpatient, partial hospital, consultation-liaison, clinical, private practice, and primary care.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most comprehensive, current, and critical resource for clinical practice available to today's mental health clinicians and researchers of all orientations. The information contained in the manual is also valuable to other physicians and health professionals, including psychologists, counselors, nurses, and occupational and rehabilitation therapists, as well as social workers and forensic and legal specialists. DSM-5 is the most definitive resource for the diagnosis and classification of mental disorders.


Readers should view the publication of Diagnostic and Statistical Manual of Mental Disorders-5 as the end of the Chemical Imbalance Paradigm for the study and treatment of mental illness. Starting with DSM-III (pub. 1980) the American Psychiatric Association (APA) instituted a paradigm of mental illness based on the idea that mental illnesses were caused by 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. Each mental disorder was thought to be caused by a specific chemical imbalance of genetic origin. However, as DSM-5 states: "Not surprisingly, as the foundational science that ultimately led to Diagnostic and Statistical Manual of Mental Disorders-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" (Diagnostic and Statistical Manual of Mental Disorders-5, p. 10). In other words, recent genetic studies and other scientific findings do not support the Chemical Imbalance Paradigm established in DSM-III. This is why the "Associated Laboratory Findings" section found in each disorder category of DSM-IV (pub. 1994) has been eliminated in DSM-5. The APA is no longer assuming that there are laboratory findings that scientifically validate each discrete mental disorder category in DSM-5.

DSM-5 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" (Diagnostic and Statistical Manual of Mental Disorders-5, p. 12).

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 " (Diagnostic and Statistical Manual of Mental Disorders-5, p. 14).

DSM-5 specifically disallows the use of a checklist approach to diagnosis. A Client-Centerd Approach is more holistic, including psychological, social, and cultural factors. "The case formulation for any given patient must 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. 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" (Diagnostic and Statistical Manual of Mental Disorders-5, p. 19).

 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.