DSM-5: two years since publication

It is now two years since the publication of DSM-5. As one might expect when a widely used manual is revised, some mental health clinicians were worried they would have to learn diagnosis from scratch. But the idea that the fifth edition would be a “paradigm shift” for psychiatry turned out to be hype. Few revisions were really major, although practitioners have to become familiar with some new terminology (such as somatic symptom disorder, neurocognitive disorder, or intellectual deficiency).

Some unanswered questions remain. Just as DSM-5 was published in the spring of 2013, Thomas Insel, Director of the National Institute for Mental Health (NIMH), attacked it, declaring that “psychiatry deserves better.” So what did Insel propose instead? The ensuing controversy gave him the opportunity to promote his own system, the Research Domains Criteria (RDoC). This model, although hardly ready for use in clinical practice, will be required as a framework for all NIMH grant applications. RDoC is an interesting but speculative system that aims to reduce all mental disorders to problems in the “connectome,” i.e., how neurons are wired up. Some consider RDoC visionary, while others think it will add little to the understanding of mental illness. We had similar hopes for the Genome Project, and they were disappointed.

Another question concerns potential disjunctions between DSM-5 and the upcoming eleventh edition of the World Health Organization’s International Classification of Diseases (ICD-11), expected in 2017. While ICD is, by treaty, the official system (even in the United States), its coding more or less corresponds to DSM diagnoses. Few clinicians in North America will have read the classification prepared by WHO.

A final question is whether the next edition, DSM-6, will only appear in 20 years, or whether there will be, as originally planned, a DSM-5.1 in the next few years. If there is, it might introduce diagnoses that were not accepted in DSM-5 a second chance. Some of these proposals can be found in Section III of the manual (containing diagnoses requiring further study). There seems no current groundswell of opinion to bring back the concept of risk psychosis. However, since the alternative model for personality disorders was not accepted because research on this model was in such an early stage, its the supporters are actively promoting it through research, in the hope that it will replace the old system retained in Section II.

My guess is that given the expense and trouble of preparing further revisions, DSM-5 will not be revised unless major research breakthroughs are made. I am old enough to remember the fierce arguments over DSM-III, which gradually became accepted, after which criticisms were fairly muted.

Since DSM-5 has all the limitations of previous editions, it should be considered the best we can do at the present state of knowledge. There is no point changing psychiatric diagnoses on the basis of speculation of what we might find in the future. Once we understand the causes of mental disorders, that will be the time for major revisions. Until then, DSM-5 still works–as a common language for clinicians.

Featured image: Narcissus by Caravaggio. Public Domain via Wikimedia Commons