Blashfield, R. K., Keeley, J. W., Flanagan, E. H., & Miles, S. R. (2014). The Cycle of Classification: DSM-I Through DSM-5. Annu. Rev. Clin. Psychol, 10, 25-51
Allen Frances, M.D DSM 5 Is Guide Not
Bible—Ignore Its Ten Worst Changes. https://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes
This is part two of the
post the Cycle of Classification: DSM-I Through DSM-5 published on June
23, 2016.
DSM4
DSM4 was published in 1994. A
major change from previous editions was the inclusion of a clinical
significance criterion to almost half of all the categories, which required
that symptoms cause "clinically significant distress or impairment in
social, occupational, or other important areas of functioning".
DSM4TR
DSM4TR was published in 1994. The diagnostic categories and most of the
specific criteria for diagnosis were not changed in this edition.
In 2005 Sadler published an important and
influential book titled "Values and Psychiatric Diagnosis". Sadler highlighted five values and the roles
they play in psychiatric nosology: (a) aesthetics—how people prefer things to
be, in the sense that they “like” or “appreciate” them; (b)
epistemology—choices about how we know what we know about classification (i.e.,
what research methods we prefer); (c) ethics—what morals the classification
upholds; (d ) ontology—what is the fundamental nature of “things,” or in the
case of psychiatry, what mental disorders are in a (meta)physical sense; and
(e) pragmatics—how useful or user-friendly the classification might be. Until
the publication of this book, most (although not all) of those assumptions were
ignored or taken for granted. This book legitimized the imperative role
philosophical discourse plays in the development of a classification of mental
disorders.
DSM5
DSM5 was published in 2013, but the
process of its development began in 1999.
Its drafts were published on an internet site, allowing people to remark
and make suggestions. The purpose of the
DSM5 task force was to match the classification system to modern molecular
biology, cognitive and affective neuroscience, and psychometrics. The suggested categories were tested in
eleven medical centers. The total number
of diagnostic categories in this classification system increased markedly. Most
of this increase was in categories which covered a vast range of reasons why
someone might be seen by a mental health professional (e.g., “overweight or
obesity,” “problems related to unwanted pregnancy”).
The axes system that existed since the
DSM3 was cancelled. DSM5 has three
parts:
Part one describes the structure of the
DSM5.
Part two describes the mental disorder
categories. Significant changes in the fifth edition are the deletion of the
subtypes of schizophrenia and the
deletion of the subsets of autistic spectrum disorder. The chapter that included disorders first
diagnosed in infancy, childhood or adolescence was also deleted.
The third part introduces
innovative models and measurement tools. Among them is an alternative model for
personality disorders, which is a hybrid model (categorical and dimensional). There
was a debate during the period preceding the DSM5 whether and how dimensional
models of personality can be integrated into the DSM. One of these models is the BIG5 model, about
which I had briefly written before.
Mental
health professionals and the British Psychological Society argue that "normal" and
"abnormal" personalities are not separate but exist on the same
continuum. It's possible to classify an
"abnormal" personality by the same BIG5 factors. It was suggested that the categories of
personality disorders in the DSM5 be replaced by dimensional models of
personality. Blashfield and Keeley write that the political pressures against such a significant
change were powerful, and the next version of the proposal involved a hybrid of
categories and dimensions. Some people
argued that adopting a dimensional model of personality was not in the financial
interest of the APA because copyrights for existing measurement instruments for
these dimensions were held by others.
Other
DSM5 criticisms:
The way
the categories were built: the DSM deals mainly with
the symptoms of mental disorders and not with their causes. It classifies disorders based on statistical
or clinical patterns. This method can
cause the classification of people who have the same symptoms for different
reasons or due to different causes into the same category. This encumbers research efforts. But what's the alternative? I'm not sure we have enough knowledge to
enable us to classify mental disorders according to their causes.
Over-diagnosis
and medicalization of normal life situations:
some professionals argue that the great
increase in the number of diagnostic categories reflects and causes an
increased medicalization of human nature, and may cause over-diagnosis of
mental disorders. One of the people
arguing this is Dr. Allen Frances, the head of the task force of the DSM4. He argues that normal life situations, like
temper tantrums or natural grief, become mental disorders in the DSM5.
The extent
to which the DSM structure is in line with the way clinicians diagnose in real
life: Research about the way experienced
clinicians make diagnostic decisions show that they are not using criteria
lists. Instead they compare the new
patient with patients they have seen previously using a prototype. Thus some professionals argue that the DSM
diagnostic criteria fit research more than clinical practice (but see one of
the previous points…). Blashfield and Keeley
suggest that prototypes would be
a better way for clinicians to learn and communicate diagnostic categories once
the categories are well defined with feature lists (i.e., criteria).
The DSM5
writing process: controversy erupted over the potentially
secretive process that was being used to make decisions as well as the
corrupting influence of income and the DSM's potential revenues. More than
once, important decisions that affected the final outcome of a DSM
categorization system were made at the level of the Board of Trustees of the
APA.
Blashfield and Keeley recommend that the APA make all financial
records about the DSM, both past and present, publicly available. This would
include information about royalties (if any) and honoraria paid to individuals
involved with these editions and funding from pharmaceutical or other companies
that could experience a financial impact because of DSM-influenced decisions.
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