DSM-5: Changes and Controversies

A Brief History of DSMThe American Psychiatric Association's (APA) 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 2013a) represents the latest iteration of a document which has been shaped by social and scientific forces. DSMI (APA, 1952) represented APA's attempt to improve on the diagnostic system of mental disorders contained in the World Health Organization's (WHO) International Classification of Diseases (ICD; see World Health Organization, 1948) which was, at that time, in its 6th revision (Grob, 1991). Based largely on War Department Technical Bulletin Medical 203, a classification system developed by the Surgeon General's Office under the leadership of William C. Menninger, DSMI reflected a psychodynamic orientation which asserted that the development and maintenance of mental disorders was explained by a person's reaction to biological, psychological, and environmental stressors (Clegg, 2012).Changes to DSM-II (1968) were minimal and characterized by an increase in the number of disorders which some attributed to the inclusion of milder forms of more serious mental conditions (Kawa & Giordano, 2012). Another change involved the slow movement away from a psychodynamic orientation (although most consider the DSM-II to be largely grounded in that tradition), characterized by the removal of the term "reaction" from the definition of mental disorders (Clegg, 2012; Houts, 2000). Bigger changes, however, were on the horizon.DSM-III (1980), under the guidance of Dr. Robert Spitzer, contained 500 pages (an increase from 132 pages in DSM-II) and embodied significant changes in classifications and scientific notions about the etiology of mental disorders (Fischer, 20121). First, the manual's authors developed a criteria-based, classificatory approach to diagnosis whereby one could determine the relative presence or absence of a set of specific psychiatric symptoms (Mayes & Horwitz, 2005). While some accused the new system of relying too heavily on a positivistic, research-based method of diagnosis for case formulation (McWilliams, 2013), others acknowledge the revision for its improvement in diagnostic clarity and reliability (Wilson, 1993). This move also represented a theoretical paradigm shiftfor DSM: from a predominantly psychodynamic to a largely atheoretical approach. No longer relying on the presence of unobserved phenomena for the codification of mental disorders, the empirically-based system allowed an increasing number of practitioners whose training reflected an array of theoretical orientations to use the manual (Neimeyer, 2013). This changed the focus of DSM from a manual of etiology (causes) to a manual for diagnosis (Wilson, 1993).Another notable addition to DSM-III was the introduction of the multi-axial system allowing the user to compile a diagnostic profile based on: (Axis I) Diagnoses of clinical attention; (Axis II) Disorders of personality or intellectual ability; (Axis III) Medical and physical disorders; (Axis IV) Psychosocial and environmental problems; and (Axis V) A rating of highest adaptive functioning. According to APA, this five-axis system was introduced "to ensure that certain information that may be of value in planning and treatment and predicting outcomes for each individual is recorded" (APA, 1980, p. 9).Subsequent revisions focused predominantly on refining the operationalization of disorders, updating statistical prevalence and incidence of disorders, and introducing and deleting new diagnoses based on prevailing clinical evidence. DSM-III-R (1987) was 594 pages in length and saw the removal of egodystonic homosexuality, the last remnant of a homosexualityrelated mental health disorder (Fischer, 2012). A notable addition to DSM-IV (under the leadership of Dr. Allen Frances in 1994) involved the inclusion of a clinical significance standard to many diagnostic criteria sets (i.e., the disorder must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning) (APA, 1994). …