The DSM-5: Hyperbole, Hope or Hypothesis?

BMC Medicine, May 2013

The furore preceding the release of the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is in contrast to the incremental changes to several diagnostic categories, which are derived from new research since its predecessor’s birth in 1990. While many of these changes are indeed controversial, they do reflect the intrinsic ambiguity of the extant literature. Additionally, this may be a mirror of the frustration of the field’s limited progress, especially given the false hopes at the dawn of the “decade of the brain”. In the absence of a coherent pathophysiology, the DSM remains no more than a set of consensus based operationalized adjectives, albeit with some degree of reliability. It does not cleave nature at its joints, nor does it aim to, but neither does alternate systems. The largest problem with the DSM system is how it’s used; sometimes too loosely by clinicians, and too rigidly by regulators, insurers, lawyers and at times researchers, who afford it reference and deference disproportionate to its overt acknowledged limitations.

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The DSM-5: Hyperbole, Hope or Hypothesis?

Michael Berk 0 1 2 0 Department of Psychiatry, Orygen Research Centre, and the Florey Institute for Neuroscience and Mental Health, The University of Melbourne , Parkville, VIC 3052 , Australia 1 School of Medicine, Deakin University , Barwon Health, Ryrie Street, Geelong, VIC 3220 , Australia 2 Competing interests Michael Berk has received Grant/Research Support from the NIH, Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation , MBF, NHMRC, Beyond Blue, Rotary Health , Geelong Medical Research Foundation, Bristol Myers Squibb, Eli Lilly , Glaxo SmithKline, Meat and Livestock Board, Organon, Novartis , Mayne Pharma, Servier and Woolworths, has been a speaker for Astra Zeneca, Bristol Myers Squibb, Eli Lilly , Glaxo SmithKline, Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo, Servier , Solvay and Wyeth, and served as a consultant to Astra Zeneca, Bristol Myers Squibb, Eli Lilly , Glaxo SmithKline, Janssen Cilag, Lundbeck Merck and Servier The furore preceding the release of the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is in contrast to the incremental changes to several diagnostic categories, which are derived from new research since its predecessor's birth in 1990. While many of these changes are indeed controversial, they do reflect the intrinsic ambiguity of the extant literature. Additionally, this may be a mirror of the frustration of the field's limited progress, especially given the false hopes at the dawn of the decade of the brain. In the absence of a coherent pathophysiology, the DSM remains no more than a set of consensus based operationalized adjectives, albeit with some degree of reliability. It does not cleave nature at its joints, nor does it aim to, but neither does alternate systems. The largest problem with the DSM system is how it's used; sometimes too loosely by clinicians, and too rigidly by regulators, insurers, lawyers and at times researchers, who afford it reference and deference disproportionate to its overt acknowledged limitations. - Editorial There has been collective flurry of introspection, debate and controversy about the impact and relevance and criteria for the diagnoses proposed in the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition (DSM-5). At least part of the issue is the prevailing zeitgeist; the launch of the DSM-III over three decades ago was paralleled by a retrospectively unrealistic enthusiasm for the manual, its validity and the potential to haul a psychoanalytically oriented discipline into a scientific era. The fundamental problem however remains; the DSM is a symptom based classification, and there remains no coherent pathophysiological foundation for the discipline, the edifice on which medical nosology traditionally is built. It is unrealistic to expect phenomenology to track pathophysiology; nowhere in the rest of medicine does this occur. Cough, pyrexia or pain are all pleomorphic manifestations of diverse pathologies, and depression, anxiety and psychosis are unlikely to be different. The issue is expecting it to be so, as the fundamental validity of the system is clearly absent, but equally obviously, no valid alternate system is in sight. The climate has thus swung to a wintery disillusionment regarding the perceived failures of the system, with little enthusiasm for the changes, and in particular the expansion of the number and subtypes of diagnostic categories. An analogy is color; using the analogy that we have no idea of the physics of light, that the construct of wavelength even exists, let alone determines color, is it useful to replace blue with a series of subtypes of blue turquoise, aquamarine, azure, etc.? In this regard, the expanded DSM-5 categorisation represents a greatly expanded series of adjectives or metaphors, able to describe what we see in a manner that is defined with some reliability, even if it fails to explain why blue really is blue. Biomarker research has largely not supported this current nosology, with markers of cognition, imaging, genetics, inflammation, oxidative stress and neurotrophins showing remarkable homology across categories. Categories including psychotic, mood, personality disorders, and anxiety disorders are associated with common etiological factors including early childhood experiences, social stressors, trauma, personality styles, interpersonal, family, lifestyle, medical, with each factor playing a differential role for each person. Lastly, with the possible exception of lithium, where lithium responsivity does seem to parse a clinically meaningful subgroup, almost all psychotropics (...truncated)


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Michael Berk. The DSM-5: Hyperbole, Hope or Hypothesis?, BMC Medicine, 2013, pp. 128, 11, DOI: 10.1186/1741-7015-11-128