SOCW6090 WK2 Assgn 2 Assignment: Video Role-Play: Strengths and Weaknesses of the DSM-5
Though the DSM-5 is the standard manual for mental illness diagnoses, it is not without weakness. In this Assignment, you analyze the strengths and limitations of the DSM-5 diagnostic system, and you differentiate between normal behavior and diagnosable symptoms using the concepts of dimensionality and spectrum.
To prepare: Review the concept of the dimensional approach with the DSM-5 and review the methods that the DSM-5 recommends to individualize where a person fits on a continuum of their illness in terms of subtypes, severity, and functional impairments. You will find these classifications in different parts of the manual and begin to be comfortable looking through it.
Next, imagine the following scenario:
You are a school social worker who has been asked to address a parent-teacher association meeting. Many parents in the audience have children who have been identified for special education services. They are confused about how to understand the diagnoses they are seeing. Others have worries about overdiagnosis. You have been advised that while these parents are generally well-informed, many don’t understand the dimensional or spectrum aspects. All are worried.
You will start your video with your introductory talk to the parents on these factors. After you provide your explanation, imagine that you open the meeting to questions. You will address the question noted below that is posed by a parent in the audience. Consider your audience, and practice explaining in terms a non-professional might understand. Do NOT read from the book.
Review the questions (in the Assignment instructions below) ahead of time and plan your answer before recording, as you will need to look up and integrate materials to answer the chosen question.
By Day 7
Submit a 3- to 5-minute video, considering the parents as your audience, in which you do the following:
Briefly describe what the DSM-5 is and how it is organized. In your description, define the concepts of spectrum and dimensionality as explained by Paris and in the DSM-5 introduction.
Explain why social workers and mental health professionals use diagnoses and what receiving a diagnosis means (and does not mean).
Explain general concerns about the risks of overdiagnosis and misdiagnosis versus not diagnosing. Also explain how diagnosis is connected to services.
Explain other details that might help your audience understand the strengths and weaknesses of the diagnostic system.
Provide a response to the following parental questions:
My teenager’s best friend died by suicide this year. It’s been months, and she doesn’t seem over it. Her teachers tell me she should get help for depression, but I think it’s just grief. She talks about her friend all the time and gets very upset. I am worried about her. Is it normal for her to still be feeling this way? I don’t want to put her on medication for normal feelings. What is the difference between grief and depression? 1
to the DSM-5®
S E C O N D E D I T I O N , R E V I S E D
Joel Paris, MD
Professor of Psychiatry
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v i i
First Edition Reviews
Dr. Paris has written a wise and well-informed book that will
help readers understand and avoid the problems created
—Allen J. Frances, MD, Professor Emeritus,
Department of Psychiatry, Duke University School of Medicine,
Psychiatry’s newest stage show (DSM-5) will draw a big audi-
ence, including health professionals, health organisations, law-
yers, and the general public. Joel Paris takes us “back stage”. . .
how can we appropriately classify and diagnose mental disor-
ders, and the complexities of distinguishing a psychiatric “case”
from a “non-case.” He details a flawed DSM-5 ideologically
based production but encourages us to recognise that while we
have to use it, we can still work our way around it. He astutely
observes that the DSM-5 editors know where Psychiatry is
going and want to help us to get there more rapidly. . . . The
book is a lucid, penetrating and perceptive “must read” critique
informing us the DSM-5 has no stronger a base in science than
its immediate predecessors. We should all respect Paris’ recom-
mended antidote to its ideology—“Apply extra caution and fol-
low common sense.”
—Gordon Parker, Scientia Professor of Psychiatry,
University of New South Wales, Sydney, Australia
v i i i | F i r s t E d i t i o n R e v i e w s
The clinician who longs for a balanced, reliable, and illuminat-
ing assessment of the state of psychiatric diagnosis and what it
all means for understanding our clients—and who yearns for a
guide who understands all the technical details but has some-
how miraculously retained his common sense—can do no better
than to turn to Joel Paris’s incisive, magisterial, tone-perfect,
and clear-as-a-bell overview. . . . If I wanted to sit down with
someone to talk over the background and meaning of psychi-
atric diagnosis as I will face it in the post-DSM-5 era, Joel Paris
is the person I would talk to. This is the clinician’s seatbelt for
surviving the diagnostic turbulence that has been tossing us
around over the past few years and, possibly, for years to come.
—Jerome C. Wakefield, PhD, DSW, School of
Social Work and Department of Psychiatry,
New York University, New York, and co-author
of All We Have to Fear: Psychiatry’s Transformation
of Natural Anxieties Into Mental Disorders
In his book, The Intelligent Clinician’s Guide to the DSM-5®,
out last month, psychiatrist Joel Paris of McGill University
in Montreal suggests that DSM has some pluses but a lot of
minuses. “The strong points would be that the manual does pro-
vide a useful guide to severe mental illness and it always has,”
he says. The closer that it gets to what people would consider
normal behavior, the less useful the DSM is, he says.
—Sharon Jayson, USA Today, May 12, 2013
This is an excellent critique of DSM-5 and psychiatry in gen-
eral. Written in an engaging style, the book draws readers in.
Although it is less than 200 pages, it covers the complex changes
in DSM-5 thoroughly and objectively In particular, it focuses on
the DSM-5’s conflation of normality and psychopathology and
the reductionist view of psychiatry solely as neuroscience. The
author challenges the DSM-5’s use of categorical and dimen-
sional organization without clinical input. He details why senior
experts from DSM-III and DSM-IV were left out of the planning
F i r s t E d i t i o n R e v i e w s | i x
process for DSM-5 and what the editors of the DSM-5 were
trying to achieve. All of this serves readers well in understand-
ing the purpose of DSM-5 and being able to make an informed
opinion about it. I highly recommend this book for anyone who
will be using the DSM-5.
—Brett C. Plyler, MD, Doody’s
A critical thinker’s best-case scenario: a reader-friendly book
that uses evidence-based critiques to point out where DSM-5 is
right, where it is wrong, and where the jury is still out.
—Leo Christie, President and CEO
of Professional Development Resources
Preface | xiii
PART I Diagnostic Principles
1. Introduction | 3
2. The History of Diagnosis in Psychiatry | 15
3. How Diagnostic Manuals Are Made | 33
4. What Is (and Is Not) a Mental Disorder | 54
5. Diagnostic Validity | 70
6. Dimensionality | 84
7. Clinical Utility | 102
PART II Specific Diagnoses
8. Schizophrenia Spectrum and Other Psychoses | 111
9. Bipolar and Related Disorders | 120
10. Depressive Disorders | 133
11. Anxiety Disorders, Trauma, and the
Obsessive–Compulsive Spectrum | 144
x i i | C o n t e n t s
12. Substance Use, Eating, and Sexual Disorders | 152
13. Neurodevelopmental and Disruptive
Behavioral Disorders | 164
14. Personality Disorders | 175
15. Other Diagnostic Groupings | 198
PART III Overview
16. Responses to DSM-5 | 211
17. Using DSM-5 in Clinical Practice | 217
18. A Guide for the Perplexed | 222
R E F E R E N C E S | 231
I N D E X | 267
x i i i
The first edition of this book was published at the same time as
DSM-5 in May 2013. The timing supported a welcome level of inter-
est in the book and met a need in the clinical community to know
what to expect from the latest edition of the standard diagnostic
However, the first edition was based on the version of the
manual that was posted on the Web in December 2012. There were
some last-minute changes in the final version of DSM-5, albeit not
major ones, that did not find their way into my book. Another rea-
son for a second edition is that research published since 2013 has
helped clarify some of the questions raised in the original book.
Also, DSM-5 stimulated a large amount of comment from the medi-
cal and scientific communities, as well as from the educated public.
Reviews of books critical of DSM-5 appeared in major media out-
lets, and only a few weeks before publication, the National Institute
of Mental Health offered a radically different alternative. All these
issues deserve discussion, and the publication of a second edition
provides me with an opportunity to address these issues.
I have also added two new chapters, one on the response to
DSM-5 and one on how to use the manual in clinical practice. Finally,
because DSM-5 is only a small part of a large story, I will have more
to say on the future of psychiatric diagnosis.
The year 2013 marked the publication of DSM-5, the fifth edition
of the Diagnostic and Statistical Manual of Mental Disorders (DSM),
published by the American Psychiatric Association (APA). This was
the first major revision in more than 30 years.
Prior to 1980, diagnostic classification of mental disorders
was an abstruse subject, of interest only to researchers and a few
experts. But if mental disorders are medical diagnoses, they require
a scientifically based classification. Moreover, since 1980, the DSM
system has had a profound influence on all the mental health pro-
fessions. The public, some of whom have been on the receiving end
of a diagnostic process, also finds the subject fascinating, so revi-
sions of psychiatry’s manual are front-page news.
This book is a guide to the main features of the latest version
of the manual. It will focus on three questions. First, what are the
most important changes? Second, what are the implications of
these changes for practice? Third, is DSM-5 better, worse, or equal
to its predecessors? This book, as a critical guide for the intelligent
clinician, will applaud the positive aspects of DSM-5 but underline
its limitations. It will be supportive of some changes but be critical
What DSM-5 Can and Cannot Do
The first two manuals published by APA, DSM-I (1952) and DSM-II
(1968), did not have a great impact on psychiatry. They were used
for statistical purposes, but they were not guides to clinical practice.
4 | Pa Rt I D I a g n o s t I C P R I n C I P l E s
In contrast, the third edition of the manual, DSM-III, published
in 1980, was a major break with the past, as well as a best-selling
book. The ideas behind this edition reflected a new paradigm for
psychiatry, and the politics that made a radical revision possible are
a fascinating story in their own right (Decker, 2013). DSM-III moved
classification from clinical impressions to some degree of rigor. It
increased reliability by taking an “atheoretical” position—that is,
making diagnoses based on what clinicians can see and agree on
as opposed to the abstract theories used in DSM-I and DSM-II.
DSM-III, and its successors, found a place on the shelf of almost
every psychiatrist, psychologist, and mental health professional.
There were no major changes in the manual during the next
30 years. DSM-III-R, published in 1987, allowed a greater degree of
overlap between diagnoses, and DSM-IV, published in 1994, added
some important new diagnoses, including bipolar II disorder and
attention-deficit hyperactivity disorder in adults. In 2000, a slightly
edited version, DSM-IV-TR, appeared. The absence of major changes
for so long could be seen as suggesting a need for a new system that
could radically revise the diagnosis of mental disorders. This was the
mandate given to the editors of DSM-5 by the APA. The work lasted
10 years, with a result that was initially claimed to be a “paradigm
Is the DSM-5 system an improvement over previous editions?
The answer has to be yes and no. One would like to believe so, but
there are reasons for doubt. Some problems derive from the concept
that psychopathology lies on a continuum with normality, making
it difficult to separate mental disorders from normal variations and
leading to a danger of overdiagnosis. Other issues derive from a
strong attachment to the principle that mental disorders are brain
disorders, even though knowledge is insufficient to develop a clas-
sification based on neuroscience. Although great progress has been
made in research on the brain, the origins of mental illness remain
When one does not know enough, one should not invest in
change for change’s sake. Sometimes it is better to keep a known sys-
tem, however faulty, than make modifications with unpredictable
1 I n t ro d u c t i o n | 5
consequences. Moreover, even the smallest changes to diagnostic
criteria can have profound effects on research and practice. Finally,
revisions with good intentions can still lack clinical utility. Revising
DSM is an enormous job, and each edition has grown larger, more
complicated, and thicker. Yet much of what is written in the manual
may never be applied in practice.
The Validity of Psychiatric Diagnosis
DSM-III aimed to make diagnosis more reliable, but reliability is
not validity. During the next 33 years, constant use of the manu-
als gave clinicians the impression that their categories were valid.
That was not true. The DSM system lacks the data to define mental
disorders in the way that physicians conceptualize medical illnesses.
Diagnoses in medicine can also be vague, but psychiatry is far behind
other specialties in grounding categories in measurements that are
independent of clinical observation.
Almost all DSM-5 diagnoses are based entirely on signs and
symptoms. Although some disorders have support for their valid-
ity, and although observation can be made more precise through
statistical evaluation and expert consensus, most other areas of
medicine use blood tests, imaging, or genetic markers to con-
firm impressions drawn from signs and symptoms. Psychiatry
is nowhere near that level of knowledge. No biological markers
or tests exist for any diagnosis in psychiatry. For this reason,
any claim that DSM-5 is more scientific than its predecessors is
In 1980, I was a strong supporter of the paradigm shift intro-
duced by DSM-III. It was progressive to make diagnosis dependent
on observation rather than on theory. But this provisional stance
became frozen in time, and progress during the succeeding decades
has been slow. Radical changes in classification would require much
more knowledge about the causes of mental disorders. And that is
just what we do not have.
6 | Pa Rt I D I a g n o s t I C P R I n C I P l E s
Psychiatry and Neuroscience
Psychiatry has bet on neuroscience as the best way to understand
mental disorders, to solve problems in diagnosis, and to plan
treatment interventions. Only time will tell how this wager will
pan out. Some psychiatrists claim that the field is on the verge of
a great breakthrough. If one were to believe the hype, a biological
explanation—and a biological cure—for mental illness lies just
around the corner. (Or as one wag put it, every few years we are told
that answers are just a few years away.)
Although progress in brain research has been rapid and impres-
sive, its application to psychiatry has thus far been very limited.
Brain scans are impressive (even if one keeps in mind that the col-
ors are artificial), but all they tell you is that activity is different at
different sites. The precise meaning of these changes is unclear, and
none are specific to any diagnosis.
We do not know enough about the brain, or about the mind, to
develop a truly scientific classification, and it could be 50–100 years
before we can even get close. It is understandable that psychiatry,
so long the Cinderella of medicine and desperate for respectability,
wanted to plant its flag on the terrain of neuroscience. But the prom-
ise of the 1990s (“the decade of the brain”) for research on mental
disorders has not been fulfilled. Neuroscience has shed much light
on how the brain functions, but we do not understand the etiology or
the pathogenesis of severe mental disorders. We know that most are
heritable, but we have no idea about which (or how many) genes are
involved. Although some disorders are associated with abnormalities
on brain imaging, the findings are neither specific nor explanatory.
Although psychopathology can be associated with changes in neu-
rotransmitters, the theory that chemical imbalances cause mental
disorders is too simple or plain wrong. Ultimately, it may be impos-
sible to fully explain mental disorders as brain disorders. The neuro-
science model attempts to reduce every twisted thought to a twisted
molecule, but it devalues studying the mind on a mental level.
Considering that it will take many decades to unravel these mys-
teries, the current situation is nothing to be ashamed of. The DSM-5
1 I n t ro d u c t i o n | 7
task force, as well as the leaders of the National Institute of Mental
Health, believe that psychiatry should give up its traditional mis-
sion, which was both scientific and humanistic, and redefine itself as
the clinical application of neuroscience. To paraphrase a famous line
from the Vietnam War, they want to destroy psychiatry in order to
save it. It is of course true that mental phenomena reflect the activ-
ity of the human brain. But the brain is the most complex structure
known in the universe. There are more synapses in the brain than
stars in the galaxy. This is a project for a century, not a decade, and
its results may never provide a full explanation of mental illness.
Unsolved Problems in Psychiatric Diagnosis
Lack of Knowledge About Mental Disorders: DSM-5 is not “the bible
of psychiatry” but, rather, a practical manual for everyday work.
Psychiatric diagnosis is primarily a way of communicating about
patients. This function is essential but pragmatic—categories of ill-
ness can be useful as heuristics without necessarily being “true.” The
DSM system is a rough-and-ready classification that brings a degree
of order to chaos. But it describes categories of disorder that are
poorly understood and that will be replaced with time. Moreover,
current diagnoses are syndromes, not true diseases. They are symp-
tomatic variants of broader processes defined by arbitrary cutoff
points. Thus, although classifications serve a necessary function,
psychiatrists can only guess how “to carve nature at its joints.” That
phrase (attributed to Aristotle) describes an impossible task. We do
not know if it is possible to find joints to be carved. Even in medi-
cine, diagnoses are not always cleanly defined or related to a specific
etiology. In contrast, mental disorders greatly overlap with each
other—and with normality.
The Need for Biological Markers: In the absence of a more funda-
mental understanding of disease processes, DSM-5, like its prede-
cessors, had no choice but to continue basing diagnostic criteria on
signs and symptoms. But observation needs to be augmented by
biological markers, as has been done in other medical specialties.
8 | Pa Rt I D I a g n o s t I C P R I n C I P l E s
In the absence of independent measures of this kind, we cannot be
sure that any category in the manual is valid. We should not there-
fore think of current psychiatric diagnoses as “real” in the same way
as medical diseases. Also, listing them in a manual does not make
them real. For example, broad categories such as “major depression”
in no way resemble diseases. Even the most “classical” concepts in
psychiatry, such as the separation of schizophrenia from bipolar dis-
order, have not fully stood up to scrutiny. In summary, psychiatrists
must make diagnoses, but they do not need to reify them. They are
best advised to stay humble and to avoid hubris.
Boundaries Between Mental Disorder and Normality: This is one
of the most nagging problems in psychiatric diagnosis. Every edi-
tion of DSM has expanded this frontier, taking on increasingly more
problems of living as diagnosable disorders. Psychiatric classifica-
tion has become seriously overinclusive, and the manual grows ever
larger with each edition. DSM-5 also errs on the side of expand-
ing boundaries—mainly out of fear of “missing something” or not
including problems that psychiatrists treat in practice. The result
is that people with normal variations in emotion, behavior, and
thought can receive a psychiatric diagnosis, leading to stigma and
inappropriate and/or unnecessary treatment.
Diagnostic Validity and Research: Because we have to live with a
diagnostic system that is provisional—and that will almost certainly
prove invalid in the long run—much of the research on mental dis-
orders has to be taken with a grain of salt. For example, although
a massive amount of data has been collected on the epidemiology
of mental illness, almost all its findings are dependent on the cur-
rent diagnostic system. Similarly, studies of treatment methods in
psychiatry that target specific disorders are sorely limited by the
problematic validity of categories. Most treatments, from antide-
pressants to cognitive behavioral therapy, have broad effects that
are not specific to any diagnosis.
Comorbidity: One of the most troubling problems with the DSM
system is that it yields multiple diagnoses in the same patient. That
is not the way medicine usually works. It is possible for patients to
suffer from more than one disease. But in psychiatry, if you follow
1 I n t ro d u c t i o n | 9
the rules, the same symptoms can be used to support two or three
diagnoses. Thus, “comorbidity” is little but an artifact of an inex-
act system in which criteria overlap. The sicker a patient, the more
mental disorders will be identified. DSM-5 considered severity rat-
ings and diagnostic spectra to address this problem, but these pro-
cedures could not resolve underlying questions about boundaries.
Algorithmic Diagnosis: Another source of uncertainty is that
diagnosis in psychiatry does not depend on “pathognomonic”
signs and symptoms that define specific diseases. The algorithmic
approach of the DSM system has been rightly popular: It uses “poly-
thetic” criteria—making a list and then requiring a given number
to be present. These quantitative thresholds are superior to asking
clinicians to determine whether the patient’s condition resembles
a prototype. But if a typical DSM diagnosis requires, for example,
five out of nine criteria, nobody knows whether four or six criteria
would have been more or less valid. Few categories have absolute
requirements for any criterion, and no system of weighting takes
into account the most characteristic features. The DSM system has
been jocularly called a “Chinese menu” approach to diagnosis. But
most clinicians need to consult the menu, and they would be hard
put to remember all criteria for any category.
Dimensionalization: The editors of DSM-5 thought that the
solution to the comorbidity problem is to view disorders as
dimensions—spectra of pathology that can be scored in terms of
severity. All previous editions have classified mental disorders as
specific categories, much like general medicine. One of the main
ideas behind DSM-III was the revival of a model based on the work
of the German psychiatrist Emil Kraepelin (1856–1926). Categories
are consistent with the view that psychiatry concerns itself with
mental illness, not with unhappiness or life itself. They also imply
that psychopathology falls into a set of categories or natural kinds,
much like tuberculosis or most forms of cancer. DSM-5 sought to
overthrow this “neo-Kraepelinian” approach and replace it with a
model in which normality and illness lie on a continuum. The ratio-
nale is that research suggests the underlying biology of mental
disorders is more dimensional than categorical. But measuring the
1 0 | Pa Rt I D I a g n o s t I C P R I n C I P l E s
severity of depression is not like taking blood pressure. The defi-
nition of dimensions is based on observation rather than biologi-
cal markers, and it can only be provisional. Dimensional diagnosis
also runs the risk of being overinclusive. Even normal people have
some symptoms of disorder but do not deserve a formal diagnosis.
Because differences in degree can become differences in kind, cat-
egories are necessary.
Expert Consensus: DSM-5 is not a scientific document but, rather,
a product of consensus by committees of experts. Sometimes the
outcome depends on who was put on these committees. Where
experts disagree, there is a way to “fix” results in advance—by ensur-
ing that membership reflects a preexisting point of view. There are
many scientific disputes affecting diagnosis, but most reflect a lack
of basic knowledge. As the American physician Alvan Feinstein once