Paradigm Shifts and the Development of the Diagnostic and Statistical Manual of Mental Disorders: Past Experiences and Future Aspirations

By First, Michael B. | Canadian Journal of Psychiatry, November 2010 | Go to article overview

Paradigm Shifts and the Development of the Diagnostic and Statistical Manual of Mental Disorders: Past Experiences and Future Aspirations


First, Michael B., Canadian Journal of Psychiatry


Objective: Work is currently under way on the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, due to be published by the American Psychiatric Association in 2013. Dissatisfaction with the current categorical descriptive approach has led to aspirations for a paradigm shift for DSM-5.

Method: A historical review of past revisions of the DSM was performed. Efforts undertaken before the start of the DSM-5 development process to conduct a state-of-the science review and set a research agenda were examined to determine if results supported a paradigm shift for DSM-5. Proposals to supplement DSM-5 categorical diagnosis with dimensional assessments are reviewed and critiqued.

Results: DSM revisions have alternated between paradigm shifts (the first edition of the DSM in 1952 and DSM-III in 1980) and incremental improvements (DSM-II in 1968, DSM-III-R in 1987, and DSM-IV in 1994). The results of the review of the DSM-5 research planning initiatives suggest that despite the scientific advances that have occurred since the descriptive approach was first introduced in 1980, the field lacks a sufficiently deep understanding of mental disorders to justify abandoning the descriptive approach in favour of a more etiologically based alternative. Proposals to add severity and cross-cutting dimensions throughout DSM-5 are neither paradigm shifting, given that simpler versions of such dimensions are already a component of DSM-IV, nor likely to be used by busy clinicians without evidence that they improve clinical outcomes.

Conclusions: Despite initial aspirations that DSM would undergo a paradigm shift with this revision, DSM-5 will continue to adopt a descriptive categorical approach, albeit with a greatly expanded dimensional component.

Can J Psychiatry. 2010;55(11):692-700.

Clinical Implications

* Despite dissatisfaction with the current categorical descriptive paradigm, lack of understanding of the pathophysiology of mental disorders necessitates continuing with this paradigm for the foreseeable future.

* Although clinicians think both categorically and dimensionally, requiring dimensional assessments may impose a significant burden with uncertain benefits.

* The possibility that the current paradigm may hinder etiological research may require an uncoupling of the clinical and research goals of the diagnostic system.

Limitations

* The pros and cons of specific DSM-5 proposals were not examined.

* Given that feasibility of dimensional assessments will be tested in field trials, concerns about their clinical utility may be premature.

* Having separate research and clinical diagnostic systems may hinder clinicians' ability to apply research results to their practice.

Key Words: Diagnostic and Statistical Manual of Mental Disorders, psychiatric diagnosis, descriptive approach, paradigm shift, categorical approach, dimensions

Abbreviations used in this article

APA American Psychiatric Association

BD bipolar disorder

DSM Diagnostic and Statistical Manual of Mental Disorders

GAD generalized anxiety disorder

GAF Global Assessment of Functioning

ICD International Classification of Diseases

MDD major depressive disorder

MDE major depressive episode

NIMH National Institutes of Mental Health

NOS not otherwise specified

OCD obsessive-compulsive disorder

PD personality disorder

Work is currently under way on the preparation of DSM-5, which is due in May 2013. From the outset of the DSM-5 revision process in 1999, its developers were hopeful that the changes would be so significant so as to constitute a paradigm shift in psychiatric diagnosis. ' Given current dissatisfaction with the limitations of the DSM-IV descriptive categorical paradigm, it is certainly understandable why such changes would be desired. But has our understanding of the underlying etiology and pathophysiology of psychiatric illnesses progressed far enough to justify such a paradigm shift? …

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