The DSM-5 Draft: Critique and Recommendations

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1 The DSM-5 Draft: Critique and Recommendations Psychological Injury and Law ISSN X Volume 3 Number 4 Psychol. Inj. and Law (2010) 3: DOI /s y 1 23

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3 Psychol. Inj. and Law (2010) 3: DOI /s y The DSM-5 Draft: Critique and Recommendations Gerald Young Received: 6 November 2010 / Accepted: 13 November 2010 / Published online: 27 November 2010 # Springer Science+Business Media, LLC Abstract The series of articles in this special topic on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) draft (American Psychiatric Association 2010), which is preparatory to publication of the DSM-5, deals with issues and disorders and conditions pertinent to the field of psychological injury and law. The articles describe and critique the changes anticipated for the diagnoses of posttraumatic stress disorder, pain disorder, and neurocognitive disorder, in particular. Further, changes suggested in the draft for personality disorder are analyzed with a critical eye. In addition, the articles examine the lack of change for dealing with malingering and the general lack of consideration of group differences such as for race, in areas pertinent to psychological injury and law. This summary of the articles concludes that some of the changes in the DSM- 5 draft are premature, and it calls for continued research and evidence-informed bases for recommended changes for the DSM-V. Keywords DSM 5. Critique. Recommendations The series of articles in this special topic on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) draft document (American Psychiatric Association 2010) reviews the proposed changes for the DSM-V (fifth edition; to be published in 2013) from the perspective of the diagnoses and areas of interest relevant to the field of psychological injury and law. The goals of the revision emphasize clinical G. Young (*) Department of Psychology, Glendon College, York University, 2275 Bayview Ave., Toronto, ON, Canada M4N 3M6 gyoung@glendon.yorku.ca utility and guidance by the research evidence, in particular. For the forensic and rehabilitation cases that are involved in psychological injuries, these goals are of prime importance, and we applaud them. Psychological injuries concern some of the most contentious diagnoses and conditions in the DSM project, such as posttraumatic stress disorder (PTSD), chronic pain, and traumatic brain injury (TBI). In addition, the most prevalent diagnoses and conditions are involved, such as major depression and other anxiety disorders. Further, our cases often involve substance abuse, personality factors, including personality disorders, and response biases, including possible malingering. Moreover, prominent court decisions in evidence law, such as Daubert (1993), and its progeny, constrain our field to proffer evidence to court that is based on good science rather than junk or poor science. Finally, the adversarial divide marks the field, and the best way for psychologists to avoid its pitfalls is to undertake comprehensive, impartial assessments that are grounded in science and scientific reasoning. Therefore, the successive versions of DSM manuals that we use in diagnosis should keep improving its scientific basis, reliability, validity (relevance), and clinical utility, in order to help us meet the requirements of our professional training and practice, and the needs defined by our legal cases. The articles in this special issue illustrate that the proposed changes to the DSM-IV-TR (fourth edition, text revision; American Psychiatric Association 2000) will not have the positive incremental changes needed for workers in the field of psychological injury and law. To the contrary, some of the changes could be confusing in terms of clinical utility, others are not scientifically justified, and yet others are clearly not supported by the science on the diagnoses involved.

4 Psychol. Inj. and Law (2010) 3: Special Topic Articles Summary The article on the proposed changes for PTSD (Frueh et al. 2010) indicates that although the empirical research was considered, some of the suggested changes still need empirical support. The changes were considered in keeping with the DSM-IV version, and should not present clinicians with difficulties, unlike the case for other changes proposed in the DSM-5 draft, such as for personality disorders. The authors deal with a fundamental criticism of the DSM system, related to the dimensional versus categorical approach to nosology: they write that perhaps PTSD should be replaced by a dimensional general stress response disorder within the DSM system. Further, the authors recommend that the revised diagnosis might best be relegated to the DSM s appendix for experimental criteria sets. With respect to TBI, Schultz (2010) clearly demonstrates that the changes have multiple inconsistencies and difficulties that contradict extant science. In particular, the proposal to have only two types of neurocognitive disorder, minor and major, and having moderate injuries most likely be considered minor, will have serious consequences in court for many TBI survivors. In addition, the nature of the neuropsychological tests that could help specify the neurocognitive deficits needs further elaboration and justification. Schultz demonstrates how scientific underpinnings should be used in guiding construction of the DSM-V. It would be beneficial that each working group of the DSM related to the area of psychological and psychiatric injury and law name a consultant with forensic and legal expertise. Indeed, given the controversies that could arise with other disorders in court, this strategy should be adopted DSM-wide. In keeping with criticisms of the DSM-IV approach, the DSM-IV category of somatoform disorders has been majorly revised in the DSM-5 draft, including in its nomenclature, primary diagnoses, inclusions of new diagnoses, specific diagnostic criteria, and so on. As for pain disorder, Young (2010) notes that it will become only a specifier of the new diagnostic category of complex somatic symptom disorder. Although the DSM-5 draft recognizes, in general, the biopsychosocial and authentic nature of the various somatic disorders, the pejorative connotations associated with them will remain in the revised DSM and there could be negative ramifications both in getting treatment and seeking compensation in court. Berry and Nelson (2010) deal with a supplementary code in the DSM that was not considered for change in the DSM-5 draft. They indicate that the status of malingering as addressed in the DSM-IV is quite problematic. The DSM criteria for identifying malingering are reviewed and they are evaluated as flawed on both conceptual and practical grounds. The authors recommend that malingering be removed from the DSM-5, and replaced by the concept of feigned psychiatric, physical, and neuropsychological symptoms. This suggestion helps avoid some of the major difficulties associated with the restrictive definition of malingering in the DSM-IV, and widens the scope of the types of response biases that the DSM should consider. Malingering is one evident aspect of the DSM-IV that merits improvement, and there are others that have had no or minor adjustments where major ones or even removal are better options. Livesley (2010) has written a dissenting commentary to the DSM-5 personality disorder (PD) working group of which he is member. The proposed changes to the DSM-IV are major. For example, the number of disorders is reduced from ten to five (antisocial, avoidant, borderline, obsessivecompulsive, and schizotypal), and their content and structure are not entirely equivalent to their predecessors in the DSM-IV. Notably, they are defined in terms of prototypes, and the clinician is asked to indicate the degree of match of patient to type. The diagnosis proceeds in a hierarchical manner, starting with a general diagnosis of PD, leading to more specific considerations, including of type, dimensions, and traits (organized into domains). Livesley argues that essentially the theoretical and empirical bases for the major changes are not elucidated in the DSM-5 draft. This suggests that the DSM-5 PD working group should examine its agendas. If the changes are implemented in the DSM-5, clinicians might find them without clinical utility, it could be harder for patients to get treatment, and it could be harder to have portions of evidence related to PD admitted to court. Young and Johnson (2010) indicate whether the changes in the DSM-5 draft with respect to PTSD lend themselves to consideration of minority, cultural, racial, and ethnic factors. They review recent literature on group differences in the prevalence and symptom manifestation of PTSD. This type of literature needs to be considered in the upcoming DSM-V in order to better guide clinicians and assessors in culturally sensitive diagnosis and treatment of PTSD. However, Young and Johnson conclude that there is much work to be done in this regard not only for PTSD but also for the DSM, in general. Conclusions The DSM-5 draft proposal reflects the effort of multiple working groups functioning under the guidance of senior figures in the field. The goal of revising it in terms of clinical utility and research support is laudable. However, if the types of problems encountered with respect to the diagnoses and conditions relevant to psychological injury and law is any indication, the direction being taken in the

5 322 Psychol. Inj. and Law (2010) 3: revisions might miss the mark in terms of both these goals for a wide array of diagnoses and conditions. It is recommended that the guiding goals underlying the revision process of the DSM-IV be inversed, with the requirement of research support for any recommended changes becoming primary. The second goal of clinical utility will be served best by the DSM-V having a strong research base. In addition, the types of working group political dealings that have characterized the working groups in past DSM revisions and the ongoing one might be tempered by such an approach. In conclusion, some of the changes in the DSM-5 draft seem premature, and there is a need for continued research. The DSM-V should be changed in some areas on the basis of evidence-supported decisions, and kept unchanged in other areas on the same basis. A full evidence-guided approach to development of the DSM-V will help workers in the area of psychological injury and law deal with the complexities of their cases in court and related venues. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington, DC: Author. American Psychiatric Association (2010). Proposed draft revisions to DSM disorders and criteria. Arlington, VA: American Psychiatric Association. Available at: Berry, D. T. R., & Nelson, N. W. (2010). DSM-5 and malingering: a modest proposal. Psychological Injury and Law, 3. Daubert v. Merrell Dow Pharmaceuticals, Inc. 113 S. Ct (1993). Frueh, B. C., Elhai, J. D., & Acierno, R. (2010). The future of posttraumatic stress disorder in the DSM. Psychological Injury and Law, 3. Livesley, W. J. (2010). Confusion and incoherence in the classification of personality disorder: commentary on the preliminary proposals for DSM-5. Psychological Injury and Law, 3. Schultz, I. Z. (2010). Neurocognitive disorders in DSM-V: forensic perspective. Psychological Injury and Law, 3. Young, G. (2010). Trends in psychological/psychiatric injury and law: practice comments, recommendations. Psychological Injury and Law, 3. Young, G., & Johnson, R. (2010). Posttraumatic stress disorder in the DSM-5: group difference commentary. Psychological Injury and Law, 3. Author Note Gerald Young, Department of Psychology, York University. Many thanks to Eric Drogin, Andrew Kane, Izabela Schultz, and Chris Frueh for their helpful comments on the text. In terms of possible conflicts of interest, the author has obtained most of his attorney referrals and psycholegal referrals from plaintiff rather than defense attorneys and assessment companies.