Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
an interview with
Anthony Tobia, MD Psychiatry
The last edition DSM-4 came out in 1994. What is new in DSM-5?
There are some significant conceptual revisions in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For example, the multiaxial system has been removed in favor of a new diagnostic system that incorporates contextual factors and disability. The chapters have also been rearranged to reflect a regrouping of mental disorders. Within each chapter, criteria of some disorders have been revised. For details of updated diagnostic criteria, I would suggest referencing:
Highlights of Changes to DSM-5
The DSM-5 is called, in part, a statistical manual. What is statistical about it?
In development for more than a decade, DSM-5 field trials were conducted for 23 mental disorders. Statistical analyses were conducted to ensure the reliability of the diagnostic criteria. On face value, statistics are also presented in the text of the manual for prevalence, comorbidity, development and course as well as other aspects of the various disorders.
Critics of DSM-5 say that it has defined common problems as clinical disorders for example hoarding. Doesn’t DSM-5 run the risk of over diagnosing problems?
Over-diagnosing disease is always a risk in any aspect of medicine. For “common problems” to be defined as a clinical disorder, they must impair social, occupational or another important area of functioning. If a particular behavior does not cause clinically significant distress in this way, then a psychiatrist will not identify it as a mental illness.
Another criticism of DSM-5 is that it defines mental disorders based on symptoms rather than underlying biological causes. Is this criticism valid?
I don’t believe so. Human behavior – normal and abnormal – has biopsychosocial factors related to its predisposition, precipitation and perpetuation. The DSM has always been atheoretical (the “psychological” of biopsychosocial) with regard to the etiology of human behavior. The manuals’ avoiding defining mental disorders by underlying biological causes is simply consistent with their atheoretical approach.
It’s also important to remember that the DSM is one of many resources psychiatrists have at their disposal; additional texts and medical education supplement the DSM by endowing knowledge of the biological basis of disease. For any individual to solely rely on the DSM as a “cookbook approach” to understanding mental illness would be a dangerous practice.
The American Psychiatric Association estimates it cost $20-$25 million to produce DSM-5. Was that money wisely spent?
Yes. The field of medicine seems to evolve exponentially every year. It’s incumbent on our profession to keep up with the latest advances so as to provide the best care to the population we serve. The (direct) economic burden of Major Depressive Disorder alone is estimated to be $30 billion per year in the US. The investment in an upgraded diagnostic tool that costs <0.1% of the economic burden of one disease the manual aims to “treat” seems like a wise investment.
Having trained in a dual residency in Internal Medicine and Psychiatry at West Virginia University, Anthony Tobia, MD currently holds titles of Associate Professor of Psychiatry and Clinical Associate Professor of Internal Medicine at Rutgers University-Robert Wood Johnson Medical School. Dr. Tobia has dual appointments with the Division of Internal Medicine and Department of Psychiatry where he serves as the Director of Undergraduate Medical Education and Associate Program Director of General Psychiatry Residency Training. Dr. Tobia is triple-boarded, having also gained certification by the Board of Psychosomatic Medicine (2010), and is currently the Director of the Division of Psychosomatic Medicine at Robert Wood Johnson University Hospital. Dr. Tobia’s clinical interests also include addiction medicine, having worked at UBHC’s Mentally Ill/Chemically Addicted (MICA) partial hospital program from 2001-2007; and is credentialed to provide electroconvulsive therapy. Dr. Tobia’s academic interests include various innovative approaches to teaching at the Graduate School of Biomedical Sciences, Robert Wood Johnson Medical School, and the Department of Psychiatry where he holds 5 patents for his teaching methodology.