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The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association
(APA). In the United States, the DSM serves as the principal authority
for psychiatric diagnoses. Treatment recommendations, as well as payment
by health care providers,
are often determined by DSM classifications, so the appearance of a new
version has practical importance. The DSM-5 is the first DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the first "living document" version of a DSM.
The DSM-5 is not a major revision of the DSM-IV-TR but there are
significant differences. Changes in the DSM-5 include the
reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the "bereavement exclusion" for depressive disorders; the renaming of gender identity disorder to gender dysphoria; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias, now called paraphilic disorders; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders.
Some authorities criticized the fifth edition both before and
after it was published. Critics assert, for example, that many DSM-5
revisions or additions lack empirical support; inter-rater reliability
is low for many disorders; several sections contain poorly written,
confusing, or contradictory information; and the psychiatric drug
industry may have unduly influenced the manual's content (many DSM-5
workgroup participants had ties to pharmaceutical companies).
Changes from DSM-IV
The DSM-5 is divided into three Sections, using Roman numerals to designate each Section.
Section I
Section
I describes DSM-5 chapter organization, its change from the multiaxial
system, and Section III's dimensional assessments.
The DSM-5 deleted the chapter that includes "disorders usually first
diagnosed in infancy, childhood, or adolescence" opting to list them in
other chapters.
A note under Anxiety Disorders says that the "sequential order" of at
least some DSM-5 chapters has significance that reflects the
relationships between diagnoses.
The introductory section describes the process of DSM revision,
including field trials, public and professional review, and expert
review. It states its goal is to harmonize with the ICD systems and
share organizational structures as much as is feasible. Concern about
the categorical system of diagnosis is expressed, but the conclusion is
the reality that alternative definitions for most disorders are
scientifically premature.
DSM-5 replaces the NOS (Not Otherwise Specified) categories with two options: other specified disorder and unspecified disorder
to increase the utility to the clinician. The first allows the
clinician to specify the reason that the criteria for a specific
disorder are not met; the second allows the clinician the option to
forgo specification.
DSM-5 has discarded the multiaxial system of diagnosis (formerly
Axis I, Axis II, Axis III), listing all disorders in Section II. It has
replaced Axis IV with significant psychosocial and contextual features
and dropped Axis V (Global Assessment of Functioning, known as GAF). The
World Health Organization's (WHO) Disability Assessment Schedule is
added to Section III (Emerging measures and models) under Assessment
Measures, as a suggested, but not required, method to assess
functioning.
Section II: diagnostic criteria and codes
Neurodevelopmental disorders
Schizophrenia spectrum and other psychotic disorders
- All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual).
- A major mood episode is required for schizoaffective disorder
(for a majority of the disorder's duration after criterion A [related
to delusions, hallucinations, disorganized speech or behavior, and
negative symptoms such as avolition] is met).
- Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder.
- Catatonia
in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a
specifier for depressive, bipolar, and psychotic disorders; part of
another medical condition; or of another specified diagnosis.
Bipolar and related disorders
Depressive disorders
Anxiety disorders
- For the various forms of phobias and anxiety
disorders, DSM-5 removes the requirement that the subject (formerly,
over 18 years old) "must recognize that their fear and anxiety are
excessive or unreasonable". Also, the duration of at least 6 months now
applies to everyone (not only to children).
- Panic attack became a specifier for all DSM-5 disorders.
- Panic disorder and agoraphobia became two separate disorders.
- Specific types of phobias became specifiers but are otherwise unchanged.
- The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.
- Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).
Obsessive-compulsive and related disorders
- A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder,
substance-/medication-induced obsessive-compulsive and related
disorder, and obsessive-compulsive and related disorder due to another
medical condition.
- Trichotillomania
(hair-pulling disorder) moved from "impulse-control disorders not
elsewhere classified" in DSM-IV, to an obsessive-compulsive disorder in
DSM-5.
- A specifier was expanded (and added to body dysmorphic disorder
and hoarding disorder) to allow for good or fair insight, poor insight,
and "absent insight/delusional" (i.e., complete conviction that
obsessive-compulsive disorder beliefs are true).
- Criteria were added to body dysmorphic disorder to describe
repetitive behaviors or mental acts that may arise with perceived
defects or flaws in physical appearance.
- The DSM-IV specifier “with obsessive-compulsive symptoms” moved from
anxiety disorders to this new category for obsessive-compulsive and
related disorders.
- There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder.
Trauma- and stressor-related disorders
- Post traumatic stress disorder (PTSD) is now included in a new section titled "Trauma- and Stressor-Related Disorders."
- The PTSD diagnostic clusters were reorganized and expanded from a
total of three clusters to four based on the results of confirmatory
factor analytic research conducted since the publication of DSM-IV.
- Separate criteria were added for children six years old or younger.
- For the diagnosis of acute stress disorder
and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified
to some extent. The requirement for specific subjective emotional
reactions (Criterion A2 in DSM-IV) was eliminated because it lacked
empirical support for its utility and predictive validity.
Previously certain groups, such as military personnel involved in
combat, law enforcement officers and other first responders, did not
meet criterion A2 in DSM-IV because their training prepared them to not
react emotionally to traumatic events.
- Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.
- Adjustment disorders
were moved to this new section and reconceptualized as stress-response
syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and
disturbed conduct are unchanged.
Dissociative disorders
Somatic symptom and related disorders
- Somatoform disorders are now called somatic symptom and related disorders.
- Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.
- Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.
- Somatic symptom and related disorders are defined by positive
symptoms, and the use of medically unexplained symptoms is minimized,
except in the cases of conversion disorder and pseudocyesis (false pregnancy).
- A new diagnosis is psychological factors affecting other medical
conditions. This was formerly found in the DSM-IV chapter "Other
Conditions That May Be a Focus of Clinical Attention".
- Criteria for conversion disorder (functional neurological symptom disorder) were changed.
Feeding and eating disorders
- Criteria for pica and rumination disorder were changed and can now refer to people of any age.
- Binge eating disorder graduated from DSM-IV's "Appendix B -- Criteria Sets and Axes Provided for Further Study" into a proper diagnosis.
- Requirements for bulimia nervosa
and binge eating disorder were changed from "at least twice weekly for 6
months to at least once weekly over the last 3 months".
- The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
- "Feeding disorder of infancy or early childhood", a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.
Elimination disorders
- No significant changes.
- Disorders in this chapter were previously classified under disorders
usually first diagnosed in infancy, childhood, or adolescence in
DSM-IV. Now it is an independent classification in DSM 5.
Sleep–wake disorders
Sexual dysfunctions
- DSM-5 has sex-specific sexual dysfunctions.
- For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.
- Sexual dysfunctions (except substance-/medication-induced sexual
dysfunction) now require a duration of approximately 6 months and more
exact severity criteria.
- A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
- Sexual aversion disorder was deleted.
- Subtypes for all disorders include only "lifelong versus acquired"
and "generalized versus situational" (one subtype was deleted from
DSM-IV).
- Two subtypes were deleted: "sexual dysfunction due to a general
medical condition" and "due to psychological versus combined factors".
Gender dysphoria
- DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria
in DSM-5. Separate criteria for children, adolescents and adults that
are appropriate for varying developmental states are added.
- Subtypes of gender identity disorder based on sexual orientation were deleted.
- Among other wording changes, criterion A and criterion B
(cross-gender identification, and aversion toward one's gender) were
combined.
Along with these changes comes the creation of a separate gender
dysphoria in children as well as one for adults and adolescents. The
grouping has been moved out of the sexual disorders category and into
its own. The name change was made in part due to stigmatization of the
term "disorder" and the relatively common use of "gender dysphoria" in
the GID literature and among specialists in the area.
The creation of a specific diagnosis for children reflects the lesser
ability of children to have insight into what they are experiencing and
ability to express it in the event that they have insight.
Disruptive, impulse-control, and conduct disorders
Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders. Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter "Impulse-Control Disorders Not Otherwise Specified".
- Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).
- Symptoms for oppositional defiant disorder
are of three types: angry/irritable mood, argumentative/defiant
behavior, and vindictiveness. The conduct disorder exclusion is deleted.
The criteria were also changed with a note on frequency requirements
and a measure of severity.
- Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited "prosocial emotion", showing callous and unemotional traits.
- People over the disorder's minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression.
Criteria were added for frequency and to specify "impulsive and/or
anger based in nature, and must cause marked distress, cause impairment
in occupational or interpersonal functioning, or be associated with
negative financial or legal consequences".
Substance-related and addictive disorders
- Gambling disorder and tobacco use disorder are new.
- Substance abuse and substance dependence
from DSM-IV-TR have been combined into single substance use disorders
specific to each substance of abuse within a new "addictions and related
disorders" category. "Recurrent legal problems" was deleted and "craving or a strong desire or urge to use a substance" was added to the criteria. The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added. New specifiers were added for early and sustained remission along with new specifiers for "in a controlled environment" and "on maintenance therapy".
There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.
Neurocognitive disorders
Personality disorders
- Personality disorder
(PD) previously belonged to a different axis than almost all other
disorders, but is now in one axis with all mental and other medical
diagnoses. However, the same ten types of personality disorder are retained.
- There is a call for the DSM-5 to provide relevant clinical
information that is empirically based to conceptualize personality as
well as psychopathology in personalities. The issue(s) of heterogeneity
of a PD is problematic as well. For example, when determining the
criteria for a PD it is possible for two individuals with the same
diagnosis to have completely different symptoms that would not
necessarily overlap.
There is also concern as to which model is better for the DSM - the
diagnostic model favored by psychiatrists or the dimensional model that
is favored by psychologists. The diagnostic approach/model is one that
follows the diagnostic approach of traditional medicine, is more
convenient to use in clinical settings, however, it does not capture the
intricacies of normal or abnormal personality. The dimensional
approach/model is better at showing varied degrees of personality; it
places emphasis on the continuum between normal and abnormal, and
abnormal as something beyond a threshold whether in unipolar or bipolar
cases.
Paraphilic disorders
- New specifiers "in a controlled environment" and "in remission" were added to criteria for all paraphilic disorders.
- A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia.
There is no change in the basic diagnostic structure since DSM-III-R;
however, people now must meet both qualitative (criterion A) and
negative consequences (criterion B) criteria to be diagnosed with a
paraphilic disorder. Otherwise they have a paraphilia (and no
diagnosis).
Section III: emerging measures and models
Alternative DSM-5 model for personality disorders
An
alternative hybrid dimensional-categorical model for personality
disorders is included to stimulate further research on this modified
classification system.
Conditions for further study
These conditions and criteria are set forth to encourage future research and are not meant for clinical use.
Development
In 1999, a DSM-5 Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health
(NIMH), was held to set the research priorities. Research Planning Work
Groups produced "white papers" on the research needed to inform and
shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature.
There were six workgroups, each focusing on a broad topic:
Nomenclature, Neuroscience and Genetics, Developmental Issues and
Diagnosis, Personality and Relational Disorders,
Mental Disorders and Disability, and Cross-Cultural Issues. Three
additional white papers were also due by 2004 concerning gender issues,
diagnostic issues in the geriatric population, and mental disorders in
infants and young children.
The white papers have been followed by a series of conferences to
produce recommendations relating to specific disorders and issues, with
attendance limited to 25 invited researchers.
On July 23, 2007, the APA announced the task force that would
oversee the development of DSM-5. The DSM-5 Task Force consisted of 27
members, including a chair and vice chair, who collectively represent
research scientists from psychiatry and other disciplines, clinical care
providers, and consumer and family advocates. Scientists working on the
revision of the DSM had a broad range of experience and interests. The
APA Board of Trustees required that all task force nominees disclose any
competing interests or potentially conflicting relationships with
entities that have an interest in psychiatric diagnoses and treatments
as a precondition to appointment to the task force. The APA made all
task force members' disclosures available during the announcement of the
task force. Several individuals were ruled ineligible for task force
appointments due to their competing interests.
The DSM-5 field trials included test-retest reliability
which involved different clinicians doing independent evaluations of
the same patient—a common approach to the study of diagnostic
reliability.
About 68% of DSM-5 task-force members and 56% of panel members reported having ties to the pharmaceutical industry, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards.
Revisions and updates
Beginning with the fifth edition, it is intended that diagnostic guideline revisions will be added incrementally. The DSM-5 is identified with Arabic rather than Roman numerals,
marking a change in how future updates will be created. Incremental
updates will be identified with decimals (DSM-5.1, DSM-5.2, etc.), until
a new edition is written.
The change reflects the intent of the APA to respond more quickly when
a preponderance of research supports a specific change in the manual.
The research base of mental disorders is evolving at different rates for
different disorders.
Criticism
General
Robert Spitzer, the head of the DSM-III task force, publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement,
effectively conducting the whole process in secret: "When I first heard
about this agreement, I just went bonkers. Transparency is necessary if
the document is to have credibility, and, in time, you're going to have
people complaining all over the place that they didn't have the
opportunity to challenge anything." Allen Frances, chair of the DSM-IV task force, expressed a similar concern.
Although the APA has since instituted a disclosure policy for
DSM-5 task force members, many still believe the association has not
gone far enough in its efforts to be transparent and to protect against
industry influence.
In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J.
Bursztajn, MD noted that "the fact that 70% of the task force members
have reported direct industry ties—an increase of almost 14% over the
percentage of DSM-IV task force members who had industry ties—shows that
disclosure policies alone, especially those that rely on an honor
system, are not enough and that more specific safeguards are needed".
David Kupfer, chair of the DSM-5 task force, and Darrel A.
Regier, MD, MPH, vice chair of the task force, whose industry ties are
disclosed with those of the task force,
countered that "collaborative relationships among government, academia,
and industry are vital to the current and future development of
pharmacological treatments for mental disorders". They asserted that the
development of DSM-5 is the "most inclusive and transparent
developmental process in the 60-year history of DSM". The developments
to this new version can be viewed on the APA website. Public input was requested for the first time in the history of the manual. During periods of public comment, members of the public could sign up at the DSM-5 website and provide feedback on the various proposed changes.
In June 2009, Allen Frances issued strongly worded criticisms of
the processes leading to DSM-5 and the risk of "serious, subtle, (...)
ubiquitous" and "dangerous" unintended consequences such as new "false
'epidemics'". He writes that "the work on DSM-V has displayed the most
unhappy combination of soaring ambition and weak methodology" and is
concerned about the task force's "inexplicably closed and secretive
process".
His and Spitzer's concerns about the contract that the APA drew up for
consultants to sign, agreeing not to discuss drafts of the fifth edition
beyond the task force and committees, have also been aired and debated.
The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them.
According to MSNBC, "The petition accuses Zucker of having engaged in
'junk science' and promoting 'hurtful theories' during his career,
especially advocating the idea that children who are unambiguously male
or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy." According to The Gay City News,
"Dr. Ray Blanchard, a psychiatry professor at the University of
Toronto, is deemed offensive for his theories that some types of
transsexuality are paraphilias, or sexual urges. In this model,
transsexuality is not an essential aspect of the individual, but a
misdirected sexual impulse."
Blanchard responded, "Naturally, it's very disappointing to me there
seems to be so much misinformation about me on the Internet. [They
didn't distort] my views, they completely reversed my views."
Zucker "rejects the junk-science charge, saying there 'has to be an
empirical basis to modify anything' in the DSM. As for hurting people,
'in my own career, my primary motivation in working with children,
adolescents and families is to help them with the distress and suffering
they are experiencing, whatever the reasons they are having these
struggles. I want to help people feel better about themselves, not hurt
them.'"
In 2011, psychologist Brent Robbins
co-authored a national letter for the Society for Humanistic Psychology
that brought thousands into the public debate about the DSM.
Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition. In a November 2011 article about the debate in the San Francisco Chronicle,
Robbins notes that under the new guidelines, certain responses to grief
could be labeled as pathological disorders, instead of being recognized
as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.
The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders.
A book-long appraisal of the DSM-5, with contributions from
philosophers, historians and anthropologists, was published in 2015.
The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest.
Of the DSM-5 task force members, 69% report having ties to the
pharmaceutical industry, an increase from the 57% of DSM-IV task force
members.
A 2015 essay from an Australian university criticized the DSM-5
for having poor cultural diversity, stating that recent work done in
cognitive sciences and cognitive anthropology is still only accepting
western psychology as the norm.
However, DSM-5 does now include a section on how to conduct a ‘cultural formulation interview’. Published in 2013, the cultural formulation interview gives information. about how a persons cultural identity may be affecting expression of signs and symptoms. This helps clinicians to make a much more valid diagnosis for disorders subject to significant cultural variation.
Borderline personality disorder controversy
In
2003, the Treatment and Research Advancements National Association for
Personality Disorders (TARA-APD) campaigned to change the name and
designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reported that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma."
Instead, it proposed the name "emotional regulation disorder" or
"emotional dysregulation disorder." There was also discussion about
changing borderline personality disorder, an Axis II diagnosis
(personality disorders and mental retardation), to an Axis I diagnosis
(clinical disorders).
The TARA-APD recommendations do not appear to have affected the
American Psychiatric Association, the publisher of the DSM. As noted
above, the DSM-5 does not employ a multi-axial diagnostic scheme,
therefore the distinction between Axis I and II disorders no longer
exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR.
British Psychological Society response
The British Psychological Society stated in its June 2011 response to DSM-5 draft versions, that it had "more concerns than plaudits".
It criticized proposed diagnoses as "clearly based largely on social
norms, with 'symptoms' that all rely on subjective judgements... not
value-free, but rather reflect[ing] current normative social
expectations", noting doubts over the reliability, validity, and value
of existing criteria, that personality disorders were not normed on the
general population, and that "not otherwise specified" categories
covered a "huge" 30% of all personality disorders.
It also expressed a major concern that "clients and the general
public are negatively affected by the continued and continuous
medicalisation of their natural and normal responses to their
experiences... which demand helping responses, but which do not reflect
illnesses so much as normal individual variation".
The Society suggested as its primary specific recommendation, a
change from using "diagnostic frameworks" to a description based on an
individual's specific experienced problems, and that mental disorders
are better explored as part of a spectrum shared with normality:
[We recommend] a revision of the
way mental distress is thought about, starting with recognition of the
overwhelming evidence that it is on a spectrum with 'normal' experience,
and that psychosocial factors such as poverty, unemployment and trauma
are the most strongly-evidenced causal factors. Rather than applying
preordained diagnostic categories to clinical populations, we believe
that any classification system should begin from the bottom up –
starting with specific experiences, problems or 'symptoms' or
'complaints'... We would like to see the base unit of measurement as
specific problems (e.g. hearing voices, feelings of anxiety etc.)? These
would be more helpful too in terms of epidemiology.
While some people find a name or a diagnostic label helpful, our
contention is that this helpfulness results from a knowledge that their
problems are recognised (in both senses of the word) understood,
validated, explained (and explicable) and have some relief. Clients
often, unfortunately, find that diagnosis offers only a spurious promise
of such benefits. Since – for example – two people with a diagnosis of
'schizophrenia' or 'personality disorder' may possess no two symptoms in
common, it is difficult to see what communicative benefit is served by
using these diagnoses. We believe that a description of a person's real
problems would suffice. Moncrieff and others have shown that diagnostic
labels are less useful than a description of a person's problems for
predicting treatment response, so again diagnoses seem positively
unhelpful compared to the alternatives. - British Psychological Society June 2011 response
National Institute of Mental Health
National Institute of Mental Health director Thomas R. Insel, MD, wrote in an April 29, 2013 blog post about the DSM-5:
The goal of this new manual, as
with all previous editions, is to provide a common language for
describing psychopathology. While DSM has been described as a "Bible"
for the field, it is, at best, a dictionary, creating a set of labels
and defining each. The strength of each of the editions of DSM has been
"reliability" – each edition has ensured that clinicians use the same
terms in the same ways. The weakness is its lack of validity ...
Patients with mental disorders deserve better.
Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only. Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as "Goodbye to the DSM-V", "Federal institute for mental health abandons controversial 'bible' of psychiatry", "National Institute of Mental Health abandoning the DSM", and "Psychiatry divided as mental health 'bible' denounced". Other responses provided a more nuanced analysis of the NIMH Director's post.
In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association,
that emphasized that DSM-5 "... represents the best information
currently available for clinical diagnosis of mental disorders.
Patients, families, and insurers can be confident that effective
treatments are available and that the DSM is the key resource for
delivering the best available care. The National Institute of Mental
Health (NIMH) has not changed its position on DSM-5." Insel and
Lieberman say that DSM-5 and RDoC "represent complementary, not
competing, frameworks" for characterizing diseases and disorders.
However, epistemologists of psychiatry tend to see the RDoC project as a
putative revolutionary system that in the long run will try to replace
the DSM, its expected early effect being a liberalization of the
research criteria, with an increasing number of research centers
adopting the RDoC definitions.