DSM-5 two years later: facts, myths and some key
open issues

A. Lasalvia, Guest Editor*

In May 2013, the American Psychiatric Association
(APA) published the fifth edition of its Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). The pro-
cess that led to the release of the DSM-5 took nearly
two decades, with working groups of experts asked
to propose revisions based on the most recent research
findings. Originally, the APA hoped to introduce a
‘paradigm shift’, in which psychiatric diagnosis
would be in greater harmony with neuroscience
(Regier et al. 2009). When it became clear the data sup-
porting these changes were too fragmentary for radical
changes, the APA backed off from major revisions
(Paris & Phillips, 2013). In fact, to date, there is no
knowledge on whether most conditions listed in the
manual are true diseases. In the meantime, while wait-
ing for genetics and neuroscience to elucidate the
causes (and guide the treatment) of psychiatric disor-
ders, we should simply acknowledge, ‘our classifica-
tion of mental disorders is no more than a collection
of fallible and limited constructs that seek, but never
find, an elusive truth. Nevertheless, this is our best cur-
rent way of defining and communicating about mental
disorders’ (Frances & Widiger, 2012).

The main and most consistent criticism of the
DSM-5 (actually it was criticised both before and
after it was formally published) is that it included a
number of new and untested psychiatric disorders
without sufficient data on prevalence, reliability, valid-
ity, treatment response and risk/benefit ratio (Frances,
2010, 2013). According to critics, all of the proposed
new diagnoses, together with lowered thresholds for
some existing diagnostic categories, would expand
psychiatric diagnosis at its fuzzy and hard-to-define
border with normality, leading to overdiagnosis, i.e.,
attributing diagnostic labels to responses to life situa-
tions that should be considered to be within normal
variation. This is both a major clinical and an ethical
issue (Wakefield, 2010, 2013a). Such overdiagnosis
could discredit psychiatry by claiming that there is
no essential difference between mental disorder and
normality, and by forcing clinicians to treat normally

functioning people with medications that they do not
necessarily need (Paris & Phillips, 2013). Psychiatry
has long been criticised for medicalising and patholo-
gising normal variations and overdiagnosis means
overtreatment, with all the existing side effects of psy-
chopharmacological interventions.

However, as critics themselves acknowledge, ‘des-
pite all its epistemological, scientific and even clinical
failings, the DSM incorporates a great deal of practical
knowledge in a convenient and useful format; it does
its job reasonably well when it is applied properly
and when its limitations are understood. One must
strike a proper balance’ (Frances & Widiger, 2012).
At its core, the DSM-5 should be simply regarded ‘as
a guidebook to help clinicians describe and diagnose
behaviours and symptoms of their patients; it provides
clinicians with a common language to deliver the best
patient care possible’ and aims to encourage future
directions in research (Kupfer, 2013).

Two years after its publication, it is time to carefully
weigh the pros and cons of the new diagnostic system
and to explore the facts and the myths surrounding the
DSM-5. For this purpose, we invited to comment in the
‘Editorial in this Issue’ of Epidemiology and Psychiatric
Sciences, two eminent scholars who have leading
roles in the DSM-5 debate taking place in the scientific
literature, Jerome Wakefield (see e.g., Wakefield, 2010,
2013a, b) and Mario Maj (see e.g., Maj, 2012, 2013,
2014).

Wakefield (2015) highlights a number of critical
issues with the DSM-5, considering this new diagnos-
tic system flawed in process, goals and outcome. The
revision process itself suffered from lack of adequate
public record of the rationale for the changes, thus mis-
leading the future scholarship. In fact, for scholars try-
ing to understand and evaluate the validity of the
DSM-5 task force’s decisions, the most important prob-
lem with the revision process was its secrecy and lack
of adequate documentation. Moreover, the declared
goals of the revision process, such as dimensionalising
diagnosis, incorporating biomarkers and separating
impairment from diagnosis (Regier et al. 2009), were
ill-considered and were eventually mostly abandoned.
In Wakefield’s view, the major drawback of the DSM-5
is the worsening of the false-positive problem. This is a
major problem: the DSM-5 has missed the opportunity

* Address for correspondence: Dr A. Lasalvia, Department of
Psychiatry, Azienda Ospedaliera Universitaria Integrata di Verona,
Policlinico “G.B. Rossi”, Piazzale L.A. Scuro, 37134 – Verona, Italy.

(Email: [email protected])

Epidemiology and Psychiatric Sciences (2015), 24, 185–187. © Cambridge University Press 2015
doi:10.1017/S2045796015000256

EDITORIALS IN THIS ISSUE,
JUNE 2015

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to increase the conceptual validity of psychiatric diag-
nosis by aggressively addressing false-positive issues;
in squandering this opportunity, the DSM-5 placed
the hard-won integrity of psychiatry as a medical dis-
cipline at risk. According to Wakefield (2015), the wor-
sening of the false positive problem specifically applies
to: (1) substance use disorder (increasing the symptom
options while decreasing the diagnostic threshold will
pathologise mild conditions), (2) major depression (the
elimination of the bereavement exclusion implies that
bereaved individuals who manifest five general dis-
tress symptoms for 2 weeks after a loss will now be
classified as having a Major Depressive Disorder), (3)
intermittent explosive disorder (allowing verbal argu-
ments among diagnostic criteria will artificially inflate
its prevalence rate) and (4) attention deficit hyperactiv-
ity disorder (expanding diagnosis to adults before
addressing its manifest false positive problems in chil-
dren will perpetuate the same high false positive rate
by encompassing normal variations within the
umbrella of the disorder). On the other hand,
Wakefield (2015) also acknowledges that the DSM-5
has made some progress in addressing the false posi-
tive problem, such as the addition of a more stringent
criterion for insomnia disorder, the exclusion of defiant
behaviour directed only at a sibling for the diagnosis of
oppositional defiant disorder, and the exclusion criter-
ion of severe relationship distress for diagnosing sex-
ual dysfunction. Moreover, the DSM-5 changes are
likely to prevent some false positives, e.g., excluding
‘irritable mood’ from manic episode criteria (only
‘abnormally and persistently increased activity or
energy’ is now required) will probably reduce mis-
diagnoses of bipolar disorders.

Maj (2015) challenges some recurring critical com-
ments in the media that have preceded and followed
the publication of the DSM-5. These include statements
such as (1) the DSM is ‘the bible of psychiatry’ (e.g.,
Horgan, 2013), (2) the DSM pathologises conditions
that are in the range of normality (e.g., Cassels,
2013), (3) the unavailability of biological tests invali-
dates psychiatric diagnoses (e.g., Insel, 2013), and (4)
the Research Domain Criteria (RDoC) project recently
launched by the NIMH in the USA (Cuthbert, 2014)
is going to transform psychiatric diagnosis by
replacing descriptive psychopathology with behav-
ioural and neurobiological measures (e.g., Insel,
2013). Maj challenges these statements by applying
rigorous reasoning and providing compelling evidence
drawn from the scientific literature. Regarding the first
issue, literature shows that only a minority of psychia-
trists around the world use formal diagnostic systems
in their ordinary practice and, when a diagnostics sys-
tem is used, only one tenth of clinicians use the DSM. It
therefore seems that the wide gap exists between

current diagnostic systems and ordinary diagnostic
practice; the scientific community keeps revising diag-
nostic systems, but the impact of these revisions on
clinical practice is much lower than expected. With
regard to the second statement, after having acknowl-
edged that some conditions included in the DSM-5
may not qualify as psychiatric disorders and that the
threshold for the diagnosis of some conditions that
do qualify may be too low. Maj argues that a pragmat-
ic set of inclusion and exclusion criteria needs to be
developed in order to apply them explicitly and con-
sistently when the introduction of a new condition in
the diagnostic system is proposed (and if a balance
between possible benefits of the inclusion and possible
risks is involved in the decision, this should be made
explicit). Moreover, non-validated thresholds should
not be used in the name of reliability or to avoid chan-
ging current assessment instruments; alternative
thresholds should be formally studied, especially
with respect to their clinical utility. As far as the
third issue is concerned, Maj points out that the crucial
element is not whether the threshold for the diagnosis
of a disorder is based on a biological test or a set of
clinical variables, but rather whether the threshold
has sufficient predictive validity (therefore, in the
absence of biological tests, an active search for clinical
thresholds that are predictively valid should be per-
formed). Finally, the notion that the RDoC approach
will transform psychiatric diagnosis in the foreseeable
future is also challenged; based on the current avail-
able research evidence, the RDoC project is more likely
to develop neurobiological measures that may help in
subtyping rather than replacing current diagnostic cat-
egories, with the aim of improving the predictions of
outcomes and treatment responses.

In summary, a number of problems do exist in our
current diagnostic systems (and the DSM-5 has
probably even worsened the situation), and many lim-
itations still affect the diagnostic process in psychiatry.
However, trashing current diagnostic practices may be
harmful for psychiatry’s image and, more importantly,
for our patients. Throwing out the baby with the
bathwater, so to speak, is always dangerous.

References

Cassels C (2013). DSM-5 officially launched, but controversy
persists. Medscape Multispecialty, May 18.

Cuthbert BN (2014). The RDoC framework: facilitating
transition from ICD/DSM to dimensional approaches that
integrate neuroscience and psychopathology. World
Psychiatry 13, 28–35.

Frances A (2010). The first draft of DSM-V if accepted will fan
the flames of false positive diagnoses. BMJ 340, 492.

186 A. Lasalvia

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Frances A (2013). Saving Normal: An Insider’s Revolt Against
Out-of-control Psychiatric Diagnosis, DSM-5, Big Pharma, and
the Medicalization of Ordinary Life. William Morrow & Co.:
New York.

Frances AJ, Widiger T (2012). Psychiatric diagnosis: lessons
from the DSM-IV past and cautions for the DSM-5 future.
Annual Review of Clinical Psychology 8, 109–130.

Horgan J (2013). Psychiatry in crisis! Mental health director
rejects psychiatric “bible” and replaces with. . . nothing.
Scientific American, May 4.

Insel T (2013). Director’s blog: Transforming diagnosis
[Online] [cited 29 Apr 2013] http://www.nimh.nih.gov/
about/director/2013/transforming-diagnosis.shtml.

Kupfer D (2013). Statement by David Kupfer. Chair of DSM-5
Task Force Discusses Future of Mental Health Research.
American Psychiatric Association: Arlington, VA; May 3,
2013 http://www.psych.org/FileLibrary/
AdvocacyandNewsroom/PressReleases/2013Releases/
13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf.

Maj M (2012). Bereavement-related depression in the DSM-5
and ICD-11. World Psychiatry 11, 1–2.

Maj M (2013). The DSM-5 approach to psychotic disorders: is
it possible to overcome the ‘inherent conservative bias’?
Schizophrenia Research 150, 38–39.

Maj M (2014). DSM-5, ICD-11 and ‘pathologization of normal
conditions’. Australian and New Zealand Journal of Psychiatry
48, 193–194.

Maj M (2015). The media campaign on the DSM-5: recurring
commentsandlessonsforthefutureofdiagnosisinpsychiatric
practice. Epidemiology and Psychiatric Sciences, this issue.

Paris J, Phillips J (eds) (2013). Making the DSM-5. Concepts and
Controversies. Springer: New York, pp. 1–180.

Regier DA, Narrow WE, Kuhl EA, Kupfer DJ (2009). The
conceptual development of DSM-5. American Journal of
Psychiatry 166, 645–650.

Wakefield JC (2010). False positives in psychiatric diagnosis:
implications for human freedom. Theoretical Medicine and
Bioethics 31, 5–17.

Wakefield JC (2013a). DSM-5 and clinical social work: mental
disorder and psychological justice as goals of clinical
intervention. Clinical Social Work Journal 41, 131–138.

Wakefield JC (2013b). The DSM-5 debate over the
bereavement exclusion: psychiatric diagnosis and the future
of empirically supported treatment. Clinical Psychology
Review 33, 825–845.

Wakefield JC (2015). DSM-5, psychiatric epidemiology, and
the false positives problem. Epidemiology and Psychiatric
Sciences, this issue.

DSM-5 two years later: facts, myths and some key open issues 187

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1

The Intelligent
Clinician’s Guide
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
McGill University
Montreal, Canada

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AN: 939818 ; Joel Paris.; The Intelligent Clinician’s Guide to the DSM-5
Account: s6527200.main.eds

1
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Oxford. It furthers the University’s objective of excellence in research,
scholarship, and education by publishing worldwide.

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All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the prior
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You must not circulate this work in any other form
and you must impose this same condition on any acquirer.

Cataloging-in-Publication data is on file at the Library of Congress
ISBN 978–0–19–939509–5

The Diagnostic and Statistical Manual of Mental Disorders, DSM, DSM-IV, DSM-IV-TR, and DSM-5 are registered
trademarks of the American Psychiatric Association. Oxford University Press USA is not associated with the
American Psychiatric Association or with any of its products or publications, nor do the views expressed herein
represent the policies and opinions of the American Psychiatric Association.

The statements and opinions in the material contained in this Oxford University Press USA publication and
material which may be accessed from the Oxford University Press USA website, or any others, are those of the
author as indicated. Oxford University Press USA has used reasonable care and skill in compiling the content of this
publication. However, Oxford University Press USA, its employees, and content providers make no warranty as to
the accuracy or completeness of any information in this publication and accept no responsibility or liability for any
inaccuracy or errors and omissions.

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Printed in the United States of America
on acid-free paper

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This book is dedicated to the memory of

Heinz Lehmann—teacher, research pioneer,

and skeptic.

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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
by DSM-5.

—Allen J. Frances, MD, Professor Emeritus,
Department of Psychiatry, Duke University School of Medicine,

Durham, NC

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

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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

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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

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Contents

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

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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

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x i i i

Preface

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
manual.

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.

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PART  I

DIAGNOSTIC PRINCIPLES

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3

1

Introduction

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
of others.

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.

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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
shift.”

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
a mystery.

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

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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
unjustified.

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.

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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

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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.

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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

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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

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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
remarked, the consensus of experts is the source of most medical
errors.

In summary, DSM-5 was a noble attempt at a revision in line
with current research, …