Although people have clearly voiced criticisms of the new manual, one change that’s regularly viewed with great approval is the move from using the old Global Assessment of Functioning scale to new severity scales that are specific to different diagnoses. Clinicians applaud the idea of having separate and unique severity scales for anorexia, bulimia, substance-use disorders, oppositional defiant disorder, and other conditions.
They also approve of the new symptom cluster for post-traumatic stress disorder (PTSD). This new symptom cluster, which comprises negative alterations in mood and cognitions, was added to the original three clusters from DSM-IV: reexperiencing, avoidance, and increased arousal. Some of the new features of the negative cognitions include persistent, distorted self-blame, persistent negative emotional state, feeling detached and estranged, and persistent inability to experience positive emotions. Clinicians feel that the emphasis on these cognitive changes better reflect ways that people with PTSD often feel most affected by their trauma exposure.
Changes in the language of gender dysphoria also seem to reflect positive movement toward a more open, inclusive point of view. The current wording in DSM-5—“some alternative gender”—indicates that we’re now thinking of gender as falling along a continuum, rather than being divided between two qualitatively different sexes. This change reflects major social and cultural shifts in the United States.
The Impact on Therapy
As the authors of DSM-5 remind us again and again, the new manual is nothing if not scientifically up to date: putting it together, they’ve drawn on nearly 20 years of international research into mental disorders since the publication of the previous manual. Yet given all the amazing new discoveries about the brain, scientists and clinicians alike still know remarkably little about the neurological underpinnings of mental disorders—which means that, just like DSM-IV, the new edition remains primarily a categorical classification of mental conditions, based on symptom lists. Except for a surprisingly modest number of genuinely significant changes, including the newly introduced dimensional scales, DSM-5 is still clearly the offspring of DSM-IV. Despite the howls of fear and outrage from its critics, it’s most definitely not a radical departure for psychiatric diagnosis, much less a revolution.
The changes in the manual won’t be critical for doing therapy; most therapists seek to understand how and why clients are troubled before they try to pin them to DSM diagnoses anyway. But the new manual will make a big difference procedurally and bureaucratically. To get paid, therapists will need to rethink how they define and document their clients’ problems according to the template DSM-5 has set before them. Further, there will be rumblings throughout the pharmaceutical companies, since changes in diagnostic practice notoriously tend to precede an increase in the sale of drugs to newly diagnosed populations.
These changes may not seem to have an immediately obvious impact on how we actually treat our clients, but they remind us—if we need reminding—of how much our work is shadowed by the looming twin juggernauts of the insurance industries and the drug companies. In a sense, most therapeutic practices are like mom-and-pop businesses trying to survive in a world increasingly dominated by huge corporations. Indeed, critics of the mental health establishment have long denounced the entire DSM enterprise as little more than a useful tool of the corporate powers that implicitly control the way we do mental health care in this country.
Certainly, DSM is the book we love to hate. And yet, what else is there? Until we have some huge breakthroughs in neurophysiological research explaining what happens neuron-by-neuron to cause mental disorders, our lumbering mental health enterprise needs a common system of diagnostic categories simply so we can talk coherently to each other about our clients. That being the case, DSM-5 isn’t really all that bad. Think of it as a way to help us organize and think about complex, labile, hard-to-understand phenomena in our clients’ lives. It might be difficult to acquire the regular habit of just using the new thing, but as most therapists know, it’s possible to practice new habits—even DSM coding—until they become second nature.
So familiarize yourself with the new print manual, or the electronic version, or one of the other spinoffs: Desk Reference to the Diagnostic Criteria from DSM-5, the Pocket Guide to the DSM-5 Diagnostic Exam, and the Desk Reference to the Diagnostic Criteria from DSM-5. Like it or not, this diagnostic system isn’t going away anytime soon.
Martha Teater, MA, LMFT, is a licensed marriage and family therapist in Waynesville, North Carolina. She was a collaborating clinical investigator for the DSM-5 field trials for routine clinical practice and has trained thousands of clinicians on the DSM-5. Contact: firstname.lastname@example.org.
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