Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, and Clinical Utility

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According to its preface, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) “was designed first and foremost to be a useful guide to clinical practice” (DSM-5, p. xli). This statement, consistent with similar statements in the introductory sections of the previous editions of the DSM (e.g., “[DSM-IV-TR’s] highest priority has been to provide a helpful guide to clinical practice”), suggests that the goal of improving clinical utility should play a preeminent role in the DSM-5 decision-making process. In his book review of The Conceptual Evolution of DSM-5 by Regier et al (2011), Phillips (2013, this issue) pointed out that the main emphasis of the DSM-5 revision process was on the introduction of a dimensional component to DSM-5 (i.e., “the single most important precondition for moving forward to improve the clinical and scientific utility of DSM-5 will be the incorporation of simple dimensional measures” and that “one of the major—if not the major—differences between DSM-IV and DSM-5 will be the more prominent use of dimensional measures in DSM-5”). As Phillips noted in his review, the theme of dimensional assessment occupied 7 of the 15 chapters of the book. This interest in adding dimensional measures to DSM-5 continued during the proposal phase of the DSM-5 process, wherein the DSM-5 workgroups were asked to either develop severity measures (self-report and/or clinician rated) or suggest existing severity measures for each of the diagnostic categories in DSM-5. Moreover, a disability measure, the World Health Organization Disability Assessment Schedule (WHO-DAS), and a modification and enhancement of psychiatric symptom measures from the National Institutes of Health’s Patient Reported Outcome Measurement Information System initiative, were tested in the DSM-5 field trials, presumably with the hope that they would be included as an official component of DSM-5. However, by the time the finalized DSM-5 hit the shelves in May 2013, virtually all of the dimensional measures ended up being relegated to Section III of DSM-5, a section containing assessment tools and diagnostic entities for which it was determined “that the scientific evidence is not yet available to support widespread clinical use” (DSM-5, p 24). Of these, only three were included in the print version of the DSM-5 (i.e., the Level 1 cross-cutting measures, the clinician-rated severity scale for psychotic symptoms, and the WHO-DAS). The remaining measures are available as part of the “on-line enhancement” on the American Psychiatric Association (APA) Web site (www.psych.org/dsm5).Given the purported importance of incorporating dimensional measures into DSM-5, what led to their placement into what is likely to be functionally equivalent to DSM-IV’s appendix of Conditions and Axes for Further Study? Phillips put his finger right on it when it he pointed out that it is a mistake to assume that what is useful for researchers will be useful for clinicians and vice versa. Although it is undeniable that quantitative symptom measurement is a fundamental element of psychiatric research, the same is not true of clinical practice. Although clinicians think dimensionally in terms of appreciating the management implications of differentiating between mild and severe cases of conditions such as depression, it does not at all follow that for the purposes of communication, which is after all the primary practical function of the DSM diagnostic system, they find clinical information expressed in terms of quantitative scales to be clinically meaningful or clinically useful.

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