The Conceptual Evolution of DSM-5

The title of this book suggests that its contents elucidate how we have come to the current point in psychiatric classification and how DSM-5 will be the next step forward. Unfortunately, for the most part, such promise was not fulfilled.

The book consists of 15 chapters grouped into five parts. In general, the chapters do not follow a uniform, coherent structure. One might have hoped that the editors would have requested of the authors to foreshadow the core issues in their respective areas. Instead, there is an admixture of chapters that are purely theoretical and conceptual and of those that report on a single study with little literature overview. The link between some chapters and considerations of changes in DSM-5 are uncertain. Authors von Korff, Andrews, and Delves provide a nice summary of research on the World Health Organization Disability Assessment Schedule, but the competing proposals to address this issue are not described, and where this assessment schedule fits in DSM-5 is not mentioned. The suggested modifications for personality disorder classification have, perhaps, received the most critical comment. Yet, the single chapter in this book that is focused on axis II disorders is a research report of a single study. To be sure, it is an erudite, high-quality piece of work. But it does not offer an evolutionary perspective.

In general, the chapters are well written by leaders in the field. However, a delineation of existing limitations that will be addressed in DSM-5 is absent. The introduction of the book, which is a reprint of an article by Regier and Kupfer published in the Journal, clearly articulates the determined effort to incorporate dimensional ratings into the nosology. But there is no effort to empirically examine the benefit of dimensional ratings. The introduction does not directly link to the ensuing chapters. Nor does it establish the framework and issues that are involved and will be subsequently elaborated in the remainder of the book.

Nowhere in the introductory article, and only in few of the 15 chapters, is the topic of incremental validity raised or addressed. Helzer discusses top-down versus bottom-up approaches toward the development of criteria and asserts that empirical comparison of the construct and predictive validity of the two approaches should guide future (DSM-6) revisions, but this concept is not applied to DSM-5. Instead, Helzer argues that the suggested changes for DSM-5, incorporation of dimensional assessment and the development of standardized tools, are sufficient rationale for revising the DSM. The inclusion of dimensional ratings seems to be one of the major changes to be incorporated into DSM-5. Wittchen et al. review issues involved in the development and selection of dimensional measures for anxiety and depression. They note the sparcity of data guiding the selection of dimensions and recommend criteria for the selection or development of such measures.

In a book whose title refers to the conceptual evolution of the DSM, it is striking that there is not a chapter devoted to a look back at the field over the past 40 years, since the publication of the Washington University criteria, or more narrowly over the past 30 years, since the publication of DSM-III. Are we more validly diagnosing psychiatric disorders today than before 1980, and by what metric can we assert a conclusion? To what extent can the pharmacopia that has arisen during the past couple of decades be attributed to the modern DSM-III era of psychiatric diagnosis? To what extent has the rise in empirically supported psychotherapies been a function of the DSM-III nosology? Is the outcome of our patients more likely to be better today than it would have been upon presentation 30 or more years ago? If patient outcome is not necessarily better, is it better predicted? A book on the conceptual evolution of the DSM should have addressed these and similar questions, as this would serve as the foundation for looking toward the future as well as proposing how the changes in DSM-5 will draw us closer to achieving ultimate goals.

In short, while most of the chapters themselves are well written, the book as a whole lacks a coherent, overriding vision that will provide future nosologists and historians with a clear idea of what was done and why.