Joel Paris,The Intelligent Clinician’s Guide to the DSM-5

Reviewed by: Deborah Gioia, University of Maryland, School of Social Work, USA

The new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has just been released (May 2013) by the American Psychiatric Association (APA) at their 166th annual meeting titled, Pursuing Wellness Across the Lifespan, held in San Francisco. I was fortunate to be able to attend on the first day as an APA neophyte and to apprehend the enormity of a conference with over 20,000 attendees. The conference guide in magazine format was over 300 pages and contained 25 pages of financial and other disclosure of the presenters with pharmaceutical and grant funders in their research, as well as ads for new psychotropic medications for schizophrenia and other disorders. As a social worker who has made her career in understanding serious mental disorders, I was ‘at home’ with the content of the meeting sessions and knew some of the psychiatrists who were presenting, especially from the psychotic disorders workgroup, but felt a bit disengaged from the overall biological presentation of the material. I was also on a mission to understand what I could of the DSM-5 changes so I could bring this understanding to my psychopathology class the following week. It was quite a task!

Since the DSM-5 was under wraps until 18 May 2013, I searched for some guidance in a text that would help me prepare my lecture material and was pleased to find Dr Paris’ book, The Intelligent Clinician’s Guide to the DSM-5, available for early purchase. Dr Joel Paris is a professor of psychiatry at McGill University in Montreal, who has made a long career of investigating borderline personality disorder in his research, and although he was not directly involved in the DSM-5 revisions, he has been involved in writing, thinking and teaching about diagnosis from DSMI to the present version for the past 30 years. Dr Paris reassures us overall that the changes are manageable, not radical, and that the new text was not the big overhaul of thinking on mental disorders that was initially promised.

So what has changed, and how was I able to incorporate some of those changes into teaching psychopathology for social work students? First, to the uninitiated, one needs to know that the DSM ‘is the standard classification of mental disorders used by mental health professionals in the United States and contains a listing of diagnostic criteria for every psychiatric disorder recognized by the US healthcare system’ (www.DSM5.org). However, it is not a ‘bible’ as has been represented in the press and sometimes used colloquially in our profession. Dr Paris increases our understanding of diagnostic principles in Chapter 1 and Chapter 2 with the history of diagnosing and the history of the DSM manuals in his opening chapters. DSM-5 was not the most controversial manual – DSM-III (1980) was the manual that many psychiatrists thought would destroy the profession because diagnosing was reduced to an algorithm. However, this criteria-based diagnosing also led to a persistent problem of individuals meeting diagnostic criteria for multiple disorders. This issue persisted throughout the DSM-IIIR and the DSM-IVs and was one I saw repeatedly that students made on exams – piling up disorders onto Axis 1. This risk of over-diagnosis has existed with the criteria-based approach of placing boundaries around the fuzziness of diagnoses, and may well exist into the new system of seeing disorders on a continuum from normal to disturbed, despite the fact that the multi-axial assessment has disappeared from the new manual. There are still a lot of blurry boundaries in the middle of the diagnostic continuum while the extremes remain clearer. This approach of scoring or counting criteria of disorders is now known as dimensionality.

According to National Association of Social Workers (NASW), clinical social workers represent the largest group of behavioral health practitioners in the nation. They are often the first to diagnose and treat people with mental disorders. While social workers take into account many factors when considering a formal diagnosis, there are many external pressures to use the DSM to prepare the case and choose an eligible code for receipt of services. Diagnosis is an essential tool for research, for practice, for the pharmaceutical industry, for the legal system, and for the general public. Misuse of diagnosis can lead to over-representation of groups in particular diagnostic categories, to medication overuse, and to stigma. These are consequences for individuals that social workers are particularly sensitive to. During the lunch hour of the APA meeting on the first day the streets surrounding the Moscone Center were filled with chanting protestors, many pushing strollers, who held signs declaring that ‘Childhood is not a mental disorder’. While I stood on the conference side of the street with the psychiatrists, my social work and parent selves pondered where my loyalties truly resided on this issue, especially since the DSM-5 repositioned and redefined disorders in the conduct disorders, mood and emotional dysregulation, and autism spectrum categories.

Psychiatric disorders are complex and on this we can all agree. At what point things are normal and at what point they are pathological is at the heart of the decision-making for clinicians. Dr Paris titles his last chapter after reviewing the individual changes in various disorders – A Guide for the Perplexed. Here he struggles with what has changed and what remains the same, and acknowledges that ‘research is nowhere near to solving the problems at the core of mental disorders’ (p. 183). He encourages us to be pragmatic and not too rigid with the diagnostic categories and always to do what we social workers do best – to consider the individual holistically and in context. He also states ‘learn it but don’t believe in it’ (p. 187) and remember that there will be changes to the manual as new information is incorporated.

I think my students grasped the idea of ‘a working diagnosis’, a sense of the continuum, and the core element of heterogeneity in mental disorders. In fact, I had them do a free write on the notion of heterogeneity which we then shared. I hope that they also understand that the DSM-5, as Dr Paris states, is not a treatment manual. Automatic and standardized ways of approaching a diagnosis are detrimental and may lead us to recommend something that is not really helpful for the individual in front of us. We are not prescribers, but we are recommenders, when we offer up our assessments and diagnoses to the psychiatrist. This has not changed with the arrival of DSM-5. Manual revisions give us an opportunity to pause, to reflect, to get a sense of change and to ask ourselves as Dr Paris advocates, ‘How is this all going to play out in our practice?’ This may well be our new mantra.