PAPER Psychiatry’s new manual (DSM-5): ethical and conceptual dimensions J S Blumenthal-Barby Correspondence to Professor J S Blumenthal- Barby, Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza, MS 420, Houston, TX 77030, USA; jsswinde@bcm.edu Received 13 March 2013 Revised 11 November 2013 Accepted 13 November 2013 To cite: Blumenthal- Barby JS. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/ medethics-2013-101468 ABSTRACT The introduction of the Diagnostic and statistical manual of mental disorders (DSM-5) in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: (1) Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview (eg, binge eating disorder, internet gaming disorder, caffeine use disorder, hoarding disorder, premenstrual dysphoric disorder). Consequence- based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of “ construct validity” and “ conceptual validity” and a failure to distinguish between “disorder” and “non disordered conditions for which we help people.” (2) The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. (3) Categorisation nosology to spectrum nosology: The move to “degrees of severity” of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. The Diagnostic and statistical manual of mental disorders (DSM) is published by the American Psychiatric Association and provides criteria for the classification of mental disorders (‘psychiatric nos- ology’). It was first published in 1952. The second version (DSM-II) was published in 1968, the DSM-III in 1984, a ‘revised’ version of DSM-III in 1987, the DSM-IV in 1994, a ‘revised’ version of DSM-IV in 2000, and the DSM-5 i was just pub- lished in May of 2013. The evolution of the DSM-5, including the rationales for all proposed changes, can be followed at http://www.dsm5.org. The table of contents for the DSM-5 was released in January 2013 (http://www.psychiatry.org/dsm5). In this paper, I examine three important issues that arise from the new manual: (1) ethical and conceptual issues relating to the relatively signifi- cant expansion of psychiatric nosology; (2) the role of claims about societal impact in rationales for changes in nosology; and (3) ethical and conceptual issues relating to the move to ‘degrees of severity’ of mental disorders (the move from ‘categorisation’ nosology to ‘spectrum’ nosology). EXPANDING NOSOLOGY Psychiatry has once again broadened its nosology to include human experiences not previously under its purview. A growing number of phenomena that were once clinically unremarkable are now labelled as mental disorders and will likely be treated pharmacologically. Examples include: the removal of the bereavement exclusion criterion for diagnosis of major depressive episode, which allows grieving persons to be diagnosed with major depression; the new disorders of premenstrual dysphoric disorder, disruptive mood dysregulation disorder, illness anxiety disorder, hoarding disorder, excoriation (skin picking) disorder, binge eating disorder, lan- guage/speech/social communication disorders and minor neurocognitive disorder; and the ‘conditions for further study’ of persistent complex bereave- ment disorder, attenuated psychosis syndrome, internet gaming disorder, caffeine use disorder, non-suicidal self-injury disorder, suicidal behaviour disorder and neurobehavioral disorder associated with prenatal alcohol disorder. Other conditions for further study that were proposed by the working groups in the draft version of the DSM-5 until a couple of months before the final table of contents was released, but ultimately not included, are mixed anxiety/depression, hypersexual disorder and paraphilic coercive disorder. Consequence-based ethical concerns about expansion There are at least five consequence-based ethical concerns about the expansion: (i) over-diagnosis/ false positives in practice; (ii) risks and costs asso- ciated with pharmacological management of new conditions; (iii) medicalisation of phenomena that results in a shift to individual responsibility and neglect of larger structural issues; (iv) trivialisation of the concept of mental disorder/decrediting of psychiatry; and (v) treatment or eradication of phe- nomena that are desirable or valuable in some way. Turning to the first concern, the authors of the DSM-IV have critiqued the authors of the DSM-5 for expansions that they believe will cause harm i Note the change from Roman numerals to Arabic numerals. Find the explanation for this change here: http://www.dsm5.org/about/Pages/faq.aspx#3 Blumenthal-Barby JS. J Med Ethics 2013;0:1–6. doi:10.1136/medethics-2013-101468 1 Clinical ethics JME Online First, published on December 10, 2013 as 10.1136/medethics-2013-101468 Copyright Article author (or their employer) 2013. Produced by BMJ Publishing Group Ltd under licence. group.bmj.com on December 11, 2013 - Published by jme.bmj.com Downloaded from