Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 5th Edition
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This new edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), used by clinicians and researchers to diagnose and classify mental disorders, is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research.
The criteria are concise and explicit, intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consultation-liaison, clinical, private practice, and primary care. New features and enhancements make DSM-5 easier to use across all settings:
- The chapter organization reflects a lifespan approach, with disorders typically diagnosed in childhood (such as neurodevelopmental disorders) at the beginning of the manual, and those more typical of older adults (such as neurocognitive disorders) placed at the end. Also included are age-related factors specific to diagnosis.
- The latest findings in neuroimaging and genetics have been integrated into each disorder along with gender and cultural considerations.
- The revised organizational structure recognizes symptoms that span multiple diagnostic categories, providing new clinical insight in diagnosis.
- Specific criteria have been streamlined, consolidated, or clarified to be consistent with clinical practice (including the consolidation of autism disorder, Asperger’s syndrome, and pervasive developmental disorder into autism spectrum disorder, the streamlined classification of bipolar and depressive disorders, the restructuring of substance use disorders for consistency and clarity, and the enhanced specificity for major and mild neurocognitive disorders).
- Dimensional assessments for research and validation of clinical results have been provided.
- Both ICD-9-CM and ICD-10-CM codes are included for each disorder, and the organizational structure is consistent with the new ICD-11 in development.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most comprehensive, current, and critical resource for clinical practice available to today's mental health clinicians and researchers of all orientations. The information contained in the manual is also valuable to other physicians and health professionals, including psychologists, counselors, nurses, and occupational and rehabilitation therapists, as well as social workers and forensic and legal specialists
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From the Back Cover
This new edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), used by clinicians and researchers to diagnose and classify mental disorders, is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research. This manual, which creates a common language for clinicians involved in the diagnosis of mental disorders, includes concise and specific criteria intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings—inpatient, outpatient, partial hospital, consultation-liaison, clinical, private practice, and primary care.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most comprehensive, current, and critical resource for clinical practice available to today's mental health clinicians and researchers of all orientations. The information contained in the manual is also valuable to other physicians and health professionals, including psychologists, counselors, nurses, and occupational and rehabilitation therapists, as well as social workers and forensic and legal specialists. DSM-5 is the most definitive resource for the diagnosis and classification of mental disorders.
Product details
- Publisher : American Psychiatric Publishing; 5th edition (May 27, 2013)
- Language : English
- Paperback : 991 pages
- ISBN-10 : 0890425558
- ISBN-13 : 978-0890425558
- Reading age : 15 years and up
- Item Weight : 3.1 pounds
- Dimensions : 7.25 x 1.5 x 10 inches
- Best Sellers Rank: #23,550 in Books (See Top 100 in Books)
- #5 in Medical Mental Illness
- #9 in Popular Psychology Reference
- #49 in Medical Psychology Pathologies
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Every 10 years or so, the American Psychiatric Association comes forth with a new or revised dictum on the right way to look at and ultimately diagnose mental disorders. This is a very exacerbating, costly and unpredictable task that makes the outsider question the mental stability and masochistic needs of this very respectable and highly educated group of men and women. The end result is always affirmed by some, criticized by others, and nullified by yet a third group who think that the whole experiment of upgrading psychiatric nomenclature in lieu of the WHO's ICD-9 and ICD-10-CM (International Statistical Classification of Diseases and Related Health Problems) is ridiculous and unwarranted.
This review is not geared toward taking a stand on the DSM-V (even though I must confess that I am impressed) but mainly to take one segment and bring it into some level of sensibility. The primary area of concentration deals with paraphilias.
The DSM-IV-TR is and was a workable treatise and the DSM-5 (published on May 17, 2013), as far as paraphilic components are concerned is a continuation of the same. The nomenclature, though, is slightly different:
DSM-IV-TR DSM-V
Exhibitionism Exhibitionistic disorder
Fetishism Fetishistic disorder
Frotteurism Frotteuristic disorder
Pedophilia Pedophilic disorder
Sexual masochism Sexual masochism disorder
Sexual sadism Sexual sadism disorder
Transvestic fetishism Transvestic disorder
Voyeurism Voyeuristic disorder
Paraphilia NOS Other specified paraphilic disorder
Unspecified paraphilic disorder
These paraphilic disorders can be explained (DSM-5) as:
Disorder Behavior
Anomalous Activity Preferences
"Courtship Disorders"
Voyeuristic disorder -spying on others in private activities
Exhibitionistic disorder -exposing the genitals
Frotteuristic disorder -touching or rubbing against a nonconsenting individual
"Algolagnic Disorders"
Or Pain and Suffering
Sexual masochism disorder -undergoing humiliation, bondage or suffering
Sexual sadism disorder -inflicting humiliation, bondage or suffering
Anomalous Target Preferences
Or Human Target
Pedophilic disorder -sexual focus on children
Other than Human Target
Fetishistic disorder -using nonliving objects or having a highly specific focus on non-genital body parts
Transvestic disorder -engaging in sexually arousing cross-dressing
Published on May 17, 2013 the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition or DSM-5 is the formal (and DSM-5 abbreviated) name of the manual. It bases diagnoses by "prioritizing behavior over biology... (Relies) primarily on physical or behavioral symptoms to categorize and diagnose psychological disorders." (Parks, 2013) Yet, the structure of the DSM-5 "should improve clinicians' ability to identify diagnoses in a disorder spectrum based on common neural circuitry, genetic vulnerability, and informal exposures." (American Psychiatric Association, DSM-5, 2013, p. xlii) The DSM-5 is many things, which will likely all be debated, with one special ingredient - cogency. It is clear and concise and except for some discrepancies fairly research based.
Clinicians when dealing with cases of sexual assault and particularly Megan's Law should make sure that they are familiar with, at a minimum, such terms/phrases as anomalous activity preferences, anomalous target preferences, algolagnic disorders, paraphilia, normal sexual behavior, intense, persistent, normophilic (sexual interest), orientation, benign paraphilia, other specified paraphilic disorder, unspecified paraphilic disorder, admitting individual and preferential.
Almost all the paraphilic disorders listed in the DSM-5 are likely criminal (when acted upon with non-consenting persons) and in many Commonwealths when adjudicated on a registered type sexual offense, violent (by statute). Some paraphilias relate to a person's erotic actions while others relate to the focus of same or the "target." The paraphilic disorders noted in the DSM-5 are the most common of the paraphilias but there are many others. None of the listed paraphilic disorders actually require physical contact, contrary to the DSM-IV-TR where sexual sadism did.
A paraphilic disorder is a paraphilia but the latter is "a necessary but not a sufficient condition for having a paraphilic disorder and a paraphilia by itself does not necessarily justify or require clinical intervention." Simply some people identify with a paraphilia, e.g., transvestism, and have an intense and persistent interest in cross-dressing but they (a genetic male) are able to go to work on some days dressed as a woman and on other days as a man, are accepted by their supervisors and coworkers, like to fondle their wife's genitals and have her fondle his, and have coitus with their playful and consenting wife while dressed as a woman. They may have had some distress about their cross-dressing when younger but now find themselves accepting of who they are and do not put themselves or others in harm's way (or at any risk).
The "paraphilia" is the condition, the "paraphilic" is the disorder. There is a need for unusual sexual stimulation but there is not a need for "extreme or dangerous" practices "in order to achieve sexual arousal or orgasm." (Encarta)
What is normal adult sexual behavior? The DSM-5 denotes "paraphilia" as "any intense and persistent sexual interest other than a sexual interest in general stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners." The interpretation of the DSM-5 definition leads one to believe that "normal" is sexual behavior that is age and maturity appropriate, consensual, humanly exchanged or in some way shared, and geared to feeling and/or rousing oneself and/or another. The DSM-5 uses the term "phenotypically normal" as part of its definition of sexually normal interactions. Phenotype means, I believe, physical appearance or "I am who I am;" e.g., my genes and environment formed me and I look and behave as such. Anything else is a paraphilia or "any intense and persistent sexual interest" other than normal sexual interests as described above. Nonetheless, and in special cases, "intense" can "be defined as any sexual interest greater than or equal to normophilic sexual interests."
The paraphilias are broken down into an "individuals erotic activities" and an "individuals erotic targets." To have a paraphilic disorder the "paraphilia has to cause distress or impairment to the individual or where the paraphilia's satisfaction has entailed personal harm, or risk of harm, to others." For a diagnosis of a paraphilic disorder both criterion A and criterion B has to be met (See DSM-5 Manual).
Without going into every paraphilic condition, a few components of the DSM-5's Paraphilic Disorder section needs to be brought to the reader's attention. Some factors below might be looked upon as criticisms of the DSM-5 when in actuality they are more questions as to "why?"
1- A paraphilia is a paraphilia (as mentioned) but it does not have to be a paraphilic disorder;
2- Two or more paraphilias can exist and each can be listed as a paraphilic disorder in its own right (p.686);
3- Self and clinician-rating measures can be an acceptable tool(s) to determining the "strength of the paraphilia" and its level of consequence (p.686). Will this acknowledgement of such rating scales prove to be a troubling element, especially in criminal prosecution of sex offenders?
4- Reactive variables (distress and impairment in other areas of functioning) in conjunction with criterion B should be a direct effect of the paraphilic disorder and not some other psychosocial dilemma. The DSM-5 promotes the quantifying of these life variables (p. 686) but how astutely can they be measured?
5- "In a controlled environment" as a remission factor - is it used more for semantics and description of reason for milieu (institutional or hospital) based respite of the condition?
6- "In full remission" requires 5 years of control and reasonably good adjustment in an "open setting" but does it not preclude a latent presence of the paraphilic disorder (pp. 686-705)?
7- Underlying some of the paraphilic disorders (i.e., excluding frotteuristic, sexual masochism, fetishistic and transvestic) is whether or not the person is attracted to prepubertal children, which ultimately are the most harmful and disturbing of the paraphilias listed. This is usually a case of comorbidity;
8- Consenting persons who experience the paraphilic disorder is not clearly explained in the DSM-5. Are these people looked upon as sublimates' (to channel impulses or energies regarded as unacceptable, especially sexual desires, toward an activity that is more socially acceptable - Escarta) or are they ardors to cooling the illegality (indiscretion) of the passion or neutral factors in an paradoxical abyss?
9- Although much research (Karl Hanson, Dennis Doren, Gene Able, Robert Hare - see page 765 under "alternative...," David Thornton, Howard Barbaree, Anna Salter, Michael Seto and many others) has been done in the last 15 years into paraphilias and sex offending, have factors related to prevalence, course, etiology, prognostics, gender, differential diagnosis and comorbidity been actuarially dismissed? Have studies done in England and Canada either been ignored or diplomatically side stepped?
10- Can a "sexual interest" (behavior, orientation, sexual orientation or arousal) versus a paraphilic disorder still be criminal if there is direct and ascertained victimization?
11- Perpetrators often rationalize to the extreme. There are only a few (admitters or "admitting individuals") who open up and acknowledge the specifics of their condition right from the start. Examiners need to look at "past episodes," arrest history, mental health records, victimization frequency, "separate patterns," and so forth (collaborating evidence) to determine whether the aspects of "recurring, motivated, distress and harm" and other DSM-5 factors within the Criterion apply. Simply, objectivity as well as common sense must be employed;
12- The DSM-5 promotes itself with impartiality, scientific findings and evidence, latest research, validated diagnoses, and empirically supported statements but are there too many unknowns, clarity problems, estimates, "might occur," "sometimes" and "have reported" among the paraphilic disorders in conjunction with associated features, prevalence, development, course, age at onset, and functional consequences (See#9)?
13- Should sexual masochism disorder be considered a primary or secondary sexual offense or a felony in and of itself or a common law crime? What of other participants? Should they be charged for abetting or encouraging this self-harming behavior? It may often co-occur or be a derivative of another paraphilia, but the pseudo-primary narcissistic components of this condition leave it in somewhat of nebulous position. What is the masochist's true goal and how should his or her actions be perceived? Can this not also be the case with transvestic and fetishistic disorders?
14- If the data on paraphilias is interpreted correctly, the DSM-5 task force are implying that in the neighborhood of 20% of our population has a paraphilia or is oriented at times (atypical sexual interest) to same. Is it really that bad? What about a recidivistic position - isn't that what our Courts and society in general are looking for?
15- DSM-5 task force members are trying to lay the groundwork for science, but how are they ever going to measure a fantasy or an urge? Neuroimaging, EEGs, EMGs and the like have come a long way, but is gauging a fantasy or urge just too far out for our generational neuroscientists? Penile plethysmograph (PPG), vaginal photoplethysmography (VPG), clinical polygraphs and ABLEs (visual timing) have evidently been dismissed by the task force as too controversial and possibly in some states illegal. Maybe the words "fantasy" and/or "urge" should be removed from the diagnostic criteria? But how can they? Can self-reporting be truly measured? Sematic differential scales, but where is the affect?
16- Etiology for paraphilias is now more confusing, hypothetical and lacking than ever (See #9)? From the standpoint of diagnosing, does it really matter?
17- Although not plausible and likely not intended, certain paraphilias and paraphilic disorders can be diagnosed at any age (e.g., voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual masochism disorder, sexual sadism disorder, fetishistic disorder, transvestic disorder). Are we going to have to keep an eye on our nursery school kids when they run around in their swimming suits?
18- Culture is brought up as a variable of contention in diagnosing certain paraphilic disorders, but doesn't criterion A and criterion B account for the same? What culture has (normative) behaviors that allow (or accepts) recurrent and intense sexual arousal for at least six months? What culture affirms sexual focus on nonliving objects and/or non-genital parts of the body? Who promotes in their culture fantasies, urges and behaviors that cause generic malfunctioning of the person and risks to their neighbor? From studies reviewed, there is only one culture in the world that promotes and approves what we classify as pedophilia and none are necrophilia proponents;
19- Is "other specified paraphilic disorder and unspecified paraphilic disorder" a peripheral alternative for sexual atypical conditions/practices outside the eight main paraphilics' listed and is "unspecified" going to be an argumentative catalyst to a courtroom state of inauspiciousness? and
20- Pornography and Internet sex obsessions which is frequently in the public mindfulness is not mentioned directly (only as associated features) and rape (now viewed as solely criminal) has no place among the paraphilic disorders. Did the task force forget something? Should these (especially pornography and Internet sex obsessions) be seen as sexual narcissistic sublimates, a derivative of a paraphilic, pseudo voyeurism in their own right or more in line with a personality disorder ("an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" p. 645) than a paraphilic disorder (other specified)? Possibly pornography and internet sex obsessions will be left in a limbo position (where it has seemed to be, not like gambling disorder or internet gaming disorder under "conditions for future study"), i.e., being a means to an end (child porn > pedophilia, sadistic porn > sadism disorder, etcetera) and not an end in itself.
In sum, the DSM-5 Paraphilic Disorders is an upgrade to the DSM-IV-TR and has opened up the door to clearer diagnostic labeling. It seems to pardon offenses of the past and gives societal parameters to accepting non-criminal intentions of sensual satisfaction and sharing. It should be read and studied by all in the professional MH community.
In DSM-5 the APA is establishing a new Client-Centered Paradigm (my term) of mental illness that favors a spectrum approach. "Although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors, and possibly shared neural substrates. In short, we have come to recognize that the boundaries between disorders are more porous than originally perceived" (DSM-5, p. 6). "Earlier editions of DSM focused on excluding false-positive results from diagnoses; thus its categories were overly narrow, as is apparent from the widespread need to use NOS diagnoses. Indeed the once plausible goal of identifying homogenous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible; like most common human ills, mental disorders are heterogeneous at many levels, ranging from genetic risk factors to symptoms" (DSM-5, p. 12). For example, it "no longer is sensible" to identify a homogenous population of people with Schizophrenia to research their supposed common brain disease simply because there is no such thing as a homogenous population of people with Schizophrenia. The disease category itself lacks vigorous scientific validity, therefore research based on this idea of a common brain disease is bound to fail. Similarly, treatment of patients based on the idea of a common brain disease becomes highly problematic and fraught with difficulties because of the heterogeneity of the population with the supposed disease of "Schizophrenia." For this reason, DSM-5 states, "It is also important to note that DSM-5 does not provide treatment guidelines for any given disorder" (DSM-5, p. 25).
The new Client-Centered Paradigm in DSM-5 emphasizes cultural differences in mental illness and help seeking, including alternative health care. "Mental disorders are defined in relation to cultural, social, and familial norms and values. In Section III, 'Cultural Formulation' contains a detailed discussion of culture and diagnosis in DSM-5, including tools for in-depth cultural assessment. The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cultures, social settings, and families. Hence, the level at which an experience becomes problematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians. Awareness of the significance of culture may correct mistaken interpretations of psychopathology, but culture may also contribute to vulnerability and suffering. Cultural meanings, habits, and traditions can also contribute to either stigma or support in the social and familial response to mental illness. Culture may provide coping strategies that enhance resilience in response to illness, or suggest help seeking and options for accessing health care of various types, including alternative and complementary health systems. Culture may influence acceptance or rejection of a diagnosis and adherence to treatments, affecting the course of illness and recovery. Culture also affects the conduct of the clinical encounter; as a result, cultural differences between the clinician and the patient have implications for the accuracy and acceptance of diagnoses as well as treatment decisions, prognostic considerations, and clinical outcomes " (DSM-5, p. 14). Cultural differences in the meanings and experiences of mental illnesses are at the heart of the new Client-Centered Paradigm and DSM-5 provides a clinical interview tool for in-depth cultural assessment (DSM-5, pp. 749-759).
DSM-5 specifically disallows the use of a simple checklist approach to diagnosis. "The case formulation for any given patient MUST (my emphasis) involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. It requires clinical training to recognize when the combination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges" (DSM-5, p. 19). In other words, a short diagnostic interview of simply counting symptoms from a DSM-IV checklist, and writing a prescription, is no longer considered an appropriate clinical practice according to DSM-5. The Client-Centered approach to diagnosis established in DSM-5 is more holistic, including psychological, social, and cultural factors in diagnosis, and development of a comprehensive treatment plan. "The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is informed by the individual's cultural and social context" (DSM-5, p. 19). The Client-Centered approach requires dealing with clients' cultural backgrounds, current life problems, and past traumas.
DSM-5 includes in-depth discussions about psychological and social sources of stress and trauma that can be implicated in the development, exacerbation, and perpetuation of mental disorders including family relational problems; multiple forms of childhood physical and sexual abuse and neglect; spouse or partner violence, abuse, and neglect; educational and occupational problems; housing and economic problems; social environment problems (e.g., victim of crime); religious and spiritual problems; and lack of access to health care (DSM-5. pp. 715-727). These in-depth discussions of psychological and social stressors are a clear rejection of the simplistic Disease-Centered Paradigm, and an acceptance of the important role played by stress and trauma in the development, exacerbation, and perpetuation of mental disorders.
DSM-5 also includes an in-depth discussion of the serious brain damage that can result from the long term use of psychiatric medications (DSM-5, pp. 709-714). This in-depth discussion is a clear recognition that treatment based on the Disease-Centered Paradigm in which patients are kept on psychiatric medications for years if not decades is dangerous for patients and should be discontinued. Psychiatric medications should be used only when necessary, and for the shortest amount of time possible. Mentally ill people do not have a chemical imbalance in the brain, and psychiatric medications do not normalize the chemistry of the brain. Psychiatric medications cause an abnormality in brain chemistry, and long term use can result in serious brain damage.
I claim substantial credit for the new Client-Centered Paradigm in DSM-5, which the APA has essentially borrowed whole from my textbook Culture and Mental Illness: A Client-Centered Approach (pub. 1996). I predicted 17 years ago in Chapter 1 of this book (p. 11) that the APA would establish a new Client-Centered Paradigm in DSM-5, and presented such a paradigm in Chapter 15 of the book.
Mental disorders need to be defined in a holistic manner that includes the interactions of the individual's sociocultural environment and effects of diagnosis and treatment on the individual's brain. I am somewhat surprised that it took so long to replace the Disease-Centered Paradigm established in DSM-III, and perpetuated in DSM-IV, but I am gratified that the change has finally been made. I am sure that this new paradigm will usher in a new era of holistic research on mental illness that will greatly benefit those suffering from mental illness.
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Reviewed in the United Kingdom 🇬🇧 on May 2, 2020
Reviewed in the United Kingdom 🇬🇧 on March 15, 2022
That said, for the price, it probably serves the purpose for those casual clinicians who don't need letter-perfect copies.
Good quality book that gets a lot of use.
A good therapist should be able to accurately ‘diagnose’ the condition and select an evidence based therapy protocol that fits this diagnosis. DSM helps guide this.











