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,” Allen Frances, MD, argued that the new DSM-5-TR category of prolonged grief disorder (PGD) mislabels grief as a psychiatric disorder, “stigmatizes the grievers, exposes them to unneeded psychiatric medication, and insults the dignity of their loss.” In response, I want first to acknowledge that colleagues who are worried about the diagnosis are making some important points but overemphasize the potential negative consequences and neglect to name the positive ones.

PGD occurs when something interferes with adapting to the loss of a loved one.

 It is analogous to a wound complication that interferes with healing. Clinically, PGD is characterized by persistence—often for years—of acute grief, accompanied by maladaptive thoughts, dysfunctional behaviors (particularly avoidance coping), and inability to effectively regulate emotions. The persistence and predominance of early grief coping responses, such as counter-factual thinking, self-blame, and avoidance, derails the process of adaptation—that is, of learning to accept the finality of the loss, and to envision a life of meaning and fulfillment in the absence of the loved one. The suffering, anguish, and disablement of PDG are profound and enduring.

Accurate diagnosis matters because there is a specific psychotherapy—prolonged grief disorder therapy (PGDT)—proven to be highly effective in 3 NIMH-sponsored randomized controlled trials involving 641 participants aged 20 to 93 (70% to 80% effective).

 PGDT enables acceptance of the finality of the loss, assists with the restoration of meaning and purpose, and facilitates a continuing bond with the loved one. PGDT is organized around 7 themes or healing milestones: (1) accepting the finality of the loss, (2) restoring the capacity for well-being, (3) seeing a promising future, (4) strengthening relationships, (5) narrating the story of the death (imaginal revisiting), (6) living with reminders (situational revisiting), and (7) connecting with memories (imaginal conversations). A PGDT tutorial to learn how this therapy has been done can be found online (

In essence, PGD is a serious mental disorder that puts the griever at risk for intense distress, poor physical health, shortened life expectancy, and suicide.

 Failure to diagnose PGD denies the patient access to a highly effective and specific psychotherapy.

We know that acute grief is a cold, dark, lonely place. In contrast to what the commentary noted, my view and that of my collaborators

 is that grief per se is not the problem. Indeed, grief is normally an adaptive process and, as Frances noted, does not have a fixed expiration date. Rather, in PGD, the grieving process has become derailed, necessitating intervention not in the form of psychiatric medication (as suggested in the commentary), but rather via a brief, specific psychotherapy which teaches the griever new coping strategies, addressing the challenge of warming things up, turning on lights, and opening doors to the outside world. Doing so not only does not stigmatize patients (contrary to the assertion), but rather honors their loss by helping them to integrate that loss into their lives—transforming and restoring lives of purpose and meaning.

is Distinguished Professor of psychiatry and UPMC Endowed Professor in geriatric psychiatry emeritus at the University of Pittsburgh School of Medicine. He is also an editor for the

 American Journal of Geriatric Psychiatry.

Acknowledgment: The author would like to thank Ronald W. Pies, MD for his comments on a draft of this article.

1. Prigerson HG, Shear MK, Reynolds CF III. 

Prolonged grief disorder diagnostic criteria: helping those with maladaptive grief responses.

2. Prigerson HG, Kakarala S, Gang J, Maciejewski PK. 

History and status of prolonged grief disorder as a psychiatric diagnosis.

3. Shear MK, Frank E, Houck PR, Reynolds CF III. 

Treatment of complicated grief: a randomized controlled trial.

4. Shear MK, Wang Y, Skritskaya N, et al. 

Treatment of complicated grief in elderly persons: a randomized clinical trial.

5. Shear MK, Reynolds CF, Simon N, et al. 

Optimizing treatment of complicated grief: a randomized clinical trial

6. The Center for Prolonged Grief; Columbia University School of Social Work. Overview. Accessed March 29, 2022. 

https://prolongedgrief.columbia.edu/professionals/complicated-grief-professionals/overview/

Is prolonged grief disorder an important addition to the DSM-5-TR?

Prolonged Grief Disorder: Helping Those With Maladaptive Grief Responses

My short answer is "No," you do not need to buy 

, the text revision of DSM-5 that went on sale this week. You don't need it for help in diagnosing your patients or getting paid for treating them. And, you do not need it for proper coding; just about all the codes for official disorders are exactly the same as the ones that are already provided in your DSM-5.

The main new codes in DSM-5-TR are in the section "Other Conditions That May Be a Focus of Clinical Attention." These cover self-destructive behaviors that do not meet criteria for an official diagnosis. By keeping these codes handy, you can save the inflated $156 purchase price. The new codes for suicidal behavior are: T14.91A for initial encounter; T14.91D for subsequent encounter; and Z91.51 for history of suicidal behavior. For 

, the new codes are: R45.88 for current nonsuicidal self-injury and Z91.52 for history of nonsuicidal self-injury. They also re-added “unspecified mood disorder.”

 have not produced new research findings that justify a revised edition at this time. The only purpose for publishing a DSM-5-TR is planned obsolescence, linked to financial gain: DSM-5-TR was published to sell more books and reap even greater publishing profits.

There is only one significant change in DSM-5-TR, and it is a disaster. DSM-5 had already made the awful mistake of eliminating the 

 exclusion for major depressive disorder. This makes it easy to diagnose someone as having MDD just 2 weeks after losing a loved one; the only symptoms required are sadness, loss of interest and energy, and trouble sleeping and eating. This DSM-5 decision defied common sense and has been widely and justly criticized by both clinicians and grievers.

DSM-5-TR now greatly compounds DSM-5's colossal error by adding an even bigger one of its own—turning 

 into an officialmental disorder and dignifying it with a separate code. “Prolonged” is defined as just 1 year in adults and 6 months in kids.

There can never be a uniform expiration date on normal grief, and the DSM-5-TR should not feel empowered to impose one. People grieve in their own ways, for periods of time that vary widely depending on the person, the nature of the loss, and relevant cultural practices. Mislabeling grief as mental disorder stigmatizes the grievers, exposes them to unneeded psychiatric medication, and insults the dignity of their loss.

 a psychiatric disorder was based on minimal research by just a few research teams; it has not been field tested in a wide array of practice settings to smoke out harmful unintended consequences; and, perhaps most importantly, it creates all these new problems while serving no useful purpose. If a diagnosis is needed for prolonged grievers suffering "clinically significant distress or impairment," major depressive disorder has always been available.

I strongly encourage clinicians to use their common sense and clinical judgment. Don't allow DSM-5-TR's “prolonged grief” to suddenly pathologize grief. It is completely normal to grieve beyond 1 year—the small price we pay for having loved someone deeply and a big part of what makes relationships meaningful and us human.

Psychiatric diagnosis for grievers is rarely necessary; only needed when patients meet full criteria for major depressive disorder and are experiencing clinically significant distress or impairment. When a code is needed just for reimbursement,the most accurate diagnosis is adjustment disorder.

DSM-5-TR would have been worth buying if it had corrected the many mistakes found in DSM-5. Revision of DSM-5 was a golden, but lost opportunity, to revisit the many controversial decisions made by the DSM-5 Task Force—or, at very least, to have included black box warnings indicating that they remain controversial and should be used with caution. Many of the sections on differential diagnosis would have benefitted by including “normal” as a rule out.

Instead, the authors of DSM-5-TR chose to remain remarkably and uncritically true to the many flawed DSM-5 decisions.

The error consistent in DSM-5 was the introduction of many new diagnoses and the reduction of the diagnostic thresholds for existing ones. The resulting diagnostic inflation caused by mislabeling the worried well results in an awful misallocation of scarce mental health resources as well as the overtreatment of those who do not need it and the concomitant neglect of the severely ill who desperately do.

DSM-5 went wrong because its experts were given free rein to expand their “pet” diagnoses. Experts always worry about missed patients and undertreatment, never about mislabeling “normal” or overtreatment. Suggestions for new diagnoses that worked for them in their carefully researched practice are usually a disaster when over applied in regular clinical practice.

DSM-5-TR not only failed to correct the diagnostic exuberance of DSM-5, it added an additional burst of its own. Some small improvements in DSM-5-TR do not make up for the disaster of including "Prolonged Grief."

Publishing DSM-5-TR is further proof that the APA cannot be trusted to properly supervise the DSMs. We need a diagnostic system untainted by APA's huge financial conflict of interest built into its role as publisher.

 LCSW, associate professor, Loyola University School of Social Work, has provided a nice summary of the changes in DSM-5-TR.

The opinions expressed is that of the author and do not necessarily reflect the opinions of 

is professor and chair emeritus in the department of psychiatry at Duke University. Find him on Twitter @AllenFrancesMD

What do you think? Was DSM-5-TR needed? Have you purchased a copy—do you plan on buying it? We want to know your thoughts. Write to us at 

It's been 9 years since DSM 5 was released. Does this revision advance psychiatric practice?

Is DSM-5-TR Worth Buying? 

“I think the DSM gives you one sense of depression,” Sidney Zisook, MD, told attendees of the 2021 Annual 

 World CME Conference. “But I think it's very, very one dimensional. A better way of really understanding what it is to be depressed and the diagnosis is getting firsthand accounts from those who have dealt with depression.”

Zisook, director of the University of California, San Diego (UCSD) Residency Training Program, Distinguished Professor of Psychiatry at UCSD, and last year’s Educator of the Year awardee, shared insights from several famous folks about their experiences with depression. Of depression, David Foster Wallace said:

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self’s most elementary levels. It is a nausea of the cells and soul.

This quote, and others like it, show a sense of hopelessness, even suicidality, more than other aspects of depression, including those recognized by the DSM 5, he noted.

To better understand the current state of diagnosis, Zisook took attendees back in time to discuss the various iterations of depression in the DSM, from being classified as psychoneurotic disorder in DSM I in 1952 through the psychoanalytic approaches through the specifiers in DSM IV. Changes continued into DSM 5, where we now have a variety of disorders: major depressive disorder, disruptive mood dysregulation disorder, persistent depressive disorders, substance- and medication-induced depressive disorder, premenstrual dysphoric disorder, depressive disorder due to another medical condition, and other specified (or unspecified) depressive disorder.

To help illustrate the problems associated with the current system, Zisook shared 2 case examples. Ms A is a 30 year old married woman complaining of stress. Upon further exploration, you learn she has been tearful and increasingly sad since her mother received a diagnosis of cancer. She has little motivation, is overeating and gaining weight, and sleeps about 12 hours a day. She has never felt like this before.

On the other hand, Mr B is a 60 year old man who is brought to you by the police after found wandering on the Coronado Bridge. He is unshaven, slovenly, and demonstrates psychomotor retardation. He shows no interest in answering questions, but an informant tells you he has not been eating or drinking for weeks. He has expressed feeling miserable and worthless. He had a similar episode 30 years prior; he achieved full recovery after responding to electroconvulsive therapy.

“What do they have in common?” Zisook asked rhetorically. “Definitely nothing except the diagnosis of major depressive disorder—without any overlap in functioning.”

In reviewing DSM 5 criteria, he posed a few questions for the authors of DSM 6 to consider. For instance, why must symptoms last 2 weeks? “This never made much sense to me,” he said. “Somebody is undergoing a horrible situation—they lost their job, they've lost their family, they've lost their money—they've never been depressed before, and the depression is relatively mild, moderate. You don't want to label them with a major depressive disorder in 2 weeks. Give me more time to see what happens. Let them take care of some of the situations.”

“On the other hand,” Zisook added, “if they had a history of severe major depressive disorder, and for the last 2 days they're despondent, hopeless, feeling worthless, feeling suicidal, you have got to wait another 12 days to make the diagnosis.”

To better understand the diagnosis, again Zisook looked to patients. He discussed studies conducted by Mark Zimmerman, MD, and colleagues looking at what was needed for patients with depression to consider themselves in remission.

 The top 3 features were: positive mental health, such as optimism and self-confidence; a return to one’s usual, normal self; and a return to a usual level of functioning. Interestingly, one-quarter of respondents who were mildly symptomatic and, per HAM-D scores, not in remission considered themselves remitters. As such, they reported better quality of life, less functional impairment due to depression, higher positive mental health scores, and better coping ability.

I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.

So, how does Zisook define and diagnosis depression? “There are screening instruments, which is fine for looking at depression,” he told attendees. “But I think there's nothing to substitute for clinical inquiry. And I diagnose depression not by counting the number of symptoms for a certain number of weeks. But is the low mood persistent, is it there most of the time, has it been there for a while? It is pervasive—affecting the way you work, the way you interact with other people, the way you function, the way you parent, etc. For me that's better than the screening questionnaire or the DSM 5 criteria.”

He also reminded attendees that differential diagnosis is very important, adding “Always look for bipolar disorder or general medical conditions.” Bereavement and burnout also need special attention, he explained, since those are often misdiagnosed and/or confused with depression. A careful examination of the criteria and symptoms will help to distinguish the disorders.

Zisook concluded by saying, “I think our diagnostic concepts are a work in progress in terms of helping us communicate with each other, helping us take into account what patients are saying about what it feels like to be depressed, and helping us to prescribe very personalized medications.”

1. Zimmerman M, McGlinchey JB, Posternak MA, et al. 

How should remission from depression be defined? The depressed patient's perspective

2. Zimmerman M, Martinez J, Attiullah N, et al. 

Why do some depressed outpatients who are not in remission according to the hamilton depression rating scale nonetheless consider themselves to be in remission?

Sidney Zisook, MD, shares insights into defining depression diagnosis.

Defining and Diagnosing Depression: Clinical and Patient-Oriented Perspectives

So, you think you have a pretty good handle on DSM-5—what the lay press loves to call, quite misleadingly, “Psychiatry’s Bible”? OK, maybe you know most of the criteria for the major categories of serious mental illness. No doubt, you are aware of serious problems with some aspects of DSM-5 (the 

, including the limited reliability and validity of many of its disorder categories.

 But how well do you understand the “deep structure” of DSM-5 as a diagnostic tool?

Just to get your adrenaline flowing, try taking this 2-minute quiz:

A. DSM-5 permits the clinician to make a mental disorder diagnosis simply by checking off the symptoms listed in a disorder’s diagnostic criteria.

B. To make a DSM-5 mental disorder diagnosis, the clinician need not assess the social, psychological and biological factors that may have contributed to the patient’s condition.

C. DSM-5 is an embodiment and expression of the “biomedical” model in psychiatry.

D. DSM-5 posits that mental disorders are discrete entities sharply distinguished both from “normality” and from each other.

Critics of psychiatric diagnosis often caricaturize the DSM process as the “Chinese Menu” approach. Thus, a professor of history and philosophy—in an article titled, “Forget talking, just fill a script: how modern psychiatry lost its mind”—

In clinical practice, DSM-III led to a “Chinese menu” approach to psychiatric diagnosis: a specific mental illness can be diagnosed if a sufficient number of boxes can be ticked. This is only of limited value in clinical practice.

Indeed, merely checking off boxes of symptoms (and signs) 

but that is not at all what DSM-5 calls for.

 As my colleague, Dr Mark Ruffalo, and I 

, the DSM-5 makes it crystal clear: Simply checking off symptoms 

cannot and does not constitute a psychiatric diagnosis—

The case formulation for any given patient must 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 of the diagnostic criteria to make a mental disorder diagnosis 

, the case formulation “. . . is a core clinical skill that links assessment information and treatment planning. It is a hypothesis about the mechanisms that cause and maintain the problem. It answers the question, ‘Why is this person, having this type of problem, now?’”

In principle, the case formulation—and by extension, the final DSM diagnosis—requires medical knowledge, or at least access to medical consultation, in order to assess the “biological factors” that may have contributed to the patient’s problem. Finally, we should note that, in addition to meeting sign/symptom criteria for a mental disorder, virtually all the major 

 require evidence of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” You cannot snag a DSM diagnosis merely by collecting a group of signs and symptoms. There must also be adverse consequences in the person’s life.

The DSM-5 Is “Biomedical”? Not So Much

It is clear from the aforementioned description of the case formulation that the DSM-5 explicitly uses a “biopsychosocial” approach to diagnosis. In addition, DSM-5 has extensive coverage of cultural issues, as they impinge on differential diagnosis. Excellent examples of the “case conceptualization” using a bio-psychosocial-cultural approach may be found in the text by Sperry and Sperry.

Nonetheless, some commentators—mainly critics of psychiatric nosology—have asserted that DSM-5 represents the “biomedical” model. For example, 1 paper 

Diagnostic and Statistical Manual of Mental Disorders

 . . . offers a biomedical framing of people’s experiences of distress and impairment, and despite decades of criticism, it remains the dominant approach.

These authors go on to argue that, “. . . a biomedical construction of ‘mental illness’ all too frequently fails to protect individuals from delegitimation and stigma.” That is a provocative claim worth examining but is beyond the scope of this essay. What is striking about the paper by these 2 psychologists is that the term “biomedical” is never fully defined. The authors do 

 the biomedical model is oriented “around the problems of the body . . . such as genetics or neurochemistry.”

If we take that rough formulation as a guide, it can be readily seen that—with a few exceptions—there is very little in DSM-5 that invokes “genetics” or “neurochemistry.” True, DSM-5’s discussion of 

 does reference abnormalities on chromosome 4; and other neurocognitive disorders, such as Lewy body disease, are linked to genetic abnormalities. But such references to specific genetic abnormalities are by far the exception, particularly for the more classically “psychiatric” disorders, such as schizophrenia and bipolar disorders. (We do find, under the rubric of “Risk and Prognostic Factors,” the statement that “Schizophrenia and bipolar disorder likely share a genetic origin . . .”

As far as I know, discussion of “neurochemistry” as a 

 in any of the common psychiatric disorders is entirely lacking in DSM-5. (So much for “chemical imbalances”). With only a few exceptions, DSM-5 avoids commitments regarding etiology. Indeed, the 

, “a diagnosis does not carry any necessary implications regarding the etiology or causes of the individual’s mental disorder. . .”

 One can see this as a serious deficiency in the DSM-5—but one cannot claim the 

endorses anything resembling neurochemical etiologies or “chemical imbalances” for the major mental disorders.

 that the DSM-5 “offers a biomedical framing of people’s experiences of distress and impairment.”

 Deacon, in a detailed review and critique, argues that “The biomedical model posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities.”

 I do not contest that description, but nothing in Deacon’s analysis shows that DSM-5 is essentially “biomedical” in the sense he explicates.

Fuzzy Boundaries, Overlapping Symptoms, and Dimensions of Pathology

Another common claim is that DSM-5 is a strictly “categorical” framework that conceptualizes mental illness as a collection of discrete, diagnostically separable entities. As one paper puts it, “. . . the DSM-5 is a categorical system. Thus, individual disorders are regarded as discrete units—“you either have it, or you don't.”

 A related claim is that DSM-5 posits a clear and distinct separation between mental abnormality and “normal” mental or psychological states. 

In truth, neither claim is supported in the DSM-5 (

). On the contrary, the Introduction to the 

The results of numerous studies of comorbidity and disease transmission . . . make strong arguments for what many astute clinicians have long observed: the boundaries between many disorder “categories” are more fluid over the life course than DSM-IV recognized, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders. These findings mean that DSM . . . should accommodate ways to introduce dimensional approaches to mental disorders, including dimensions that cut across categories . . . 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 substates . . . 

In short, we have come to recognize that the boundaries between disorders are more porous than originally believed.

Furthermore, the DSM-5 does not argue for a hard and fast boundary between “normal” and “abnormal” states and conditions. On the contrary, it states:

The boundaries between normality and pathology vary across cultures for specific types of behaviors…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.

All this is not to say that psychiatric illnesses are merely “

” labels that have no corresponding physical or pathological referents in “the real world”—a thorny topic for another time.

 DSM-5 merely affirms what all good clinicians know: There are many 

 in the realm of psychopathology, often influenced by culture; and it is very doubtful that we can “carve Nature at its joints.”

 that democracy is the very worst form of government, except for all the others that have been tried.

 It is tempting to suggest, tongue slightly in cheek, that DSM-5 is by far the worst diagnostic framework psychiatry could have chosen—except for all the rest. To be sure, many different approaches to psychiatric diagnosis have been 

Personally, I favor a prototype-based diagnostic approach for every-day clinical work; and a parallel set of “research diagnostic criteria” for investigative purposes (

). “Prototype” diagnosis refers to the use of idealized models or archetypes of disease, rather than either “categorical” or “dimensional” methods of classification. 

 discuss and debate various diagnostic models in a wide-ranging colloquium.

It seems very clear that diagnosis is, and will always remain, a necessary part of clinical care, both in general medicine and psychiatry. When a patient presents with the complaint, “I hear threatening voices in my head,” we simply must

—a word whose etymology means, “knowing the difference between.” For example, we must know the difference between “threatening voices” stemming from combat-related trauma, on the one hand, versus schizophrenia or anti-NMDA receptor encephalitis

 on the other. Otherwise, our treatment is likely to be misguided.

No, whatever the lay press claims, DSM-5 is not “The Bible of psychiatry.’ It is not a sacred, eternal, and inviolable text, or even a very sophisticated diagnostic tool. John Talbott, MD, professor emeritus of psychiatry and former president of the 

, “If you let the specifics of the DSM tie you down, it prevents you from practicing the art of medicine. So, I would hope people would not be bound by it, but be flexible and use their clinical judgment instead.”

I agree. But before we use the DSM-5’s text to line our bird cages—as a renowned British psychiatrist I once met described the utility of the DSM-III—we should at least understand what DSM-5 does, and does not, represent.

 is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

 Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

1. jmm1000. Dr Pepper "So Misunderstood" feat Carol Kane - 1973-1974. YouTube. June 30, 2017. Accessed March 17, 2021. 

https://www.youtube.com/watch?v=WA_NnXyDDLk

2. Regier DA, Narrow WE, Clarke DE, et al. DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. 

3. Pols H: Forget talking, just fill a script: how modern psychiatry lost its mind. 

 October 21, 2012. Accessed March 17, 2021. 

https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569

4. Ruffalo ML. Pies RW. Psychiatric Diagnosis 2.0: The Myth of the Symptom Checklist. 

 June 14, 2020. Accessed March 17, 2021. 

https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/psychiatric-diagnosis-20-the-myth-the-symptom-checklist

. Washington, DC; American Psychiatric Publishing, Inc: 2013.

6. Gintner GG. Using DSM-5 in Case Formulation. Louisiana Counseling Association presentation. Accessed March 17, 2021. 

http://www.lacounseling.org/images/lca/Conference/DSM-5%20LCA%20Case%20Formulation%20Rev.pdf

Mastering this Competency with Ease and Confidence.

9. Deacon BJ. The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research. 

10. van Heugten-van der Kloet D, van Heugten T. The classification of psychiatric disorders according to DSM-5 deserves an internationally standardized psychological test battery on symptom level. 

What kinds of things are psychiatric disorders?

12. Gabor, GT. ‘Carving nature at its joint’: The Platonic method of division in Plato, Aristotle, and their Neoplatonic commentators. 

. AAI3466699. 2011. Accessed March 17, 2021. https://research.library.fordham.edu/dissertations/AAI3466699

13. Churchill W. The Worst Form of Government. International Churchill Society. November 11, 1947. Accessed March 17, 2021. 

https://winstonchurchill.org/resources/quotes/the-worst-form-of-government/

14. Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis. 

. 2012;7:9. Accessed March 17, 2021. https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-7-9

15. Kayser MS, Dalmau J. Anti-NMDA receptor encephalitis, autoimmunity, and psychosis. 

16. Vlessides M. The Past, Present, and Future of the DSM. 

. December 15, 2020. Accessed March 17, 2021. 

https://www.medscape.com/viewarticle/942694#vp_1

A DSM-5 diagnosis requires a biopsychosocial case formulation—not just a symptom checklist.

Poor DSM-5—So Misunderstood!

John J. Miller, MD, talks through the changes and developments of DSM. 

DSM 1 was published in 1952, and sadly the terms were less than kind; but it was based on the information available at the time. DSM 2, published in 1968, consisted of mostly psychodynamics and therapy, when psychopharmacology was very young.  DSM 3 published in 1980, introduced PTSD – only 40 yrs ago. 1994 saw the publication of DSM 4, and DSM 5 in 2013. 

is Medical Director, Brain Health, Exeter, NH; Editor in Chief,

Staff Psychiatrist, Seacoast Mental Health Center, Exeter, NH; Consulting Psychiatrist, Exeter Hospital, Exeter, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, MA.

How did DSM begin and how did the most recent DSM get to its current state? 

A Tale of the DSMs

Dr Aftab is a geriatric psychiatry fellow at University of California San Diego (UCSD) in La Jolla, CA, and a former psychiatry resident at Case Western Reserve University/University Hospitals Cleveland Medical Center in Cleveland. He is also a member of the 

 Advisory Board. He can be reached at awaisaftab@gmail.com.

This is the third and final part of a three-part series on a pertinent philosophical question in the era of diagnostic inflation: What conceptual means are available to prevent deviant and undesirable behavioral conditions from being diagnosed as mental disorders as a result of social bias and stigma? The series is based on an essay (“Social Misuse of Disorder Designation: Exploring Dysfunction and Harm-Based Conceptual Defenses”) that was awarded the 2018 Karl Jaspers Award by the Association for the Advancement of Philosophy and Psychiatry. Dr Aftab has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry, and this series constitutes one effort to bring this discussion to a wider audience. 

, I argued that a dysfunction-based defense strategy does not adequately protect against arbitrary disorder designations. In Part 3 of this series, I will explore the notion of a harm-based defense.

At a minimum, a mental disorder is considered an undesirable and unwanted condition either for the individual or the society. However, that is clearly very relativistic and does little to protect against social misuse of disorder designation. 

 in a broad fashion, barely distinguishable from negative social evaluation. For instance, Wakefield writes: "As traditional value accounts suggest, a condition is a mental disorder only if it is harmful according to social values and thus at least potentially warrants medical attention. . . . ‘Harm’ is construed broadly here to include all negative conditions."

We can, however, restrict undesirability to certain kinds of harm to come up with a criterion that offers more protection. Consider the following degrees of undesirability:

1. Unwanted/undesired/negatively evaluated by the individual only;
	2. Unwanted/undesired/negatively evaluated by the society;
	3. Associated with harm (distress/disability/harm to others) (DSM);
	4. Associated with intrinsic harm (distress or disability which is a direct result of a specific biological or psychological process).

The only way to reliably exclude ego-dystonic homosexuality from the realm of mental disorders is to require intrinsic harm to be a necessary criterion for a mental disorder definition. Homosexuality can be (and was) negatively evaluated by individuals as well as society, and it can be (and was) perceived to be harmful according to social values; ego-dystonic homosexuality is also associated with distress.

 reason for limiting harm in the definition of mental disorder to intrinsic harm. It is an artificial maneuver that is difficult to justify on conceptual analysis aside from saying that it offers protection against social prejudice. This point has been well-articulated by 

In any case, it would be an artificial polarisation to attempt to understand distress or harm as separable from cultural values, and it is not obviously desirable for healthcare to be informed by a narrow view of harm. This would run counter to ideals of holistic healthcare and attempts understand people in context. If correct, Wakefield rightly extends ‘harm’ to cultural standards. But if so, then socially undesirable conditions are not excluded from the definition of disorder by distress or harm criteria.

I agree with Bingham and Banner that such a move would conceptually be an artificial polarization. There is, however, a strong ethical argument to be made requiring 

 as a necessary criterion for mental disorder designation in the practice of psychiatry. We have an ethical obligation to prevent social misuse of disorder designation, and we need a conceptualization of mental disorder that would exclude “states that are wrongly pathologised due to prejudice and social exclusion, including those we might not have identified as such yet.”

Distress refers to some sort of psychological suffering. Although the DSM makes no further classifications, the following distinctions can be made regarding types of distress:

 is distress that is the direct result of a specific biological or psychological process.

 is not the direct result of a specific biological or psychological process. It can originate from conflict with society (ie, individual would not experience distress if society were to accept the condition as normal-exogenous distress) or it can originate from within the individual due to internalized moral and social values (ie, internalized distress) but not as a direct result of biological or psychological processes.

The distinction between intrinsic distress and extrinsic distress in the case of a particular condition can be facilitated by means of a thought experiment. If social norms were to change such that the condition in question is no longer considered disordered, does the distress disappear? Even if society were to accept generalized anxiety as a normal variant, the persistent anxiety remains distressing for the individual experiencing it. In the past, homosexual individuals were distressed by the sexual orientation due to the antagonism with social norms and sought conversion therapy for that reason. However, with change of social norms, homosexual individuals are (by and large) no longer distressed.

As utilized in the harm criterion, “functional impairment” (or “functional disability”) refers to the negative consequences in social or occupational functioning or other important activities of life. For instance, heart failure is impairing as it restricts physical activity; agoraphobia can be impairing if one becomes unable to leave the house. 

 is a product of the interaction between a deficit and the environment, and the presence of impairment and the degree of impairment may depend on the environmental context. For instance, attention deficits and hyperactivity in a child may be quite impairing in a highly structured modern classroom but may have had little to no impairment in pre-modern societies.

One important consideration is whether functional impairment is direct product of the biological processes in question or is a result of society’s stigmatization. For instance, red hair by itself leads to no functional impairment, but individuals with red hair may not be able to find employment because of social stigma.

Paraphilias can cause impairment in sexual life in the absence of appropriate stimulus. However, it is unclear if this is an impairment just because society considers the behaviors pathological. Voyeurism or sadomasochism can be highly impairing if one is unable to find consensual sexual partners with whom to engage. Similarly, the more stigmatized these conditions are in a society, the more difficult it will be to find consensual partners. If impairment disappears simply by society’s acceptance of that behavior as a non-pathological normal variant, it is likely a result of society’s discrimination and I will term it 

, which is a direct result of a specific biological or psychological process).

It is fairly obvious that distress occurs in cases of socially deviant behavior and conflicts between individual and society. The requirement for distress alone does not protect social deviance from being pathologized. Distress or impairment that results from social deviance and conflict is extrinsic. It is different from intrinsic distress and intrinsic impairment, which are a direct result of the biological or psychological processes in question. A harm criterion that restricts disorder designation only to cases of intrinsic distress and intrinsic functional impairment can, therefore, protect against disorder designations of extrinsic distress and extrinsic impairment. (

At a minimum, a mental disorder is considered an undesirable and unwanted condition either for the individual or the society. However, that is clearly very relativistic and does little to protect against social misuse of disorder designation.

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