The Conceptual Evolution of DSM-5

edited by Darrel A. Regier, MD, MPH; William E. Narrow, MD; Emily A. Kuhl, PhD; and David J. Kupfer, MD. American Psychiatric Publishing, Inc, Washington, DC, 2011, 359 pages, $71.00 (paper).

The Conceptual Evolution of DSM-5, edited by Regier, Narrow, Kuhl, and Kupfer, is a 359-page book that is an intellectually stimulating discourse on the history and development of DSM-5 beginning from the early years of the Diagnostic and Statistical Manual of Mental Disorders (DSM). An impressive collection of authors has set forth a detailed review of the history of categorical assessment in DSM and the case for introducing dimensional measurements to improve performance of the DSM in clinical practice and to facilitate research innovation. This fascinating journey is strewed with controversy in the forging of a DSM that will achieve the goals of being a user-friendly clinical guide, being a more evidence-based classification system, and promoting innovative research. The book will be of benefit to mental health professionals who desire a deeper understanding of this journey and the complexities of developing a reliable and valid DSM.

The book is divided into 5 sections with a total of 15 chapters. The authors are experts in the field, and this volume reflects an extensive international collaboration. The first section, on diagnostic spectra, reviews many of the concerns about the use of a strictly categorical system. Steven Hyman summarizes that “a significant fraction of patients do not fit the highly specified criteria of named disorders. In this case, the rigidity of operationalized diagnostic criteria, based on phenomenology, trades interrater reliability for ability to capture the true heterogeneity of clinical populations” (p 7). This section is elegantly developed and explores the fundamental tasks that will confront a revised DSM, such as constructing and testing quantitative scales and ensuring the clinical utility of the DSM.

The second section, on integrating dimensional concepts into a categorical system, explores the options and dilemmas of dimensional measures and describes the approach of a mixed categorical-dimensional assessment. The authors present current research supporting the addition of dimensional measures to some categorical diagnoses. The third section, on assessing functional impairment for clinical significance and disability, makes a compelling argument for the use of the World Health Organization’s International Classification of Functioning, Disability, and Health as a guideline for the assessment of activity limitations and disability. The authors review current research and how use of this guideline may “provide a strong foundation for future development of brief, reliable, and valid methods of assessment” (p 183). The additional benefit of such assessments is that they are “capable of capturing the disabling consequences of mental, cognitive, and physical health conditions” (p 221). The fourth section, on identifying important culture- and gender-related expressions of disorders, reviews the current literature concerning cross-cultural measurement of mental illness and emphasizes the need for greater attention to the influence of environmental living conditions on the development of psychopathology. The discussion on the issue of gender neutrality is of particular interest; the complexities of exploring whether potential gender bias exists within certain categories are explored in detail. The last section, on incorporating developmental variations of disorder expression across the lifespan, provides a discussion about integrating recent developmental data into the DSM text revisions.

The Conceptual Evolution of DSM-5 is an outstanding book that provides the reader with an in-depth understanding of the complexities of developing a new DSM that is clinically useful and yet also reflects the most current research findings in the field. The book is highly recommended, as it will provide an excellent platform to “jump” into DSM-5.

Frank W. Brown, MD

Author affiliation: Emory University School of Medicine, Atlanta, Georgia.

Potential conflicts of interest: None reported.