The Successes and Failures of the DSM Revolution

Forty years after the DSM-III diagnostic revolution, the fundamental dilemmas that have perennially confronted psychiatry (and other mental health professions) remain unresolved. Neuroscientific and epidemiologic findings show that the current DSM system poorly characterizes the nature of mental disorder. Contrary to the intentions of the researchers who developed the DSM-III, its conditions have tremendous internal heterogeneity, artificial comorbidity, and an inability to separate contextually appropriate from dysfunctional symptoms. These inadequacies led the DSM-5 Task Force to propose fundamental changes in the categorical system that was at the heart of these problems. Yet, the pathway they choose to remedy the situation—the introduction of dimensions—would have made these problems even worse. The American Psychiatric Association assembly and board of trustees rejected this premature upheaval in psychiatric diagnosis. The DSM-5, however, did implement other changes, in particular, the abolition of the bereavement exclusion to the diagnosis of major depression, which exacerbated the confusion between normality and pathology. Despite the intentions of its developers, the DSM-5 did not improve understandings of mental disorder.