What is a Mental Disorder in the DSM-5?

DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders of the APA (American Psychiatric Association). In this text, we will address what is a Mental Disorder and what is not a Mental Disorder.

Hello friends!

As you all know, we have a Complete Video Course on DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, which was published by the American Psychiatric Association (APA) in 2013, in English, and in 2014, by Artmed, in Portuguese.

However, to begin studying the DSM, it is essential to understand what a Mental Disorder is. After all, the DSM is this huge catalog of Mental Disorders, with categories for diagnosis, prevalence, course, prognosis, and treatment.

The truth is that many criticize the DSM for being atheoretical, for being an instrument of creating diseases to sell drugs by the pharmaceutical industry. However, like all knowledge, the Manual can be used for good or for evil, to transform healthy people into sick people or to transform sick people into healthy ones. Everything will depend on the clinical practice and the interests of those who are practicing.

It is also true that the DSM is the international reference for the nomenclatures of Mental Disorders, that is, a clinical psychologist who wants to refer a patient for concomitant psychiatric treatment will have to use the DSM. It is important to note that the DSM has the same nomenclature as the CID, as the two Manuals were merged, insofar as, according to DSM-5:

– The existence of two main classifications of mental disorders hinders the collection and use of national health statistics, the design of clinical trials aimed at developing new treatments and the consideration of the global applicability of results by international regulatory agencies;

– On a broader spectrum, the existence of two classifications complicates attempts to replicate scientific results across countries;

– Even when the intention was to identify identical patient populations, the DSM-IV and ICD-10 diagnoses did not always agree.

Therefore, DSM-5 and ICD-11 were harmonized and currently the listing of mental illnesses is identical both in one and in the other Handbook.

Above, I mentioned that one of the uses of the DSM is as a reference for diagnosis and treatment. From the beginning (we study the history of the DSM in our Course), the DSM had two basic goals:

– standardize the nomenclature and thus facilitate the diagnosis;

– allow statistics, the prevalence of each disorder in a given population (hospitalized population, population assisted in hospitals, population by age group, by country, etc.).

Those who work in clinics and have the minimum of respect for patients, in order to study all the theories in depth, are able to see the correspondence between a disorder in a theoretical approach and another approach. For example, those who work in psychoanalysis will see that what Freud calls obsessive neurosis is similar to what the DSM (and cognitive-behavioral psychology) calls OCD, Obsessive Compulsive Disorder.

However, if we want to study a population of, say, 1000 patients who undergo psychotherapy with a psychology professional – whatever the approach may be – we will have difficulties in identifying the most common disorders, the rarest, since the approaches present phenomenological descriptions and different psychopathologies. Therefore, since the DSM-I, perhaps the main objective of the Manual has been this standardization – so that mental health professionals speak the same language in the description of what the patient suffers, although, evidently, the theoretical practice, the approach could continue to be the same.

So, since we’ve been talking about the objectives of the DSM and some criticisms that are attributed to the book, it’s essential to start with the definition:

What is a Mental Disorder in the DSM-5

According to the DSM-5:

“A Mental Disorder is a syndrome characterized by a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects dysfunction in the psychological, biological, or developmental processes underlying mental functioning.

Mental Disorders are often associated with significant distress or disability that affect social, professional, or other important activities. A culturally expected or approved response to a common stressor or loss, such as the death of a loved one, does not constitute a mental disorder. Social deviant behavior (e.g., of a political, religious or sexual nature) and conflicts that are primarily concerned with the individual and society are not mental disorders unless the deviance or conflict is the result of a dysfunction in the individual as described. (DSM-5, p. 20).

Therefore, the main point to start thinking about a Mental Disorder – in the clinical evaluation of a patient – ​​is suffering or disability. Virtually all Mental Disorders listed in the DSM-5 have the following as one of the diagnostic criteria:

Criterion – Symptoms cause clinically significant distress to the individual.

An interesting Disorder to think about this question of what is or is not a disorder is the so-called Paraphilic Disorder, which includes:

– Voyeuristic disorder;

– Exhibitionist Disorder;

– Frotteurist Disorder;

– Sexual Masochism Disorder;

– Sexual Sadism Disorder;

– Pedophilic Disorder;

– Fetish Disorder;

– Transvestic Disorder;

– Other Specified Paraphilic Disorder.

For those familiar with psychoanalysis or who have studied Freud’s Three Essays on Sexual Theory, it will be evident that the so-called Paraphilic Disorders constitute the framework of perversion. And, as we know, it is relatively uncommon for a pervert to seek therapy.

For DSM-5 this question is posed in the following terms, which represents a major change from its predecessor, DSM-IV:

“In the DSM-5, paraphilias are not ipso facto mental disorders. There is a distinction between paraphilias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing the individual distress or impairment, or a paraphilia whose satisfaction has involved personal harm, or risk of harm, to others. A paraphilia is a necessary but not sufficient condition for having a paraphilic disorder, and a paraphilia alone does not automatically warrant or require clinical intervention” (DSM-5, p. 816).

Therefore, what defines whether a class of behaviors, feelings and thoughts is or is not a mental disorder is clinically significant distress and/or disability academically, professionally or in another important area of ​​life. (Do not forget the loss or harm that it can cause to other people as relevant information).

Thus, a person can have all the characteristics for a Mental Disorder, but if he is not suffering, if he is not having a negative impact on one of the areas of his life, there is no need to be diagnosed. Overdiagnosis, therefore, is an ethical problem for the clinician doing the assessment. In many, many cases, diagnosing is both unnecessary and harmful.

On the other hand, this huge list of disorders that is the DSM-5 is useful for describing certain types of suffering that could pass off as just personality traits. An example I cite for this is Social Phobia, which is often confused with shyness or introversion and undiagnosed ends up being a big problem, like an anxiety disorder, for many people who stop going to college, stop being promoted in work with fear of public speaking, in addition to the suffering hidden behind other social interactions.

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