Do Psychotherapists Need to Buy DSM-5-TR? By Allen Frances, MD on 4/14/22 - 2:06 PM

There is no need to waste $156 buying DSM-5-TR, the minor text revision of DSM-5 that went on sale on March 18th of this year. All its codes are exactly the same as those already provided in DSM-5, and the nine years since DSM-5 have produced no new research justifying publication of a revised edition. Planned obsolescence is the sole purpose of DSM-5-TR, tricking people into buying more books so that the American Psychiatric Association can reap even greater publishing profits.

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There’s only one significant change in DSM-5-TR, and it is a big mistake: adding the new diagnosis “Prolonged Grief Disorder.” There can never be a uniform expiration date on normal grief, and APA should not feel empowered to set a limit of one year. People grieve in their own ways, for durations that vary widely depending on the person, the loss, and cultural/religious practices.

Mislabeling grief as mental disorder stigmatizes grievers, exposes them to unneeded psychiatric medication, and insults the dignity of their loss.

The decision to declare “Prolonged Grief” a psychiatric disorder was based on minimal research by just a few research teams, has not been field tested in a wide array of practice settings to smoke out harmful unintended consequences, and, perhaps most importantly, creates many new problems while serving no useful purpose. If a diagnosis is needed for prolonged grievers, “Major Depressive Disorder” and “Adjustment Disorder” are already available.

My belief that DSM-5-TR is worthless, and my numerous previous critiques of DSM-5, do not in any way put me in the same camp with those who say all psychiatric diagnosis is worthless. Quite the contrary. I equally distrust clinicians who worship DSM and those who deride it.

Psychiatric diagnosis is never sufficient for creating an accurate case formulation and choosing the best treatment plan—but it is always necessary. Psychotherapists who don’t know their clients’ psychiatric diagnoses will have worse results and sometimes do a grave disservice to their clients.

The crucial step in differential diagnosis is to ensure that symptoms are primary—i.e., not due to a medical illness, to a medication side effect or withdrawal syndrome, or to substance intoxication or withdrawal. Primary causes of psychiatric symptoms are missed far too often, putting to lie the claims of some psychotherapists that diagnosis is unnecessary. Psychotherapy doesn’t work well when the client’s problems are caused by a compromised brain—and neglecting the primary problem can lead to devastating medical consequences.

Treatment planning is never fully determined by psychiatric diagnosis, but it is always heavily influenced by it. The range of suitable treatment techniques and durations will vary greatly depending on whether the diagnosis relates to anxiety, mood, eating, substance, sleep, psychotic, personality, or other disorders. DSM disorders are heterogeneous both in presentation and treatment choice, but diagnosis helps establish the most likely best approaches.

DSM diagnosis describes features clients share with other clients. It is complementary to, not competing with, formulation, which describes what is unique in each person’s presentation. Diagnosis without formulation is general and vague. Formulation without diagnosis is often off point.

So good formulations begin with accurate diagnosis, but don’t end with it. It is essential to know DSM diagnosis, but also its limitations—and also to know a lot more about the client beyond the diagnosis.

DSM-5-TR is a publishing trick, not the least bit essential to good psychotherapy practice. If you already use DSM-5, you can safely ignore DSM-5-TR and put its hefty purchase price to some far better use.

File under: Musings and Reflections