Ill-Treatment of Pain in the DSM-5

The just-published psychiatric diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), American Psychiatric Association (2013), has been lauded by its organizers (e.g., Regier, Kuhl, and Kupfer in World Psychiatry 12, pp. 92–98, 2013), but has been criticized on multiple grounds, as well. Several of its major diagnostic categories concern the area of psychological injury and law (e.g., tort cases involving posttraumatic stress disorder (PTSD), chronic pain, and traumatic brain injury (TBI)). The one for chronic pain seems the one most greatly changed. The approach to chronic pain in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (American Psychiatric Association 2000) and the DSM-5 are compared, leading to an alternative diagnostic criteria list partly based on the changes in the DSM-5. The DSM-5 should be used with caution in forensic assessments. This applies especially to the psychological injury patient, including the pain one, given the high stakes involved and the need for accuracy in assessment based on a reliable and valid diagnostic system. Future iterations of the manual should be improved in both these regards.     

Erratum to: Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses on current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Posttraumatic Stress Disorder in the DSM-5: Group Difference Commentary

This article provides a commentary on the proposed Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 changes with respect to diagnosing posttraumatic stress disorder (PTSD) in diverse cultural groups in clinical and forensic settings. PTSD is the most common diagnosis in personal injury litigants (Koch et al. 2006). By reviewing the symptoms that have been changed in the DSM-5 draft for PTSD in terms of ethnoracial and minority–cultural factors, this article highlights the lack of data needed in the area and that the DSM project should pay more attention to such factors.     

Trends in Psychological/Psychiatric Injury and Law: Continuing Education, Practice Comments, Recommendations

This literature review of the major topics in the field of psychological/psychiatric injury and law is aimed at developing commentary for practice in the area. The field is a fast-developing one, with over ten major topics that it needs to integrate. In particular, the present review focuses current work on: law (evidence, tort); forensic psychology; assessment and testing; psychological injuries (posttraumatic stress disorder, chronic pain, traumatic brain injury, other); the APA DSM-5 draft (Diagnostic and statistical manual of mental disorders; American Psychiatric Association 2010); malingering; causality; multicultural considerations; disability; the American Medical Association (AMA) Guides to the evaluation of permanent impairment (Rondinelli et al. 2008); models; and treatment. At the end of each section of the article, practice comments introduce critical issues in applying the research to psychological work in the area. Whether undertaking tort evaluations, disability, and treatment plan assessments or treating individuals with psychological injuries, the professional needs state-of-the-art information in all the areas listed in order to remain scientifically informed, comprehensive, and impartial. The article concludes with recommendations for an integrated field in psychological/psychiatric injury and law, study in the field, research in its major areas, best practice policies, for example in assessment and treatment, and model building.     

Confusion and Incoherence in the Classification of Personality Disorder: Commentary on the Preliminary Proposals for DSM-5

The compilation of Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 afforded an unprecedented opportunity to advance the study of personality disorder by constructing an evidence-based, etiologically informed classification. The conceptual models and empirical knowledge are available and the field is looking for substantial changes to the way personality disorder is classified and diagnosed. Given the opportunity and need, the preliminary proposal by the DSM-5 Personality and Personality Disorders Work Group is disappointing. The proposal totally reformulates the way personality disorders are classified so that there is virtually no continuity with the previous system. The reformulation is a confusing mixture of innovation and a return to previous ways of representing diagnostic constructs that is inconsistent, incoherent, impractical, and frequently incompatible with empirical facts. Particularly problematic is the replacement of criterion-based diagnosis with a prototype matching system that, if implemented, will result in personality disorder being diagnosed in a fundamentally different way from all other disorders in psychiatry and medicine. Implementation of the proposal would have serious adverse consequences for patients, treatment, research, and administrative and legal applications, especially in the area of psychological injury and law.     

Breaking Bad: DSM-5 Description, Criticisms, and Recommendations

The special issue on the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, American Psychiatric Association, 2013) in the journal Psychological Injury and Law has considered its changes relative to the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, American Psychiatric Association, 2000) from both a clinical utility and scientific point of view. Although the manual did not undergo wholesale change, the changes to diagnostic categories relevant to the area of psychological injuries (especially posttraumatic stress disorder, mild traumatic brain injury, and chronic pain) present both practical and forensic conundrums, complicating clinical and legal work in the area. The articles in the special issue number nine (including the present one), and involve ones on the major psychological injuries, as well as personality. Separate articles deal with forensics and ethics, with a final one considering forensic psychiatric work using the DSMs. The authors collectively indicate that the DSM-5 is rife with utility and scientific difficulties, although it still might be used in practice and for court in the context of careful, comprehensive assessments and critical analysis. More importantly, ongoing and future research should be considered in revising the DSM-5. Some of the articles review in depth the extant research on their topics and all make recommendations that are useful. The articles include those (in order in the special issue) by: Zoellner et al. (Psychological Injury and Law, 6, 2013); Biehn et al. (Psychological Injury and Law, 6, 2013); Schultz (Psychological Injury and Law, 6, 2013); Young (2013); Hopwood and Sellbom (Psychological Injury and Law, 6, 2013); Thomas (Psychological Injury and Law, 6, 2013); Gordon and Cosgrove (Psychological Injury and Law, 6, 2013); and an opinion piece by Frances and Halon (Psychological Injury and Law, 6, 2013), the chief chair of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, American Psychiatric Association 1994).     

Chronic Pain in the DSM-IV and the DSM-5 Draft: The Pain of It All

The Diagnostic and Statistical Manual, DSM-IV-TR (American Psychiatric Association 2000) includes the diagnosis of pain disorder, and it has been revised in major ways in the DSM-5 draft (American Psychiatric Association 2010). Pain disorder has been relegated as a specifier of the new diagnosis of complex somatic symptom disorder. It cannot be diagnosed prior to 6 months of the pain’s onset. Also, there are still the pejorative connotations with which the disorder is associated. In terms of treatment, it might be more difficult to get treatment plans accepted as a result of the changes, and in terms of the legal arena, it might prove more difficult to have the disorder serve as the basis of action in legal proceedings.     

DSM-5 proposed diagnostic criteria for sexual paraphilias: tensions between diagnostic validity and forensic utility

In order to prevent sexual crimes, “sexual predator” laws now allow indefinite preventive civil commitment of criminals who have completed their prison sentences but are judged to have a paraphilic mental disorder that makes them likely to commit another crime. Such proceedings can bypass the usual protections of criminal law as long as the basis for incarceration is the attribution of a mental disorder. Thus, the difficult conceptual distinction between deviant sexual desires that are mental disorders versus those that are normal variations in sexual preference (even if they are eccentric, repugnant, or illegal if acted upon) has attained critical forensic significance. Yet, the concept of paraphilic disorders - called “perversions” in earlier times - is inherently fuzzy and controversial and thus open to conceptual abuse for social control purposes. Consequently, the criteria used in diagnosing paraphilic disorders deserve careful scrutiny.The DSM-5 sexual disorders work group is proposing substantial revisions to the paraphilia diagnostic criteria in the DSM-5 nosology. It is claimed that the new criteria provide a reconceptualization that clarifies the distinction between normal variation and paraphilic disorder in a way relevant to forensic settings. In this article, after considering the logic of the concept of a paraphilic disorder, I examine each of the proposed changes to the DSM-5 paraphilia criteria and assess their conceptual validity. I argue that the DSM-5 proposals, while containing a kernel of an advance in distinguishing paraphilias from paraphilic disorders, nonetheless would yield criteria for paraphilic disorders that are conceptually invalid in ways open to serious forensic abuse.     

DSM-5 Neurocognitive Disorders: Validity, Reliability, Fairness, and Utility in Forensic Applications

A previously published paper (Schultz Psychological Injury and Law 3: 271–288, 2010) on forensic considerations regarding neurocognitive disorders within the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5; American Psychiatric Association, 2013) reviewed evidence for internal and external validity, as well as the fairness and utility of the proposed classification. Given recent publication of the DSM-5, in May 2013, the current paper provides an update on this review. It focuses on changes in the final version of the neurocognitive disorders section of the DSM-5 as compared with the earlier proposal in 2010 and raises a range of new conceptual, methodological, and clinical practice issues related to this classification. An examination of forensic neuropsychologists’ diagnostic choices and their associated pitfalls follows. Discussion extends to the unresolved issue of disorder threshold, associated risks of overdiagnosis of mild neurocognitive disorder and underdiagnosis of major neurocognitive disorder, and the absence of a moderately severe disorder classification. Methodological concerns in diagnostic determinations, especially with DSM-5 Criteria A and B, issues associated with subtypes and specifiers, as well as functional assessments of activities of daily living, now embedded in the diagnosis, follow. Subtype omissions and methodological inconsistencies are highlighted.The vulnerability of neuropsychologists and psychiatrists during courtroom testimony on neurocognitive disorders-particularly with conceptual, methodological, and practical issues-will be addressed through clinical and forensic practice recommendations.     

Psychological Injury and Law: A Biopsychosocial and Forensic Perspective

The articles in the present special issue on the area of psychological injury and law broaden understanding of the area by considering topics outside the range of the seven major areas that mark the field. In the articles in this special issue, common themes include: (a) having comprehensive, recent literature reviews, (b) presentation of models related to psychological injury and law in which existing models are integrated, (c) integration of biopsychological and forensic perspectives, and (d) consideration of development or change processes, and examination of causality. (e) All the articles discuss possible improvements to the DSM-IV; for example, there should be a separate, sixth axis pertaining to causality.     

Posttraumatic Stress Disorder in DSM-5: New Criteria,New Measures,and Implications for Assessment

The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders—5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.     

The DSM-5 and Forensic Relationship Status: It’s Complicated

Psychologists who work in the civil forensic context are tasked with providing legal decision makers with sufficient valid and reliable data to aid them in deciding the penultimate question of whether the claimant has a psychological injury and whether that injury was the direct result of an event that preceded the injury. In May 2013, amidst a barrage of criticism from mental health professionals, the American Psychiatric Association released the long awaited fifth edition of its Diagnostic and Statistical Manual (DSM), oft referred to in legal and non-psychiatric contexts as the gold standard or bible of psychiatric disorders. Previous editions of the DSM have traditionally acknowledged the inadequacy of fit between the DSM and forensic environments. In its most current iteration, DSM-5 framers underscore the DSM’s utility in clinical and research settings, while also highlighting the level of forensic review that occurred in the vetting of DSM-5. Notwithstanding, (a) the vetting among forensic professionals and (b) the framers contention that the diagnostic categories are “concise and explicit,” the DSM-5 diagnostic categories, while perhaps fitting for the educational, clinical, and research contexts, just as its predecessors, are likely to lead to unexpected consequences in forensic contexts. Thus, it is incumbent upon psychologists serving as experts in civil forensic contexts to ensure that their findings are supported by data that are sufficiently reliable and based on sound methodology.     

The PTSD Stressor Criterion as a Barrier to Malingering: DSM-5 Draft Commentaries

This commentary focuses on the proposed changes to the trauma stressor criterion for PTSD for DSM-5, specifically its likely impact on malingering. PTSD is particularly susceptible to malingering because the diagnosis relies so heavily on a patient’s subjective symptoms. Because the traumatic event that is the trigger of the PTSD syndrome is generally based on objective fact and thus often easily corroborated, this element of the diagnosis is usually more challenging to malinger than subjective reports of symptoms. Therefore, one of the main gateways for limiting the misuse of the PTSD diagnosis in forensic settings is the criterion defining the range of qualifying traumas. Proposed changes to criterion A of PTSD in the draft include modifying the types of qualifying trauma by replacing “threat to physical integrity” with “sexual violation,” and clarifying the modes of exposure by replacing the phrase “confronted with” with two criterion: “learning that the event occurred to a close relative or close friend” and “experiencing repeated or extreme exposure to aversive details of the event.” Each of these changes has the potential to significantly broaden the range of qualifying stressors and consequently expand the potential pool of individuals who might be in a position to malinger the disorder. Given the likelihood that the DSM-5 field trials will be unable to provide information relevant to assessing the impact of making these changes in forensic settings, it would be prudent to resist the inclination to tinker with the wording unless other mechanisms are available to ensure that the wording changes do more good than harm.     

Trauma and Psychological Injury: Practice, Clinical, Legal, and Ethical Issues

Psychologists need continuing education in areas pertinent to their practice. The area of psychological injury and law presents issues and conundrums that need careful ongoing evaluation for appropriate clinical practice, adherence to ethical standards, and functioning in the legal context. In this article, we prepared a series of vignettes that illustrate these difficulties in the practice, clinical, legal, and ethical spheres related to the area of psychological injury and law. The vignettes, together with accompanying commentaries, are meant for use in workshops, and they aim to educate, stimulate, and provoke. Furthermore, the article has been written with the aim of interaction with readers, in that we seek commentaries from readers both for purposes of publication and use in workshops.     

Implications of DSM-5 Personality Traits for Forensic Psychology

One of the major innovations in the DSM-5 involves the introduction of evidence-based, dimensional approaches to diagnostic assessment. One way in which dimensions are being incorporated into the DSM-5 is in the form of a trait system that offers an alternative strategy for the diagnosis of personality disorders. The traits that comprise this system rest on the foundation of decades of quantitative research in personality and clinical psychology. Although they are conceptualized in the DSM-5 as primarily relevant to the diagnosis of personality disorder, emerging evidence suggests that these traits offer an evidence-based framework for organizing psychopathology more generally. For instance, trait approaches provide promising solutions to widely cited problems in clinical and forensic assessment such as diagnostic co-occurrence, heterogeneity, and arbitrary cut-offs. In this paper, rather than focusing specifically on the diagnosis of personality disorder, we review the rapidly emerging literature on the DSM-5 traits with special attention to their application beyond personality disorder diagnosis and their use and implications for forensic psychology.     

Underlying Dimensions of DSM-5 Posttraumatic Stress Disorder and Major Depressive Disorder Symptoms

This study examined the relationship between the underlying latent factors of major depression symptoms and DSM-5 posttraumatic stress disorder (PTSD) symptoms (American Psychiatric Association, 2013). A nonclinical sample of 266 participants with a trauma history participated in the study. Confirmatory factor analyses were conducted to evaluate the fit of the DSM-5 PTSD model and dysphoria model, as well as a depression model comprised of somatic and nonsomatic factors. The DSM-5 PTSD model demonstrated somewhat better fit over the dysphoria model. Wald tests indicated that PTSD’s negative alterations in cognitions and mood factor was more strongly related to depression’s nonsomatic factor than its somatic factor. This study furthers a nascent line of research examining the relationship between PTSD and depression factors in order to better understand the nature of the high comorbidity rates between the two disorders. Moreover, this study provides an initial analysis of the new DSM-5 diagnostic criteria for PTSD.     

Determining Disability: New Advances in Conceptualization and Research

This special issue of Psychological Injury and Law on disability presents state-of-the-art conceptualization and empirical research that will help psychologists and attorneys in the area of disability determination. This paper constitutes an introduction to and contextualization of the articles in the issue. It focuses on key advances in the field of disability research that are anticipated to move forward the practice of psychological injury and law. These new advances include the following: (1) a theoretical shift toward an integrative and dynamic biopsychosocial framework of health and disability, (2) development of complex multidimensional constructs of motivation, including primary, secondary, and tertiary gains and losses involved in disability claims, (3) increased emphasis on the perception of fairness and justice in disability claims from both psychological and legal perspectives, (4) increased understanding of the functional impact of psychological impairment, (5) inclusion of age-related factors in predicting disability, and (6) the interdisciplinary growth of this field.     

The Evolving Construct of Posttraumatic Stress Disorder (PTSD): DSM-5 Criteria Changes and Legal Implications

In the DSM-5, the diagnosis of posttraumatic stress disorder (PTSD) has undergone multiple, albeit minor, changes. These changes include shifting PTSD placement from within the anxiety disorders into a new category of traumatic and stressor-related disorders, alterations in the definition of a traumatic event, shifting of the symptom cluster structure from three to four clusters, the addition of new symptoms including persistent negative beliefs and expectations about oneself or the world, persistent distorted blame of self or others, persistent negative trauma-related emotions, and risky or reckless behaviors, and the addition of a dissociative specifier. The evidence or lack thereof behind each of these changes is briefly reviewed. These changes, although not likely to change overall prevalence, have the potential to increase the heterogeneity of individuals receiving a PTSD diagnosis both by altering what qualifies as a traumatic event and by adding symptoms commonly occurring in other disorders such as depression, borderline personality disorder, and dissociative disorders. Legal implications of these changes include continued confusion regarding what constitutes a traumatic stressor, difficulties with differential diagnosis, increased ease in malingering, and improper linking of symptoms to causes of behavior. These PTSD changes are discussed within the broader context of DSM reliability and validity concerns.     

One Quintillion Ways to Have PTSD Comorbidity: Recommendations for the Disordered DSM-5

Galatzer-Levy and Bryant (Perspect Psychol Sci 8:651–662, 2013) have calculated the number of ways that Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) posttraumatic stress disorder (PTSD) symptoms can be combined as over 600,000. They concluded that the amount is astounding and the category is rendered amorphous. PTSD often occurs in the context of polytrauma or comorbidity. The epidemiological literature indicates that the most common comorbid conditions in cases of PTSD include major depressive disorder (MDD), chronic pain, neurocognitive disorder due to traumatic brain injury (e.g., mild), and alcohol use disorder, with premorbid personality disorder possible, as well (which we consider as exacerbated due to the traumatic incident at issue, as in borderline personality disorder). We calculated the possible symptom combinations for each of these disorders and then in comorbid combination with PTSD (e.g., PTSD with MDD, but also when all six conditions are present). The number of symptom combinations in full polytrauma involving all six conditions listed is truly astounding, over one quintillion. Also, we reviewed the range of PTSD comorbidities, which adds to the symptom heterogeneity in cases. We make recommendations to prioritize symptoms in disorders as primary (e.g., unique, marker), secondary (e.g., core essential), and tertiary (e.g., common, cross-diagnostic). The latter tertiary type of symptoms in a disorder, if any, should be kept apart in its own criterion. This approach might help make the next version of the DSM more clinically useful both to clinicians and to court.     

Assessing Latent Level Associations Between PTSD and Dissociative Factors: Is Depersonalization and Derealization Related to PTSD Factors More So than Alternative Dissociative Factors?

Posttraumatic stress disorder (PTSD) criteria in DSM-5 included a dissociative diagnostic subtype characterized by a depersonalization item and a derealization item. Researchers have queried whether this was too restrictive, as alternative dissociative symptomatology may also be characteristic of the subtype. The current study utilized data from 318 Northern Irish students, of which 165 were trauma exposed. Participants were assessed for PTSD symptomatology based on DSM-5 criteria via a modified version of the PTSD Symptom Scale-Self-Report (PSS-5) and dissociative experiences via the Dissociative Experiences Scale (DES). Confirmatory factor analysis of PTSD and DES models revealed an optimal four-factor DSM-5 PTSD model including reexperiencing, avoidance, negative alterations in mood and cognitions, and alterations in hyperarousal and reactivity factors, and an optimal three-factor DES model including absorption, amnesia, and depersonalization/derealization factors. When comparing the correlations between depersonalization/derealization and the four PTSD factors, significant Wald tests of parameter constraints revealed that depersonalization/derealization is more related to alterations in arousal and reactivity (r?=?.432) compared to avoidance (r?=?.289), χ ² (1, N?=?165)?=?8.352, p?=?.004. We discuss whether the mechanism for comorbid PTSD and dissociation may be related to PTSD’s arousal factor.