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.     

The DSM-5 Draft: Critique and Recommendations

The series of articles in this special topic on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) draft (American Psychiatric Association 2010), which is preparatory to publication of the DSM-5, deals with issues and disorders and conditions pertinent to the field of psychological injury and law. The articles describe and critique the changes anticipated for the diagnoses of posttraumatic stress disorder, pain disorder, and neurocognitive disorder, in particular. Further, changes suggested in the draft for personality disorder are analyzed with a critical eye. In addition, the articles examine the lack of change for dealing with malingering and the general lack of consideration of group differences such as for race, in areas pertinent to psychological injury and law. This summary of the articles concludes that some of the changes in the DSM-5 draft are premature, and it calls for continued research and evidence-informed bases for recommended changes for the DSM-V.     

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.     

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.     

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).     

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.     

Neurocognitive Disorders in DSM-V: Forensic Perspective

Although determination of diagnosis of cognitive impairments constitutes one of the core objectives of forensic neuropsychological assessment, the diagnostic criteria for cognitive disorders provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association 2000) have been of low internal and external validity and limited utility. This paper reviews the evolution of diagnosis of cognitive disorders from current DSM-IV-TR to the proposed DSM-V (American Psychiatric Association 2010). The conceptual framework is tracked, along with the body of literature associated with the DSM-V proposal on Minor and Major Neurocognitive Disorders. The quality of evidence for internal and external validity is reviewed, as well as the fairness and utility of newly proposed diagnoses from both clinical and forensic perspectives. Significant conceptual, evidentiary, psychometric, assessment, and practical questions are raised related to the new classification, and recommendations are offered for improvement to the proposal of the DSM-V Work Group on Neurocognitive Disorders.     

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.     

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.     

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.     

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.     

Ethical Considerations in the Development and Application of Mental and Behavioral Nosologies: Lessons from DSM-5

We are not likely to find a diagnostic system as “unethical,” per se, but rather find that it creates ethical concerns in its formulation and application. There is an increased risk of misuse and misunderstanding of the DSM-5 particularly when applied to forensic assessment because of documented problems with reliability and validity. For example, when field tested, the American Psychiatric Association reported diagnostic category kappa levels as acceptable that were far below the standard level of acceptability. The DSM-5 does not offer sensitivity and specificity levels and thus psychologists must keep this in mind when using or teaching this manual. Also, especially in light of concerns about diagnostic inflation, we recommend that psychologists exercise caution when using the DSM-5 in forensic assessments, including civil and criminal cases. Alternatives to the DSM-5, such as the International Classification of Diseases and the Psychodynamic Diagnostic Manual are reviewed.     

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.     

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.     

The Prevalence of Mental Health Problems in Men Arrested for Domestic Violence

The problem of male perpetrated intimate partner violence (IPV) is widespread. In an effort to identify risk factors for perpetrating IPV, researchers have examined mental health problems among perpetrators. However, the majority of research in this area has examined personality psychopathology and/or limited their investigation to posttraumatic stress disorder (PTSD) or depression. Thus, the present study examined self-reported Axis I psychopathology among men arrested for domestic violence (N?=?308). Results replicated past research showing high rates of PTSD and depression. In addition, the prevalence of generalized anxiety disorder (GAD), panic disorder, social phobia, and alcohol and drug disorders were very high. All types of mental health problems were positively associated with aggression perpetration. Males meeting probable diagnostic classification reported significantly more frequent aggression than males not meeting diagnostic classification, even after controlling for social desirability. Directions for future research and implications of these findings are discussed.     

Mental disorder is a cause of crime: The cornerstone of forensic psychiatry

The assumption that mental disorder is a cause of crime is the foundation of forensic psychiatry, but conceptual, epistemological, and empirical analyses show that neither mental nor crime, or the causation implied, are clear-cut concepts. “Mental” denotes heterogeneous aspects of a person such as inner experiences, cognitive abilities, and behaviour patterns described in a non-physical vocabulary. In psychology and psychiatry, mental describes law-bound, caused aspects of human functioning that are predictable and generalizable. Problems defined as mental disorders are end-points of dimensional inter-individual differences rather than natural categories. Deficits in cognitive faculties, such as attention, verbal understanding, impulse control, and reality assessment, may be susceptibility factors that relate to behaviours (such as crimes) by increasing the probability (risk) for a negative behaviour or constitute causes in the sense of INUS conditions (Insufficient but Non-redundant parts of Unnecessary but Sufficient conditions). Attributing causes to complex behaviours such as crimes is not an unbiased process, and mental disorders will attract disproportionate attention when it comes to explanations of behaviours that we wish to distance ourselves from. Only by rigorous interpretation of what psychiatry actually can inform us about, using empirical analyses of quantified aggressive antisocial behaviours and their possible explanatory factors, can we gain a clearer notion of the relationship between mental disorder and crime.     

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.     

Major depression – a study on the validity of clinicians’ diagnoses in medicolegal assessment

Major depression ranges among the most frequently diagnosed psychiatric disorders. Accordingly, diagnoses of depression are often underlying insurance, compensation or disability claims. This report evaluates the validity of clinicians’ diagnoses of major depression in a sample of claimants. In 2015, n = 127 consecutive cases were examined for medicolegal assessment. For all of them, a diagnosis of major depression had been established by clinicians. All testees underwent a psychiatric interview, a physical examination, they answered questionnaires for depressive symptoms according to DSM-5, embitterment disorder, post concussion syndrome (PCS) and unspecific somatic complaints. Performance and symptom validity tests were administered. Only 31% fulfilled the diagnostic criteria for DSM-5 major depression according to self-report, while none did so according to psychiatric assessment. Negative response bias was found in 64% of cases, feigned neurologic symptoms in 22%. Symptom exaggeration was indiscriminate rather than depression-specific. By self-report, 64% of the participants qualified for embitterment disorder and 93% for PCS. In conclusion, clinicians’ diagnoses of depression seem often confounded by improper assessment of the diagnostic criteria, confusion of depression with bereavement or embitterment and also by response bias.     

Forensic neuropsychology: a selective introduction

During the last decade, neuropsychology has emerged as one of the fastest growing disciplines within clinical psychology. One of the most important roles for neuropsychologists is their contribution to the forensic sciences. The present paper reviews how lawyers may best utilize the services of clinical neuropsychologists. Suggestions are also offered to neuropsychologists on how better to meet the needs of lawyers. The following forensic science issues are discussed: the legal framework in which neuropsychologists function; contributions psychologists may make towards answering basic medicolegal questions such as the elucidation of the nature, extent, and duration of head injury sequelae; criteria for acceptable neuropsychological reports; medicolegal aspects of severe head injury, minor head injury (posttraumatic syndrome), and pseudo-head injury (malingering). There are many causes of damage to the nervous system (for example, industrial toxins and medical malpractice) that are eligible for compensation. Examples will be confined to head injury since the basic forensic science principles remain the same, whatever the etiology of such brain damage.