The DSM-5: From “Insanity” to “Developmental Trauma Disorder”

By Michelle Jurkiewicz, Winter 2010 - Online Exlusive

The categorization of mental illness has come a long way since the U.S. Census of 1880 sought statistical data on “idiocy/insanity,” which included seven categories such as melancholia and epilepsy. Data collection continued for decades and finally culminated in the 1952 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The manual introduced the notion of utilizing statistical categories for clinical purposes in mental health. Over the years disorders have been added, refined, and deleted (such as the removal of Homosexuality in 1973). The multi-axial system has been introduced and diagnostic criteria made more specific.

So like all mental health providers in the United States, I use the DSM-IV to categorize my clients, even though many don’t fit so neatly into diagnostic boxes. I learn and use the manual, albeit begrudgingly at times, because it is a requirement. Yet, in anticipation of the publication of DSM-5 in May 2013, I have reconsidered the political and clinical importance of diagnostic categorization.

The bottom line is that only the diagnoses in the DSM are covered by insurance, and it is predominantly these diagnoses that are researched in order to create best practices in treatment.

For example, children and teenagers who are survivors of chronic interpersonal trauma often carry a list of comorbid disorders such as ADHD, Oppositional Defiant Disorder, and PTSD. A string of diagnoses does not begin to capture the unique set of symptoms and challenges faced by these youth. These diagnoses also do very little to guide clinicians in treating young trauma survivors because they are notoriously absent from the DSM-IV.

Bessel van der Kolk and several other clinicians are in a work group advocating for the creation of a diagnosis called Developmental Trauma Disorder. Not only will this diagnosis help child survivors of chronic trauma receive the treatment that they need, it will broaden the definition of “trauma” to include interpersonal factors such as abandonment and emotional abuse. The inclusion of Developmental Trauma Disorder in the DSM-5 would also make it more likely to fund further research for this marginalized population.

I have come to the conclusion that the DSM revision is not simply about re-categorization, it is about advocating for the groups of people that we serve as a profession. The current diagnostic categories may be flawed, but they have the potential to bring visibility to the unique circumstances and challenges faced by certain individuals. The publication of the DSM-5 is not likely to be perfect, but it can be a step forward that will inevitably be followed by another step.

While the window has closed for submissions, people across mental health fields have been instrumental in advocating for change in the DSM-5. You, too, can follow the progress of all changes under consideration on the American Psychiatric Association website.