DSM-5 and the Law – Changes and Challenges

After the American Psychiatric Association released the newest edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), psychiatrists and mental health professionals struggled to make the transition from its predecessor. The DSM-5 introduced significant changes, not only to the conceptualization of psychiatric disorders, but also to definitions, nomenclatures, classifications, and even the existence of certain disorders. The publication of DSM-5 and the Law updated users of the DSM-5 and helped them navigate the implications of this transition in various legal contexts.

As a Professor of Clinical Psychiatry, Chief of the Division of Psychiatry and the Law, and training director for the forensic psychiatry fellowship at the University of California-Davis School of Medicine, Dr. Charles Scott is an educator who has kept up with the ever-evolving fields of law and mental health. In the yearly forensic psychiatry review course offered by the American Academy of Psychiatry and the Law, his lectures depict the changes and new challenges that the DSM-5 has brought to forensic experts. This book is another venue through which Dr. Scott tactfully offers those updates, and where non-experts and experts of all levels alike will find new information to learn. Important to note, as well, are the contributions of various chapter authors.

This book is composed of four sections encompassing 11 individual chapters that build on one another without necessarily being intricately tied together. This book is a helpful reference when specific questions arise because the chapters are independently structured, with detailed titles and subtitles that facilitate finding desired information. A brief summary concludes each chapter with bullet points that remind readers of the highlights of each topic. Clinical vignettes offer illustrative examples that underline the differences from DSM-IV-TR that are introduced by the new DSM-5 language. Chapter 2 is rich with such vignettes as it tackles the major changes in the larger diagnostic categories. In addition to the vignettes, shorter examples are scattered throughout the book, which keeps the text light and easy to absorb, particularly for newer forensic experts (or non-experts). Although it is not exhaustive in reviewing all of the operational changes between the two DSM versions, chapter 2 also outlines the foundation that precedes more specific descriptions in later chapters.

For those interested in the transition between DSM-IV-TR and DSM-5, chapter 1 offers a rich historical, practical, and contextual perspective, citing major studies that contributed to the various changes. Chapter 1 also mentions points of contention between nonforensic experts that have arisen from the transition and remain unresolved. The authors also cite relevant landmark cases that highlight the challenges brought about by the DSM-5 changes regarding the admissibility and validity of diagnoses or diagnostic tools and rating scales. Chapter 3, dedicated to diagnosing and report writing, highlights the intricacies of reporting diagnoses, specifying the appropriateness of certain nomenclature and pointing out the limitations of the DSM that face professionals engaged in making a diagnosis. For example, chapter 3 mentions inconsistencies within the DSM-5, such as remission criteria in pedophilic disorders, to alert evaluators to a dilemma they may encounter in their work. I viewed this chapter as a user's manual for the DSM-5 and a helpful teaching tool that walks the evaluator through a stepwise approach to formulating a diagnosis, including specifiers, severity ratings, exclusion criteria, and so on. Chapter 3 also briefly addresses the use of non-standardized assessment instruments, which can be double-edged swords in courts and forensic settings when their validity and reliability have not yet been fully established.

Chapters 4–6 focus on the implications of the DSM-5 in criminal settings and evaluations. In chapter 4, “DSM-5 and Psychiatric Evaluations of Individuals in the Criminal Justice System,” the author takes the DSM-5 diagnoses and descriptions outlined in chapter 2 and explains their use in relevant contexts such as drug and mental health courts, violence risk and sex offender assessment, death penalty litigations, and treatment in correctional settings. For example, in the section on sex-offender assessment, the author reviews the difference between paraphilias and paraphilic disorders, the language used in the DSM-5 to describe the disorders, and the implications for formulating an opinion following a forensic assessment. Chapters 5 and 6 address criminal competency and responsibility, respectively. These chapters are similarly structured, with the first half of each chapter offering a general overview of the topic and the second half addressing the impact of the DSM-5 changes on the assessment of criminal competencies and responsibility. While readers who are less familiar with these topics may benefit from this review, more advanced readers may find it basic and skip to the second half of these chapters to explore the relevance of the DSM-5 in each category of evaluations. Diagnoses that qualify for severe mental illness are discussed in both chapters, as are less commonly discussed disorders, such as premenstrual dysphoric disorder and disruptive mood dysregulation disorder.

Chapters 7 to 10 comprise the civil section of the book, starting with a chapter on civil competencies. Although competency is subject-specific, chapter 7 describes how the constituent elements of competencies present substantial overlaps and require similar cognitive faculties. Unfortunately, in this chapter, the authors' choice to review each civil competency theme separately dilutes the focus on the DSM-5 itself. Throughout the subsections, after offering descriptions of the fundamentals of those assessments (e.g., testamentary capacity, competency to manage medical decisions, to manage financial affairs, enter into contracts, to marry, and so on), the authors mention the insignificant impact that the DSM changes will have on the various competency assessments. For readers interested in legislative influence on those evaluations in California, Oregon, or Washington, various acts and statutes relevant to these states are cited as a matter of illustration and comparison.

Chapters 8 and 9 delve into personal injury litigation and disability evaluations, respectively. With short and succinct introductions to each topic at the outset of the respective chapter, the authors address those topics in the case-based learning approach that will remind early-career psychiatrists of their medical school and residency teaching methods: a detailed and rich major case vignette constitutes the basis upon which a multitude of potential complaint scenarios are explored. Medication-induced mental and movement disorders, as well as somatic symptom disorders, are discussed frequently. Posttraumatic stress disorder is also thoroughly reviewed in chapter 8. Chapter 9 focuses on workers' compensation claim evaluations and a review of the various DSM-5 disorders under the Americans with Disabilities Act, discussing how eligibility is likely to be affected with the new diagnostic criteria.

Chapter 10, the only chapter of the book specifically addressing juvenile evaluations, is titled “DSM-5 and Education Evaluations in School-Aged Children.” After briefly introducing the Individuals with Disabilities Education Act, the authors focus the discussion on relevant disorders such as autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), intellectual disability, and others. Because no other chapters are dedicated to the evaluation of juveniles in criminal settings, it is noteworthy that ASD and ADHD were not discussed in the context of competencies (chapters 5 and 7) or criminal responsibility evaluations (chapter 6), as both conditions extend into adulthood and are sometimes posited as an underlying reason for lack of competency across age groups. Hence, a review of the applicability of the DSM-5 changes, particularly for ASD, given that it underwent major changes between DSM editions, would have been a valuable addition to those chapters.

Malingering, one of the most fascinating topics a clinician may encounter, was removed from the index of the DSM-5. This book nevertheless dedicates the entirety of chapter 11 to explore this topic in the context of the DSM-5 and forensic evaluations. The book explicates how the challenges of identifying and correctly diagnosing those who feign mental illness will be compounded by the changes that the DSM-5 has introduced to the field. With the broadening categories and definitions in the DSM-5, the incentives to feign mental illness in either the criminal or civil realm will likely increase, as suggested by the authors. This final chapter offers some new insights and summarizes challenges brought forth in previous sections of the book. A short but helpful subsection on testing strategies introduces readers unfamiliar with neuropsychological testing to a few methods that could assist in formulating diagnostic opinions about potential malingering.

Although primarily addressed to guiding forensic evaluators in their evaluations and report-writing (and, by extension, testifying), the book is not beyond the reach of other professionals. Attorneys and judges who deal with a variety of criminal and civil cases with mental health questions can refer to this text to update their understanding of the language evaluators might use. Social workers and educators who wish to understand the likely impact of diagnostic changes on children's eligibility for educational services might refer to chapter 10 for a general overview. Clinical providers, particularly those who work in correctional or forensic settings, may also find valuable information in an efficient and convenient manner in this text.

The organization of the book allows readers interested in a particular type of assessment to access a high-yield overview of the topic with the relevant DSM-5 changes in individual chapters. This structure focuses the interpretation of available data to answer specific questions, such as examining trauma (e.g., PTSD) in a competency setting versus in malpractice litigation. The downside is that the reader may have to put some effort into looking for a comprehensive description of diagnostic changes and their implications, and readers who consume the book in its totality will notice some redundancy and overlap created by its layout. With its overall concentration on providing high-yield information, the text is a fluid read that will equip clinicians and evaluators with a better grasp of the intricacies of the transition to the new DSM.

• © 2019 American Academy of Psychiatry and the Law