Despite the problem posed by categorical diagnoses, the DSM-5 Task Force recognized that it is premature scientifically to propose alternative definitions for most disorders. The organizational structure is meant to serve as a bridge to new diagnostic approaches with- out disrupting current clinical practice or research. With support from DSM-associated training materials, the National Institutes of Health other funding agencies, and scientific publications, the more dimensional DSM-S approach and organizational structure can fa- within the proposed chapters and across adjacent chapters. Such a reformulation of re- search goals should also keep DSM-S central to the development of dimensional approaches coming years.
To improve clinical utility, DSM—5 is organized on developmental and lifespan consider- ations. It begins with diagnoses thought to reﬂect developmental processes that manifest early in life (e.g., neurodevelopmental and schizophrenia spectrum and other psychotic disorders), followed by diagnoses that more commonly manifest in adolescence and young adulthood (e.g., bipolar, depressive, and anxiety disorders), and ends with diagno- ses relevant to adulthood and later life (e.g., neurocognitive disorders). A similar approach has been taken, where possible, within each chapter. This organizational structure facili- tates the comprehensive use of lifespan information as a way to assist in diagnostic deci- sion making.
The proposed organization of chapters of DSM-5, after the neurodevelopmental disor- ders, is based on groups of internalizing (emotional and somatic) disorders, externalizing disorders, neurocognitive disorders, and other disorders. It is hoped that this organization will encourage further study of underlying pathophysiological processes that give rise to diagnostic comorbidity and symptom heterogeneity. Furthermore, by arranging disorder clusters to mirror clinical reality, DSM-5 should facilitate identification of potential diag- noses by non—mental health specialists, such as primary care physicians.
The organizational structure of DSM-5, along with ICD harmonization, is designed to provide better and more ﬂexible diagnostic concepts for the next epoch of research and to serve as a useful guide to clinicians in explaining to patients why they might have received their lifespan.
Mental disorders are defined in relation to cultural, social, and familial norms and values.
Culture provides interpretive frameworks that shape the experience and expression of the symptoms, signs, and behaviors that are criteria for diagnosis. Culture is transmitted, re- vised, and recreated within the family and other social systems and institutions. Diagnostic assessment must therefore consider whether an individual’s experiences, symptoms, and behaviors differ from sociocultural norms and lead to difficulties in adaptation in the cul- tures of origin and in specific social or familial contexts. Key aspects of culture relevant to di- agnostic classification and assessment have been considered in the development of DSM-S.
In Section III, the ”Cultural Formulation” contains a detailed discussion of culture and diagnosis in DSM-5, including tools for in-depth cultural assessment. In the Appendix, the ”Glossary of Cultural Concepts of Distress” provides a description of some common cul- tural syndromes, idioms of distress, and causal explanations relevant to clinical practice.
The boundaries between normality and pathology vary across cultures for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cul- tures, social settings, and families. Hence, the level at which an experience becomes prob- lematic or pathological will differ. The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them, including family members and clinicians. Awareness of the significance of culture may correct mistaken interpretations of psychopathology, but cul- ture may also contribute to vulnerability and suffering (e.g., by amplifying fears that main- tain panic disorder or health anxiety). Cultural meanings, habits, and traditions can also contribute to either stigma or support in the social and familial response to mental illness.