Foreword
I am writing this Foreword to the Sixth Edition of The American Psychiatric Publishing Textbook of Psychiatry (the Textbook) several months after the publication of DSM-5, for which I served as Chair of the Task Force charged with development. DSM-5 was issued almost 20 years after the publication of DSM-IV, which I reviewed carefully prior to undertaking this revision. I found the process of review not only a vital orientation to the task, but also a valuable representation of the advances in our field over the past two decades. As might be expected for a work of its scope and international importance, DSM-5 has stimulated considerable, spirited controversy. Much of the controversy has revolved around two fundamental issues: 1) what in DSM-5 was changed from DSM-IV and 2) what in DSM-5 remained essentially unchanged from DSM-IV. I believe that it is a useful and revealing exercise to review how these controversial issues are reflected in the changes in this Sixth Edition of the Textbook as compared with its First Edition, which was completed 25 years previously.
The DSM-5 development occurred over a decade. In 2000, the American Psychiatric Association (APA) authorized a series of workshops to identify high-priority issues and processes, and in 2008, members of the specific, disorder-related tasks forces were selected. This was the largest project in which most of the participants had ever been engaged. It involved more than 400 experts from the United States and around the world and the review of years of science relevant to the diagnosis and classification of mental disorders. The DSM-5 process was thus both a highly participatory and a highly transparent one, with Web postings of potential revisions opened for three online comment periods that attracted approximately 13,000 responses—all of which were reviewed carefully by the relevant task force members and responded to as relevant and indicated. Finally, great effort was taken to minimize conflicts of interest of all kinds.
Three fundamental principles in determining whether or not changes would be made to DSM-IV were 1) the relevance of the change to both patients and practitioners; 2) the degree of difficulty the change would pose for clinicians; and 3) evidence of increased validity of diagnosis from empirical research. We were also careful not to make the new volume so large and inclusive that it would be impractical for professionals to use in their busy clinical practices. In fact, for the first time in the history of DSM, there are fewer diagnoses than in the previous edition. Finally, we viewed the 20 years that had passed between the major revision of DSM-IV and DSM-5 as much too long. Our plan going forward is to take advantage of newer technologies to have a more fluid, rapidly evolving product by making it an electronic document. Specifically, if there are new discoveries that warrant revisions by being relevant to our patients and practical for clinicians, we will change the document. We specifically changed DSM designations from Roman numerals to Arabic numerals to accommodate this change—thus, the current edition can be conceptualized as DSM-5.0, with the next authorized revision being DSM-5.1.
As readily revealed from perusal of the changes between the First and Sixth Editions of the Textbook, there are several key similarities in fundamentals and operational principles of DSM-5 and this volume. In the brief Preface to the First Edition of the Textbook, the editors—John Talbott, M.D., Robert Hales, M.D., and Stuart Yudofsky, M.D.—clearly articulated their goals:
"The goal of the American Psychiatric Press Textbook is to assemble a textbook that presents, as comprehensively as possible in a single volume, the clinically relevant topics in psychiatry ... We have also endeavored to offer a book that is pleasant to read, promotes the learning process, and facilitates the rapid location of reference data. Among the many challenges involved in accomplishing these goals were 1) decisions about which topics and information to include and which to omit, 2) the minimization of redundancy, and 3) the maintenance of the fluidity and continuity of the text."
When the Textbook was first published in 1988, psychiatry was undergoing a renaissance in its re-embrace of and reintegration with both clinical medicine and the basic sciences of the field. The result was that the existing textbooks of psychiatry were expanding rapidly in both scope and content. Several texts at the time had become large, comprehensive references, en route to encompassing several volumes. Similar to the DSM-5 Task Force, the editors of the Textbook realized that there was a need for a textbook that was practical and utilitarian for both active clinicians and learners, including medical students and residents. Although the scientific bases of psychiatry and of the related fields of neurology and neuroscience have grown rapidly and progressively since that time, the editors have managed to maintain the Textbook's clinical relevance and practicality without increasing its size. They have accomplished this feat through continuous revisions and changed areas of focus that are based on how students and clinicians learn and practice. Examples are profoundly evident when one compares and contrasts the First and Sixth Editions.
Despite the tremendous growth in the field since 1988, the Sixth Edition of the Textbook contains the same number of chapters as the First Edition. In addition, the overall content has been reduced in the Sixth Edition, when the change from the larger, more traditional textbook format to the smaller format (the format used for DSM-5) is taken into account. This restraint reflects the editors' understanding that the use of the Internet, search engines, apps, and 'smart' phones has revolutionized how students and professionals learn and acquire information. Rather than including comprehensive information, the editors' focus has continued to be on synthesizing information to enhance efficient learning and practice. This principle is also reflected in the evolution of the Textbook's structure. For example, Part I of the First Edition was titled "Theoretical Foundations" and included the chapters "Neuroscience and Psychiatry," "Genetics," "Epidemiology of Mental Disorders," Normal Growth and Development," and "Theories of Mind and Psychopathology." Radically reorganized around the patient, the Sixth Edition of the Textbook begins with outstanding chapters on "The Psychiatric Interview and Mental Status Examination," "DSM-5 as a Framework for Psychiatric Diagnosis," "Psychological Assessment," "Laboratory Testing and Imaging Studies in Psychiatry," etc. The net result is that, given their similar fundamental principles and organizational foci, the Sixth Edition of the Textbook makes an outstanding complement to DSM-5.
One issue regarding the publication of DSM-5 that raised considerable controversy was how well the book reflected recent research findings in psychiatry and whether or not the new manual would set the stage for future research. Although this question created what I consider to be healthy tension throughout the development of DSM-5, it came to a head in an article that appeared on May 6, 2013, in the New York Times, only a few weeks before its publication. Under the headline "Psychiatry's Guide Is Out of Touch With Science, Experts Say," the article quoted my friend and colleague Thomas R. Insel, M.D., director of the National Institute of Mental Health (NIMH), as saying that DSM-5 suffers from "a scientific lack of validity." He was also quoted as having said that his goal was "to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms." In addition, Steven E. Hyman, M.D., psychiatrist, neuroscientist, and former director of NIMH, was quoted as saying, "The creators of DSM in the 1960s and 1970s ... chose a model in which all psychiatric illnesses were represented as categories discontinuous with 'normal.' But this is totally wrong in a way they couldn't have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don't have five diseases—they have one underlying condition."
I (and many other psychiatrists familiar with the complex issues and challenges involved in developing classification systems) responded that, while we all look forward to a time when science advances to the point when we can diagnose psychiatric disorders using valid and reliable biological and genetic markers, that day has not yet arrived. In the meantime, DSM-5 is an excellent tool for psychiatrists to use in providing state-of-the-art care for our patients who suffer at the present time. Additionally, I pointed out in an American Psychiatric Association (2013) news release that great progress was made with DSM-5 in several key areas, including the following:
In that news release, I also stated that "DSM, at its core, is a guidebook to help clinicians describe and diagnose the behaviors and symptoms of their patients. It provides clinicians with a common language to deliver the best patient care possible. And through content such as the new Section III, the [new] manual also aims to encourage future directions in research" (American Psychiatric Association 2013).
I raise this particular controversy in this Foreword for a specific reason beyond intrinsic and historical interests. A stated goal of all editions of the Textbook is to help clinicians glean from the current avalanche of available information guidance to understand what is accurate, relevant, and useful to them in caring for their patients.
To gauge the success of this edition of the Textbook in achieving this goal, I review below the second chapter, "DSM-5 as a Framework for Psychiatric Diagnosis" by Jack D. Burke, M.D., M.P.H., and Helena C. Kraemer, Ph.D. Chapter 2 begins by stating the purpose of diagnostic classification systems:
"In medicine and public health, diagnostic classifications provide a framework for understanding and communicating about clinical conditions. They offer a systematic presentation of diagnostic categories, based on delineation of specific clinical conditions organized into meaningful groups ... Classification systems reflect the current state of scientific knowledge, so that they need to be revised periodically."
I was delighted to find in the very first paragraph of this chapter the point that I and so many others were making in our responses to the aforementioned controversy: namely, that a future hope and ideal that has not been realized should not replace a current model that is workable and useful to our patients.
The authors' (and my) point was elaborated further in the third paragraph under the topic heading "Challenges for Psychiatric Classification."
"An ideal classification system might be the periodic table. Chemical elements fit into an array based on their atomic numbers; this classification provides a clear, unduplicated placement for each element. The periodic table is exclusive, because each element fits into only one category; it is exhaustive because every element can be classified within it; and it is discrete, because the defining characteristic, the atomic number, matches one integer or another, rather than one of the infinite real numbers between two integers. Its columns group elements by similar properties, and its rows demonstrate their electron structures.
If each illness could be shown to have just one cause, illnesses could be categorized on the basis of etiology and the associated mechanism of disease. Infectious diseases and nutritional deficiencies provide a model for this approach. Once an etiological agent or cause becomes established, researchers can study methods to cure the illness or prevent it. This model has been the accepted standard for thinking about diagnoses in medicine.
Defining illnesses, however, is challenging. Even with a single cause, a clinical condition can present with a variable mix of symptoms, as in myocardial infarction. In many conditions, especially psychiatric disorders, multiple biological, psychological, and environmental factors interact in complex ways over time to produce an illness. Specification of the way these factors interact is difficult because so many processes in neuroscience and psychology are complex and poorly understood. As a result, it is not possible to classify psychiatric illnesses as diseases based on etiology and mechanism, using a reductionistic, one-level explanation.
Diagnostic Entities
Clinical conditions are not freestanding entities like chemical elements, so the periodic table is an unrealistic model for classification in medicine. Even for medical conditions with a single known etiology, types of causes vary considerably, such as infectious agents, chromosomal abnormalities, or neoplasms. There is no single defining characteristic, like an atomic number, to govern their classification. Even a single defining characteristic of a disease may produce ambiguity in distinguishing between' normality and disease; for example, an individual can be a carrier of an infectious agent, such as tubercle bacillus, without having an illness. The defining characteristics of some conditions are continuous measures, such as blood pressure or hormone levels, and require a threshold to be set for a category to be identified. Research on epigenomics, proteomics, and other aspects of systems biology will lead to even greater complexity of disease classifications."
I quote this chapter so extensively because not only does it eloquently address the controversy raised, but it also accomplishes what the editors proclaim as their goal. The section in this chapter on "Key Changes in DSM-5" is particularly noteworthy. I also believe that the clarity and relevance of this "sampling" is exemplary of the remainder of this extraordinary chapter, and of the entire Sixth Edition of the Textbook. Many of the controversies over DSM-5 involve changes in specific diagnoses, including autism spectrum disorder, binge-eating disorder, disruptive mood dysregulation disorder, post-traumatic stress disorder, substance use disorder, and the removal of the bereavement exclusion from major depressive disorder. A careful review of the Sixth Edition of the Textbook reveals that these changes are portrayed and explained as lucidly as was the material quoted above from Chapter 2.
I was gratified and even somewhat surprised by the extent and success of the integration of this new edition of the Textbook with DSM-5. Given how soon the publication of the Textbook followed that of DSM-5, this remarkable accomplishment took foresight, careful planning, and thoughtful implementation on the parts of the book's editors and authors. Clearly, their intention was for clinicians, residents, and students to be able to use the two volumes in a complementary, seamless fashion wherein the sum would be greater than the two individual parts. Examples of this integration are apparent throughout the book.
The organizational format of the Sixth Edition of the Textbook parallels that of DSM-5. This is particularly evident where DSM-5 implemented changes from DSM-IV. For example, consistent with DSM-5 categorical modifications in diagnostic categories, there are separate chapters in the Textbook for Bipolar and Related Disorders and Depressive Disorders, instead of a single chapter on Mood Disorders. As in DSM-5, rather than being discussed in a separate chapter, Childhood-Onset Disorders are redistributed to the previously identified "adult" disorders in the new edition of the Textbook. These changes in structure and format apply throughout the 19 chapters comprising Part II of the Textbook.
The net result of the Textbook's structural integration with DSM-5 is a unique facilitation of the learning process by students as well as the practical application of the contents of both books by residents and clinicians. For example, if a student or psychiatrist were consulting one disorder category within DSM-5 and needed to learn more about treatment of that particular disorder, he or she could turn to the Textbook, which is ordered in a parallel fashion. Conversely, if that reader were learning about a particular disorder in a chapter of the Textbook and required more detailed diagnostic information, this material would be readily available in the correspondingly titled chapter of DSM-5. By design, the Sixth Edition Textbook serves as an ideal companion volume to DSM-5.
Another feature of the new edition of the Textbook that I found very appealing is its enhanced presentation of the important topics that are also emphasized and highlighted in DSM-5. Examples of this feature abound and include separate chapters on treatment of seniors; women; lesbian, gay, bisexual, and transgender patients; and culturally diverse populations. Clearly, the editors of the Textbook agreed with DSM-5 Task Force members that the new edition of the Textbook would be vastly improved by emphasis on these important topics that are relevant to all psychiatric disorders.
As noted above, editorial discipline had to be exercised to maintain the size and format of the new edition of the Textbook, so that it would be practical for and accessible to its many readership constituencies. Toward this end, there have been several changes in this edition of the Textbook. For example, the size of the Textbook was changed from 8.5" x 11" to 7" x 10" to be consistent with the size of DSM-5, making it easy for the clinician or student to place the two books next to one another on a book shelf to facilitate cross-referencing.
Finally, I noted that most of the chapters on specific psychiatric disorders have been written by psychiatrists who participated in the DSM-5 process. Specifically, 17 DSM-5 Task Force and Work Group members were authors of chapters in the Sixth Edition Textbook. This is consistent with the Textbook editors' aim to ensure that the diagnostic material presented is consistent with DSM-5. As Chair of the Task Force on DSM-5,1 can confirm that they have achieved this goal.
Finally, I wish to comment briefly on the transitions that have occurred over the six editions of this Textbook. These transitions also parallel the evolution of DSM to its current Fifth Edition. It has been my privilege to have had the opportunity to work with many gifted contributors to the rich 61-year history of DSM leading up to this most recent effort in the evolution of the manual.
Additionally, as commented on by the late Melvin Sabshin, M.D., then President and Chairman of the Board of the American Psychiatric Press, Inc. (APPI), and Medical Director of the APA, in his Preface to the First Edition of this Textbook, the editorship of this text series also has a rich history. The founding editors were John Talbott, M.D., Robert Hales, M.D., and Stuart Yudofsky, M.D., the latter two collaborating in all subsequent editions. In his Preface, Dr. Sabshin described the backgrounds of each editor. About Dr. Talbott, he wrote, "While we have not yet located an editorship gene, Dr. John Talbott comes from a family of editors. His father edited the Journal of the American Medical Association for many years and served as a marvelous model ... His leadership qualities have been evident in a myriad of national roles, including the presidency of APA in 1984-1985."
Dr. Talbott served as a mentor to Dr. Hales during his years as Chair of the APA Scientific Program Committee and to Dr. Yudofsky during his time as a resident and young member of the Faculty at Columbia University and the New York State Psychiatric Institute. Dr. Sabshin wrote the following about Dr. Hales' accomplishments as Chair of APA's Scientific Program Committee: "Not only has he vitalized the scientific excellence, educational scope, and clinical utility of these meetings, but he has accomplished these important functions with flair and elan." About Dr. Yudofsky, Dr. Sabshin wrote, "He has served as editor of the recently published and highly praised Textbook of Neuropsychiatry. Furthermore, he is editor of the new psychiatric journal being edited by APPI, The Journal of Neuropsychiatry and Clinical Neurosciences. This major undertaking under Dr. Yudofsky's stewardship will be a balanced reflection of and vanguard for the re-emergence of neuropsychiatry." Hales and Yudofsky have continued to collaborate as editors of The American Psychiatric Publishing Textbook of Neuropsychiatry and Behavioral Neuroscience, now in its Fifth Edition, as well as on the Journal of Neuropsychiatry and Clinical Neurosciences, currently in its 25th year and the official journal of the American Neuropsychiatric Association.
In this Sixth Edition of the Textbook, Dr. Laura Weiss Roberts joins Drs. Hales and Yudofsky as the third editor. This is particularly gratifying to Dr. Yudofsky, who served as one of Dr. Roberts' mentors when she was a medical student at the University of Chicago School of Medicine, where he was Professor and Chair of the Department of Psychiatry. Currently, Dr. Roberts is Professor and Chair of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine and collaborates closely with Dr. Hales in his position of Professor and Chair of the Department of Psychiatry and Behavioral Sciences at the University of California Davis School of Medicine. Additionally, Dr. Roberts serves as a Deputy Editor of American Psychiatric Publishing's Books Division, of which Dr. Hales is in his thirteenth year as Editor-in-Chief. Dr. Roberts is also Editor-in-Chief of the journal Academic Psychiatry.
In summary, I believe that the Sixth Edition of the The American Psychiatric Publishing Textbook of Psychiatry continues to meet its original goal as a single-volume text that is clinically relevant, practical to use, pleasant to read, and promotes the learning process. With the addition of Dr. Roberts as a co-editor, the future of the Textbook is in capable hands. To the editors and the authors of the Sixth Edition Textbook, I can only say, "Another job very well done."
David J. Kupfer, M.D., Chair, DSM-5 Task Force.
American Psychiatric Association: Statement by David Kupfer, MD: Chair of DSM-5 Task Force Discusses Future of Mental Flealth Research. News Release, May 3, 2013. Available at: http://www.psychiatry.org/advocacy—newsroom/news-releases/13-33-statement-from-dsm-chair-david-kupfer~md.pdf. Accessed July 20,2013.
Belluck P, Carey B: Psychiatry's guide is out of touch with science, experts say. New York Times, May 6, 2013, p A13. Available at: http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html. Accessed July 20,2013.