Fink! Still at Large : The DSM-5 promises to change the practice of psychiatry in a big way. What do you think of the proposal to eliminate Asperger's disorder and to put it under the heading of autism spectrum disorders?

The power of DSM throughout the world should not be underestimated, and it is the problem for all the psychiatrists of the future–at least until the DSM-6 is written.

But the most important mission of the DSM for me is to identify mistakes and flaws, and correct the concepts that have proven to be incorrect over the last 16 years.

Psychiatric research has continued throughout that time, and new ideas, therapies, and approaches have evolved around specific diagnostic categories.

This evolutionary process is very important for the field and is taken seriously by the new set of authors brought together for the DSM-5.

Importance of the PDM

Several years ago, the Psychodynamic Diagnostic Manual (PDM) was published with Dr. Stanley Greenspan as the primary author (“Manual's Breadth May Aid Diagnosis,” March 2006, p. 1). He recruited many of the senior analysts in America to help in producing the volume. The ostensible reason for all the work was Stan's feeling, shared by many, that the DSM's approach is too mechanical and mathematical, and inadequately describes the mental and emotional functioning of the patient with a given illness.

I think this publication, which was assembled by a committee of leaders within the American Psychoanalytic Association, the International Psychoanalytical Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, the division of psychoanalysis of the American Psychological Association, and the National Membership Comittee on Psychoanalysis in Clinical Social Work, is important.

After all, the PDM opens up a lot of ideas about what a patient with a given illness feels, thinks, and senses, and it provides a great deal of insight into the inner workings of the individual. Its approach to mental illness is dimensional rather than categorical.

I helped write a little of it, and I was shocked by the number of ways we found to describe things that go on inside of a person. None of it is in previous DSMs and most likely will not be in the DSM-5.

I suspect that in some instances, the DSM-5 changes will tighten up areas that have been too vague and difficult to nail down. The concentration on aggressive behaviors is terrific, in my opinion.

We all have evaluated and treated people with various kinds of aggressive behavior with no clear-cut category into which to put them. If the new DSM leads to research that will help us categorize such patients, it will be a blessing.

Many years ago, a couple came in to see me because the wife had taken an ax and destroyed her husband's car. There was no recognized therapy at the time that could guarantee an end to her impulsive outbursts of aggression. The borderline personality disorder diagnosis had not yet come on the scene. Now there are several places to put such patients in the diagnostic scheme, but no real in-depth understanding of why and how the behavior can be treated and stopped.

Role of Politics

What I think is important at this moment in the evolution of the DSM-5 is to realize that many of the controversies are and will be political with proponents on each side of the issue. All of us love rhetoric that seems reasonable to the reader.

One such area is parental alienation syndrome (PAS). I am personally involved in opposing the inclusion of this bit of junk science invented by a psychiatrist in the 1980s, the late Dr. Richard A. Gardner.

All of his books and most of his papers were published by his own publishing company. He protected child sexual abusers in court and was very abusive to the mothers of the children caught up in custody hearings.

Many children and mothers have been hurt by this man's beliefs, but over 15 years, he developed many converts to his beliefs, including judges, lawyers, guardians at litem, and psychologists who liked the neat packaging of his ideas.

In recent years, the ball has been picked up by “father's rights” groups who don't like to be interfered with when they are sexually abusing their children. This group has petitioned the DSM task force to include PAS in the publication.

This is a good example of the political activity into which DSM is drawn. The task force members want to be fair to all parties, so we are now involved in putting together data around this issue to disprove it to the DSM task force.

During the development of the DSM-IV, the question of whether homosexuality was an illness was hotly debated. In that instance, wise heads helped sort out the best route to take, and I am hopeful that the same process will be used with regard to PAS. For more information about PAS, go to the Web site of the Leadership Council on Child Abuse and Interpersonal Violence, which is