Psychological Injuries in the DSM-5: Courting Troubles

Abstract

Introduction: The Diagnostic and Statistical Manual of Mental Disorders has been criticized for its reliability and validity, including for the major psychological injuries [Posttraumatic Stress Disorder (PTSD), chronic pain-related disorders, and neurocognitive disorders, pertinent for mild traumatic brain injury (MTBI)/persistent post-concussion syndrome (PPCS)]. Methods: This review article examines both the mental health/psychiatric and legal literature on the DSM-5 and its criticisms. The DSM-5 uses a polythetic approach, which leads to many complicating ways of expressing disorders (e.g., PTSD). Disorders related to chronic pain refer to somatic symptom disorders (e.g., with predominant pain), which leads to less focus on the chronic pain itself. The neurocognitive disorder diagnosis includes minor and major classifications, but excludes moderate ones. The international diagnostic system (International Classification of Diseases (ICD-11)) and alternate approaches to psychiatric nosology [the Research Domain Criteria (RDoC) and Hierarchal Taxonomy of Psychopathology (HiTOP)] do not help resolve these issues. Results: The comprehensive literature review undertaken indicates the limitations of the DSM-5 clinically and in court, especially for psychological injuries. The article includes tables and boxes that complement the text with specificities related to the issues raised. Conclusions: The article recommends supplementary diagnostic criteria for the three major psychological injuries (PTSD, chronic pain, and MTBI) for forensic use. This paper is an original contribution to improving the diagnostics/description and forensic use of the major psychological injuries: aside from the paper’s clinical contributions, these disorders/conditions are contentious in court, and their better specification in diagnosis, as attempted herein, is important to undertake forensically.

1. Introduction

This article has three main foci: (a) description and critique of the standard psychiatric classification manual in the field; and (b) description and discussion of its treatment of the major psychological injuries in the field. Each of these topics is analyzed from a forensic lens as it relates to diagnosis and assessment. (c) The article concludes with recommendation and description of a four-component forensic module related to the three major psychological injuries. It includes seven text boxes that provide background detail, and three tables on proposals for forensic-oriented diagnoses of the major psychological injuries.

In terms of the first topic of the article, this article examines the fifth edition of the psychiatric classification manual of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders [1]. The DSM-5 is the most commonly used diagnostic manual in psychiatry, and it is widely consulted when forensic psychological injury assessments and diagnoses are offered. It was recently revised, without much change, and little pertinent to psychological injury and law [2]. The DSM-5 had been critically analyzed even before its release, for example, when its draft was made available [3]. Criticisms of the DSM-5 continued after its official release in 2013 and have not abated since then. That said, the DSM-5 is the standard diagnostic manual in psychiatry, with no realistic competitor on the horizon, aside from some diagnostic categories in the International Classification of Diseases 11th Revision [4], especially for PTSD [5]. Alternate diagnostic approaches are works in progress (e.g., Research Domain Criteria [RDoC] [6]; Hierarchal Taxonomy of Psychopathology [HiTOP]) [7]. This means that the DSM-5 merits close scrutiny for its reliability and validity, especially for the major psychological injuries.

In terms of the second topic of the article, psychological injuries encompass Posttraumatic Stress Disorder (PTSD), mild traumatic brain injury (MTBI, with neurocognitive disorder (NCD) being the relevant diagnostic category in the DSM-5), and chronic pain (pain disorder, chronic) associated with both psychological factors and a general medical condition, per the Diagnostic and Statistical Manual of Mental Disorders, fourth ed. (DSM-IV, American Psychiatric Association, 2000) (referred to as Somatic Symptom Disorder (SSD) with predominant pain, in the DSM-IV) [8]. Young, Bailey et al. (e.g., 2025a) [9] have published a handbook on psychological injuries in relation to law, and the reader can consult this comprehensive source for background information.

As for the third primary topic of this article, we propose supplementary diagnostic approaches for these disorders and conditions for use in the forensic context. In addition, we propose a forensic module to accompany this three-component diagnostic module and indicate how it can be applied (see the end of Table 1, Table 3 and Table 4).

This article examines the extensive criticisms of the DSM-5, both earlier (e.g., Bearden 2012) [10] and more recently (e.g., Young, 2016) [11]. First (2010) [12] pointed to forensic deficits in the DSM-5, in part because it was not properly vetted forensically compared to the process followed for the DSM-IV [13]. This deficit in its construction speaks to the point of the article.

2. The DSM-5 and Its Discontents

2.1. Introduction

The DSM-5 is the major psychiatric manual for mental disorders in North America, while the ICD-11 is used worldwide. The DSM-5 is a much more detailed classification manual of mental disorders than the ICD-11, with several pages of text accompanying each disorder. The two manuals are complementary, especially for some disorders, such as PTSD, for which the ICD-11 has two separate psychological injury disorders—PTSD and Complex PTSD (CPTSD). Here, we examine the criticisms levied at the DSM-5, and they are still applicable to the DSM-5-TR.

In order to obtain a survey of recent criticisms of the DSM-5, data search engines were tapped on 6 August 2025, using the key words DSM-5, criticism, and forensic. A second round limited the searches to PTSD, chronic pain, and NCD. Data engine searches over the years used similar terms. Peer review articles were the focus. The search engines were PsychInfo, PubMed, Scopus, and Web of Science. Google and Google scholar were also searched. References in Young (2016) [11] were checked. All sources found book chapters aside from peer-reviewed articles, but only a few of these were used. About 1000 articles were tapped in the searches, but a review of the abstracts indicated less than 100 being relevant, and, even then, at the time of writing, less than 50 (48) were considered necessary for the goal of the review. A book entitled “DSM-5 and the law” added five chapters to the review. Most of the flagged articles and chapters best fit the next section on earlier DSM-5 critiques, and a few of them best fit the section after that on later critiques, with only one meriting description. Other articles flagged in the data engine search better fit the section below on alternate approaches to the DSM-5, and they were placed there. Critical references within the selected articles/chapters were added as appropriate. The studies considered in the review, with multiple relevant publications, were about 10 years old, from 2012 to 2016, with only one recent one being relevant, as mentioned. Therefore, the present review of and recommendations for the DSM-5 stand as a relevant update on its status, criticisms, and recommendations.

2.2. Earlier Criticisms of the DSM-5

Bearden (2012) [10] wrote a scathing criticism of the DSM-5 from a forensic point of view and proposed solutions that have gone unheeded. Her criticisms and proposed solutions are still valid today. Bearden (2012) [10] cataloged criticisms of the DSM-5 into three categories: influence of pharmaceutical companies (also see Davis et al., 2024) [14]; concealment of the DSM’s methodology; and problems with the DSM-5 as a diagnostic tool. The DSM-5 “has been criticized by its own past editors and contributors” concerning its “scientific reliability and validity” [10] (p. 99). The DSM is no stranger to court, having been cited in over 5500 court cases and over 300 state legislative statutes in the year 2011 [10] (p. 94). The states have “reached varying conclusions on the overall admissibility of the DSM standards” [10] (p. 94). The APA included cautions about the use of the DSM-5 forensically, but should work toward developing a manual that the court will accept as scientifically verifiable, reliable, sound, and valid [10].

Gordon and Cosgrove (2013) [15] addressed ethical issues related to the DSM-5. The DSM is published in parts, without sufficient reliability and validity. Some DSM diagnoses were included in the DSM-5 because of pressures on working groups. The DSM workgroup/panel members were influenced by the pharmaceutical industry [16,17]. Welch et al. (2013) [18] focused their criticisms on the working groups. Wakefield (2013) [19] even argued that most diagnostic categories in the DSM-5 do not possess “construct validity.” Many lack specific cause (etiology) [20]. Kendler (2012) [21] argued that psychiatric classificatory systems do not appreciate the multifactorial side of etiology (are “deeply problematic”).

Moreover, Frances (2013a, 2013b, 2013c, 2013d, 2013e) [22,23,24,25,26] offered specific criticisms of a range of issues related to the DSM-5, such as in the writing, ambiguity, and diagnostic inflation. First (2014) [27] argued that the DSM should be empirically derived. Lilienfeld (2014) [28] also called for a scientific foundation to the DSM-5. Paris (2013a) referred to the field trials as “inadequate.” Freedman et al. (2013) [29] reported their mixed results. Jones (2012) [30] referred to its insufficient validity testing, lowering the bar for diagnosis of some disorders. The levels of “acceptable” reliability in the DSM-5 [31] were lowered. Regier, Narrow et al. (2013) [32] provided the details of the DSM-5 field trials. MTBI obtained questionable reliability, as did generalized anxiety disorder and antisocial personality disorder. There were low results for major depressive disorder.

Young (2013a) [33] reviewed the Special Issue on the DSM-5, summarizing the different critiques. For example, Young (2013b) [34] criticized its approach to chronic pain, while Schultz (2013) [35] criticized its approach to MTBI/NCD. Simpson (2014) [36] and Wortzel and Arciniegas (2014) [37] elaborated a critique for MTBI/NCD. Biehn et al. (2013) [38] and Zoellner (2013) [39] criticized the DSM-5’s approach to PTSD, and Levin et al. (2014) [40] noted that, for the trauma section of the DSM-5, many changes complicate the forensic use of the document, including those with respect to determining malingering (also see Milchman, 2016, with respect to CPTSD) [41]. Hopwood and Sellbom (2013) [42] criticized its approach to personality disorder. Also, the changes proposed for personality disorder [43] were not included in the final version of the manual, but relegated to a section for further study.

Blashfield, Keeley, Flanagan, and Miles (2014) [44] argued that the DSM-5 did not attain its goals. Paris (2013a) [20] concluded that the greatest risk in using the DSM-5 is its potential to over-pathologize, while Paris (2013b) [45] referred to its “ideology.” Pierre (2013) [46] agreed that the DSM-5 promotes overdiagnosis, Frances and Widiger (2012) [47] referred to “diagnostic inflation,” as did Frances (2013c) [23] and Blumenthal-Barby (2013) [48]. Similarly, Wakefield (2015) [49] referred to its “false positive” problem. Fried, Nesse, Zivin, Guille, and Sen (2014) [50] referred to symptom summation procedures as “obfuscating.” Sisti and Johnson (2015) [51] referred to the DSM-5 revision as “controversial.” Nemeroff et al. (2013) [52] referred to its scientific deficiencies. The DSM-5 has been given a “fatal diagnosis” for its overreach [53]. Jablensky (2016) [54] argued that the DSM-5-categories lack validity in the sense of missing differentiating etiology. Berk (2013) [55] maintained that in using the DSM-5, clinicians need to conduct comprehensive clinical assessments before the diagnosis. Pickersgill (2013) [56] offered a sociological critique. Paris (2013a) [20] argued that, given the problems with the DSM-5, psychiatrists should function with a biopsychosocial perspective.

Forensically, Thomas (2013) [57] was concerned about whether the DSM-5 had been sufficiently vetted from a forensic viewpoint. Applebaum (2014) [58] referred to it needing the test of time. Wortzel (2013) [59] noted that there will be effects in civil proceedings. Haydt (2015) [60] referred to confused application of the DSM-5 in the forensic context. Willis and Gold (2014) [61] noted similar limitations, referring to the forensic cautionary statement in the DSM-5 and the controversial changes to the criteria for PTSD, for example. Collectively, in the present author’s opinion, these criticisms of the DSM-5 at the forensic level leave its use open to the biases found in the forensic mental health field [62].

The most comprehensive legal/forensic source of analysis and critique of the DSM-5 consists of an edited book by Scott (2015) [63], entitled “DSM-5 and the law.” In the book, Ferranti (2015) [64] indicated that the forensic cautionary statement has limits, and prior versions of the DSM-5 have been contested in court (e.g., in the U.S. Supreme Court, Clark v Arizona, 2006) [65]. Newman and Holoyda (2015) [66] reviewed the major diagnostic changes to the DSM-5, including for trauma/anxiety, SSD, and related diagnoses. Scott, Wagoner, and Beckson (2015) [67] elaborated on the forensic difficulties posed by diagnoses in the DSM-5 related to the three major psychological injuries (PTSD, SSD, and NCD). For SSD (with predominant pain), the DSM-5 does not consider malingering and factitious disorder as factors in the differential diagnosis, unlike the case for the DSM-IV (for somatoform-related and pain disorders). The adjective “excessive” for specifying the level of experienced symptoms is ambiguous and could use quantification (as undertaken presently below). For PTSD, entry criterion A has been changed substantially, which lowers the bar for the diagnosis in some ways while excluding some traumas as entry ones to PTSD in other ways. The changing of the wording for many symptoms in the DSM-5 also serves either to raise or lower the bar for diagnosis, depending on which one is discussed. Removal of malingering in differential diagnosis is as problematic for PTSD as has been indicated for SSD. For NCD, once more, the differential diagnosis related to malingering should be considered even if not included in the textual description. Greene and Scott (2015) [68] noted that SSD (with predominant pain) is more similar to hypochondriasis than pain disorder in the DSM-IV. For PTSD, entry criterion A lowers the bar for some work experiences qualifying as PTSD triggers, and some symptoms otherwise problematic in the workplace can be considered consistent with PTSD. For mild NCD, the evidence required to attribute it is minimal, and workers can take advantage of this facility to claim disability. McDermott and Scott (2015) [69] reviewed malingering detection strategies, including which psychometric tests to use (performance validity tests, PVTs, and symptom validity tests, SVTs. For both psychiatrists and psychologists, finding clinical inconsistencies raises doubts about examinee malingering, as well (for a comprehensive presentation on detecting malingering of PTSD, see Rosenberg et al., 2025) [70].

Young (2016) [11] noted that the DSM-5 was published in 2013, with multiple changes implemented, but with a proliferation of new disorders. Also, it had been criticized for lowering the bar for meeting diagnostic criteria. It was created through working groups for each chapter, comprising leading experts and researchers in the field. It was supposed to balance ongoing research findings and clinical utility, but some critics noted that some working groups did not consider all available research. In addition, certain working group members were criticized for their conflicts of interest, especially related to receiving financial remuneration from pharmaceutical companies. The underlying theme was that “Big Pharma” had undue influence on the DSM-5 working groups. Also, there were issues related to the field trials and the reliability of psychometric properties of certain diagnoses. For example, the field trials used the draft version of the DSM-5, not the final version. Moreover, changes to the final version in some cases were significant, and so the changes represent changes that were not tested for reliability in the field trials. Young (2016) [11] gave pertinent examples about the unvetted changes to the PTSD diagnosis, for instance. Finally, from a forensic point of view, the DSM-5 was not vetted as closely as the DSM-IV, although the authors argue that it was not meant to be a forensic document. Presently, the DSM-5 remains essentially intact since its inception in 2013, and its weaknesses have not been addressed, for example, in the DSM-5-TR.

Young (2016) [11] queried the lack of the DSM-5’s biopsychosocial formulation and noted that the term was included in the DSM-5 draft, but the term was removed in the final 2013 version. While the DSM’s polythetic approach remained, which allows for diagnosis based on meeting a proportion of symptoms within each diagnostic subcategory of symptoms, the heterogeneity of the expression of the disorders in the DSM-5 can be astronomically high (e.g., Young et al., 2014; also see Bryant et al., 2023; Spiller et al., 2024) [71,72,73]. This latter problem is coupled with its heterogeneity problem, given its 300+ categories of mental disorders. These constraints mean that application of the DSM-5 in diagnosis leads to disorder profiles that lack specificity and precision.

Here, as an example, we present an incomplete list of wording changes for PTSD that are not insignificant and were not field tested (see Young, 2016, Table 23.3, p. 599) [11]: (a) internal reminders changed to distressing; (b) alteration changed to marked alteration, and (c) aggressive behavior changed to “angry outbursts/with little or no provocation typically expressed as verbal/physical aggression toward people/objects.” Young (2016) [11] referred to the latter language as possibly opening the “criminal floodgates” to using PTSD as a defense against criminal charges. Further, for two symptom clusters in PTSD under the polythetic approach of the DSM-5 relative to the DSM-IV, the number of required symptoms to reach the diagnostic threshold was reduced from three in the symptom lists involved to two of them. The latter change is consistent with the common criticism of the DSM-5 contributing to “diagnostic inflation.”

Box 1 summarizes the earlier criticisms of the DSM-5. The box gives greater detail for some of them.

Box 1. Criticisms of the DSM-5

Criticism	Explanation
General Criticisms
Medical model	Medical models consider mental health conditions as residing in an individual’s biological, brain-based, or physiological abnormalities. Interventions are biomedical, like medication or surgery related to the (presumed) medical etiology of the conditions. This contrasts with more biopsychosocial or social/societal models of disability. Moreover, etiology is rarely known for psychiatric disorders, unlike for strictly medical ones.
Big Pharma	“Big Pharma” is a disparaging term used for the undue influence, based on profit motive that the pharmaceutical industry has on the mental health field, from research on diagnostic disorders to the disorders included in the psychiatric classification manuals. Big Pharma is seen as contributing to the over-medicalization of mental health conditions, including dissemination of potentially misleading information and over-prescription of medications.
Working groups	The DSM iterations are products of working groups constituted by expert researchers and clinicians in specified fields related to the chapters in the manuals. The members are mostly psychiatrists (as well as psychologists), and they are required to declare conflicts of interest. However, the concern is that members receive grants from Big Pharma to conduct the research, and that the latter even might employ ghost writers. Working groups are criticized for lacking transparency, in documentation used and in decision making.
Clinical utility	Clinical utility in psychiatric classification systems refers to the practical help the systems offer to clinicians in real-world settings. For example, if the systems are too complex and research-focused such that clinicians cannot use them easily enough, this will lead to problems in diagnosis, treatment planning, and clinical care. However, if research addressing diagnostic and clinical questions is ignored in favor of clinical utility, the same problems arise.
Evidence-based	Mental health diagnostic manuals strive to include diagnoses of mental disorders that are supported by clinical research. They construct symptom lists that are based on research evidence for each diagnosis; otherwise, they include proposals for new diagnoses in appendices so that research can continue. That said, different psychiatric classification manuals will include different versions of the same disorder and even different disorders. Clinical utility can take primacy over research considerations.
Categorical	In psychiatric classification, the categorical approach considers disorders distinct, qualitatively different, and separate with clear boundaries, while the dimensional approach considers disorders as existing on a continuum of different degrees of severity. The uniquely dimensional approach is more quantitative than qualitative, but this makes it difficult to determine diagnostic clinical cut-offs. The DSM-5 arranged separate categorical disorders on dimensional spectra (e.g., in autism).
Comorbidities	Psychiatric classification manuals struggle with the question of co-morbidities. Diagnostic manuals, like the DSM, are criticized for facility in diagnosing multiple disorders in the patient. Diagnostic categories are rampant, diagnostic categories overlap, diagnostic criteria are too broad, symptoms overlap across disorders, diagnostic thresholds have been lowered, and clinicians cannot conduct comprehensive differentiating assessments in the limited time available with each patient.
Reliability	Psychometric reliability in mental health diagnostic manuals refers to the degree of inter-clinician agreement in field trials for each psychiatric condition diagnosed. Over the same category of cases, are the diagnoses agreed upon by independent, trained clinicians? For the DSM-5, reliability did not arrive at acceptable limits for some diagnoses, including depression and antisocial personality disorder, even after the criteria for levels of kappa interrater agreement were adjusted downward.
Validity	In mental health diagnosis, psychometric validity refers to whether a diagnosis is accurately, validly, or correctly representing the condition it is meant to represent. This depends on whether the diagnosis has been adequately constructed. Also, it depends on how its validity has been demonstrated, for example, with respect to potential causes, treatment response, and stability despite demographic and cultural variation. Certain critical disorders in the DSM-5 have been criticized in these regards, including personality disorders.
Aforensic	By definition, psychiatric disorder classification manuals are constructed for clinical and research purposes, with little attention paid to their forensic use. The DSM-IV took better care in this regard, compared to the DSM-5 (Young, 2016) [11]. Forensic work requires that expert witnesses use replicable valid procedures to arrive at opinions that are probative rather than prejudicial, aiding the trier of fact. The main issues in these regards are reviewed next.
Forensic Criticisms of the DSM-5 in Young (2016) [11] and its Cited Sources
Vetting	The DSM working groups did not engage in vetting the drafts of the DSM-5, when compared to procedures followed for the DSM-IV.
Wording	The wording of the symptoms in the DSM-5 is not always tight and unambiguous.
Loopholes	The description of some categories in the DSM-5 leaves loopholes that can be exploited forensically.
Lowering the bar	The threshold criteria for some disorders have been lowered, allowing for increased diagnoses of the disorders.
Diagnostic inflation	This has led to an increase in the diagnoses given to individuals, as in comorbidities, as well as an increase in prevalence of some disorders.
Diagnostic overlap	Part of the reason is that the diagnoses have symptom overlap, conceptual overlap, and the same lowering of the diagnostic bar.
Assessment	Clinicians might diagnose without full-scale assessment, which lowers reliability and validity.
Preexisting	Clinicians do not typically determine whether diagnoses reflect in any way pre-existing stressors, vulnerabilities, or diagnosed disorders.
Causation	Generally, clinicians typically do not investigate causation behind diagnoses sufficiently for forensic needs, e.g., negligent accidents.
PTSD	There are hundreds of thousands of ways an individual might express a symptom profile consistent with PTSD, making it not very useful as a label that captures the patient’s specific experience. Wording ambiguities/imprecisions/omissions risk missing valid PTSD diagnoses or over-diagnosing it, harming plaintiffs or defendants, respectively.
Chronic pain	Referring to chronic pain with the label of somatic symptom disorder (SSD), as in the DSM-5, risks undervaluing the pain experience contributing to its functional impairments. Referring to chronic pain as pain disorder, as in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), risks overvaluing the physical injury component of the condition. The former risk potentially harms plaintiffs; the latter risk potentially harms defendants.
Neuro-cognitive Disorder (NCD)	There are mild and major classes of NCD in the DSM-5, but no moderate class, which leads to shunting moderate cases into the mild class. This would not be problematic for MTBI/concussion, but is quite problematic for moderate TBI, which risks undervaluing such cases in court.
Malingering	Malingering is not well defined in the DSM-5, with its red flags, in particular, being problematic [74].
Daubert (1993)/Frye (1929)	Forensic evidence needs to meet standards of good as opposed to poor or junk science, aside from having general acceptance. The DSM-5 was not constructed forensically. Further, some critical diagnoses can be questioned in court, e.g., for reliability or validity.
Case law	Case law indicates that expert witness testimony on the DSM-5 is considered for admissibility on a case-by-case basis (Freckelton, 2023) [75]. As far as is known, case law has not found that refers to criticisms or admissibility issues with respect to the DSM-5 for the three major psychological injury conditions. Ferranti (2015) [64] reported case law that involved criticism of the DSM-IV-TR [65].

The next section of the paper reviews recent forensic criticisms of the DSM-5. The review was conducted after a comprehensive literature search, as described above.

2.3. Recent Criticisms of the DSM-5

More recent criticisms of the DSM-5 present omnibus critiques against diagnosing, per se, which is beyond the scope of the article to detail here (e.g., Kinderman et al., 2022, and Caballo et al., 2024, in this regard with respect to personality disorder) [76,77]. Other critiques are more targeted and repeat the earlier critiques in their substance (e.g., Mehdi et al., 2022) [78].

As for newer criticisms of the DSM-5, only one deserves a more detailed description: First et al. (2021) [79] compared the DSM-5 and the ICD-11 and found significant differences. This comparison carries implicit criticisms of the DSM-5, as well as the ICD-11, for their deficiencies. First et al. (2021) [79] noted that 19 ICD-11 disorder categories are not found in the DSM-5, and seven DSM-5 disorder categories are not found in the ICD-11. They rated 20 disorders (19.4%) as having major definitional differences across the manuals, 42 disorders (40.8%) as having minor differences, 10 disorders (9.7%) as having minor differences, and 31 disorders (30.1%) were rated as essentially identical.

3. Alternative Systems to the DSM-5

Given the concerns about the DSM-5, alternate diagnostic approaches have been proposed. In particular, the RDoC [6] and the HiTOP [7] have been developed [see Velasco et al. (2025) [80] for a comprehensive review]. Box 2 describes the DSM-5 and various alternative approaches to psychiatric classification.

Box 2. Standard psychiatric classification systems and alternate systems

System	Description
DSM-5	The DSM-5 is the latest version of the American Psychiatric Association’s psychiatric classification system of diagnosable mental disorders. It is considered the standard reference in North America. For each of its disorders, it provides specific diagnostic criteria. The list of symptoms for each diagnostic category is arranged into separate clusters, with a specified amount of symptoms required in each cluster (polythetic). There are over 300 mental health diagnoses in the DSM, some arranged on spectra (e.g., autism).
ICD-11	The ICD-11 includes a revised comprehensive module on mental, behavioral, and neurodevelopmental disorders (MBNDs). As with the DSM-5, the ICD-11 provides a structured classification system for MBND conditions. It is the standard reference for mental health professionals globally for use across different countries and languages [4], with ongoing research [81]. It provides detailed descriptions and diagnostic criteria for each disorder. It is not as detailed as the DSM-5.
RDoC	The RDoC is a framework for mental health and psychopathology developed by the American National Institute of Health [6,82]. It considers basic human neurobehavioral functioning and its development in an environmental context, but in practice focuses on neuroscience/neurobiology. Its domains are meant to be studied along the full range of functioning from normal to abnormal. It focuses on different sources of variables (units of analysis, for instance, behavioral, physiological, and self-report data).
HiTOP	The RDoC is not the product of institutional initiatives but is researcher-driven. It considers mental health in terms of continua or dimensions rather than discrete categories. Further, mental health reflects a hierarchical structure, with the top level having broader spectra (e.g., internalizing, externalizing (further divided into disinhibited and antagonistic), thought disorder) and the bottom level having more specific symptom clusters and traits.
Networks	The network approach to mental disorders focuses on symptoms and their interconnections without focusing on presumed top-down latent variables that they are presumed to reflect. In addition, the symptoms (nodes) are considered interconnected links (edges), and their interactions are considered to form causal systems, with symptoms influencing others to manifest. Centrality refers to the influence a symptom has within the system, and some symptoms are considered causal drivers of others.
Biopsychosocial	The biopsychosocial model describes the influence of, and interaction among, multiple factors on behavior and mental health. Examples—Biological: genetic predisposition, brain structure, and function, physiology of the individual, e.g., the stress response. Psychological: intelligence, personality (temperament) emotions, thoughts, behaviors, motivation, and coping. Social: family, peers, culture, socioeconomic status, and environmental factors (e.g., see Fayed et al., 2020; Young, 2016) [11,83].
Relational	A relational psychiatric mental disorder classification system proposes placing disorders in their relational and environmental context, rather than considering disorders as uniquely within the individual [84,85]. In the present view, relational mental disorders should not be conceived as secondary to individual disorders; rather, they should characterize all disorders, although there are specific primary mental health disorders related to family/romantic couples.
Clinical staging	This refers to specifying steps in a dynamic progression of mental disorder, rather than statically describing symptoms [86,87]. Stages-0: At risk, not yet expressing symptoms or seeking help. 0a: [as proposed by the present author, based on the dynamic change model [88] Oscillating between absence/presence of mild-to-moderate symptoms/functional impairments]. 1: Mild-to-moderate symptoms or functional impairments. 2: Discrete disorder(s). 3: Recurrent/persistent. 4: Severe, persistent/unremitting.
Psychodynamic (PDM)	The psychodynamic psychiatric classification system, the Psychodynamic Diagnostic Manual, 3rd ed. (PDM, Lingiardi & McWilliams, 2025) [89] emphasizes understanding of the underlying dynamics of mental experience and personality, focusing on a person’s unique developmental history, context, personality patterns, interpersonal relationships, and internal mental world (subjective experience and perceptions, unconscious processes), rather than only on observable symptoms.
Developmental (DC: 0–5)	The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood [90,91] is a developmental psychiatric classification manual specifically for diagnosing mental health and developmental disorders in infants and young children (birth through age 5). It includes a five-axis system—clinical disorders, relational context, medical conditions, stressors, and emotional development.
Note. DSM = Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). ICD-11 = International Classification of Diseases for Mortality and Morbidity Statistics (11th Revision). RDoC = Research Domain Criteria. HiTOP = Hierarchical Taxonomy of Psychopathology.

RDoC. The RDoC assumes that mental illness especially involves brain function and structure, for example, as found in research on the brain and in genetics [6,92,93]. The RDoC concerns five broad spectra—negative valence systems, positive valence systems, cognitive systems, systems for social processes, and the arousal/regulatory system. Each one must map directly onto specific biological systems, such as neural circuits. Eight units of analysis need to be considered in research, from genes to behavior to paradigms. For example, the negative valence domain is constituted by the systems of acute threat (fear), potential threat (anxiety), sustained threat, loss, and frustrative non-reward. The RDoC is dimensional in approach [94].

Cuthbert and Kozak (2013) [94] maintained that the RDoC is more than neurobiogical in emphasis. But Paris (2013a) [20], as well as Lilienfeld (2014), Phillips (2014), Sartorius (2014), Stein (2014), Wakefield (2014), and Whooley (2014), criticized the RDoC for its neurobiological emphasis [28,95,96,97,98,99]. Weinberger and Goldberg (2014) [100] queried the validity of the behavioral, neural genetic, and functional dimensions of the RDoC. First (2014), Fulford (2014), Maj (2014), and Parnas (2014) queried if it is sufficiently clinical [27,101,102,103]. However, Cuthbert [104,105] argued that the RDoC is inclusive of these factors and that the RDoC eventually will be proven useful clinically.

HiTOP. Balling et al. (2023) demonstrated that clinicians regard the HiTOP system as having better clinical utility than the DSM-5 [106]. But few forensic practitioners endorse using the HiTOP [107]. Ringwald et al. (2023) found correspondence between the dimensions evident in studies of DSM-5 research and HiTOP research, in a quantitative meta-analytic study [108]. Forbes et al. (2024a) enunciated principles that could serve in its revision [109]. A study by Forbes et al. (2024b) [110] suggested that the HiTOP is a preliminary model. Carmichael et al. (2025) extended the model for TBI [111]. They found a hierarchical structure involving broad internalizing and externalizing spectra, which split into seven narrower dimensions: detachment, dysregulated negative emotionality, somatic symptoms, compensatory and phobic reactions, self-harm and psychoticism, rigid constraint, and harmful substance use.

Forbes et al. (2024b) re-organized the DSM according to a hierarchical principle component and hierarchical clustering of the responses of 11,762 participants to an online survey involving 186 symptoms/syndrome constructs derived from the pool of symptoms in the DSM-5 [111]. In response, the respondents had to report their mental health issues in the prior 12 months. Eight clusters emerged, referred to as spectra, and some were similar to HiTOP terminology, while others were not. Briefly, the spectra that emerged were externalizing, harmful substance abuse, mania/low detachment, thought disorder, somatoform, eating pathology, internalizing, and neurodevelopmental/cognitive difficulties (two subspectra). Each spectra had multiple lower-order subfactors, for example, externalizing (disinhibition, externalized negative affect, callousness, antagonism, and antisocial behavior). The number of symptoms/syndromes in each of these five factors varied from 14 to 3. For mania and low detachment, the subfactors were mania, detachment, and low sexual function. For thought disorder, they were dissociation, positive psychosis, and major loss of bodily control. For somatoform, they were somatic, dysregulated sleep, low sexual function, dysregulated eating, and elimination/sleep apnea. For internalizing, they were distress, social withdrawal, dysregulated sleep and trauma, and fear. For cognitive difficulties, they were neurocognitive impairment, organizational difficulties, and forgetfulness. [It is beyond the scope of the present review to define the spectra and factors, and show how they are operationalized, given the extensive description involved; the reader can consult the original article.].

The study was an online survey one and so is limited, but it makes the point about the HiTOP, while giving a new organizational structure to work with in revising or replacing the DSM-5. Some of Forbes et al. (2024b) article [110] empirical findings do not comport with how the DSM-5 is used in the area of psychological injury and law. For example, there is no separate trauma factor, and there is no subfactor that clearly involves PTSD, the symptoms of which appear decomposed. There is nothing like the ICD-11’s CPTSD. Dissociation is grouped with thought disorder, but in the DSM-5, it could be a subtype of PTSD, as well. For somatoform, pain does not emerge as a separate subfactor. For cognitive difficulties, the severity of neurocognitive dysfunction in the DSM-5 is not recognized.

Until there is confirmatory research of the HITOP and its variations [109] in the clinical context, while using multiple design and statistical analysis paradigms, psychological injury assessors and diagnosticians should keep using the DSM-5 and ICD-11, as befits the issues in the case at hand.

Networks. A promising approach to diagnosis involves the symptom network approach (Borsboom et al., 2017) [112]. There are burgeoning recent studies on the network approach to PTSD (e.g., Alshabani et al., 2025; Bridges-Curry, 2025; Graziano et al., 2024; Robinaugh et al., 2025; Robinson et al., 2025; Wu et al., 2025) [113,114,115,116,117,118]. Essentially, the network approach seeks symptom clusters among the symptoms of a disorder through robust statistic approaches and their links. The critical symptoms are referred to as nodes and the links as edges. Stronger links indicate potential drivers, e.g., poor sleep driving other PTSD symptoms. Clusters are described in terms of their centrality. Causality is deemed to reside in the symptom links rather than in higher-order factors or variables acting top-down on them. For chronic pain and MTBI symptoms, the network approach is just beginning (respectively, Anarte-Lazo et al., 2024; Fonda et al., 2022, and Goodwin et al., 2023) [119,120,121]. Future research might examine networks of symptoms/syndromes and relate the networks to combined systems/higher-order and network modeling (e.g., Young, 2015) [122]. Although promising as an approach to understanding the major psychological injuries and other diagnoses in the DSM-5, the network approach does not lead to immediate approaches to help in diagnostic formulations.

Comment. Paris (2024) [123] has argued that these alternate diagnostic systems are not ready, neither for practice nor court. He focused especially on the RDoC and HiTOP systems, which are works in progress and not established yet as practical psychiatric nosological diagnostic systems. Consequently, we are left with the DSM-5 as the premiere psychiatric diagnostic manual in North America. This behooves the forensic assessor to use the DSM-5 prudently and to make sure that the diagnostic labels are not used as proxies to represent the examinee’s symptoms and impairments. Nothing should replace the careful forensic elucidation of the examinee’s symptoms and impairments, with diagnostic labels used as summary terms, at best.

Young (2016) [11] adopted a dimensional approach to psychiatric nosology and proposed it for the DSM. In particular, he referred to major psychiatric dimensions: communication/language; mood (externalizing and internalizing); thought (thought disorder and cognitive difficulties); activity/energy; and function. The latter is critical in establishing impairments, as found generally for disorders in the DSM-5. Young (2016) [11] added medical/physical/neurovegetative dimensions (like somatoform, eating psychopathology) and substance abuse, as well as self/personality, which surprisingly did not come up separately in the Forbes et al. (2024b) article [110]. A second set of dimensions involved environmental/relational and demographic dimensions; psychiatrics evaluating dimensions such as these give a better contextual picture of patients.

Research-wise, Forbes et al.’s (2024b) [110] statistical approach uses parametric clustering techniques. Future research might examine networks of symptoms/syndromes and relate them to combined systems/network modeling (e.g., Young, 2015) [122].

4. Psychological Injuries

Box 3 summarizes the major points about the present diagnostic proposals for the three psychological injuries under consideration.

Box 3. Forensically vetted proposals for psychological injuries

Proposal	Explanation
Posttraumatic Stress Disorder (PTSD)
Eight-dimensional model, with CPTSD criteria added consistent with DSM-5, ICD-11	The DSM-5’s 20 symptoms are organized into four symptom clusters. The research points to a 7-factor model of PTSD, covering its 20 symptoms; adding a factor for the dissociative subtypes suggests an 8-factor model [123]. CPTSD refers to PTSD from long-term adverse experiences, which needs to be included in the PTSD factors in a forensic diagnostic procedure. This approach produces a 9-factor/cluster PTSD model. All factors/clusters should have core symptoms noted for the diagnosis.
Organized as a symptom checklist	PTSD symptoms should be expressed in the first person so that the symptom lists can be used as checklists or self-report questionnaires by patients, aside from the clinician determining the presence of the symptoms. This paper presents a novel 25-item PTSD questionnaire paraphrased after DSM-5 and ICD-11 items that is organized into 9 factors, with patient or clinical scoring on a 5-point Likert scale (1 = never; 2 = rare; 3 = sometimes; 4 = often; and 5 = very often).
Note. CPTSD = Complex PTSD.
Chronic Pain
Considers the complications of chronic pain	Young (2013b) [34] argued that instead of attempting to diagnose chronic pain from a psychological perspective, it is more important to indicate the extent of complications occasioned by the chronic pain. The DSM-IV used categories of pain conditions without and without a psychological component, and the DSM-5 removed pain as a primary focus in considering it a somatic symptom disorder (with predominant pain). Young’s formulation considered the extensive effects of chronic pain rather than specifically its symptomology.
Avoids the DSM-5 SSD with predominant pain	The SSD formulation implies that there is a psychological component that is important in the causal matrix of the pain condition, which is the case. However, this can be used against the victim in that it could be argued that the patient’s pain experience is partly due to the exacerbatory effects of the person’s psychology rather than the incident at issue. The SSD formulation can be used in the sense of a medically unexplained condition, contributing to blaming the victim.
Somatic Symptom Disorder (SSD) With Predominant Post Concussion-like Symptoms
Considers Persistent post-concussion syndrome (PPCS)	Although SSD is not the best way of approaching a diagnosis for chronic pain, it works well when considering the long-term effects of MTBI/concussion. The latter normally dissipates in days to weeks, if not months, but cases persist and become heavily psychological in origin and focus. This led Young (2020) [124] to propose that PPCS is an SSD, with predominant post-concussion-like symptoms. The cognitive, emotional, and behavioral overfocus on its symptoms is consistent with SSD. The condition formulated in these regards reduces the patient’s overwhelming belief that they have brain damage that could be serious and opens their condition to focused psychological treatments.
Avoids Neurocognitive disorder (NCD)	In the present formulation, MTBI/concussion is not a neurocognitive disorder; it is a psychological one. In the DSM-5, applying the mild NCD class to MTBI/concussion would be the usual procedure, but that condition should be reserved for genuine neurocognitive disorder as ascertained in comprehensive neurological/neuropsychological assessment. Young (2020) [124] considered PPCS a biopsychosocial condition in which the original cerebral insult did not persist but set the stage for other biopsychosocial factors to propagate and maintain concussion-like symptoms.
Cross-Diagnostic Considerations
Polytrauma	The incident or context at issue might elicit comorbidities involving all three major psychological injuries—chronic pain, MTBI/concussion, and PTSD. Their interaction complicates and more deeply ingrains the disorders, making them more difficult to treat. Polytrauma like this makes it more difficult to assess the examinee; diagnose the disorders; understand their core, driving symptoms; understand their functional effects and impairments; and propose targeted treatment modalities.
Adds a forensic module	The clinician should determine to the possible causation and whether malingering or related attributions seem involved, while supporting the opinion with irrefutable evidence. Forensically, the court needs to be certain that the clinician tried to specify the origin of the PTSD, e.g., the traumatic stressor, and whether other independent causal factors are involved, e.g., pre-existing, independent peri-traumatic, or independent post-traumatic. The module refers to degree of negative response bias or presentation, including those of feigning and malingering, which go beyond exaggeration.
Consistent with the biopsychosocial model	The biopsychosocial model seeks influences and causes related to multifactorial processes that are involved in normal and abnormal behavior. Working from this perspective helps the forensic mental health assessor understand the role of the index incident in relation to other factors in the causation of the disorder at hand. Young (2008) referred to the forensic biopsychosocial model in this regard [125].
Consistent with the sensitization model	Young, Thielen, et al. (2025c) [126] proposed, for the first time, an integrated model across the three major psychological injuries (chronic pain, PTSD, and MTBI/concussion). They posited that, in all three conditions, sensitization takes place, involving reciprocal symptom-exacerbatory interaction between central and peripheral sensitization. The locus and nature of the peripheral interaction differ across the conditions (respectively, reception, sensation, and perception, with all three involving conception/cognition).

In this section of the paper, we present different approaches to the diagnosis/description of the major psychological injuries in ways that facilitate their use forensically. We accomplish this by creating new symptom lists for the disorders/conditions, while adding specific forensic issues.

With respect to the primary diagnostic categories in the DSM-5 related to psychological injuries, for PTSD, Young (2016) [11] described an eight-cluster model to cover the 22 symptoms of PTSD and its dissociation subtype (see Table 1). The model is based on the factor analytic research on the dimensions of PTSD, as described in Young (2016) [11]. The DSM-5-TR diagnostic approach for PTSD involves classifying its 20 major symptoms into four categories. This contrasts with empirical research, indicating that its twenty primary symptoms factor into seven dimensions.

Here, in Table 1, we show the equivalence of the ICD-11 symptoms of PTSD and the DSM-5-TR symptoms, where applicable. We note the extra cluster for the dissociation subtype. Also, we add a cluster for the extra symptoms in Complex PTSD, as described in the ICD-11. Finally, all the symptoms are redescribed in the first person, to facilitate use of the table as a questionnaire for patients/examinees, including an adjunct section for forensic use.

Table 1. Questionnaire: combined DSM-5-TR and ICD-11 PTSD/Complex PTSD symptoms ¹ over nine Clusters/dimensions.

Clusters and Symptoms	DSM Symptoms Description, with ICD-11 Symptom Equivalences 1
1. Intrusive memories 1	1.  Re-experiencing-Intrusion 1 I get repeated and unwanted memories that disturb me about what happened that are uncontrollable (they come at any time), and that bother me (distress me)
2. Recurrent nightmares 1	I get repeated unpleasant or disturbing dreams (nightmares) related to what happened that bother me (distress me) in the content of the dreams, their emotions, or both
3. Dissociative reactions/flashbacks 1	I get sudden experiences or feelings as if what had happened is actually happening again, or I am acting as if it were actually happening again. These experiences include things like getting flashbacks, or memories of what had happened, or even a complete loss of awareness of my immediate surroundings, which is called dissociation
4. Heightened emotional reactivity to signals 1	I ger intense or lengthy emotional bothers or upsets whenever I get even one reminder of as little as one aspect of what happened. I get this whether the reminder is either internal in the body (e.g., reacting to a flashback) or external to the body (e.g., seeing something that brings it back in my mind)
5. Physiological reactivity to reminders	I get marked (which means strong) reactions (e.g., a panicky reaction, heart pounding, trouble breathing, sweating) to something that reminded of what happened. I get this whether the reminders are internal in the body (e.g., reacting to a flashback) or external to the body (e.g., seeing something that brings it back in my mind)
6. Avoids reminders (thoughts/feelings/memories)	2.  Avoidance 1 I avoid (or try to avoid) memories, thoughts, or feelings that make me emotionally upset or distressed about what happened or about things closely associated with what happened
7. Avoids external reminders 1	I avoid (or try to avoid) reminders that are external (a person, place, conversation, activity, object, situation) that could make me emotionally upset or distressed in my memories, thoughts, or feelings about what happened
8. Inability to recall important aspects (“amnesia”) 1	3.  Negative Affect I get inability to remember at least one important part of what happened. This takes place when I have memory loss because of a complete loss of awareness about my immediate surroundings (dissociation). This inability does not happen because I was knocked unconscious or was intoxicated by a substance, such as alcohol
9. Persistent heightened negative beliefs	I get strong negative beliefs or expectations (something that I expect) that either keep coming into my mind (persist) or that are clearly exaggerated. These negative thoughts could be about myself, about other people, or about the world (e.g., for me: being bad, the nervous system is destroyed; for others: they are trustworthy, or the whole world is dangerous)
10. Persistent self/other blame	I get distorted (twisted) thoughts that keep coming back (persist) to the point that I blame myself either for what happened or for what happened after it, or I blame other people this way
11. Persistent negative emotional state	I get strong negative feelings or emotional reactions that keep coming back to me (they persist). These emotions could be fear, anger, horror, guilt, or shame
12. Marked loss of interest	4.  Anhedonia (Without Feeling) I get marked (strong) lessening of my interest in activities that I used to enjoy and also a lowering of my participation in these activities
13. Detachment	I experience feeling very distant, or apart, cut off, or removed from people (I feel estranged)
14. Restricted positive affect	5.  Externalizing Behavior I have no ability to get a positive feeling or emotion. That is, I do not experience long (persistent) positive feelings of happiness, satisfaction, and even love
15. Irritability/anger 1	BI do show behavior such as outbursts, feeling especially irritable or angry, and this happens for no or little reason (which means they occur without provocation). When I feel irritability or anger this way, I can express it either verbally or physically, and I can do so either toward objects or toward people
16. Reckless/Self destructive	I behave in ways that involve either taking more risks (being reckless) or behaving in ways that are harmful to me (that are self destructive)
17. Hypervigilance	6.  Anxious Arousal I get very (excessively) alert or watchful (being super on guard), even when there is no evident danger to me (I am hypervigilant)
18. Exaggerated startle 1	I startled easily and strongly or get so jumpy (that is, in ways that are exaggerated)
19. Difficulty concentrating 1	7.  Dysphoric Arousal 1 I get problems in concentration, even when I really try
20. Sleep disturbance 1	Disturbed sleep. This means I experience a problem in either falling or staying asleep, or I get restless sleep
21. Depersonalization	8.  Dissociation Subtype I get repeated experiences that are lengthy (persist) of feeling detached (e.g., being outside of my mind or outside of my body, observing it); Or, I get feelings as if I were in a dream, or with time moving so slowly; Or, I get feelings of being unreal either in my self or in my body [but not because I was under the influence of a substance, such as alcohol, or had a medical problem, such as a brain seizure]
22. Derealization	I get repeated experiences that are lengthy (persist) of my surroundings feeling unreal (or like a dream, distorted, or distant from me) [but not because I was under the influence of a substance, such as alcohol, or had a medical problem, such as a brain seizure]
23. Affective Dysregulation 1	9.  Disturbances in Self-Organization 1 I have difficulty regulating my emotions, which means trouble calming myself down or experiencing emotional numbing
24. Negative Self-Concept 1	I have a negative view of myself, which includes getting feelings of being worthless or being ashamed of myself
25. Disturbed Relationships 1	I have difficulty creating and keeping healthy social relationships, including experiencing difficulty feeling close to other people

Note. The symptoms are written in the first person for use in determining their presence in patients/examinees from their perspective, allowing the use of the table as a questionnaire. The questionnaire is not meant to replace more standardized questionnaires. The DSM-5-TR PTSD items are organized into seven clusters or dimensions following the factor analytic research on their organization (Young, 2016) [11]. The eighth one is for the dissociation subtype. The ninth cluster/dimension related to the extra symptoms relative to PTSD for diagnosis of CPTSD. ¹ The equivalent symptoms and clusters in the ICD-11 are indicated by a superscript next to the corresponding DSM-5-TR symptoms and clusters. The extra cluster and symptoms for the ICD-11 classification of CPTSD are indicated after presentation of the DSM-5-TR ones. The underlined symptoms are considered core ones according to one or more criteria: (a) prevalence (the first three are the most prevalent according to Bryant et al., 2023) [72]; (b) unique association with the disorder rather than being transdiagnostic; and (c) emotional rather than cognitive.

Table 1. Questionnaire: combined DSM-5-TR and ICD-11 PTSD/Complex PTSD symptoms ¹ over nine Clusters/dimensions.

Clusters and Symptoms	DSM Symptoms Description, with ICD-11 Symptom Equivalences 1
1. Intrusive memories 1	1.  Re-experiencing-Intrusion 1 I get repeated and unwanted memories that disturb me about what happened that are uncontrollable (they come at any time), and that bother me (distress me)
2. Recurrent nightmares 1	I get repeated unpleasant or disturbing dreams (nightmares) related to what happened that bother me (distress me) in the content of the dreams, their emotions, or both
3. Dissociative reactions/flashbacks 1	I get sudden experiences or feelings as if what had happened is actually happening again, or I am acting as if it were actually happening again. These experiences include things like getting flashbacks, or memories of what had happened, or even a complete loss of awareness of my immediate surroundings, which is called dissociation
4. Heightened emotional reactivity to signals 1	I ger intense or lengthy emotional bothers or upsets whenever I get even one reminder of as little as one aspect of what happened. I get this whether the reminder is either internal in the body (e.g., reacting to a flashback) or external to the body (e.g., seeing something that brings it back in my mind)
5. Physiological reactivity to reminders	I get marked (which means strong) reactions (e.g., a panicky reaction, heart pounding, trouble breathing, sweating) to something that reminded of what happened. I get this whether the reminders are internal in the body (e.g., reacting to a flashback) or external to the body (e.g., seeing something that brings it back in my mind)
6. Avoids reminders (thoughts/feelings/memories)	2.  Avoidance 1 I avoid (or try to avoid) memories, thoughts, or feelings that make me emotionally upset or distressed about what happened or about things closely associated with what happened
7. Avoids external reminders 1	I avoid (or try to avoid) reminders that are external (a person, place, conversation, activity, object, situation) that could make me emotionally upset or distressed in my memories, thoughts, or feelings about what happened
8. Inability to recall important aspects (“amnesia”) 1	3.  Negative Affect I get inability to remember at least one important part of what happened. This takes place when I have memory loss because of a complete loss of awareness about my immediate surroundings (dissociation). This inability does not happen because I was knocked unconscious or was intoxicated by a substance, such as alcohol
9. Persistent heightened negative beliefs	I get strong negative beliefs or expectations (something that I expect) that either keep coming into my mind (persist) or that are clearly exaggerated. These negative thoughts could be about myself, about other people, or about the world (e.g., for me: being bad, the nervous system is destroyed; for others: they are trustworthy, or the whole world is dangerous)
10. Persistent self/other blame	I get distorted (twisted) thoughts that keep coming back (persist) to the point that I blame myself either for what happened or for what happened after it, or I blame other people this way
11. Persistent negative emotional state	I get strong negative feelings or emotional reactions that keep coming back to me (they persist). These emotions could be fear, anger, horror, guilt, or shame
12. Marked loss of interest	4.  Anhedonia (Without Feeling) I get marked (strong) lessening of my interest in activities that I used to enjoy and also a lowering of my participation in these activities
13. Detachment	I experience feeling very distant, or apart, cut off, or removed from people (I feel estranged)
14. Restricted positive affect	5.  Externalizing Behavior I have no ability to get a positive feeling or emotion. That is, I do not experience long (persistent) positive feelings of happiness, satisfaction, and even love
15. Irritability/anger 1	BI do show behavior such as outbursts, feeling especially irritable or angry, and this happens for no or little reason (which means they occur without provocation). When I feel irritability or anger this way, I can express it either verbally or physically, and I can do so either toward objects or toward people
16. Reckless/Self destructive	I behave in ways that involve either taking more risks (being reckless) or behaving in ways that are harmful to me (that are self destructive)
17. Hypervigilance	6.  Anxious Arousal I get very (excessively) alert or watchful (being super on guard), even when there is no evident danger to me (I am hypervigilant)
18. Exaggerated startle 1	I startled easily and strongly or get so jumpy (that is, in ways that are exaggerated)
19. Difficulty concentrating 1	7.  Dysphoric Arousal 1 I get problems in concentration, even when I really try
20. Sleep disturbance 1	Disturbed sleep. This means I experience a problem in either falling or staying asleep, or I get restless sleep
21. Depersonalization	8.  Dissociation Subtype I get repeated experiences that are lengthy (persist) of feeling detached (e.g., being outside of my mind or outside of my body, observing it); Or, I get feelings as if I were in a dream, or with time moving so slowly; Or, I get feelings of being unreal either in my self or in my body [but not because I was under the influence of a substance, such as alcohol, or had a medical problem, such as a brain seizure]
22. Derealization	I get repeated experiences that are lengthy (persist) of my surroundings feeling unreal (or like a dream, distorted, or distant from me) [but not because I was under the influence of a substance, such as alcohol, or had a medical problem, such as a brain seizure]
23. Affective Dysregulation 1	9.  Disturbances in Self-Organization 1 I have difficulty regulating my emotions, which means trouble calming myself down or experiencing emotional numbing
24. Negative Self-Concept 1	I have a negative view of myself, which includes getting feelings of being worthless or being ashamed of myself
25. Disturbed Relationships 1	I have difficulty creating and keeping healthy social relationships, including experiencing difficulty feeling close to other people

Note. The symptoms are written in the first person for use in determining their presence in patients/examinees from their perspective, allowing the use of the table as a questionnaire. The questionnaire is not meant to replace more standardized questionnaires. The DSM-5-TR PTSD items are organized into seven clusters or dimensions following the factor analytic research on their organization (Young, 2016) [11]. The eighth one is for the dissociation subtype. The ninth cluster/dimension related to the extra symptoms relative to PTSD for diagnosis of CPTSD. ¹ The equivalent symptoms and clusters in the ICD-11 are indicated by a superscript next to the corresponding DSM-5-TR symptoms and clusters. The extra cluster and symptoms for the ICD-11 classification of CPTSD are indicated after presentation of the DSM-5-TR ones. The underlined symptoms are considered core ones according to one or more criteria: (a) prevalence (the first three are the most prevalent according to Bryant et al., 2023) [72]; (b) unique association with the disorder rather than being transdiagnostic; and (c) emotional rather than cognitive.

Scoring Grid: Combined PTSD/Complex PTSD Symptoms.

Item 1 1. never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __.

Item 2 1. never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __.

Etc.

In addition, the article presents a generic diagnostic framework for stress and trauma reactions that could be used to develop a new disorder in the DSM-6.

Table 2. Presenting Problem/stressor/trigger/trauma (generalized and individualized) dysregulation.

Template for Stress Dysregulation Disorder
(A) Stressor/Trigger/Trauma/Presenting Problem
(a) Acute Stressor/Trigger/Trauma. An immediate event such as a motor vehicle accident or natural disaster
(b) Chronic Stressor/Trigger/Trauma. An ongoing trauma or a past one with lingering effects
(c) General Presenting Problem. Endless possibilities described by the patient(s)
(B) Psychological Components Dysregulated
(B1) Core (higher-order, top-down)
1. Reaction
i. Immediate/Tonic/Short term (e.g., peritraumatic)
(a) Hyper-react/greatly emote. For example, fight or flight, scream/rage, catastrophize
(b) Hypo-react/no reaction. For example, freeze, put on a shell, confusion/shock/in a fog/dazed; dissociate (includes reports of dissociative amnesia, and depersonalization/derealization)
(c) Delayed
ii. Phasic/Long term
(a) Constant reaction
(b) Variable, off and on
2. Executive Function (EF).
For example, problems in inhibition, self-control, reward management, working memory (also called updating), goal orientation/intentionality, motivation/purposefulness, decision making, cognitive flexibility/shifting set, problem-solving, planning/organizing, monitoring.
3. Biobehavioral/Neurovegetative function.
For example, problems in sleep, fatigue, eating habits, sexual drive, pain/headaches.
(a) Hyper. For example, excessive sleep, nightmares, mania includes excess energy, inflated self-esteem, hyper goal orientation, overeating, stomach/digestion issues, dizziness, hypersexual, hypersensitivity, muscle tension/pain/headaches/pressure in the head.
(b) Hypo. For example, poor sleep, low energy, poor appetite, lost sexual drive, hyposensitivity.
4. Experiential/Existential (for self/other factors).
(a) OTHER: For example, distrust of others/world, different in relating to others/humanity, paranoia.
(b) SELF: For example, loss of identity/meaning, don’t feel the same person anymore or feel changed on the inside (personality change), negative self-esteem (e.g., worthlessness, helplessness, hopelessness, giving up), lost self-confidence, changed life story/narrative or world view.
5. Coping
For example, unstable, disorganized; poor coping, poor social support; leading to being overwhelmed.
(B2) Consequences (lower-order, bottom-up)
6. Physiological.
(a) Hyper. For example, panic, hyper-arousal, exaggerated startling.
(b) Hypo. For example, no reaction despite an expected fight or flight response/panic.
7. Behavioral.
(a) Hyper. For example, argumentative, out of character behavior, motor agitation or restlessness/retardation or slowing, substance abuse/addiction, destructive/risky behavior, distress at reminders and reliving; endless checking/repetitions/preoccupations.
(b) Hypo. For example, avoidance, stopping pleasurable activities, social isolation.
8. Cognitive.
(a) Hyper. For example, mind racing, trying to suppress thoughts and can’t, ruminate, reminders are salient, hyper-vigilant, narrowed hyper-focusing/appraising, recurrent thoughts of death or dying.
(b) Hypo. For example, can’t focus, can’t concentrate, mind wandering, distracted, slow/delayed responsivity, can’t think rationally anymore; avoiding distressing thoughts, memories (and feelings).
9. Emotional/Affective.
(a) Hyper. For example, a lot of negative affect, especially anxiety, depression, irritability, fear, blame, guilt, shame.
(b) Hypo. For example, blunted affect, flat affect.
10. Social/Relational.
(a) Hyper. For example, don’t want to be alone, over-dependent, loss of social control, disturbed social behavior.
(b) Hypo. For example, withdrawn, detached, distant, abandoning, numb, aloof, estranged.
11. Language/Communication.
(a) Hyper. For example, can’t stop talking, interrupting, can’t follow/lose track, disputing, very tangential, disordered speech.
(b) Hypo. For example, word finding difficulties, short answers, avoiding or little listening, cutting off communication, articulation disruption/slurring.
12. Other.
For example, extreme or quite inappropriate reactions, such as psychotic reactions (hallucinations, delusions, catatonia); suicidal ideation, gestures, and attempts; and/or homicidal or violent ideation, actions.
(C) Functional disruption in life roles and tasks
For example, dysfunctions in ADLs, work, school, parenting, interpersonal relations.
(D) Specify appropriate demographics and context
For example, age, sex, life roles, medications, over-medicating.

Note. This recommended addition to the DSM-6 or future iterations of the DSM-5 is broad, involving trauma-related disorders that can encompass PTSD in the DSM-5 and complex PTSD (CPTSD) in the ICD-11, along with other disorders. It can serve as a questionnaire for children, youth, and adults exposed to trauma, abuse, etc. An advantage of the template is that it includes both hyper and hypo reactions at multiple points. Adopted from Young (2022; Table 9.3) [88].

presents an outline for the assessment of patient trauma symptomatology, and it is consistent with nosology of trauma disorders in the DSM-5/ICD 11 (taken from Young, 2022) [88]. The table describes the parameters to query patients expressing stress dysregulation, which can be the basis for developing an inclusive trauma-based disorder for the DSM-6, referred to as Stress Dysregulation Disorder. The table stands as a questionnaire template for assessing common reactions to stress, triggers, and trauma. It attempts to include symptoms for PTSD, acute stress disorder, adjustment disorder, major depression, and multiple anxiety and panic disorders, as well as the extra complex PTSD symptomatology in the ICD-11 (affect dysregulation, negative self-esteem, and social dysregulation, among others). Specifically, the table indicates the core psychological factors that can be dysregulated due to stress/trauma. These dysregulations can take the form of being hyper or hypo (e.g., hypervigilant, no energy, respectively).

For pain experience diagnoses, the DSM-5 switched from pain disorders in the DSM-IV to the one of SSD with predominant pain. For Young (2016) [11], pain experience was considered especially problematic for the complications it leads to in the patient/examinee, leading him to propose a disorder along the lines of SSD for these complications (see Table 3). This SSD approach to chronic pain includes the forensic module added to the PTSD table.

Table 3. Proposal for DSM-6: Chronic Pain Complications Disorder.

Criterion	Explanation
I. Apparent Authentic Biopsychosocial Presentation/Causation
A.	Pain in one or more anatomical sites is distressing and is the predominant focus of the clinical presentation
B.	The pain causes clinically significant impairment in social, occupational, or other important areas of functioning (post-pain onset complications)
C.	Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain (excessive, persistent, maladaptive thoughts, feelings, or behaviors), as manifested by at least two of the following: excessive, persistent, maladaptive thoughts about the symptom seriousness; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive anxiety, depression, or frustration, about the experienced pain and its perceived consequences; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive time, effort, and energy expended about them never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __
D.	The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering)
E.	The pain is not better accounted for by another disorder
Specifiers	Duration: Acute: <3 months; Transitional Chronic: ≥3 months; Persistent Chronic: ≥6 months
	Severity: Specify below Mild: Consider not diagnosing SSD as clinical, given its manageability at this level Moderate: Consider diagnosing SSD as a feature or sub-syndromally, although even this level is hard to manage Severe: This level is definitely SSD Reported: Symptoms ___ Distress ___ Impairment ___

Note. All terms and qualifiers that could be ambiguous or contentious must be attributed only if clearly evidenced and documented and go beyond the minimal/mild and, if applicable, the moderate range, as the case may be, for example, (a) excessive and persistent psychological factors in the pain experience; (b) severe pain/distress/impairment; (c) gross exaggeration/malingering; and (d) pre-existing and post-onset factors, as well as any extraneous factors (e.g., an unrelated death of a loved one). Adapted from Young (2013b) [Table 2, p. 311] [34].

Table 3. Proposal for DSM-6: Chronic Pain Complications Disorder.

Criterion	Explanation
I. Apparent Authentic Biopsychosocial Presentation/Causation
A.	Pain in one or more anatomical sites is distressing and is the predominant focus of the clinical presentation
B.	The pain causes clinically significant impairment in social, occupational, or other important areas of functioning (post-pain onset complications)
C.	Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain (excessive, persistent, maladaptive thoughts, feelings, or behaviors), as manifested by at least two of the following: excessive, persistent, maladaptive thoughts about the symptom seriousness; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive anxiety, depression, or frustration, about the experienced pain and its perceived consequences; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive time, effort, and energy expended about them never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __
D.	The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering)
E.	The pain is not better accounted for by another disorder
Specifiers	Duration: Acute: <3 months; Transitional Chronic: ≥3 months; Persistent Chronic: ≥6 months
	Severity: Specify below Mild: Consider not diagnosing SSD as clinical, given its manageability at this level Moderate: Consider diagnosing SSD as a feature or sub-syndromally, although even this level is hard to manage Severe: This level is definitely SSD Reported: Symptoms ___ Distress ___ Impairment ___

Note. All terms and qualifiers that could be ambiguous or contentious must be attributed only if clearly evidenced and documented and go beyond the minimal/mild and, if applicable, the moderate range, as the case may be, for example, (a) excessive and persistent psychological factors in the pain experience; (b) severe pain/distress/impairment; (c) gross exaggeration/malingering; and (d) pre-existing and post-onset factors, as well as any extraneous factors (e.g., an unrelated death of a loved one). Adapted from Young (2013b) [Table 2, p. 311] [34].

Finally, for NCD, Hagan and Guilmette (2015) [127] took to task the DSM-5 for the changes it implemented for NCD, in particular. These authors note that NCD is categorized as either minor or major. The DSM-5 acknowledged that “the distinction between major and mild NCD is inherently arbitrary… Precise thresholds are therefore difficult to determine” [3] (p. 608). Hagan and Guilmette (2015) [127] continued that the reliability of the distinction is unknown, given the absence of empirical findings justifying it. Curiously, they note that, for traumatic brain injuries (TBIs), the DSM-5 does categorize them according to standard nomenclature of mild, moderate, and severe. In this sense, it makes no sense to have only Major and Minor NCD, as found in the DSM-5, because moderate cases will be shunted to the minor classification, thereby devaluing the severity of the patient’s condition. Clearly, the next version of the DSM should accommodate this lacuna. Relatedly, for MTBI, the syndrome of persistent post-concussion syndrome (PPCS) has been proposed in the literature for the small minority of patients who continue to have persistent subjective complaints. Young (2020) has proposed using an SSD categorization instead of PPCS, to remove any connotation that the syndrome is found due to the ongoing effects of the original concussion (see Table 4) [88]. The forensic module is included in this table, as well.

Table 4. Proposal for DSM-6: somatic symptom disorder with predominant post-concussion-like symptoms.

Criterion	Explanation
I.  Symptoms: Apparent authentic biopsychosocial presentation/causation
A	Post-concussion-like symptoms [as in the Note below to the table on the Symptoms] are distressing and are the predominant focus of the clinical presentation
B	The symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning (post-symptom onset complications)
C	Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the symptoms (excessive, persistent, maladaptive thoughts, feelings, or behaviors), as manifested by at least two of the following: excessive, persistent, maladaptive thoughts about the symptom seriousness; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive anxiety, depression, or frustration about the experienced pain and its perceived consequences; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive time, effort, and energy expended about them never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __
D	Social/ecological/environmental factors are judged to possibly have an important role in the onset, severity, exacerbation, or maintenance of the symptoms (excessive, persistent, maladaptive thoughts, feelings, or behaviors), as manifested by at least one of the following: (a) family dynamics involved, e.g., encouraging the sick role (b) social support lacking, socially isolated or withdrawing (c) institutional support perceived as lacking, e.g., by the workplace, third party payors, the court or related venues, health professionals involved; a sense of injustice or even undue entitlement in consequence
E	The symptoms or deficits are not intentionally produced or feigned (as in Factitious Disorder or Malingering)
F	The symptoms are not better accounted for by another disorder
II.  Specifiers
A	Duration: Acute: <3 months; Transitional Chronic: ≥3 months; Persistent Chronic: ≥6 months
B	Severity: Specify below Mild: Consider not diagnosing SSD as clinical, given its manageability at this level Moderate: Consider diagnosing SSD as a feature or sub-syndromally, although even this level is hard to manage Severe: This level is definitely SSD Reported: Symptoms ____ Distress ____ Impairment ____
III.  Feigning
A	If Confusing or Complicated Presentation/Causation, Specify Degree of Feigning, if any None ____ Minor exaggeration ____ Gross exaggeration ____ Deliberate feigning (motivation not evident) ____ More than that: Outright malingering for monetary or other secondary gain ____
B	Specify Source of Confusion, if any: □ Can be fully explained by pre-existing factors (e.g., psychopathology) □ Pre-existing factors exacerbate the symptoms □ Post-onset factors exacerbate the symptoms (e.g., family, work, litigation, distress) □ Incidental factors exacerbate the symptoms (e.g., death in family, societal unrest)
C	Specify Certainty of These Ratings Unsure ____ Some information ____ Clear information ____
A	Note. All terms and qualifiers that could be ambiguous or contentious must be attributed only if clearly evidenced and documented and go beyond the minimal/mild and, if applicable, the moderate range, as the case may be, for example: (a) Excessive and persistent psychological factors in the symptom experience; (b) Severe symptoms/distress/impairment; (c) Gross exaggeration/malingering; and (d) Pre-existing and post-onset factors, as well as any extraneous factors (e.g., an unrelated death of a loved one)

Table 4. Proposal for DSM-6: somatic symptom disorder with predominant post-concussion-like symptoms.

Criterion	Explanation
I.  Symptoms: Apparent authentic biopsychosocial presentation/causation
A	Post-concussion-like symptoms [as in the Note below to the table on the Symptoms] are distressing and are the predominant focus of the clinical presentation
B	The symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning (post-symptom onset complications)
C	Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the symptoms (excessive, persistent, maladaptive thoughts, feelings, or behaviors), as manifested by at least two of the following: excessive, persistent, maladaptive thoughts about the symptom seriousness; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive anxiety, depression, or frustration about the experienced pain and its perceived consequences; never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __ excessive, persistent, maladaptive time, effort, and energy expended about them never __ 2. rare __ 3. sometimes __ 4. often __ 5. very often __
D	Social/ecological/environmental factors are judged to possibly have an important role in the onset, severity, exacerbation, or maintenance of the symptoms (excessive, persistent, maladaptive thoughts, feelings, or behaviors), as manifested by at least one of the following: (a) family dynamics involved, e.g., encouraging the sick role (b) social support lacking, socially isolated or withdrawing (c) institutional support perceived as lacking, e.g., by the workplace, third party payors, the court or related venues, health professionals involved; a sense of injustice or even undue entitlement in consequence
E	The symptoms or deficits are not intentionally produced or feigned (as in Factitious Disorder or Malingering)
F	The symptoms are not better accounted for by another disorder
II.  Specifiers
A	Duration: Acute: <3 months; Transitional Chronic: ≥3 months; Persistent Chronic: ≥6 months
B	Severity: Specify below Mild: Consider not diagnosing SSD as clinical, given its manageability at this level Moderate: Consider diagnosing SSD as a feature or sub-syndromally, although even this level is hard to manage Severe: This level is definitely SSD Reported: Symptoms ____ Distress ____ Impairment ____
III.  Feigning
A	If Confusing or Complicated Presentation/Causation, Specify Degree of Feigning, if any None ____ Minor exaggeration ____ Gross exaggeration ____ Deliberate feigning (motivation not evident) ____ More than that: Outright malingering for monetary or other secondary gain ____
B	Specify Source of Confusion, if any: □ Can be fully explained by pre-existing factors (e.g., psychopathology) □ Pre-existing factors exacerbate the symptoms □ Post-onset factors exacerbate the symptoms (e.g., family, work, litigation, distress) □ Incidental factors exacerbate the symptoms (e.g., death in family, societal unrest)
C	Specify Certainty of These Ratings Unsure ____ Some information ____ Clear information ____
A	Note. All terms and qualifiers that could be ambiguous or contentious must be attributed only if clearly evidenced and documented and go beyond the minimal/mild and, if applicable, the moderate range, as the case may be, for example: (a) Excessive and persistent psychological factors in the symptom experience; (b) Severe symptoms/distress/impairment; (c) Gross exaggeration/malingering; and (d) Pre-existing and post-onset factors, as well as any extraneous factors (e.g., an unrelated death of a loved one)

The Symptoms. Specify the specific symptoms and if they have been derived by (a) self-report, (b) collateral nonprofessional sources, (c) collateral professional sources, (d) file/record/document review, (e) observation, (f) qualitative data, (g) quantitative data, (h) neuropsychological assessment/testing, and/or (i) neurological assessment/scanning/investigation. For example, if using this form for the examinee record, put the alphabet representation of the data source above the symptoms for the symptoms below that are being expressed by the examinee in order to indicate their presence and source.

Cognition Symptoms: Confusion, taking longer to think/speed of processing, dazed/stunned/disoriented/feeling foggy, memory problems, concentration problems, attention problems, executive function problems, perceptual problems, speech/language problems/slurring, judgment affected, etc. Mild TBI can induce pre-trauma retrograde amnesia as well as post-trauma anterograde amnesia (PTA).

Emotions/Social Symptoms: (a) Worry/anxiety, preoccupation with symptoms/anxiety sensitivity, depression/sadness, irritability/quickness to anger/frustration/aggression, bitterness, fear, etc.; (b) poor emotional regulation/responsivity, lability/disinhibition/impulsivity, behavior problems, restlessness/hyperactivity/agitation, personality disturbance, inappropriate behavior, and affected self-confidence/self-worth; and (c) interference in social skills/social cognition.

Physical/Bodily Symptoms: (a) Headaches, pain, poor sleep, fatigue/apathy/lethargy, arousal/stress responses, shock, panics, dizziness/light-headedness, vertigo/loss of balance/unsteady gait/motor incoordination, and nausea/vomiting; (b) visual disturbance (blurriness, double vision, light sensitivity, and difficulties in smooth pursuits, saccades, and convergence), auditory disturbance/noise intolerance/sensitivity, and tinnitus; and (c) (transient) neurological abnormalities/seizures, sensitivity to alcohol, etc.

Adapted from Young (2020) [Table 2, p. 439] [88]

Next, the article describes a forensically informed approach to psychological injuries that is based especially on the proposals for the forensically informed diagnoses of the three major psychological injuries. This section of the article required three explanatory boxes.

5. Discussion

This article reviewed the DSM-5, given its decade-long presence. The DSM-5 has been subject to criticism. The DSM-5 was constructed by working groups, who worked in greater secrecy compared to the working groups of prior iterations of the DSM. The research base had not been more elaborate, but there had been a 700% increase in the DSM’s diagnostic categories. Moreover, the diagnostic reliability of practitioners had not increased. Some of its field trials were abandoned or retained despite low reliability. Many changes were instituted in the DSM-5 to the point that the US Supreme Court in Hall v. Florida (2014) [128] opined that the DSM’s publisher, the APA, “change their minds” (Judge Scalia). The DSM cautions that it is not a forensic document. Indeed, forensic vetting of the DSM-5 was even less than had been the case for the DSM-IV; see Young (2016) [11].

We showed that alternate systems (RDoC, HiTOP, networks) are promising but not yet ready for practice or the DSM’s replacement. In the forensic arena, assessors need to be aware of the limitations of the DSM-5(-TR) and adapt accordingly to give credible diagnoses in their reports and in-court testimony. The DSM-6 should consider our recommendations for the diagnoses of PTSD, chronic pain (SSD), and neurocognitive disorder (important for MTBI). Professionals in the field should note our concerns and use the DSM-5 judiciously in their work. This relates especially to the forensic context.

Above all, relying on the DSM-5 as a forensic document is questionable, at best. Moreover, practitioners who consider its treatment of the major psychological injury disorders (PTSD, chronic pain, and MTBI) reliable and valid can be led to possibly improper diagnoses and forensic formulations in their conclusions to reports/testimony, The risk is that there will be admissibility challenges to their proffers to court, or stringent cross-examinations to the detriment of the proffers, per Daubert, 1993; see Young & Goodman-Delahunty, 2021 [129,130].

This article recommends the development of a specialized forensic diagnostic workbook for the three major psychological injuries based on the article content described herein. The psychological injury manual created by the work group should present the diagnostic approaches in the DSM-5 and the ICD-11 diagnostic manuals. Then, it should indicate which core or central symptoms (nodes) characterize each disorder/condition according to the literature, while emphasizing the need for an individualized listing of these core symptoms for any one patient/examinee. Finally, alternate diagnostic approaches that consider forensics with respect to the conditions/disorders should be listed as guides for further forensic specification, with the initial diagnostic formulations in the present article serving as initiation points for their development.

Whether clinically or forensically, the symptom overlap across the three major psychological injuries presents challenges. For potential cases of polytraumatic comorbidity, the aforementioned work group should aim toward isolating core symptoms for each condition/disorder to guide practitioners in their diagnostic formulations. This procedure will help in diagnostic formulation by removing some influence of symptom overlap compared to when the full symptom set of each diagnosis/condition is considered. In addition, the working group should specify that diagnosticians should try to qualify which overlapping symptoms might be stronger drivers than others in the patient, for example, based on the overall symptom profile. Along with other traditional psychotherapeutic approaches, symptoms such as these might be possible foci in treating these polytraumatic cases, aside from other identified drivers.

Note, the extension of revised DSM-5 diagnostic disorders and conditions proposed herein for the major psychological injuries (PTSD, chronic pain, MTBI/NCD) might help in revising these diagnoses and conditions for the DSM-6, as indicated. Moreover, the forensic module might help in revising the forensic cautionary statement. Finally, the specific quantitative indices added to the three proposed psychological injury revisions might be useful for other diagnostic conditions in the DSM-6. Finally, designating core symptoms for PTSD and expanding its clusters/dimensions to the nine indicated ones affords increased empirical analysis of PTSD and its severity levels. For example, depending on research findings, it might be useful to designate PTSD severity in terms of the presence of the different numbers of (core) symptoms expressed by the individual.

To conclude, the article provides an Appendix A of detailed explanatory boxes on the proposed four-component psychological injury forensic module. The first one gives details, and the second one elaborates malingering. The last one gives vignettes that help illustrate the psychological injury and malingering issue.