Caution Is Needed When Adding Etiology to Mental Disorder Criteria: The Case of Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been cautiously restrictive in incorporating etiological variables into diagnostic criteria. This etiologically agnostic approach seems appropriate given the lack of evidence for single dominant causal factors for most mental disorders. Moving toward an etiologically based diagnostic system was, however, articulated as one of the research goals for DSM-5. Unfortunately, the threshold of evidence justifying inclusion of an etiology in the criteria of a mental disorder in the DSM has not, to our knowledge, been explicitly articulated. Nevertheless, DSM-5 proposes a new exception with the introduction of "Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure" (ND-PAE) in the chapter on "Conditions for Further Study." Criteria for this new diagnosis include (A) "more than minimal exposure to alcohol during gestation…," (B) "impaired neurocognitive functioning as manifested by one or more…" from a list of five domains, and (C) impaired self-regulation (p.798). The basis for an exception for this particular etiologic variable, prenatal alcohol exposure (PAE), along with the implied hypothesis that it is causal for this cluster of neurobehavioral abnormalities, is not detailed in the DSM-5.