Edited by: Eesha Joshi
I know, I know! Not very nice to Mr. DSM, but let me explain.
If you didn’t already know, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication by the American Psychiatric Association (APA) aiming to organize, define, and provide diagnostic criteria for mental health conditions. The DSM, which identifies almost 300 disorders, is most often used by mental health professionals but also by social workers, insurance companies (treatment reimbursement), researchers, and the legal system.
Although the DSM is used in the U.S. and many other countries, the International Classification of Diseases (ICD), published by the World Health Organization (WHO), serves as the official world classification standard for physical and mental diagnostic health information. Although both were developed independently from one another, the DSM slowly shifted from a psychoanalytical approach—based on the unconscious mind and early childhood experiences—towards the ICD’s evidence-based guidelines approach.
Both manuals are now highly coordinated with one another in publishing similar diagnostic criteria and codes for overlapping conditions. Nonetheless, in this article, we will specifically discuss the DSM-5 and its benefits, evolution, and criticisms, as well as its overall influence in the world of Western psychiatry and medicine.
First off, let’s go over why something like the DSM would even exist in the first place. Classification has always been an integral part of human history as humans continuously try to identify and communicate about the things around us.
A well-known example that’ll take you back to high school is taxonomy: the study and classification of organisms, using specific ranks (ex. domain, kingdom, family, species, etc.). Taxonomy paved the way for future classification systems to thrive, as it provided benefits such as universal communication as well as aid in conservation efforts, public health, and research.
A diagnostic manual for classifying human disease and disorder then makes sense as it helps organize individual symptoms to classify and help diagnose mental health conditions. It can also benefit professional communication as a symptom or disorder name can be used to describe a plethora of information, as well as help validate client experiences and further research.
The evolution of the DSM started with the inclusion of additional tally columns in the sixth decennial census of the United States in 1840 that collected data on defined physical and mental conditions at the time, such as blindness, deafness, and intellectual disabilities. The U.S. used this data to classify mental disorders as one category: idiocy/insanity.
In 1880, the U.S. census upgraded to 7 categories: mania, melancholia, monomania (obsession), paresis (weakness), dementia, dipsomania (alcohol cravings), and epilepsy. In 1917, the direct ancestor of the DSM was published by the American Medico-Psychological Association (now known as the APA) and the National Committee for Mental Hygiene called the Statistical Manual for the Use of Institutions for the Insane which comprised 22 disorders.
The United States would also go on to publish the Standard Classified Nomenclature of Disease in 1933 which consisted of a psychiatric section amongst the multitude of described physical diseases. Soon after the United States, in 1949, the WHO followed suit by including a mental disorders section in the 6th edition of the ICD.
Officially in 1952, the DSM-1 was published by the APA in an attempt to consolidate knowledge about mental illnesses in the United States in one standard manual. The DSM-2 was published shortly after in 1968 with disorders being described in long paragraphs, unreliable due to clinician bias, but also validity due to the DSM’s psychodynamic philosophy which, if you remember Freud, heavily linked mental health with an individual’s ‘unconscious’.
To test this, psychologist David Rosenhan ran an experiment testing the validity and reliability of psychiatric diagnoses in an inpatient hospital context. In 1973, he recruited participants to act as “pseudopatients” by presenting at psychiatric hospitals with the sole symptom of auditory hallucination. All participants were admitted, diagnosed, and medicated, despite the participants returning to normal behavior after admission.
Disclaimer, however, is that in 2019, journalist Susannah Cahalan published her book The Great Pretender which revealed criticisms and possible data fabrication involving Rosenhan’s study. Nonetheless, the findings of the study shocked the world and embarrassed healthcare, leading to a new DSM being published in 1980 which was more evidence-based and uses research diagnostic criteria. The DSM has continued to evolve to the current DSM-5-TR published in 2022 based on the DSM-5 published in 2013.
Although the DSM has always been controversial in nature, the latest version, the DSM-5, has received its unique criticisms apart from its other versions. We will go over 5 major criticisms of the DSM-5, starting with:
- Lowering the threshold for distress and impairment criteria
-
Firstly, many critique the diagnostic criteria of certain disorders in the DSM, claiming that it enters areas of normal-range distress, which can lead to overmedicalization and poor client outcomes.
- High comorbidity and within-disorder symptom heterogeneity
-
High comorbidity is another problem found in the DSM, where more than half of percents with a lifetime DSM diagnosis will be diagnosed with a comorbid disorder. This opens the question of overlap between diagnostic criteria and their validity: are they measuring what they are truly intended to?
- Binary and categorical approach
-
Another criticism is the DSM’s categorical approach to classifying mental illness, with specific and a certain number of criteria being needed to be diagnosed, no matter how close you are to checking off that box. Critics instead propose a dimensional approach which measures items across a continuous spectrum, unlike strict boxed categories.
- Issue of physical symptoms
-
Although it can be beneficial to include physical symptoms to include more objective criteria in a mental health assessment, physical symptoms may be side effects of a physical condition rather than a mental disorder. Another layer to this issue is many physical symptoms associated with mental disorders overlap such as difficulty sleeping, difficulty concentrating, and much more.
- Controversial and secretive revision processes
-
One of the last criticisms for the DSM which I found particularly interesting is the controversy over their revision processes. Critics claim that their revision process is not transparent and may involve a conflict of interest through strong financial ties with the pharmaceutical industry (which would benefit from the increasing number/variety of mental disorders).
Overall, although it can be a helpful tool, many critics are calling for a revolution of the DSM towards a dimensional-approach focused on key symptoms rather than a categorical approach focused on the average picture of a disorder.
Adding on to these criticisms with my own personal experience, I find with an increase in types of mental disorders and increase in the leniency of criteria that individuals may be overmedicalized and perceive their normal behaviors as “pathological.” I’ve definitely fallen into the trap of overanalyzing how I think, feel, and behave, searching for some sort of label or answer to summarize what was “wrong with me.”
It’s eye-opening to realize that the DSM is literally just based on the consensus of specific psychiatric experts around the world, and the media often treats it like God’s word. ADHD, OCD, MDD, GAD… these are all the best interpretations that certain experts have on grouping different disorders; they are not objectively real, just like how we consider many DSM disorders of the past, such as homosexuality, as not real anymore.
The main point that I want to make and I hope touches the hearts of other neurodivergent cuties like myself is to try not to assume that having or identifying with some diagnosis will lead to the path of cure-all. Mental health care should be extremely tailored to the individual as it comprises a series of interactions between their unique genetics and environment.
Something that I’ve been picking up and I find is actually really benefiting my mental well-being is realizing that Western medicine and science is not the ultimate truth, and our ancestors before that relied on movement and mindfulness.
However, our Western society isn’t good at incorporating either of these things. In fact, we see lots of individuals today becoming less active and aching for any distraction, whether that’s consumerism, substance use, or something else. I urge you to try to incorporate some aspect of movement and mindfulness in its own right in your daily routine and see how that influences your mental wellbeing.
In conclusion, psychiatry is decades behind in the classification and treatment of disorders compared to other disciplines of medicine. Especially with the lack (or current lack) of biomarkers used for psychiatry compared to physical disease, an evidence-based, reliable, and valid framework is needed to separate the main dimensions of psychopathology with normal functioning, as well as with each other.
As our world continues to grow and seemingly get crazier, mental health will continue to be in the forefront of our well-being—for better or for worse—and we should continue striving for advocacy, research, and better treatment for everyone.