An Overview of Psychiatry's Diagnostic Manual (the DSM)
This article discusses the history, uses, scientific controversies and immense social influence of the Diagnostic and Statistical Manual of Mental Disorders.
What is the DSM?
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook used by health care practitioners in the United States. The DSM contains descriptions of human experiences and behaviors. These experiences and behaviors are identified as “symptoms” of “mental disorders” and are clustered based on categories and themes that are believed to be in some ways related to each other. For example, experiences such as sadness, fatigue, insomnia, disinterest and restlessness are clustered as symptoms under the broad category of Depressive Disorders. Similarly, the section on Anxiety Disorders includes panic attacks, social anxiety, and many related types of fear and nervousness.
American Psychiatric Association. DSM-5. (2013)
What is the DSM used for?
The precursors of the DSM were written during the 19th and early 20th centuries. Their purpose was to try to group "idiocy/insanity" into subtypes for census takers and general administrative purposes at mental institutions. By the time of the first official edition of the DSM in 1952, the number of classifications had grown from 7 to 106. Since the publication of the third official edition in 1980, the DSM has incorporated more detailed lists of characteristics/symptoms and added hundreds of new “mental disorders”.
One aim of the DSM is to establish a particular, illness-focused way of understanding and discussing emotional and behavioral difficulties; unlike medical diagnostic manuals, though, the DSM categories are based on loosely defined behaviors that are not detectable by scientifically or biologically objective means. The DSM’s categorizations instead simply provide a “common language” or set of references for use among certain people and institutions such as mental health practitioners and researchers, governments, survey and census takers, the legal system, policy makers, insurance companies, medical facilities, pharmaceutical companies, and drug regulation agencies. The DSM’s categories, labels, numbered codes and descriptions are used to aid in diagnoses, guide research and consider intervention possibilities. The lists of symptoms in the DSM are also used to help create both formal diagnostic interviews and mental health screening questionnaires. (For more information on these interviews and questionnaires, see ICI’s “How "Mental Disorders" are Diagnosed”.) And most importantly, under U.S. law, the DSM labels and codes must be used by all medical and mental health professionals when they are conducting billing with private and public health insurers.
The DSM has helped popularize many mental illness ideas and terms, and has had enormous cultural influence. It has become common for news reporters, health websites, television show hosts, celebrities, scientists, entertainers, artists and many of us in our daily lives to describe various human experiences as “symptoms” of various DSM-defined “mental disorders”, such as "depression," "anxiety disorder", "schizophrenia" or "bipolar".
American Psychiatric Association. DSM History.
How is the DSM used to help make a diagnosis?
If a person exhibits or reports a certain number of experiences or behaviors that appear to match the ones that are listed under the name of a particular mental disorder in the DSM, then that person can be labeled by a mental health practitioner as having that particular disorder. For instance, to receive a diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD), the DSM-5 states that a child must exhibit or report at least 6 of 9 listed behaviors, such as often talking excessively, often not engaging in play quietly, often having difficulty waiting in line, or often interrupting others. For most disorders, it is also a criterion that the experiences or behaviors seem to be causing some level of “impairment” in a person’s functioning, such as in his or her ability to attend to school, work or daily errands.
In that sense, diagnosing a mental disorder is a relatively simple process at its heart. Notably, though, the DSM-5 does not explain many key terms and ideas such as how frequently these behaviors must occur in a child to be considered "often", how much constitutes "excessive" amounts, or what level of “impairment” is considered to be abnormal and unacceptable. Consequently, the assigning of a diagnosis is strongly influenced by the personal opinions of particular mental health practitioners. This large leeway for personal opinion in the diagnostic process is typical of most of the disorders described in the DSM. And because practitioners often in turn rely heavily on the testimonies of patients or patients' family members, friends, teachers, landlords, employers etc., the opinions of ordinary people also contribute significantly towards forming most practitioners' diagnoses.
How are mental disorders and their lists of symptoms developed for the DSM?
The inclusion and exclusion of mental disorders, symptoms and diagnostic criteria in the DSM are based to varying degrees on research and clinical practice experiences, and are ultimately determined by votes of small committees of people appointed by the American Psychiatric Association. In general, proposals for new mental disorders are submitted by practitioners or researchers to be considered for inclusion in the DSM. An appointed committee will evaluate the research and clinical experience in support of the proposal, and then vote on whether or not a particular disorder should be included in the DSM.
The process of revising the DSM, therefore, is strongly influenced not just by scientific research but by dominant social values, politics, changing ideals of normality, cultural biases, and vested interests such as those of pharmaceutical companies. For example, under public pressure, homosexuality was removed as a listed mental disorder from the DSM in the 1970s. More recently, some of the DSM disorders relating to people's feelings about their own gender were removed or changed to be more in sync with changing cultural attitudes. Today, conversely, it has become common for people, groups and organizations to lobby for certain perspectives or emotional experiences to be added to the DSM as mental disorders rather than removed from it -- this is because official DSM-designations can often lead to opportunities for obtaining health insurance reimbursement, enhanced school funding, school- or work-related accommodations, unemployment benefits, or disability rights.
Is the DSM accurate, valid and reliable?
Though often presented to the public as valid and reliable, by scientific standards and by the ordinary way in which most laypersons would understand these words, the DSM diagnostic categories are neither valid nor reliable.
In psychiatry, and specifically with respect to testing the DSM, the term reliability refers to how frequently two or more clinicians will agree upon a diagnosis for a person, or agree at slightly different times. Validity has a variety of different meanings in different scientific contents, but within psychiatry it generally refers to the ability of a diagnosis to determine what a person’s mental or emotional problem is and what caused it, to predict how well the person might be dealing with this problem in the future, and to decide what treatments will help alleviate the person's problem.
If we understand validity as the ability to match a diagnosis to a biologically detectable illness or disorder, then the DSM has no validity at all. As has been acknowledged by the Task Force leader of the recent fifth edition of the DSM and in an official statement from the APA, not a single mental disorder listed in the DSM can be detected through any kinds of biological tests. However, many supporters of the DSM have argued that a DSM diagnosis nevertheless may still have somepredictive validity, or value for predicting how well people will do in future or what type of “treatment” might make them better. But this predictive value of diagnoses depends a lot, obviously, on whether or not expert clinicians can even reliably agree with each other on their diagnoses in the first place.
So is the DSM reliable? For each new edition of the DSM, trials have taken place across varied settings to statistically test for reliability, and generally the results have been very weak. The official field trials for the DSM-5, for example, tested only 23 categories of disorders, even though there are over 300 listed mental disorders (depending on how one counts them). After the tests, the APA stated that their findings showed that absolutely none of the 23 disorders that they tested achieved “excellent” reliability. For five of the diagnoses, they stated, psychiatrists agreed with “very good” reliability and for nine they agreed with “good” reliability. On the other nine diagnostic categories psychiatrists reportedly had “questionable” or “unacceptable” levels of disagreement.
However, these results were even weaker than they may sound. This is because, since 1980, the APA and its DSM task forces have taken the position that the more commonly agreed-upon standards in medicine to determine expert agreement or reliability values are too ambitious for psychiatry. As the Task Force leaders behind the DSM-5 clarified in an essay discussing this issue in the American Journal of Psychiatry in 2012, psychiatric diagnoses are generally so unreliable that achieving reliability levels considered to be simply passably good in other fields of medicine are “miraculous” and a “cause for celebration” in psychiatry. Consequently, the DSM test standards were placed lower and the researchers shifted their interpretations of their findings upwards. That is to say, they described ratings as “good” and “very good” when by more common medical standards the actual numbers showed that those particular ratings were “poor” and “moderate”.
And it’s important to note that these field trials were conducted under highly biased and controlled conditions with a pre-selected patient population, where the psychiatrists knew they were being tested on their ability to agree with each other on a small number of possible diagnoses. These levels of disagreement even among people with the same professional training using the same diagnostic processes are not altogether surprising since, as explained above, the criteria for defining a mental disorder are vague and widely open to personal interpretation, and there are no biological tests of any kind for detecting the existence of any mental disorder. In real-world conditions with widely varying clients, widely varying diagnostic processes, hundreds of possible mental disorder labels, and no one evaluating each other’s decisions, we would expect even less agreement to occur – unless a practitioner’s diagnosis is merely being influenced by the diagnosis that a previous practitioner put in a person’s medical record (which often happens).
In summary, DSM diagnoses have generally low levels of reliability, and they have no validity. According to the U.S. National Institute of Mental Health, the "lack of validity" of the DSM is a major reason why the government has stopped funding research that relies on DSM categories.
Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6(4), 284-290.
Insel, T. Director’s blog: Transforming diagnosis. National Institute of Mental Health (April, 2013).
Kraemer, Helena Chmura, David J. Kupfer, Diana E. Clarke, William E. Narrow, and Darrel A. Regier. “DSM-5: How Reliable Is Reliable Enough?” American Journal of Psychiatry 169, no. 1 (January 1, 2012): 13–15. doi:10.1176/appi.ajp.2011.11010050.
Kupfer, David. “The DSM-5 - an Interview with David Kupfer.” BMC Medicine 11 (2013): 203. doi:10.1186/1741-7015-11-203.
Kupfer, David. "News Release: Chair of DSM-5 Task Force Discusses Future of Mental Health Research." American Psychiatric Association. (May 3, 2013).
Regier, D. A., Narrow, W. E., Clarke, D. E., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canade, Part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170, 59-70.
Who wrote the DSM-5 and why is that important?
The DSM is a copyrighted product of the American Psychiatric Association (APA). Through its most recent three editions, the DSM has so far generated over $100 million in direct profits for the APA, ranking it among the most financially lucrative books of any kind published in America since the 1950s.
There are, however, many additional, indirect profits that are closely linked to the DSM. The DSM-5 was written by different task forces made up of mental health clinicians, academics and researchers chosen by the American Psychiatric Association, where each small task force was responsible for a particular diagnostic section or category. Nearly 70% of the DSM-5 task force members reported having financial ties to pharmaceutical companies, and at least 56% of those who posted disclosure statements admitted having industry ties such as holding stock in pharmaceutical companies or serving on the boards of pharmaceutical companies.
One reason these conflicts of interest are important is this: Each time new disorders are added to the DSM or the lists of possible symptoms are loosened or expanded, the changes can result in upsurges in the numbers of people being diagnosed with those disorders. This in turn can lead to millions or even billions of dollars in profits for the sellers of interventions targeting those disorders such as mental health professionals, pharmacies, pharmaceutical companies and medical device manufacturers. Psychiatrist Allen Frances, the chair of the DSM-IV task force, for example, has publicly lamented what he has called the "false epidemics" of ADHD and autism that he partially caused by allowing the definitions of those disorders in the DSM-IV to be broadly expanded.
Cosgrove, L., Bursztajn, H. J., & Krimsky, S. (2009). "Developing unbiased diagnostic and treatment guidelines in psychiatry" [Letter to the Editor]. The New England Journal of Medicine, 360, 2035-2036.
Cosgrove, L., Krimsky, S., Wheeler, E. E., Kaitz, J., Greenspan, S. B., & DiPentima, N. L. (2014). Tripartite conflicts of interest and high stakes patent extensions in the DSM-5. Psychotherapy and Psychosomatics, 83, 106-113.
“DSM-5 By the Book”. The Economist. (May 18, 2013).
Frances, Allen. “Psychiatric Diagnosis Gone Wild: The "Epidemic" Of Childhood Bipolar Disorder”. Psychiatric Times. (April 8, 2010).
If a DSM diagnosis for a person in emotional distress isn’t scientifically valid, then what is happening to the person?
Just because the DSM and the diagnoses that come from it have no scientific validity or reliability does not mean that people never suffer significant inner distress and never experience or behave in ways that are very unusual. It simply means that we do not have any way of precisely, scientifically describing and naming exactly what is happening for any particular individual, explaining why it is happening, or reaching objective agreement on what’s happening and why. (Please read ICI’s “How "Mental Disorders" are Diagnosed” for more information on this topic.) For some people, this lack of knowledge seems frightening, while for others it opens up new possibilities for different ways of thinking about and responding to distressing, socially censured, or unusual experiences or behaviors.