DSM Reflections

Analysis of the DSM's history, critiques, and role in modern psychology.

The entwined worlds of traditional medicine and psychology place a great deal of both clout and doubt upon a commonly consulted resource: the Diagnostic and Statistical Manual of Mental Disorders, or DSM. As the study of psychology evolved and its subsets took shape, it was inevitable that a core text would develop to help organize the piles of accrued knowledge. The function and revision of the DSM were and continue to be at the mercy of subjectivity. The manual’s pages serve to assist licensed professionals with treatments through a detailed system of disorder categories and definitions. Those who criticize the DSM for seeming to mandate a rigid classification system may be adhering to the text to a stricter degree than scientific reasoning might suggest they should. The scientific foundations of psychology, the principles of which can be found in the work and methods of any psychiatrist or psychologist that retains their skepticism, open-mindedness, and ability to consider their patients as unique individuals with complex traits (even when manifesting behavior categorically classified in the DSM text), are what should allow the DSM to remain in its proper place as a useful guide, second in value to the mind and experience of the individual that wields it. By this logic, it seems the text will continue to do more good than harm, despite continued controversy since its conception. Regardless of the position one takes regarding the content of the DSM, its overall use as an interface with the healthcare system is simply invaluable and irreplaceable.

Classification in psychiatry can be traced back to the early work of Emil Kraepelin when he proposed the subdivision of certain psychotic disorders. In 1883, Kraepelin was motivated by his irritation with the vast differences in terminology presented to him in the discussion of the disorders of his day and went on to author Psychiatry: A Textbook for Students and Physicians (Decker, 2013, p. 43). Completing his work across the Atlantic in the heart of Germany, he predates the original DSM by over 50 years. When Westerners eventually accepted his ideas, it established a common vocabulary for discussing relevant disorders. Kraepelin’s work, or more importantly, his attitude toward categorization as a logical approach, influenced the minds of many who would later shape what became the modern DSM (Decker, 2013, p. 51). Kraepelin himself was not motivated because he believed classification cemented definitive answers but because it united the work of those who were asking similar questions. The concept of classification, when separated from the impurities inevitably projected upon it by its interpreters and modifiers, is scientific and sound.

When investigating the relevance of the DSM, it is critical to assess what percentage of the population is considered by it to be disordered. According to the World Health Organization, records of recent years show that around 450 million individuals (roughly 7% of the globe) suffer from mental or behavioral disorders (Myers, 2010, p.593). Regarding disorders themselves, an important concept used by the American Psychological Association for the DSM’s contents is deviation. Deviant behavior is behavior that is considered to deviate from concepts of normalcy. It is in the identification of deviant behavior and its varying degrees that mental disorders and normalcy both take shape. Many consider the integrity of the DSM (and by the transitive property, psychiatry) to lay in the consistency of diagnosis between its users. **“The central assumption of the view of diagnosis as technical rationality is that mental health professionals will arrive at the same diagnostic conclusion when assessing the same client”** (Kirk & Kutchins, 1992, p. 230). The DSM outlines the process by which disorders are diagnosed and describes 16 clinical syndromes. Without presuming to explain their causes, it describes various disorders with the underlying momentum of the text being the separation of normal and abnormal.

A central part of the DSM is the interview procedure, in which the diagnosing professional asks their patient a series of classifying questions. The interview process is difficult to control, as patients can be totally unstructured and unique in terms of the way they reveal relevant information about themselves in the context of the interview process (Kirk & Kutchins, 1992, p. 52). While the push for classification of disorders is in itself a scientific endeavor, the subjectivity involved in the process by which an individual patient is diagnosed is underestimated. Normal vs. abnormal is not consistent enough to warrant labeling across multiple patients, as both the defined disorders and applied diagnoses are about “identifying important differences. However, not all differences are the same” (Murray, 2011, p. 47). Even though the DSM-III was praised for establishing diagnostic criteria, the subjectivity of the interview process slipped through the cracks unaddressed and remains today a huge inhibiting factor when aiming for a proper diagnosis (Kirk & Kutchins, 1992, p. 221).

In his book Mental Health Ethics, Barker asks if the creation and/or removal of disorder classifications from the DSM is controlled by medical, political, or social forces (or perhaps a combination of several). Citing the LGBT community’s opposition to the inclusion of a classification of Gender Identity Disorder as a listed disorder in the DSM-V, Barker suggests that when “significant pressure can be brought to bear,” ‘mental disorders’ can be created or made to disappear (Barker, 2011, p. 144). While a priority of allotting sensitivity and long overdue attention to issues that involve the LGBT community is critical to psychology in the coming decades, Barker’s use of this example as a suggestion that the DSM is a political bulletin board is not unwarranted. He cites the DSM’s depathologization of homosexuality in 1973 as further evidence that cultural momentum (independent of or in conjunction with psychological research) plays a key role regarding the focus of the text and its implied interpretations. With the pardoning of homosexuality, one can see that psychology itself was evolving from infancy, in parallel with its concept of deviant behavior (Myers, 2010, p. 594). At the root of issues concerning the DSM’s focus is the vocational importance of the appearance of a functional scientific process to the outside world, for “If psychiatrists could not agree on what the disorder was for an individual client, how could they agree on a prognosis or treatment, and how could they [as psychiatrists] maintain social legitimacy?” (Kirk & Kutchins, 1992, p. 219).

The media played a large social role in the early changes of the DSM, as pressure for the APA to revise the DSM-II came from coverage of gay activist groups staging protests in the early 1970s, with the demand homosexuality be removed as a classified disorder (Kirk & Kutchins, 1992, p. 78). While history may reflect that the world of psychology rightfully depathologized (and helped to, on a grander scale, culturally destigmatize) homosexuality, the process was not without debate or resistance. In hindsight, it is difficult to say that the attempt to withhold a declaration of normalcy from the homosexual community (when current thought suggests they were deserving of one) was not outright homophobia. Instead of altogether pardoning homosexuality from the DSM, the influential psychiatrist Robert Spitzer suggested a new diagnosis of “Sexual Orientation Disturbance” for those previously thought pathologically suffering from homosexuality, in an attempt to reach a compromise with gay activists (Kirk & Kutchins, 1992, p. 78).

The idea that personal prejudices and archaic values were of inappropriate influence on the formation of the DSM-III is hard to deny, with Spitzer again serving as an example when a request was made that racism be included as a mental disorder. The request came from a group of African-American Psychiatrists, and Spitzer flat out rejected the proposal (Kirk & Kutchins, 1992, p. 102). Why a racist individual, possessing feelings of mistrust, hatred, or outright disgust for those of a different ethnic background, was declared normal, while a person possessing feelings of same-sex attraction was defended as not, suggests confusingly subjective thinking (especially when the origins of both was not relevant to the pages of the DSM). The request for both minority and female representation on the task force in charge of the DSM was also an issue in the early days, with Spitzer again being cited as an obstructer (Kirk & Kutchins, 1992, p. 79). From history, we might infer that DSM content is at times controlled less by scientific research and more by excessive individualism in the custodial power structure that governs the document.

This subjective, compromised structure also might play a role in the increasing amount of classifications presented in every subsequent version of the text. Many professionals wonder what, if anything, has happened in the last 40 years to warrant a triple inflation in the number of available diagnoses (Houts in Beutler & Malik, 2002, p. 18). The concept of an exciting growth of psychological knowledge is a popularly cited factor in relation to the DSM’s gradual bloom into intellectual obesity. A more grounded, subjective explanation is frequently discussed as well. The rise in available diagnoses between DSM versions was significantly larger than any corresponding increase in overall supporting knowledge, and this concern is often cited alongside observations that creators of the DSM-III were mostly aging Caucasian males who “embedded the documents with their biases” (Beutler & Malik, 2002, p. 6). To complicate things further, the growing swarm of classifications also came with a hierarchy, the exclusive rules of which meant certain diagnoses could not be applied if symptoms were found to occur during another disorder existing at a higher hierarchical level (Beutler & Malik, 2002, p. 5). These changes may seem of little significance, but they cannot be taken lightly, as the number of reported diagnoses rose comparably alongside the number of available categories (Myers, 2010, p.593), increasing the amount of affected people and raising the stakes. In contrast with the past, symptoms nowadays are increasingly lumped in with corresponding disorders, with mood swings (which many consider normal for a teenager) currently considered to be indicative of Bipolar Disorder (Myers, 2010, p. 598).

Apart from the obvious subjective undercurrents, there lies defendable merit in the idea of scientific progress driving historical DSM revisions. The DSM-III was considered the dawn of a more reputable age in psychiatry, with the style of the revision aiming to “achieve a more objective and rational approach by describing mental disorders in a manner that would be beneficial and reinforce psychiatry as a genuine branch of medicine” (Demazeux & Singy, 2015, p.4). With this insight, we see goals regarding not only the creation of the manual itself but the attempt as well to legitimize the world it represents via the text’s widespread publication and recognition. This begs the question of how any group of qualified professionals, large or small, can find a balance between development of the content of the DSM for its objective use in the diagnostic and treatment processes, and the grander public relations goals for their field. The subjective nature of the DSM’s definitions and interpretations can bring to mind such similar paradoxes as the ancient Council of Nicaea, at which the Emperor Constantine hosted a totally subjective discussion to create, for ruling purposes, the Holy Bible; a text subsequently claimed by many Christians to be the unaltered word of the divine, or the contemporary annual Academy Awards, at which the Academy of Motion Picture Arts & Sciences selectively recognizes the year's “greatest” cinematic achievements, purely from a public relations perspective. History tells us that the ignoring of compromising subjectivity is an easily triggered reflex of humanity when our own grandiosity is at stake. Regarding the seemingly continuous revision of the DSM, Demezeux cites “Constant innovation [as] the price to be paid for scientific progress” (Demezeux & Singy, 2015, p.10). One might interpret this perspective as cognitive dissonance, with “scientific progress” a rationalizing label and “constant innovation” an overly optimistic substitute for what some perceive to be endless subjective deliberation.

Arthur C. Houts touches on the idea that certain narratives drive many cultural and scientific progressions, and his discussion of the discovery narrative is particularly resonant in regards to the DSM’s inflation (Houts in Beutler & Malik, 2002, p. 23): "When it can be made to work, the discovery narrative reassures us by convincing us that our current formulations of mental disorders are the result of painstakingly careful scientific investigations that belong to a grand picture of human triumph over ignorance and cruelty. Believing in and reciting the discovery narrative makes us feel good."

Houts elaborates with a suggestion that psychology may itself be submerged in the discovery narrative, as hiding behind it can shield many from accusations that personal biases may be clouding their involvement when it comes to charting a new course for psychology’s future, and that a massive expansion in complexity of the DSM is simply a continuation of this pattern. The discovery narrative unfortunately pervades and distorts the same scientific activities it helps to organize and defend (Beutler & Malik, 2002, p. 24).

Beyond criticism of the changes in the DSM, some professionals, students, scholars, and patients simply protest the use of diagnostic labels. We know that labels spawn preconceptions that manipulate our interpretation of what we observe and perceive (Myers, 2010, p. 599). In the context of therapy, all interaction with a patient done after the assignment of a diagnostic label could be considered as subjective to the limitations of the characteristics and traits of that diagnosis. The DSM may very well be able to describe the behavior and attitude of a person suffering from Bipolar Disorder and may assist in the discovery of the disorder in a patient in the first place, but it cannot explain the origin of the disorder nor predict the future behavior of one’s patient. Correlation does not imply causation, and a patient that features traits and symptoms described by the DSM to be present in a patient with Bipolar Disorder does not guarantee Bipolar disorder to be present in the patient, nor does it guarantee that they will benefit from the disorder-related treatment. The value of the DSM is truly determined by the consulting therapist, but if someone intends to truly help a patient, how is assigning a diagnostic label the ethically correct first step in the process? (Barker, 2011, p. 146).

As the contents of the DSM itself continue to be refined over the years, the process through which these revisions occur is evolving as well. Each major edition of the DSM was ushered into existence under the banner of a central theme: III seemed to be establishment, IV was expansion, and the recent development and publication of V placed new importance upon revision, making the refinement process public, thereby allowing it to be scrutinized prior to publication (Demezeux & Singy, 2015, p.16). The DSM-V’s formation of the SRC, the Scientific Review Committee, allowed a group of experts separate from the core DSM Task Force to explore the validity of research behind proposed changes in the DSM-V. Considering the historical inclination to give a select homogenous few the final say regarding the content of the manual, expanding the revision process to feature separate bodies of diverse personnel appears to be a healthy direction.

Lastly, and perhaps most importantly and definitively, there exist practical reasons for the existence of the DSM; without a catalog of disorders, how would we identify and decide which patients qualify to be covered by insurance or who is given access to beneficial medications or procedures? The DSM enables the healthcare system to include mental health issues and to process its conditions with the same level of sincerity as physical ailments. The idea that a disorder diagnosis allows for financial interface with the healthcare system is widely recognized as a key part of its existence. “Diagnosis in mental health, now more than ever before, is a business act as well as a clinical one” (Kirk & Kutchins, 1992, p. 233). A diagnosis with a referenced label is often required for insurance companies to become involved (Myers, 2010, p. 597), injecting the money needed to perpetuate the system that allows many who need care to receive it. There can be no argument against the DSM's usefulness in facilitating accessibility of paid care and medication, and this might be the very reason it will remain on shelves worldwide, regardless of how much dust some copies will collect.

While knowledge and treatment of various internal and external physical ailments and conditions are able to evolve more rapidly due to immediately observable and objectively measurable results, the minutiae of effective clinical psychology and psychiatry can, unfortunately, lay in the patient tinkering of the invisible mind and its influence on behavior and the body, with results often subject to interpretation. This is reality. It is understandable, therefore, that one of psychology’s core documents can present as equally amorphous yet be as effective as its disorder’s symptoms are potent. The disagreement over the changing details of the DSM should not put in jeopardy the effectiveness of psychological treatment so long as those who may formally utilize the DSM retain their ability to approach each patient as an individual that may contradict their corresponding pages in the DSM. Kraepelin himself began classification to allow a simplified discussion of such unique individuals, not to homogenize them by linking shared traits under umbrella definitions.

A useful area of research for the future of the DSM would be to maintain consistent experiments that compare differences in diagnoses of a single patient by larger groups of psychologists with a goal of similar consensus. Perhaps even more relevant (though impossible to study) would be the reported results of treatment of the same patient with two different professionals, one who diagnosed by-the-book vs. one who did not apply a diagnostic label. The results might show the DSM as ultimately forgettable and suggest a real need to exercise restraint from embracing the discovery narrative’s idea that psychology is progressing at an exponential rate towards ultimate truths and perfected classifications.

Despite a history of complex revisions and a persistent debate on its accuracy, the document’s usefulness remains unchanged, as it provides a language and ultimately does not limit the abilities of psychologists and psychiatrists to approach their treatments with the very same innovation, skepticism, and experimentation that led to psychology’s early maturation. In some technical ways, such as a medium by which to communicate with the insurance system and provide healthcare, the DSM is simply a necessity. Wielders of the DSM, like the science of psychology they represent, continue to improve the quality of life in a sizable portion of the world’s population, and that is enough to prove their relevance to humanity.

• Barker, Phil (Ed). 2011. Mental Health Ethics. New York, NY: Routledge Publishers.
• Demazeux, Steeves & Singy, Patrick (Eds). 2015. The DSM-5 in Perspective. New York, NY: Springer Publishers.
• Kirk, Stuart A. & Kutchins, Herb (Eds). 1992. The Selling of the DSM. New York, NY: Aldine De Gruyter.
• American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Decker, Hannah S. 2013. The Making of DSM-III. New York, NY: Oxford University Press.
• Plante. Thomas G (Ed). 2006. Mental Disorders of the New Millenium Vol 1. Westport, CT: Praeger Publishers.
• Murray, Greg (Ed). 2011. A Critical Introduction to DSM. New York, NY: Nova Science Publishers, Inc.
• Beutler, Larry E. & Malik, Mary L. (Eds) 2002. Rethinking The DSM. Washington, DC: APA.
• Myers, David G. 2010. Psychology. New York, NY: Worth Publishers.