The DSM Controversy

The New England Journal of Medicine recently published some articles on the use and misuse of the  DSM. The DSM or Diagnostic and Statistical Manual of Mental Disorders has drawn controversy since its inception in 1952.  The latest is the DSM-IV-TR which was introduced in 2000.  Psychiatrists and psychologists use the DSM to diagnose disorders.  In my practice this involves categorizing patients, my clients, with specific disorders according to a checklist provided in the DSM.

Now established as the master reference work for U.S. psychiatrists, the DSM initially emerged, like the companion volume for internists, the International Classification of Diseases, with a public health interest in the incidence and prevalence of illnesses. But with its third edition in 1980 (DSM-III), the DSM began prescribing how clinicians should identify psychiatric disorders.  A new revised Diagnostic and Statistical Manual of Mental Disorders, the DSM 5, is due in 2013.

Undeniably, the DSM-III brought some gains to psychiatric practice, including consistency of diagnosis, uniformity in therapeutic regimens, and confidence in clinical research based on the reliable inclusionary and exclusionary criteria that DSM diagnoses can provide to investigators.

Yet the publication of a fifth revision of the DSM — now promised in 2013 — has been repeatedly postponed, mainly because fundamental problems tied to the approach of the DSM-III proved hard to solve. A most serious problem, common to field guides, is the difficulty of separating entities that are similar in appearance.

Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.

Although the DSM attempts to create easily operationalized behavioral criteria, Garber and Strassberg (1991) point out that for several common childhood disorders, terms like “persistent pattern,” “considerably more frequent,” and “more common” are used to determine diagnostic criteria. This language seems to rely on clinical judgment; without clearer definitions for disorders, there is considerable room for individual variation in diagnostic determination.

Identifying a disorder by its symptoms does not translate into understanding it. When you subject a person to psychological and psychiatric evaluations by doctors hired by the defense, corporation, insurance company, or others interested in minimizing or debating causation, the DSM can create problems.  Clinicians need some concept of a disorder’s nature, grasped in terms of cause or mechanism, to render it intelligible and to justify their actions in practice and research.

For now we will wait for the DSM 5 to be published and will deal with its limitations for years to come.  Fair warning!