Is the DSM doing it wrong?

Posted on: February 19, 2012

  The DSM (The Diagnostic and Statistical Manual of Mental Disorders) is, in simple terms, a giant book with pages and pages of different catagorisations of mental disorders, first made and published by the APA in 1952.  With 5 axis covering anything from personality disorders to intellectual disabilities affected by mental health, it is considered the bible for clinical psychologists; diagnosing clients and attaching disorders at a person using the criterias in this glorious book.  But is this really the ethical way to go about things?

The current edition (The DSM-iv-text revision) is being redeveloped for the first time since 1994 and this is causing a giant uproar within the psychology community (See this article for more).  The APA say that they “now understand” much more about psychology and mental illnesses than they did in 1994, and so a newer, up to date textbook is in order – the DSM-V – but the DSM has been far from understanding in the past.

Homosexuality for example was considered a  mental health disorder in the DSM up until 1987, where they replaced the title of “Sexual Orientation Disorder” with “Sexual Disorder Not Otherwise Specified; persistent and marked distress about ones own sexual orientation“, that means up until this time, any attraction towards the same sex would have you labelled by the DSM as having a mental disorder.  And if you were curious or unsure (most popularised now by society as ‘bicurious’) then Sexual Disorder Not Otherwise Specified would still have you in its catagory noose (Hayes and Horwitz, 2005)!

The newest rumoured disorder to be under the DSM-V is ‘internet addiction’, under non-substance addictions [article here] (shared with other disorders such as pathological gambling), not a compulsion or part of routine, or even an OCD, but an addiction of its own (it makes me wonder how they are going to classify this; perhaps ‘if clinent spends X amount of time at a computer, they are liable to have the disorder’ – it makes me wonder how many of us will be labelled under this!).    Within the childhood illnesses catagory is my personal favourite ‘Oppositional Defiant Disorder’ – whereby your child says ‘no’ too often or does things against a parents wishes.  In my opinion, this is walking a fine line to use an excuse for poor parenting, or perhaps even covering a more sinister condition such as ADD/ADHD or behavioural related problems that could need medication – blaming it on the child when all they could really need is good disipline and consistent parenting would perhaps lead to overdiagnosis.  Are these really the type of things that should be labelled under a mental health disorder?

According to the WHO-CIDI, the population of those with a mental health disorder has increased over the last ten years; diagnoses are at an all time high – with diagnoses being made 47% more often than they were in the 90’s.  The chart above shows the disorder prevelance amongst the population as of 2012.  Does ease of access to the DSM mean that psychologists are overdiagnosing, or does it simply mean that we are more understanding of mental health disorders?  According to Bowden (2009) the misdiagnosis of bipolar patients has risen from 15% to 40% and believes that there is an overlap between how many psychologists are quick to diagnose (whether it be for money gain or otherwise) and the criterion in the DSM, believing that there is much more to the complex condition of bipolar that is mentioned within the diagnostic textbook.

That said, the DSM is far from a ‘tick-box’ book, it contains pages and pages of relentless titles within disorders that can all affect the outcomes as well as criteria, such as ‘Diagnostic Features’, ‘Associated Disorders’ ‘Familial Pattern’, ‘Specific Culture Features’, ‘Prevelance’, and ‘Differential Diagnosis’ – just to name a few!   The DSM attempts to provide a simple basic outline for mental health disorders – helping people and psychologists alike to generate a ‘most likely’ diagnosis and understand conditions better.  Of course, mental health can be difficult to judge accurately; there are psychologists who feel that the DSM is attempting to create firm ‘must-haves’ to qualify for disorders (Bowden, 2001😉 which can often lead to misdiagnosis (Walker,2007) but personally, looking through the DSM-iv-TR, I find even the most basic mental health issues extremely lieniant in their diagnostic criteria (example: client must display 2/5 of these symptoms for a longer period than 6 weeks etc.).

As we know, psychology in itself is difficult to measure (Zimmerman, 2011) – research and conclusions are often argued and opinions of the ‘true’ outcomes are agreed-to-disagree which could lead to false positive or false negative diagnoses.  The DSM/APA recommend using ‘sourcebooks’ to check and double check diagnoses and these are left at the discretion of the researcher/clinician (1994).

In conclusion, the DSM is not there to diagnose, but to assist those who do.  Much of what is diagnosed is down to the clinician/psychologist and within psychology, there is only so much we can take from books.  The DSM attempts to remain ethical, but of course there will always be discrepancies – mental health is vast and often misunderstood, and the DSM does it’s best with what information is known and since it generates many of its disorders and criteria from society, including psychologists and the general public, it is near impossible to please everybody in what it does and what it says!  The DSM is not ‘doing it wrong’ but doing what it can.  Unlike most factual textbooks, the DSM can only write as far as our own understanding and help us, and the psychologists of tomorrow understand more about the big topic of mental health.


2 Responses to "Is the DSM doing it wrong?"

Good subject, I find the DSM a little daunting, and potentially a bit too old school, stiff upper lip, patronising and even judgemental. Ok, so it’s not that bad, but it is just a tad over the top at times. The example you mentioned really saddened me, to think that when Freddie Mercury (one of the greatest queens of our time (or at least of MY time)) died his sexuality was still considered to be some sort of illness.

Another interesting point you made was that of the diagnosis of children. Oppositional Defiance Disorder huh, well, as a parent of an oppositional, defiant and occasionally disorderly child, I must disagree that it is down to bad parenting per se. I was an oppositional defiant and disorderly child myself, and my mother was keen to bring us up to be polite, to behave properly and to be responsible people, (as I also try to do with my children) my brother was all of these things (as is my daughter) but me and my son (even though he drives me nuts) have much more defiant personalities. I don’t suppose it’s bad enough to warrant a diagnosis, or indeed that it is even a valid diagnosis for anyone. Surely a whole generation of punks, hippies or even protesters (any type of protesters, anyone who stands up against authority at all even?) Is the diagnosis of ODD a useful label to be placed on anyone who really just doesn’t want to do as they’re told?

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