The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), offers a common language and standard criteria for the classification of mental disorders. It is used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers together with alternatives such as the International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO). The DSM is now in its fifth edition, DSM-5, published on May 18, 2013.
The DSM evolved from systems for collecting census and psychiatric hospital statistics, and from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, although also removing those no longer considered to be mental disorders.
The ICD is the other commonly used manual for mental disorders. It is distinguished from the DSM in that it covers health as a whole. While the DSM is the official diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world. The DSM-IV-TR (4th. ed.) contains, in Appendix G, an “ICD-9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders” that allows for comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated.
While the DSM has been praised for standardizing psychiatric diagnostic categories and criteria, it has also generated controversy and criticism. Critics, including the National Institute of Mental Health, argue that the DSM represents an unscientific and subjective system. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from “normality”; possible cultural bias; and medicalization of human distress. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically totaling over $100 million.
Uses and definition – DSM
Many mental health professionals use the manual to determine and help communicate a patient’s diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.
DSM-5, and all previous editions, are registered trademarks owned by the APA.
History – DSM
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category: “idiocy/insanity”. Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that “the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation”, pointing out that in many towns African-Americans were all marked as insane, and calling the statistics essentially useless.
The Association of Medical Superintendents of American Institutions for the Insane was formed in 1844, changing its name in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association (APA).
Edward Jarvis and later Francis Amasa Walker helped expand the census, from 2 volumes in 1870 to 25 volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880) (published 1888). Wines used seven categories of mental illness: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania and paresis. These categories were also adopted by the Association.
In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the APA developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This included 22 diagnoses and would be revised several times by the APA over the years. Along with the New York Academy of Medicine, the APA also provided the psychiatric nomenclature subsection of the US general medical guide, the Standard Classified Nomenclature of Disease, referred to as the Standard.
World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist Brigadier General William C. Menninger developed a new classification scheme called Medical 203, that was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the US Navy had itself made some minor revisions but “the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces”, and “assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty.” The Veterans Administration also adopted a slightly modified version of Medical 203. In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time.
The foreword to DSM-1 states this “categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature.” An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system, and the Standard’s Nomenclature to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of “personality disturbance”, generally distinguished from “neurosis” (nervousness, egodystonic). In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was widely influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study that compared the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a hero to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.
In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was merely another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry’s fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA’s listing of homosexuality as a mental disorder. A study published in Science by Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.
Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to go ahead with a revision of the DSM. It was published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. The term “reaction” was dropped, but the term “neurosis” was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although they also included biological perspectives and concepts from Kraepelin’s system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.
An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. They found that different practitioners using the DSM-II were rarely in agreement when diagnosing patients with similar problems. In reviewing previous studies of 18 major diagnostic categories, Fleiss and Spitzer concluded that “there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories”.
Seventh printing of the DSM-II, 1974
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA’s convention. At the 1971 conference, Kameny grabbed the microphone and yelled: “Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you.”
This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations.
Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of “sexual orientation disturbance”.
In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a need to standardize diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA. The establishment of these criteria was an attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute.
Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by federal administrative offices), rather than assumptions of etiology, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as “neo-Kraepelinian”). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model.
A new “multiaxial” system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued that “mental disorders are a subset of medical disorders” but the task force decided on the DSM statement: “Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.” The personality disorders were placed on axis II along with mental retardation.
The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced, while some were deleted or changed. A number of the unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity; a political compromise reinserted the term in parentheses after the word “disorder” in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of “sexual orientation disturbance”.
Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry. However, Robert Spitzer later criticized his own work on it in an interview with Adam Curtis, saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.
When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:
“Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator…”
In 1987, the DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. “Ego-dystonic homosexuality” was also removed and was largely subsumed under “sexual disorder not otherwise specified”, which can include “persistent and marked distress about one’s sexual orientation.” Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated that for at least some disorders, “particularly the Personality Disorders, the criteria require much more inference on the part of the observer” (p. xxiii).
In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a 3-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. Some personality disorder diagnoses were deleted or moved to the appendix.
A “text revision” of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. The DSM-IV-TR was organized into a five-part axial system. The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.
The DSM-IV-TR characterizes a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress… or disability… or with a significant increased risk of suffering.” It also notes that “no definition adequately specifies precise boundaries for the concept of ‘mental disorder’… different situations call for different definitions”. It states that “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder” (APA, 1994 and 2000). There are attempts to adjust the wording for the upcoming DSM-V.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in twenty years.
A significant change in the fifth edition is the deletion of the subtypes of schizophrenia. All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated and residual).
The deletion of the subsets of autistic spectrum disorder (namely, Asperger’s Syndrome, classic autism, Rett Syndrome, Childhood Disintegrative Disorder and pervasive developmental disorder not otherwise specified) was also implemented, with specifiers with regard to intensity (mild, moderate and severe). Severity is based on social communication impairments and restricted, repetitive patterns of behaviour, with three levels: 1 (requiring support), 2 (requiring substantial support) and 3 (requiring very substantial support).
During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.
Future revisions and updates
Beginning with the fifth edition, it is intended that diagnostic guidelines revisions will be added more frequently. It is notable that The DSM-5 is identified with Hindu rather than Roman numerals. Incremental updates will be identified with decimals (DSM-5.1,DSM-5.2, etc.). A new edition will be signified by whole number changes (DSM-5,DSM-6, etc.). The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”, although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
With the advent of the DSM-5 in 2013, the APA eliminated the longstanding multiaxial system for mental disorders.
Previously, the DSM-IV organized each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:
Axis I: All psychological diagnostic categories except mental retardation and personality disorder
Axis II: Personality disorders and mental retardation
Axis III: General medical condition; acute medical conditions and physical disorders
Axis IV: Psychosocial and environmental factors contributing to the disorder
Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children and teens under the age of 18
Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.
Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”. The APA notes diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered “illnesses”.
The DSM-IV does not specifically cite its sources, but there are four volumes of “sourcebooks” intended to be APA’s documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials. The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.
Reliability and validity concerns
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. It was argued that a science of psychiatry can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about a diagnosis with a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with “tweaking” the diagnostic criteria. Unfortunately, neither the issue of reliability or validity was settled. However, most psychiatric education post DSM-III focused on issues of treatment—especially drug treatment—and less on diagnostic concerns. In fact, Thomas R. Insel, M.D., Director of the NIMH, stated in 2013 that the agency would no longer fund research projects that rely exclusively on DSM criteria due to its lack of validity. Field trials of DSM-5 brought the debate of reliability back into the limelight as some disorders showed poor reliability. For example, major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on this diagnosis in the same patients. The most reliable diagnosis was major neurocognitive disorder with a kappa of 0.78.
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, “little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology.”
The DSM’s focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.
Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists’ criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology. Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that “Instead of replacing ‘metaphysical’ terms such as ‘desire’ and ‘purpose’, they used it to legitimize them by giving them operational definitions…the initial, quite radical operationalist ideas eventually came to serve as little more than a ‘reassurance fetish’ (Koch 1992) for mainstream methodological practice.”
A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience states “that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects.” As an example of the problem of the superficial characterization of psychiatric signs and symptoms, the authors gave the example of a patient saying they “feel depressed, sad, or down”, showing that such a statement could indicate various underlying experiences: “not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth.” The structured interview comes with “danger of over confidence in the face value of the answers, as if a simple ‘yes’ or ‘no’ truly confirmed or denied the diagnostic criterion at issue.” The authors gave an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a “conversational, phenomenological interview”, a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not “recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question”, or the experience did not “fully articulate itself” until the patient started talking about his experiences.
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step (“Axis IV”) for outlining “Psychosocial and environmental factors contributing to the disorder” once someone is diagnosed with that particular disorder.
Because an individual’s degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM’s standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as “culture-bound”, whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman’s negative view toward the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One of the results was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM to treat African and African American patients.
Medicalization and financial conflicts of interest
It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had “allowed the biopsychosocial model to become the bio-bio-bio model”.
However, although the number of identified diagnoses has increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients. However, William Glasser refers to the DSM as “phony diagnostic categories”, arguing that “it was developed to help psychiatrists – to help them make money”. In addition, the publishing of the DSM, with tightly guarded copyrights, has in itself earned over $100 million for the APA.
Clients and survivors
A client is a person who accesses psychiatric services and may have been given a diagnosis from the DSM, while a survivor self-identifies as a person who has endured a psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). Some individuals are relieved to find that they have a recognized condition that they can apply a name to and this has led to many people self-diagnosing. Others, however, question the accuracy of the diagnosis, or feel they have been given a “label” that invites social stigma and discrimination (the terms “mentalism” and “sanism” have been used to describe such discriminatory treatment).
Diagnoses can become internalized and affect an individual’s self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, and/or against the DSM system in general. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple “comorbid” diagnoses) or chronicity.
Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, it will “medicalize normality and result in a glut of unnecessary and harmful drug prescription.” In a December 2, 2012 blog post in Psychology Today, Frances lists the ten “most potentially harmful changes” to DSM-5:
-Disruptive Mood Dysregulation Disorder, for temper tantrums
-Major Depressive Disorder, includes normal grief
-Minor Neurocognitive Disorder, for normal forgetting in old age
-Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
-Binge Eating Disorder, for excessive eating
-Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
-First time drug users will be lumped in with addicts
-Behavioral Addictions, making a “mental disorder of everything we like to do a lot.”
-Generalized Anxiety Disorder, includes everyday worries
-Post-traumatic stress disorder, changes opening “the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.”
Frances and others have published debates on what they see as the six most essential questions in psychiatric diagnosis:
-are they more like theoretical constructs or more like diseases
-how to reach an agreed definition
-whether the DSM-5 should take a cautious or conservative approach
-the role of practical rather than scientific considerations
-the issue of use by clinicians or researchers
-whether an entirely different diagnostic system is required.
In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 14,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other American Psychological Association divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association’s (APA) classification and diagnostic tool.
In the United States the DSM serves as a universal authority for psychiatric diagnosis. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has significant practical importance.
The DSM-5 was published on May 18, 2013,
superseding the DSM-IV-TR, which was published in 2000.
The development of the new edition began with a conference in 1999, and proceeded with the formation of a Task Force in 2007, which developed and field-tested a variety of new classifications. In most respects DSM-5 is not greatly changed from DSM-IV-TR. Notable changes include dropping Asperger syndrome as a distinct classification; loss of subtype classifications for variant forms of schizophrenia; dropping the “bereavement exclusion” for depressive disorders; a revised treatment and naming of gender identity disorder to gender dysphoria, and removing the A2 criterion for posttraumatic stress disorder (PTSD) because its requirement for specific emotional reactions to trauma did not apply to combat veterans and first responders with PTSD.
The fifth edition was criticized by various authorities both before and after it was formally published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry unduly influenced the manual’s content. Various scientists have argued that the DSM-5 forces clinicians to make distinctions that are not supported by solid evidence, distinctions that have major treatment implications, including drug prescriptions and the availability of health insurance coverage. General criticism of the DSM-5 ultimately resulted in a petition signed by 13,000, and sponsored by many mental health organizations, which called for outside review of the document.
Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III’s dimensional assessments. The DSM-5 deleted the chapter that includes “disorders usually first diagnosed in infancy, childhood, or adolescence” opting to list them in other chapters. A note under Anxiety Disorders says that the “sequential order” of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses.
This introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the ICD systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders is scientifically premature.
The new version replaces the NOS categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.
DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II.
It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF).
The World Health Organization’s (WHO) Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.
Section II: diagnostic criteria and codes
-“Mental retardation” has a new name: “intellectual disability (intellectual developmental disorder).”
-Phonological disorder and stuttering are now called communication disorders—which include language disorder, speech sound disorder, childhood-onset fluency disorder, and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder.
-Autism spectrum disorder incorporates Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) – see Diagnosis of Asperger syndrome#DSM-5 changes.
-A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome.
Schizophrenia spectrum and other psychotic disorders
-All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual).
-A major mood episode is required for schizoaffective disorder (for a majority of the disorder’s duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met).
-Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder.
-Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.
Bipolar and related disorders
-New specifier “with mixed features” can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called “NOS”, not otherwise specified) and MDD.
-Allows other specified bipolar and related disorder for particular conditions.
-Anxiety symptoms are a specifier ( called “anxious distress”) added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).
-The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.
-New disruptive mood dysregulation disorder (DMDD) for children up to age 18 years.
-Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.
-Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality.
-The term dysthymia now also would be called persistent depressive disorder.
-For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) “must recognize that their fear and anxiety are excessive or unreasonable”. Also, the duration of at least 6 months now applies to everyone (not only to children).
-Panic attack became a specifier for all DSM-5 disorders.
-Panic disorder and agoraphobia became two separate disorders.
-Specific types of phobias became specifiers but are otherwise unchanged.
-The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.
-Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).
Obsessive-compulsive and related disorders
-A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition.
-Trichotillomania (hair-pulling disorder) moved from “impulse-control disorders not elsewhere classified” in DSM-IV, to an obsessive-compulsive disorder in DSM-5.
-A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and “absent insight/delusional” (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).
-Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance.
-The DSM-IV specifier “with obsessive-compulsive symptoms” moved from anxiety disorders to this new category for obsessive-compulsive and related disorders.
-There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder.
Trauma- and stressor-related disorders
-Posttraumatic stress disorder (PTSD) is now included in a new section titled “Trauma- and Stressor-Related Disorders.”
-The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV.
-Separate criteria were added for children six years old or younger.
-For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity. Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events.
-Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.
-Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.
-Depersonalization disorder is now called depersonalization/derealization disorder.
-Dissociative fugue became a specifier for dissociative amnesia.
-The criteria for dissociative identity disorder were expanded to include “possession-form phenomena and functional neurological symptoms”. It is made clear that “transitions in identity may be observable by others or self-reported”. Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma).
Somatic symptom and related disorders
-Somatoform disorders are now called somatic symptom and related disorders.
-Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder were deleted.
-Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.
-Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.
-Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy).
-A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention”.
-Criteria for conversion disorder (functional neurological symptom disorder) were changed.
Feeding and eating disorders
-Criteria for pica and rumination disorder were changed and can now refer to people of any age.
-Binge eating disorder graduated from DSM-IV’s “Appendix B — Criteria Sets and Axes Provided for Further Study” into a proper diagnosis.
-Requirements for bulimia nervosa and binge eating disorder were changed from “at least twice weekly for 6 months to at least once weekly over the last 3 months”.
-The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
-“Feeding disorder of infancy or early childhood”, a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.
-“Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition” were deleted.
-Primary insomnia became insomnia disorder, and narcolepsy is separate from other hypersomnolence.
-There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation.
-Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type. Jet lag was removed.
-Rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder, instead of both being listed under “dyssomnia not otherwise specified” in DSM-IV.
-DSM-5 has sex-specific sexual dysfunctions.
-For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.
-Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria.
-A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
-Sexual aversion disorder was deleted.
-Subtypes for all disorders include only “lifelong versus acquired” and “generalized versus situational” (one subtype was deleted from DSM-IV).
-Two subtypes were deleted: “sexual dysfunction due to a general medical condition” and “due to psychological versus combined factors”.
-DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added.
-Subtypes of gender identity disorder based on sexual orientation were deleted.
-Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one’s gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The grouping has been moved out of the sexual disorders category and into its own. The name change was made in part due to stigmatization of the term “disorder” and the relatively common use of “gender dysphoria” in the GID literature and among specialists in the area. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.
Disruptive, impulse-control, and conduct disorders
Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders.Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter “Impulse-Control Disorders Not Otherwise Specified”.
-Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).
-Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity.
-Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited “prosocial emotion”, showing callous and unemotional traits.
-People over the disorder’s minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify “impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences”.
Substance-related and addictive disorders
-Gambling disorder and tobacco use disorder are new.
-Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new “addictions and related disorders” category. “Recurrent legal problems” was deleted and “craving or a strong desire or urge to use a substance” was added to the criteria. The threshold of the number of criteria that must be met was changed. Severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added. New specifiers were added for early and sustained remission along with new specifiers for “in a controlled environment” and “on maintenance therapy”.
DSM-5 substance dependencies include:
-303.90 Alcohol dependence
-304.00 Opioid dependence
-304.10 Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence)
-304.20 Cocaine dependence
-304.30 Cannabis dependence
-304.40 Amphetamine dependence (or amphetamine-like)
-304.50 Hallucinogen dependence
-304.60 Inhalant dependence
-304.80 Polysubstance dependence
-304.90 Phencyclidine (or phencyclidine-like) dependence
-304.90 Other (or unknown) substance dependence
-305.10 Nicotine dependence
-Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. “New separate criteria are now presented” for major or mild NCD due to various conditions. Substance/medication-induced NCD and unspecified NCD are new diagnoses.
-New specifiers “in a controlled environment” and “in remission” were added to criteria for all paraphilic disorders.
-A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).
-Personality disorder previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained.
Section III: emerging measures and models
Alternative DSM-5 model for personality disorders
Conditions for further study
These conditions and criteria are set forth to encourage future research and are not meant for clinical use.
-Attenuated psychosis syndrome
-Depressive episodes with short-duration hypomania
-Persistent complex bereavement disorder
-Caffeine use disorder
-Internet gaming disorder
-Neurobehavioral disorder associated with prenatal alcohol exposure
-Suicidal behavior disorder
Development – DSM–5
In 1999, a DSM–5 Research Planning Conference; sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced “white papers” on the research needed to inform and shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.
On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM had a broad range of experience and interests. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members’ disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests.
The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability.
Revisions and updates to DSM-5
Beginning with the fifth edition, it is intended that diagnostic guidelines revisions will be added incrementally. The DSM-5 is identified with Arabic rather than Roman numerals, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1,DSM-5.2, etc.), until a new edition is written. The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.
Robert Spitzer, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: “When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.” Allen Frances, chair of the DSM-IV task force, expressed a similar concern.
Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that “the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed.”
David Kupfer, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, vice chair of the task force, whose industry ties are disclosed with those of the task force, countered that “collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders.” They asserted that the development of DSM-5 is the “most inclusive and transparent developmental process in the 60-year history of DSM.” The developments to this new version can be viewed on the APA website. Public input was requested for the first time in the history of the manual. During periods of public comment, members of the public could sign up at the DSM-5 website and provide feedback on the various proposed changes.
In June 2009, Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of “serious, subtle, (…) ubiquitous” and “dangerous” unintended consequences such as new “false ‘epidemics'”. He writes that “the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology” and is concerned about the task force’s “inexplicably closed and secretive process”. His and Spitzer’s concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.
The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them. According to MSNBC, “The petition accuses Zucker of having engaged in ‘junk science’ and promoting ‘hurtful theories’ during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy.” According to The Gay City News, “Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse.” Blanchard responded, “Naturally, it’s very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn’t distort] my views, they completely reversed my views.” Zucker “rejects the junk-science charge, saying there ‘has to be an empirical basis to modify anything’ in the DSM. As for hurting people, ‘in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'”
In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition. In a November 2011 article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.
The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders. A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015.
Borderline personality disorder controversy
In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reported that “the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma.” Instead, it proposed the name “emotional regulation disorder” or “emotional dysregulation disorder.” There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).
The TARA-APD recommendations do not appear to have had an impact on the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR.
More radical criticisms
Some authors believe that the problem is not simply of a few criteria to be deleted or modified. For example, a Kuhnian reformulation of the diagnostic debate suggested that apparently trivial problems of the DSM, like the extremely high rates of comorbidity, might fruitfully be analysed as Kuhnian anomalies leading the DSM system to a scientific crisis. As a consequence, a radical rethinking of the concept of mental disorder was proposed, addressing its constructive nature. Based on similar views, several revolutionary approaches were proposed, ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis.
The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest. Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members.
British Psychological Society response
The British Psychological Society stated in its June 2011 response that it had “more concerns than plaudits”. It criticized proposed diagnoses as “clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements… not value-free, but rather reflect[ing] current normative social expectations”, noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that “not otherwise specified” categories covered a “huge” 30% of all personality disorders.
It also expressed a major concern that “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences… which demand helping responses, but which do not reflect illnesses so much as normal individual variation”.
The Society suggested as its primary specific recommendation, a change from using “diagnostic frameworks” to a description based on an individual’s specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:
“[We recommend] a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with ‘normal’ experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’… We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc.)? These would be more helpful too in terms of epidemiology.
While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person’s problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives. ”
– British Psychological Society June 2011 response.
NIMH – National Institute of Mental Health
National Institute of Mental Health director Thomas R. Insel, MD, wrote in an April 29, 2013 blog post:
“The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity … Patients with mental disorders deserve better.”
Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only. Insel’s post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as “Goodbye to the DSM-V”, “Federal institute for mental health abandons controversial ‘bible’ of psychiatry”, “National Institute of Mental Health abandoning the DSM”, and “Psychiatry divided as mental health ‘bible’ denounced.” Other responses provided a more nuanced analysis of the NIMH Director’s post.
In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association, that emphasized that DSM-5 “… represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.” Insel and Lieberman say that DSM-5 and RDoC “represent complementary, not competing, frameworks” for characterizing diseases and disorders. However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions.