Opinions about the Diagnostic and Statistical Manual (DSM)

This video describes my opinion of the Diagnostic and Statistical Manual, specifically the DSM-5. The Diagnostic and Statistical Manual is a classification manual. It has mental health disorder classifications in it and it's used by members of a variety of professions. It's written primarily by psychiatrists and published by the American Psychiatric Association, but it's also used by mental health counselors, psychologists, social workers, marriage and family therapists, as well as other mental health professionals. I'm going to go over what I like about the DSM, some criticisms I have of the DSM, and I'm also going to address some criticisms I've heard from others about the DSM. First, I'll talk about what I like about the DSM. Overall, I'm a fan of the DSM. I think it's generally well organized, it tends to use precise language, and I generally find it to be helpful. I like the way the DSM incorporates current research into the different classifications. Our field is subjective, so of course this is can be limited and we are talking about a complex subject matter, but I think that the DSM does a good job in this area overall. I have a few criticisms of the DSM. It doesn't appear to be a particularly collaborative document in terms of the way it was developed. The development process could be more transparent. I know that there are others that will argue that it was collaborative and it was transparent but I disagree. I realize that it's published by the American Psychiatric Association as I mentioned most of the authors are psychiatrists, but it is used by a number of other professions so it seems reasonable that all the different groups should have some ability to really contribute to what we see in the DSM. Another criticism I have is the way the sections are organized. Although I generally like it, they're not standardized, for example, you can see comorbidity listed in a number of classifications, but not in others. If this information isn't available then list it in the DSM, but specify “unknown.” That helps us to know what areas we need to continue to research. One of the most popular criticisms is that it over-pathologizes the population. It makes too many people eligible for a diagnosis of a mental disorder. Here I have to disagree. I understand that some of the wording and some of the way the classifications are structured could lead to overdiagnosis. You could also argue that some of the language and structure could lead to underdiagnosis. This criticism of the DSM is not about the DSM as much as it is about clinical practice. How the DSM is used is up to a practitioner and doesn't necessarily speak to the quality of the document itself. I think that one of the problems we have with diagnosing in the mental health treatment community is really about clinical skill and judgment and not about how correct or incorrect the DSM is. As clinicians it's our responsibility to look at the DSM and make our own judgment about how reliable or valid the classifications are. I think that the DSM has done a reasonable job in terms of the way it's structured the classifications, and I don't think it's really leaning toward over-pathologizing or underdiagnosing. Another criticism is there are no treatments indicated in the DSM. This is simply a matter of what the DSM is supposed to do. It's a manual full of descriptions of mental disorders and it's not designed to directly inform treatment by providing the treatments right there in the same document. It's designed to inform treatment by allowing us to accurately classify psychopathology and then we can look to the literature and see what treatments would be applicable. Overall, I tend to like the DSM. I think that the way it's arranged makes sense, although of course it could use improvements. I understand there are many others with different opinions and a lot of times with the Diagnostic and Statistical Manual there are strong opinions in both directions. I believe that continued research can help future versions of the DSM become more helpful for our work and mental health treatment.

[oopalonga]

appreciate your candidness when it comes to the subjectivity of the DSM.


it's amazing how someone's entire life can be transformed thru involuntary medication for a "mental illness" entirely diagnosed using a manual based upon convention rather than objective, measurable criteria.

[tsbcmhc]

Thank you Dr. Grande. Your balanced approach to explaining the pros and cons of the DSM was refreshing. I too had a criticism about the lack of treatment options, but you explained why there is not any in DSM very clearly.

[veronicabetz]

Dr. Grande, your detailed appraisal of the DSM (benefits, criticisms, and limitations) was very insightful and a great learning tool. For a neophyte counselor with limited knowledge and use of the manual, this breakdown provided a better understanding of how interrupt the DSM.

[virginiamurrey]

I agree, the DSM seems to be very helpful towards looking at symptoms and behaviors and their measurements within the mental health field. I also agree that their may be a lack of collaboration in different fields of study. If a majority of fields use this manual as a guide, there should be more diversity within the publication.

[devinpratt]

I'm surprised that what I consider the primary criticism for the DSM was not mentioned. As many experts have noted, a primary problem with the DSM and is that it is unable to adequately define it's own main subject matter - disorders. The DSM essentially defines disorders in a roundabout way by listing sets of symptoms, some majority of which much exist in tandem for a certain period of time in order for the so-called disorder to exist. The issue with this is that there is never anything separate from the symptoms pointed to, no underlying cause of all of the symptoms supposedly associated with the disorder. This is a major issue, as otherwise all we have is a set of symptoms which have no connection to one another.

I suspect that many psychiatrist don't think this is an issue, and simply say that this is precisely what a disorder is (the nebulous relation or thing that ties the symptoms together), and there is nothing further to it. This is not only unsatisfactory, but tends to lead to ad hoc defenses of the concept of disorder and the DSM in general. Psychiatry is so utterly convinced that disorders are real that they think doubling down on descriptions and categorizations of symptoms somehow explains disorders and makes them real. In other words, they desperately want to legitimize their own diagnostic criteria and their field in general, as well as make sense of mental health, and so they continue to argue for the concept of disorder, not because there is any independent reason for believing that disorders are real, but rather because they already believe they are and are trying to legitimize the idea ad hoc.

I have some sympathy for this way of thinking: we tend to use physical health as the paradigm for all health, and for good reason - because we understand it better and that model has had a lot of successes in treatment and explanation. Unfortunately, mental health is not physical health, and we have no reason to believe that it operates on that paradigm, i.e. identifiable diseases that we have independent reason for believing exist, and that are the direct cause of symptoms. The fact of the matter is, there is nothing in the brain, body, or even mind that we can point to and say "this is the disorder, this is the thing that is causing all these symptoms, but is ontologically distinct from them". Perhaps some day we will be able to do this, but I highly suspect that we won't because it just isn't a thing, aside from perhaps some clear genetic differences that lead to a small set of well defined conditions like ASD or psychopathy.

Some might argue that the cause of disorders is not particularly important for diagnosing and treating, but this misses the point really. While strictly speaking we may not need to know the cause, we still have to know what we're treating, and that it exists. I can accept that it is sometimes useful to give a name to a grouping of symptoms simply for the sake of being able to refer to that group of symptoms more easily, more like pointing to common patterns. The main issue though is that this tends to lead to treatments that aim at the whole group as if it were one thing, one cause, of the symptoms, when if fact there is no evidence for this and no reason to believe it is the case. This is dangerous in my opinion - both for treating clients in therapy/counselling, and philosophically.

I'd be interested to get Dr. Grande's insights on this issue.

[cforest]

I have enjoyed and learned a lot from these recent videos. They are very clear, precise and helpful in sorting through and comparing the disorders.I think something that has to change is the differences or difference of expression with gender in certain disorders.
female sociopathy/psychopathy, conduct disorder, ADHD, aspergers, narcissism(especially covert)..
Males... borderlines, bipolar.

[angelinastanton]

I agree that being able to identify patterns in the DSM is helpful. However, overlap and comorbidity does exist with certain disorders. You have to be careful who you are diagnosing and why, or avoid misdiagnosing someone. For example, I think it is always helpful to consider how drugs are contributing to a client's behaviors.

[adambrowne]

I know that people can be misjudged or stigmatized because of their mental health diagnosis but I also agree that labels are helpful. It can be comforting to know that whatever symptoms you are experiencing have been documented and seen in other people. Therefore the person feels somewhat normalized in that they aren't the only one going through similar circumstances.

[deniseswindell]

Dr. Grande, I liked the comment about the diagnostic skills and judgement of the clinician are an important piece in using the DSM as a diagnostic tool. As a student learning about diagnosis and use of the DSM I find this statement to be extremely helpful in teaching me the required responsibilities in labeling an individual with a diagnosis.

[wandamixon]

Thank you for the overview. I find it helpful. Rather than view the DSM (5) as cumbersome, I have a better idea of what to expect and not expect. I understand the arguments of overpathologizing and labeling of individuals. I view the manual as a useful resource for serious consideration among other resources.

[meagain]

I can always come here & find answers thank you so much dr

[JoeDirt-elfr]

The DSM is a useful tool in grouping mental illness into certain categories. I just dont think putting labels on a client is going to help them in therapy. Some things are better left unsaid. However I do see where it helps mental health professionals treat clients.

[corinneporter]

I like how you said that diagnosis should focus more on our clinical judgement as counselors rather than solely on DSM characteristics. I do believe there is more to clinical diagnosis than just checking of certain criteria. I am looking forward to this class so we can learn how to incorporate clinical judgment towards the DSM.

[jean-pierredevent]

A lot of things in psychology/psychiatry look very convincing and seem to work: the DSM but also the big five, transactional analysis, the enneagram etc. But astrology seems to work too and so do chakras or Chinese medicine or astrology. So I can only hope everybody stays aware of that line where it becomes pseudoscience. As a system to bring structure in a wide variety of mental behaviour, the DSM succeeds. But it resembles a lot a book to determine plants: is the leaf hairy, go to page ... But compared to plants, I think an almost identical phenotype is here even less a guarantee of a close real relation under the hood. The psychiatrists know themselves it's all about a good descriptive label and not much more but anyone else could make to much of it and think all these disorders are diseases.

[yvoferdinandvanderhoek]

My main criticism is that it's too focused on English language research... There is another world out there.

[davidsweeney]

Do you think that psychopathology will ever be classified based on biology or genomics? Will this make for a simpler more rational diagnostic manual with less conditions?

[gingerlori]

Just a thought about diagnosing narcissism. If one could find a narcissist that is willing (lol) would it be of value to the narcissist to question their family and friends, rather than just one clinicians questioning and observing.?

[kristiewatunya]

I can find myself agreeing to this video. From transitioning from the DSM-IV to the DSM-V, the change was difficult for me. Once I utilized the DSM-V more and read more of the different criteria, I was able to conceptualize diagnosis more. I love the analogy used in this video about not reading a car manual prior to using it.

[kelly]

It was very interesting to hear your insight on the DSM. I did not realize that they are not all categorized the same. I think that would help if they were and it could help to alleviate some confusion had by those reading it.

[janicedixon]

Thanks for your insight on the DSM!

I'm not familiar with the DSM yet so I can't give an opinion on this particular video. However, I see both sides to the stigma that the DSM puts on an individual. On one hand having a diagnosis to an ongoing problem can be beneficial but on the other hand it can validate negative thoughts the client and outsiders have in regards to mental health. It really depends on the client and his or her experience.