The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the “bible” of mental health, originally was intended to bring order to the chaos of classifying mental disorders. Its underlying purpose was to give psychiatrists and other mental health professionals a common language and perspective for discussing clients’ presenting problems. But with the publication of DSM-5 this year, an unprecedented number of critics are making the venerable DSM seem more like the Tower of Babel, in danger of crashing down under its own weight and what they claim is its fundamentally flawed architecture.
Many critics, including psychiatrist Allen Frances, one of the prime movers of DSM-IV, are urging therapists not to buy the book, pointing to other free sources for insurance coding. Frances has been relentlessly criticizing the new edition through blogs, articles, and email blasts. “DSM-5 is recklessly disorganized and makes the fallacious claim that its decisions are science based,” he says.
In the early 1950s, three different classification systems for mental disorders existed, emanating from the Veterans Administration, the Armed Forces, and a coalition of the major medical associations in the United States, which issued the Standard Classified Nomenclature of Disease. Each system reflected the relatively limited concerns of its own clinician and client populations. Then, in 1952, the first edition of DSM—145 pages, listing 106 disorders—carved out mental disorders from physical disorders and described them in psychological (mostly psychoanalytic) terms. Now DSM-5 is out—over 900 pages, listing more than 300 disorders—and its roots have remained tied to the medical model. Many clinicians who use its codes don’t know that those diagnosis numbers are taken directly from a medical tome—the 9th revision of the World Health Organization’s International Classification of Diseases (ICD-9).
Critics of DSM claim it hasn’t been able to resolve basic issues related to its medical origins. “Therapists don’t provide a medical service,” says therapist Gary Greenberg, author of The Book of Woe: The DSM and the Unmaking of Psychiatry. Buying into DSM (or even buying DSM), he says, acknowledges that mental disorders are medical disorders, which misrepresents how therapists actually think and what they do. The notion that we can precisely describe the causes, symptoms, or even the existence of mental disorders is misguided, asserts Greenberg, and, therefore, we have to reject the DSM if we want to be honest with our clients and with ourselves—a prerequisite of every therapy relationship.
Research oriented mental health experts take issue with DSM-5 as well. In his April 29, 2013 blog post, Thomas Insel, director of the National Institute of Mental Health (NIMH), announced that NIMH plans to shift its focus from research that automatically uses DSM classifications for disorders. Since each new edition of DSM is fundamentally research based, this strikes at the heart of DSM’s claim to be the authority on mental health.
Insel likened DSM to a dictionary that creates labels and definitions for mental disorders which have poor scientific validity. Unlike physical diseases, he wrote, “The DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.” In a later statement, Insel softened his stance, noting that DSM is “still the best dictionary we have,” and it’s invaluable in helping mental health professionals “speak the same language.” But it seems clear that unless DSM more firmly joins the march toward biological psychiatry, it’s going to be left behind by NIMH.
That dilemma over what direction to take is nothing new to DSM. In trying to be too many things to too many people, DSM has ended up doing little of it well, claims Rutgers psychologist Nancy McWilliams, who’s involved in updating the Psychodynamic Diagnostic Manual (PDM), an alternative to DSM. “DSM doesn’t meet the needs of clinicians,” she states. McWilliams traces many of its current problems back to DSM-III, published in 1980. Trying to address the rise of different theoretical orientations, such as cognitive-behavioral therapy, self-psychology, and family systems, DSM-III “had to find syndromes and language which every therapist could buy into.” This led to a narrowing—many say denaturing—of the complexities of mental disorders, changing not only the way many therapists thought of clients and disorders, but forcing research into narrower channels.
Critics who’re encouraging therapists to find their insurance codes elsewhere and for free have also pointed to the hefty price tag of DSM-5—$199 for the complete book and $69 for the compact Desk Reference. In addition, there may be even more trouble ahead for DSM-5 since the new edition of PDM is due out in late 2014. PDM’s richer descriptions of disorders include such information as clients’ subjective experiences, treatment guidelines, and a dimensional perspective of disorders from mild to severe that makes diagnosis less of an either/or decision.
PDM hasn’t been on many therapists’ radar screens, partly because the first edition was self-published by a consortium of psychodynamic organizations and lacked a large promotional budget, and partly because many therapists believed they needed DSM for insurance coding. But the new PDM will be published by Guilford Press, a major publisher. As DSM-5’s critics keep hammering away at the new edition, therapists may find the new PDM to be a more clinically rich and useful tool.