A great number of people who are diagnosed with a mental health condition will have heard of the DSM-5. It’s because the Diagnostic and Statistical Manual of Mental Disorders (fifth edition), to give its full title, is the handbook used by healthcare professionals in America as the definitive guide to the diagnosis of mental health disorders.
Produced by the American Psychiatric Association (APA), such is its authority it is also used around much of the world. The APA is the largest psychiatric organization in the world and with nearly 40,000 members is the main professional organization of psychiatrists in the US.
Published in 2013, DSM-5 has detailed descriptions, symptoms, and other vital aspects that are useful for diagnosing mental health disorders. It also has the average age of onset for various disorders, treatment approaches, possible treatment effects, and statistics about who – for instance, which sex – is most affected by a particular disorder.
Written using standard criteria and a common language, it is regularly used by pharmaceutical companies, health insurance companies, clinicians, psychiatric drug regulation agencies, mental health researchers, policymakers, and those in the legal system.
The DSM was first published in 1952. It has undergone a number of revisions over the years and still remains America’s authoritative text on mental health disorders.
Who wrote the DSM-5?
The APA selected 160 leading clinicians and researchers from around the world for its DSM-5 Task Force. They are from several mental health and medical disciplines including psychology, psychiatry, pediatrics, social work, and nursing.
For a few years, they extensively reviewed literature and gathered information from experts in social and behavioral sciences, neuroscience, epidemiology, biology, primary care, genetics, statistics, public health, and nosology (the branch of medical science dealing with the classification of diseases). This included more than 400 experts from diverse fields taking part in a series of international conferences.
Then after a disorder was proposed for inclusion in the book, members of the Task Force reviewed current research on the condition. Sometimes they would also commission studies to explore the proposed disorder in further detail.
In writing the DSM–5, perhaps the main aim was to produce an evidence-based handbook that’s useful to clinicians in assisting them in accurately assessing and diagnosing mental health disorders. But it doesn’t include guidelines for the treatment of disorders.
What is the history of the DSM?
Historically, the start of what has become the DSM is considered to be the 1840 US census. In that census it used a single category of “idiocy/insanity”.
In 1888 a 582-page volume was published that was entitled Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States. It used seven categories of mental illness: mania, melancholia, paresis, monomania, dementia, dipsomania (uncontrollable craving for alcohol), and epilepsy.
In 1917, the American Medico-Psychological Association with the National Commission on Mental Hygiene (now Mental Health America) published a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. It contained 22 diagnoses.
Over the years this handbook was revised several times by the American Medico-Psychological Association and then its successor the American Psychiatric Association. It was eventually published as the Statistical Manual for the Use of Hospitals of Mental Diseases.
During the Second World War American psychiatrists were increasingly involved in the selection, assessing and treatment of soldiers. This moved the focus away from traditional clinical perspectives.
A few years after the war ended the World Health Organization (WHO) published a sixth revision of the International Statistical Classification of Diseases in 1949. For the first time, this contained a section on mental disorders.
All of this meant that there was a diverse range of literature that was being used to assess and diagnose people with mental health disorders. So an APA committee was given the task of standardizing everything and putting it in one book.
The result was the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) that was published in 1952. It listed 102 diagnoses.
As knowledge increased, the APA decided that a revision of the DSM was needed. DSM-II was published in 1968, listing 182 diagnoses.
Published in 1980, DSM-III listed 265 diagnoses. In 1987, DSM-III-R (R standing for revision) was published as an update of the DSM-III, containing 292 diagnoses. Then in 1994, DSM-IV was published, listing 297 diagnoses; and in the DSM-IV-TR (text revision) that was published in 2000 there were 365 diagnoses.
Bringing it up to the present book, published in 2013 the current edition – the DSM-5 – changed the system of how disorders were categorized, listing categories of disorders along with a number of different related disorders. It lists 157 diagnoses, including some new ones such as Binge Eating Disorder; Hoarding Disorder; Cannabis Withdrawal; and Caffeine Withdrawal.
Are there any criticisms of the DSM?
Such a widely used book on the subject of mental health disorders has perhaps unsurprisingly received some criticism. This includes questions about the validity of many diagnoses; and whether there has been a medicalization of what are normal human conditions, such as saying that grief is depression.
Psychiatrist Dr. Allen Frances, who was the chair of the DSM-IV Task Force, wrote in 2012 just before the publication of the DSM-5 in an article that was published in The New York Times that “even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription”.
Also in 2012 in an article published in Psychology Today, Frances wrote “DSM 5 will turn temper tantrums into a mental disorder”. He also said: “Normal grief will become Major Depressive Disorder”; “Excessive eating 12 times in three months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder”; and “DSM 5 obscures the already fuzzy boundary between Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.”
Some critics stated that with each revised edition of the DSM, changes in diagnostic criteria reduced thresholds for a diagnosis. This meant that it in effect created an increase in prevalence.
In particular, the DSM-IV and DSM-IV-TR were criticized mostly for the significant rise in the number of diagnoses. Some critics said they felt this could be due to the increasing influence and power of big pharmaceutical companies, whose medications were of course prescribed to treat some of the disorders, often for years on end. Such connections concerned critics, who thought that the inclusion in the book of certain mental health disorders could be linked to their potential to generate enormous sums of money for drug companies.
One report published in 2006 in the peer-reviewed medical journal Psychotherapy and Psychosomatics stated: “By using multimodal screening techniques the authors investigated the financial ties to the pharmaceutical industry of 170-panel members who contributed to the diagnostic criteria produced for the DSM-IV and the DSM-IV-TR. Of the 170 DSM panel members, 95 (56 percent) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies.”
The report stated that the leading categories of financial interest held by panel members were research funding (42 percent), consultancies (22 percent), and speakers bureau (16 percent). It concluded: “Our inquiry into the relationships between DSM panel members and the pharmaceutical industry demonstrates that there are strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.”
In defense, some psychiatrists said that the rise in the number of diagnoses was due to greater specification of the forms of pathology – the science of the causes and effects of diseases. It is also due to there being more research into disorders and a greater understanding.
While some critics say there are too many diagnoses in the DSM, there are also some diagnoses that are not yet in there. For instance, two disorders presently not in the book are sex addiction and internet addiction.
In many cases, this exclusion comes down to the amount of available research on the particular disorder. For instance, with internet addiction, some experts state that it shares many of the symptoms of other addictive disorders that are already included in the DSM, while others say it’s too early to consider it a distinct and separate diagnosis.
Self-diagnosing has increased with more people using the DSM and can be both a blessing and a curse. Some people find great relief in discovering what might be their problem. However, many people who are not experts misdiagnose themselves and others.
This can cause a lot of problems, including negative stigma and some people feeling even worse about themselves. Many experts feel it is damaging that people are given a “label” for life when many mental health disorders can be greatly lessened and often beaten with such as effective talk therapy.
But some people will internalize their diagnosis, which negatively affects their self-identity. Their symptoms can consequently worsen and recovery becomes more difficult, particularly perhaps for some people who become overly dependent on their prescribed medication.
“New diagnoses in psychiatry are more dangerous than new drugs,” said Dr. Frances, “because they influence whether or not millions of people are placed on drugs – often by primary care doctors after brief visits.”
Is the DSM the only handbook used for mental health diagnoses?
Another widely used publication is the International Classification of Diseases (ICD), which is produced by WHO. DSM–5 and the ICD are considered by experts to be “companion publications”.
While the DSM is certainly the most popular diagnostic system used for mental health disorders in the United States, the ICD is considered to be used more widely in Europe and other areas of the world. The ICD differs from the DSM in that it covers general health as well as mental health. It is in the ICD’s sixth chapter that mental and behavioral disorders are specifically covered.
The APA works closely with staff from the WHO to make sure that both the ICD and DSM are as compatible as possible. An international survey of psychiatrists from 66 countries compared the use of both books and found that the ICD was more often used for clinical diagnosis while the DSM was more valued for research.
DSM–5 contains the most up-to-date criteria for diagnosing mental disorders, along with the extensive descriptive text. It provides a common language for clinicians to communicate about their patients.
Despite the previously mentioned criticisms of the DSM by some experts, it is still used extensively by most American experts and around the globe too. Many healthcare professionals are undoubtedly indebted to what most people still consider to be an extremely valuable book in the field of mental health. Our friendly experienced team of carefully selected experts has treated people with all types of mental health disorders. Call us today to have a confidential chat about how we can help you or someone you love.