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News & Views - Jul,
1999 Issue #59
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A Criticism of America’s Diagnostic Bible:
The DSM (Diagnostic and Statistical Manual of Mental Disorders)
By: Michael G. Conner, Psy.D., Clinical & Medical Psychologist
Portland, Oregon
Conner@OregonCounseling.Org
503-423-6244
(The following is excerpts from a paper by Mr. Conner. The full
text can be found on his web site.)
The most common, widely used and nearly mandatory diagnostic system in the
United States is the Diagnostic and Statistical Manual of Mental Disorders (commonly referred to as the DSM). The DSM, published and
controlled by the American Psychiatric Association (APA), has been promoted by the APA as a technological triumph, supported by hard
data and good science. (The American Psychiatric Association and the American Psychological Association are both known as the APA,
but are different organizations.)
The organization and the structure of the DSM present precise and exacting
criteria to be used to diagnose a mental disorder. The level of precision and specificity of criteria have persuaded many professionals
to conclude (without critical evaluation) that the DSM identifies and describes clear and distinct disorders, in a manner both useful
and beneficial to professionals and consumers.
The DSM does have merit. When used correctly, it is very reliable, that
is, one group of professionals using the DSM will often reach a similar diagnosis as another. Yet scientists and practitioners are
concerned that these diagnoses, although reliable, are often wrong and may do more harm than good.
There is considerable overlap among diagnostic categories in the DSM. A more
desirable or less desirable diagnosis can be made depending on the evaluator. Even when agreeing upon diagnoses, many professionals
question the usefulness of the diagnoses and conclusions reached using the DSM. In other words, the diagnosis is not much more than
a label based on an arbitrary set of symptoms. Frequently, a DSM diagnosis does not indicate the best course of action or even what
treatment is necessary. Unfortunately there does not appear to be any clearly useful relationship between the DSM diagnosis, treatment
and its outcome. For all the apparent precision and reliability, the DSM diagnostic system minimizes one important fact. The DSM was
not constructed scientifically but is based on a consensus building process that is highly political, partially democratic and even
resistant to scientific evidence. The mere fact that any diagnostic system is reliable does not mean the system is valid, useful or
beneficial.
Another important scientific observation is that very similar symptoms and
behaviors resulting in a specific DSM diagnosis, can have many entirely different causes. More importantly, each cause can require
an entirely different treatment. Diagnosis using the DSM does not identify the necessary treatment. The differences between people
and their social environments can have a dramatic influence on how symptoms are expressed. Individuals might express a problem arising
from the same source, by manifesting very different symptoms and behaviors. Culture and ethnicity are powerful moderators that strongly
influence how people behave and how symptoms are reported and even experienced. The diagnostic process employed by the DSM is nowhere
near the quality and sophistication of the diagnostic process in medicine - and many physicians argue that the medical diagnostic
process is not sufficiently reliable or valid. And while there are similar diagnostic processes in medicine, most medical diagnoses
are at least based on objective findings and scientific methods. For example, diagnosis of various forms of cancer are based on the
observation of distinct physical structures and variations in biochemistry.
The diagnosis of pneumonia is based on the presence of a bacterial or viral
agent with fairly distinct symptoms, histories and responsiveness to treatment. Hypertension is identified by numerical measures of
blood pressure, within normal deviations.
Only a few areas of medical diagnoses are based purely on the patient’s subjective
complaints or vague medical terms. The overall diagnostic process employed in the DSM is not much more sophisticated than those used
to reach the most general diagnosis of headache, a stomach ache or inner ear problems. There are many forms of headaches, stomachaches
and inner ear problems. There are many things that can cause a headache: for example, a tumor, tension, injury, disease, flu, allergies,
a cold or bacterial infection. In mental health, no matter how rigid the application of the DSM diagnostic or how sophisticated the
interview process, the emerging patterns may have many origins. There can be many sources and causes of a particular problem; one
type of traumatic experience can result in many different responses. As a result, the outcomes and treatment approaches can vary
with the individual’s beliefs, values, attitudes, culture, ethnicity and resources.
Mental health professionals can rarely make a diagnosis based on identifiable
changes or deviations in the structure or functions of the human body. With the exception of injury, aging, disease or forms of poisoning,
very few mental health problems are medically related. Depending on whom you ask, between 70 and 90% of all diagnoses are the result
of social, psychological and cultural factors that influence our lives. In sharp contrast, the pharmaceutical companies, which support
a great deal of research and medical training, generally promote the assumption that disorders are the result of defective biology
or genetics. Some people are simply different. They are not necessarily defective if they have difficulty fitting into rigid societal
roles. But even when problems are psychological, drug companies promote that disorders can still be treated safely and in a cost
effective manner with drugs as an alternative or as an adjunct to psychotherapy.
Other issues created by the use of DSM are subtler, but they are real and
they are important. For one thing, some professionals are losing sight of the patient as human being. They are also losing sight of
how diagnostic labels impact upon patient rights, and the risks associated with using health insurance. (These risks are outlined
in the full article, web reference above). Needless to say, teenagers’ entire future and prospects for employment can be altered by
a seemingly innocent diagnosis. Professionals are increasingly at risk of becoming involved in a diagnostic process that does little
more than expose consumers to significant risk in order to generate an authorization for payment from a managed care company. Of
greater concern is the growing pressure by managed care to treat the symptoms of a DSM diagnosis and not the patient. The life-style,
values and processes that create or sustain a patient’s distress are ignored. Instead, the management or reduction of DSM defined
symptoms becomes the focus. In the world of managed mental health care there is a growing emphasis on quick diagnosis and treatment
of symptoms, not causes. When managing the initial set of symptoms, underlying causes may be missed. For instance, a cyclical mood
disorder, such as cyclothymia, can coexist with another diagnosis, for example, obsessive compulsive disorder or rare hormonal conditions.
The growing emphasis on DSM diagnosis has complicated the practice of counseling
psychotherapy and evaluation, making it overly intricate and superficial, with questionable value for managed care professionals and
consumers. Patients should not be comforted by a specific and reliable diagnosis if it plays no role in finding a beneficial treatment
outcome and improved quality of life.
Copyright © 1999, Woodbury Reports, Inc. (This article may be reproduced
without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)
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