Many criticisms have been leveled against the DSM and its usefulness as a diagnostic manual.
Reliability and validity The revisions of the DSM from the 3rd Edition forward have been mainly concerned with
diagnostic reliabilitythe degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of 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. Neither the issue of reliability or validity was settled. In 2013, shortly before the publication of DSM-5, the director of the
National Institute of Mental Health (NIMH),
Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response." Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of
major depressive disorder, a common mental illness, had a poor reliability
kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.
Diagnosis based on superficial symptoms By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect these disorders 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. Proponents argue this absence of explanatory classification is necessary, but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria. 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 cause 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." While there is generally a lack of consensus on underlying causation for most psychiatric disorders, some proponents of specific
psychopathological paradigms have faulted the DSM for failing to incorporate evidence from other disciplines. For instance,
evolutionary psychology distinguishes between genuine cognitive malfunctions and malfunctions due to psychological
adaptations (that is learned behaviors may be adaptive in one context but maladaptive in another). However, this distinction is one that is challenged within general psychology. There is also criticism of the strong
operationalist viewpoint of the DSM. The DSM relies on
operational definitions, which means that intuitive concepts like
depression are defined by specific measurable criteria (observable behavior, specific timelines). Some have argued that instead of replacing metaphysical terms like "desire" or "purpose" the DSM chose to legitimize them by giving them operational definitions. However, this may have served only to provide a "reassurance fetish" for mainstream methodological practice, rather than representing a substantial and meaningful alteration of mainstream psychiatric practice. A central problem with the use of superficial symptoms is that psychiatry deals with the
phenomena of
consciousness, which adds much more complexity than the
somatic symptoms and
signs used by most of medicine. A 2013 review published in the
European Archives of Psychiatry and Clinical Neuroscience gives the example of the problem of superficial characterization of psychiatric signs and symptoms. If a patient says they "feel depressed, sad, or down" there are actually a wide variety of underlying experiences they could be referencing: "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." This criticism is especially pertinent to the
structured interview, as simple "yes or no" questions may not be specific enough to truly confirm or deny the
diagnostic criterion at issue. That is, whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience. There is thus danger in being overconfident in the face value of the answers. The authors of the 2013 review give 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.
Obscuring root causes Economic causes The DSM-5 has been criticized for overlooking
capitalism's interconnectivity with pathology. One example is the development and treatment of diagnoses: around 69% of psychiatrists involved in the development of the
DSM-5 were reported to have financial ties to the
pharmaceutical industry. These ties situate many care services within the
medical-industrial complex, a framework that prioritizes profit instead of the care of individuals. Lane found the
medical-industrial complex intertwined with setting the parameters to diagnose conditions such as
social anxiety disorder. Other authors have supported similar findings. Kincaid and Sullivan estimate that the cost of the industry surrounding diagnosis will rise to around six trillion dollars by 2030. Scholars differ in the extent of
capitalism's influence on diagnosis. Davies supports the
social model of disability in explaining that diagnosis at present relies on considering conditions a consequence of a "broken brain." His wider logic on mental illness in response to societal issues problematizes diagnosis as a tool of the
medical-industrial complex. Others find that the dependency of patients on their psychiatric care providers makes the industry vulnerable to economic exploitation under
capitalism. These individuals argue that diagnosis is manipulated, but not caused, by capitalistic forces.
Institutional causes Diagnoses of mental conditions have been used to obscure institutional practices of
discrimination. Late nineteenth-century diagnoses of white women with
hysteria, for instance, were said to be caused by "overcivilization," shaped by racially discriminatory
Social Darwinism. Similarly, American physician
Samuel Cartwright coined "
drapetomania" in 1851 as a mental condition which "caused" slaves to escape captivity. In the present day, Brinkmann finds that "contemporary diagnostic cultures," whereby humans assess their conditions through a psychiatric lens, can "risk losing sight of the larger historical and social forces that affect [their] lives." Contemporary diagnostic cultures help explain how diagnosis reflect larger historical biases. Critics have argued that the DSM-5's criteria pathologize a wide range of people with distress or impairment. Chapman et al. discuss the implications for obscuring distress in the
incarceration and confinement of "intellectually disabled" populations; they argue that "differentiation based on
psychiatric and intellectual disability" is arbitrarily set and altered based on
capitalism's needs for "mobile and free workers." Metzl demonstrates that the shifting diagnostic parameters of
schizophrenia became a method for institutionalizing Black men during the
Civil Rights Movement.
Overdiagnosis Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]." Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and
autism spectrum disorder. Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by
heuristics. 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.
Axis I/II distinction, and discontinuation of the axial system in DSM 5 The four factor model by Roysamb and others (2011) suggests, at the very least, that each DSM-IV axis could have been divided into two new axes each; roughly, factors 1 and 2 (Internalizing and Externalizing, respectively) correspond to Axis I and factors 3 and 4 (Cognitive-Relational Disturbance and Anhedonic Introversion, respectively) correspond to Axis II. Moreover, the placement of Anti-Social Personality Disorder and Dysthymia within the four factor model congregate these disorders with disorders from the opposite axis in DSM-IV. Additionally, the four factor model places Borderline Personality Disorder and Depressive Personality Disorder at the intersection of different factors i.e. estimates cross-loadings between different factors onto these disorders. After Roysamb and others, Keyes and others (2012) approximately replicated the Internalizing/Externalizing distinction in their factor model. The only exception was in placing Dysthymia with Internalizing disorders. Finally, in 2013, the DSM 5 was published without an axial system. Psychiatrist
Allen Frances previously expressed concern similar to, "eliminating the structured approach for gathering and organizing clinical assessment data will hinder clinical practice".
Cultural bias Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. 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 criterion-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 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. Other cross-cultural critics largely share Kleinman's negative view toward the
culture-bound syndrome, 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. Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of 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.
Medicalization and financial conflicts of interest There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing
medicalization of human nature, very possibly attributable to
disease mongering by psychiatrists and
pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. 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". It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct
conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving 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.
William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". A 2012 article in
The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million. However, although the number of identified diagnoses had increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients. Others, however, question the accuracy of 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, 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. In a December 2012, blog post on
Psychology Today, Frances provides his "list of DSM 5's ten most potentially harmful changes:" • Disruptive Mood Dysregulation Disorder, for temper tantrums • Major Depressive Disorder, includes normal grief • Minor Neurocognitive Disorder, for normal forgetfulness 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 "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings." • Are they more like theoretical constructs or more like diseases? • How to reach an agreed definition? • Should the DSM-5 take a cautious or conservative approach? • What is the role of practical rather than scientific considerations? • How should it be used by clinicians or researchers? • Is an entirely different diagnostic system 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. Over 15,000 individuals and
mental health professionals have signed a petition in support of the letter. 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.
Cultural responses to the DSM There are several works written in recent years by scholars of the disabled community that specifically critique the cultural impact of the DSM-5. These pieces criticize the DSM-5 from different cultural perspectives, integrating the experiences of disabled people identifying as
crip,
feminists,
Asian Americans,
Black Americans and other marginalized viewpoints.
DSM CRIP DSM CRIP is a collection of essays by various authors that explore the critiques of the DSM-5 from feminist and crip perspectives. These essays tackle the critiques of the DSM using specific diagnoses such as
gender dysphoria,
transvestic disorder, complex
somatic symptom disorder, hypoactive sexual desire disorder, schizophrenia and autism. These are used as case studies to tackle the topics of the potential harm of labels,
overmedicalization,
overdiagnosis, pathologizing normality and various other critiques informed by the feminist and crip lens.
Open in Emergency Open in Emergency is a multimedia collaborative project of the
Asian American Literary Review that takes the lens of an Asian American Experience and redefines wellness in terms of care instead of focusing on diagnosis, unlike the original DSM V. This included mock versions of DSM diagnoses such as gender dysphoria, social anxiety disorder and cannabis use disorder that mean to recharacterize the disorders under the lens of wellness and care. The project was said to contextualize mental disorders with their relationship to
structures of power like
patriarchy,
colonialism and
violence (here).
The Protest Psychosis: How Schizophrenia became a Black disease The Protest Psychosis: How Schizophrenia became a Black disease is a critically acclaimed book that was written to analyze the history of schizophrenia and how perceptions of the condition have changed. In this book, Metzl shows how the condition of schizophrenia was experienced against the backdrop of the
Civil Rights Movement. == See also ==