The Downfalls of the DSM-5
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered to be a bible among mental health professionals, but should it be taken as the word of God?
The DSM has been around for many years, dating back to 1952, and has gone through a few versions in that time. Today, mental health professionals work with the 5th generation of this book, the DSM-5, which was published in 2013. Although it’s the authority on mental health disorders in the U.S., there have always been problems with the DSM. And the DSM-5 is no different.
In fact, in some ways, the DSM-5 is worse. Just weeks before the publications of the DSM-5, the National Institute of Mental Health (NIMH) explained it was “re-orienting its research away from DSM categories” for research purposes and withdrew support for the manual. Why?
Problems with the DSM-5
We must first consider its history. The DSM is written from a culturally biased perspective and perpetuates Western medicine narratives. Decisions are based more on cultural and political norms, and less on actual science. This is problematic because what is considered to be a cultural norm in some cultures may be seen as a symptom of disease in others. This can, and has, led to both over-diagnosis and under-diagnosis of certain conditions in certain demographics.
Research shows that “69% of the DSM-5 task force members report having ties to the pharmaceutical industry.” They promote a medication-first model of treatment, and that’s not surprising considering the people in the room.
While some will say the DSM is based on science, others argue otherwise. The Psychological Care & Healing Center explains, “Of the 297 mental disorders listed in the DSM-5, almost all of them lack any scientific basis.” They go on to explain that the DSM pushes the idea that most mental health disorders have a “genetic component, yet there is no known gene variant for about 97% of diagnoses.” Further, the DSM pushes the chemical imbalance theory, which is also just that: a theory. Regardless of where you land on these theories, the DSM only reflects one view on mental health philosophy - it does not reflect the whole story. It does not reflect all of the science.
Aside from the politics, there are a couple of serious problems with the DSM-5 that come up again and again. The first is validity. The second is reliability.
Validity and the DSM
Just for quick reference, the difference between validity and reliability is that validity is about the accuracy of a measure (does it measure what it’s saying it is measuring?), and reliability looks at how consistent a measurement is (can I reproduce the same results under the same conditions again?).
On the issue of validity, the American National Institute of Mental Health’s (NIMH) 2002-2015 director psychiatrist Thomas Insel wrote prior to DSM-5’s publication, “While DSM has been described as a ‘bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each… The weakness is its lack of validity.”
The problem with validity is the DSM lacks evidence. The book is a summary of the reflected opinions of its writers, who are American mental health professionals trained in Western medicine ideology and many of whom are tied to the pharmaceutical industry. Dr. Paula Caplan, an American psychologist with an impressive career, was invited as a consultant for two committees involved in the creation of the DSM-5. In 2014, here’s what she said: “I resigned from those committees after two years because I was appalled by the way I saw that good scientific research was often being ignored, distorted, or lied about and the way that junk science was being used as though it were of high quality.”
Even for a mental health condition as uncontroversial as depression, is there any validity to the criteria used to determine if someone has depression or major depression disorder? In the best-selling book Beyond Prozac, Dr. Terry Lynch asked, “Why did the American Psychiatric Association select five criteria as the magic figure? … Why five criteria? Why not three? Or seven? How valid are these criteria?” No one can point to science to answer this question. From my understanding, the answer is that they put it to a vote and that’s the number that won.
The DSM-5’s Reliability Problems
The second major problem with the DSM-5 in particular is reliability. When used in the real world, the DSM-5’s reliability doesn’t hold water, and there are a couple of reasons why. Psychology Today explains that one suggestion for its low reliability is that “it is written so ambiguously as to be unusable in clinical practice, research, and forensics.” In other words, the bar for when a disorder is diagnosed has been reduced significantly due to ambiguous definitions and criteria. Perhaps too low. To dive into the science for all you math junkies,
“In the past, 'acceptable' meant kappas of 0.6 or above. When the personality disorders in DSM III came in at 0.54, they were roundly derided and given only a reluctant bye. For DSM 5, 'acceptable' reliability has been reduced to a startling 0.2-0.4. This barely exceeds the level of agreement you might expect to get by pure chance.”
So, basically, anyone can be diagnosed with a “disorder” based on current diagnostic criteria from the DSM-5. And they often are.
The Next Epidemic
Quick, Quick!
The age of Zoloft is here!
Let’s all grab our fake cocktails
And drown our normal tears.
Feeling sad and depressed you say?
Let’s not talk about it or work through those problems
Just take this pill and pretend it’s ok.
Come one, Come all!
Hop on the Prozac train!
Your anxiety is a disease
Let us fix your fucked up brain.
Having problems, life got you down?
No need for therapy with that chemical imbalance
Pop this pill and turn your personality around!
Hurry up, don’t miss out!
Don’t miss the epidemic heading our way!
Grab all your hyper children
And set up their drug dependency today.
Change disorder definition and disqualifications
So everyone and anyone with problems can join
No matter their different situations.
Let those with real disorders seep through the cracks
But we’ll notice after their suicide
Or another school was attacked.
Don’t know what to do? – Here, take some Xanax.
— Katie Waecther
There is power to a label. But there is also just the opposite. In the mainstreaming of mental health, diagnoses can be used as an excuse to escape the responsibility for our actions. We don't want to use a social anxiety diagnosis to stop us from living our lives. We don’t want to use an autism diagnosis to escape doing tasks that make us uncomfortable at the moment but are good for us in the long run. It’s important to learn how to live well in this world, regardless of diagnosis.
Why is Over-diagnosis a Problem?
Why is it such a problem to diagnose people with disorders who may not have those disorders? Psychology Today explains, “Poor reliability degrades our ability to communicate with one another clinically, and prohibits meaningful research.” Gerald Young, author of DSM-5: Basics and Critics, explains, “Often it sets a bar too low, and exposes both vulnerable people and normal ones to the risks of overdiagnosis and of pathologizing normal conditions.” Over-diagnosis makes normal reactions to bad shit meaningless and leaves behind people who are suffering from an actual disorder.
When everyone has anxiety, then it’s almost like no one has anxiety. When everyone is sick and can still go about their lives, then no one will give those who are truly suffering the help and understanding they need.
At the end of the day, the bar was drastically lowered to meet the criteria for a disorder in the DSM-5. But the truth is that it can be very difficult to achieve the balance of over-diagnosing or under-diagnosing mental health conditions. We’ve been trying for hundreds of years. The disease of the mind is no easy task to study and heal. But that balance is important to distinguish between someone who feels awkward in the world and someone who genuinely can’t communicate with others due to an actual mental health disorder. Regardless of where we are with that balance right now, the DSM isn’t perfect, but it’s considered a bible in the U.S. mental health community — so it ain’t going anywhere anytime soon.
*excerpt from my book, Watching Worry
