DSM-5: Diagnosing for Status and Money
Summary Critique of the DSM-5
By Ofer Zur, Ph.D., and Nola Nordmarken, MFT
TABLE OF CONTENTS
- Disruptive Mood Dysregulation Disorder
- Minor Neurocognitive Disorder
- Binge Eating Disorder
- Substance Abuse
- Anxiety Disorders
- Intellectual Disability & Forensic Implications
- Pathologizing Women
- Pathologizing Lower Socio-Economic Class
- Pathologizing Geriatric Populations
- Pathologizing Ethnic Minorities
- Pathologizing Children
- Pathologizing Members of the LGB Community
- Pathologizing Autistic People
Because most undergraduate, graduate and postgraduate courses relatively uncritically present the DSM as an objective scientific document, this summary focuses exclusively on the critical view. It neither provides a complete analysis of psychiatric diagnosis nor denies that the DSM, if used cautiously and appropriately, can be useful, nor does it advocate against psychiatric diagnostic.
The primary goal of this web page is to promote critical thinking in psychology and psychiatry by presenting a controversial critique of psychiatric diagnosis. The following summary was inspired by the work of both Allen Frances, M.D., chair of the DSM-IV task force, Dr. Paula Caplan, and the writing cited in the Selected Bibliography at the end of this page.
The DSM has undergone a sociopolitical, economically driven evolution since its inception in 1952 when it emerged as a diagnostic tool for physicians who framed it in the medical model. Emerging from a psychoanalytic perspective, pathology was seen to reside within the individual, resulting in expression through neurotic conflict. Subsequent revisions in 1980 and 1987 evolved toward a more firmly biopsychological perspective. In a response to the need of insurance companies for increasing specificity in diagnoses, we saw an increase in the number of available diagnostic labels from 297 in 1994 to 374 in 2000. The DSM-5, while not adding a large number of diagnoses, opens diagnosis to many more individuals because of its loosening of criteria. The current criterion focuses on medication management of behavioral symptomology over psychotherapy. The primary elements that have survived all revisions are the intrapsychic focus and the power of political and economic influence.
Historically, many clinicians have been unaware that the DSM is more political than scientific, that there is little agreement among professionals regarding the meaning of vaguely defined terms, and that it includes only scant empirical data. This lack of awareness began to alter radically as the media and Internet drew attention to, and forced, a greater transparency in the development of DSM-5, which was presented at the 2013 annual meeting of the APA. Not only have mental health professionals engaged more actively in observation and action, but the general public has also become involved in making their opinions heard, to the point of certain groups actually demonstrating outside the meeting of the American Psychiatric Associations’ “unveiling” of DSM-5. A petition signed by 13,000 and sponsored by multiple mental health agencies called for an outside review of the document. It would have been difficult to remain unaware of this diagnostic controversy when major news sources reported that NIMH has “re-oriented its research away from the DSM-5 due to lack of scientific validity” and that Allen Frances, M.D., chair of the DSM-IV, was an active, highly vocal critic of the DSM-5 developmental process from its beginning. NIMH and Allen Frances, M.D., chairman of the DSM-IV task force, put major concerns forth in the statements below.
This is the saddest moment in my 45-year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM 5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public – be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the ten changes that make no sense.
Brief background. DSM 5 got off to a bad start and was never able to establish sure footing. Its leaders initially articulated a premature and unrealizable goal- to produce a paradigm shift in psychiatry. Excessive ambition combined with disorganized execution led inevitably to many ill conceived and risky proposals.
These were vigorously opposed. More than fifty mental health professional associations petitioned for an outside review of DSM 5 to provide an independent judgment of its supporting evidence and to evaluate the balance between its risks and benefits. Professional journals, the press, and the public also weighed in- expressing widespread astonishment about decisions that sometimes seemed not only to lack scientific support but also to defy common sense. (Allen J. Frances, M.D. in DSM5 in Distress)
Director of the National Institutes of Mental Health (NIMH), Dr. Thomas Insel, has rejected the DSM, stating:
“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.Patients with mental disorders deserve better…NIMH will be re-orienting its research away from DSM categories.(NIMH, 2013)
The voices of DSM-5 critics form a chorus of concern with many of the central refrains being the same. Are we pathologizing “normal” and what are the potential negative consequences in doing this? Following is a critique of some of the DSM-5 diagnostic categories.
- Disruptive Mood Dysregulation Disorder:
Some proponents of this new DSM-5 childhood disorder hope that the new diagnostic criteria will help clinicians in their differentiation processes and, therefore, keep them from inappropriately and prematurely diagnosing childhood Bipolar disorder. Critics wonder, however, why it is necessary to create a new disorder in an attempt to correct the over-diagnosing of another disorder. Critics also voice fear that the criteria of this new disorder are likely to be used clinically to include the normal emotional disregulations of childhood. The DSM-5 itself states, “disruptive mood dysregulation disorder is common among children presenting to pediatric mental health clinics” (DSM-5, 2013). One can assume, then, that it might become “common” for children to be diagnosed with this disorder. Imagine all the possible consequences of a child starting out life with this label being applied to his or her identity. One wonders. Will temper tantrums now be diagnosed as a mental disorder? Will our young ones be unnecessarily burdened with a diagnosis of mental illness and be medicated with powerful psychotropic medications? Will new medications be developed to treat the new disorder? Will pharmaceutical companies conduct educational advertising campaigns targeting the attention of concerned parents via the television and glossy adds in parenting magazines? It is stunning to consider the long-term implications resulting from these decisions. The DSM, and pharmaceutical companies, have historically tended to ignite and fuel diagnostic trends, some of which have turned into wild fires. During the past two decades, child psychiatry has already fired up three fads — a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. Only time will tell how this new diagnosis will help or damage our vulnerable children.
DSM-IV had an arbitrary two-month cutoff period that excluded a diagnosis of depression for a grieving person. The two month criteria (which did not have clinical or research credibility) has been removed in the DSM-5, therefore making it even easier to diagnose a grieving person with depression. Most likely a large number of people experiencing normal “symptoms” of grief will now be diagnosed with a depressive disorder and placed on medication. Some normal, necessary human reactions can now be medicalized and medicated.
- Minor Neurocognitive Disorder:
The new DSM-5 diagnosis, Minor Neurocognitive Disorder, burdens a large false positive population of normal people experiencing natural minor decline in cognitive function with a label of mental illness. As this group is not necessarily at special risk for developing dementia, an unnecessary diagnosis can engender fear, humiliation and anxiety about the future. Since there is no treatment for this “condition,” it creates a true lose-lose situation and can only cause suffering.
The DSM-5 is more oriented to behavioral symptoms accompanying PSTD and includes four basic major symptom clusters. These include re-experiencing, arousal, avoidance and persistent negative alterations in cognitions and mood. Diagnostic thresholds have been lowered for children and adolescents and separate criteria have been added for children 6 and under. Some were originally concerned that the new criteria would relax the criteria to include normal reactions to stress, but this does not seem to be the case.
- Binge Eating Disorder:
Excessive eating, 12 times in 3 months, has become the criteria for inclusion to a psychiatric illness called Binge Eating Disorder. This might include most people during the holidays, if one starts with Halloween candy and ends with New Years leftovers. Many of us could be mentally ill for a quarter each year.
The changes in the DSM 5 definition of Autism will result in lowered rates. This covers a possible range of 10% to 50% according to different research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific but, those concerned with the well being of children affected, fear a disruption or discontinuation of services for some. The problem here has less to do with the change in diagnostic criteria and more that school services should be tied to educational need and less to psychiatric diagnosis. Some have reasonably argued that, rather than concern ourselves with the impact that changes in the DSM might have on some children’s access to educational accommodations, perhaps we would do better to take a step back and ask why a manual designed for psychiatric diagnosis is being used as a tool for assessing educational needs in the first place.
- Substance Abuse:
New criteria calls for first time substance abusers to be lumped in with hard-core addicts. This creates unnecessary confusion regarding treatment needs and prognosis, not to mention how it will confuse the public’s, and perhaps the legal system’s, perception of health and illness, culpability and responsibility.
Imagine how introducing the concept of Behavioral Addictions (e.g., Gambling Disorder) may eventually expand and inflate to include a multitude of behaviors that capture our time, energy and attention. Imagine the marketing potential for treatment programs and new medications. Where will normal go?
- Anxiety disorders:
The biggest change in these disorders is that the person no longer needs to perceive their anxiety to be excessive or unreasonable. That may open up diagnosis and medicating to very general everyday worries that last more than 6 month. This covers a lot. We have all seen that the DSM-IV sometimes obscured the line between a psychiatric diagnosis and the worries of everyday living. Loosening of criteria can create new numbers of “mentally ill”, with all of the possible complicating related negative effects of that, including prescription of addictive, anti-anxiety drugs; perhaps being overlooked for a job; and elevated insurance costs.
- PMDD: Premenstrual Dysphoric Disorder
PMDD was invented as a diagnostic category even though there is no compelling empirically identified cluster of symptoms identifiable as PMDD. There is no link between symptoms attributed to PMDD and hormonal levels, nor does adjustment of hormonal levels affect the symptoms of PMDD. There are no parallel diagnoses of PMDD for men (e.g., TDDD for “Testosterone Deficiency Dysphoric Disorder”), nor are there gender-neutral categories for dysphoria related to other hormonal imbalance. Interestingly, just as the patent protections were about to run out, Eli Lilly introduced a new trade name, “Sarafem,” for the antidepressant Prozac and markets it for treatment of PMDD.
- Intellectual Disability & Forensic Implications:
One of the earliest concerns related to legal complications surrounding DSM-5 change involves criteria for the diagnosis of intellectual disability, which could allow courts to execute convicted mentally handicapped criminals more easily. The DSM-IV defined intellectual disability as an IQ score below 70. Based on that, the U.S. Supreme Court ruled in Atkins v. Virginia that it is illegal to execute a mentally handicapped person. The DSM-5 dropped the IQ criteria in favor of a more subjective clinical analysis of behavior-related developmental indices. Such shifts can have enormous social and legal implications that are of life and death in nature. This is just one of the earliest implications to arise forensically. Many others will follow. DSM-5 contains a page titled, Cautionary Statement for Forensic Use of DSM-5, which states, among other things, that the DSM-5 was developed to meet clinical needs rather than the technical needs of the court or to provide treatment guidelines. One can only assume this concern originated in reaction to the many ways in which the DSM has been used to manipulate the legal system.
The term “Internet Addiction” has been used since about 1996 and has caught the attention of clinicians and the public, as well. The topic has been discussed and researched for almost 20 years, but the data is not easily generalizable. Many of the research instruments have been found to be flawed.
Parental Alienation is not a disorder in an individual. It is a relationship problem between parent-child or parent-parent. Relationship problems, per se, are not mental disorders. Many believe an inclusion of parental alienation disorder might have been used more for legal than for clinical reasons. Its exclusion may have saved many parents and children from unnecessary emotional pain.
The constructors of the DSM point to the following positive uses for its system of psychiatric diagnostic codes: It can be helpful for clinicians and mental health practitioners as they construct treatment plans, especially evidence-based treatment plans. It provides a consistent structure and vocabulary for professionals, which helps with communication and collaboration. It can facilitate continuity of medical care and collaboration between professionals of varying treatment modalities. It is consistent with many forms of current medical record keeping. It can facilitate unified data collection for survey, pharmacological and other research purposes. It can be instrumental for the compilation and retrieval of statistical health information. It simplifies the reporting of unified data to interested third parties, such as the World Health Organization and insurance companies.
The concern with the DSM did not start with the DSM-5. It has been voiced for many decades prior to the May/2013 publication of the DSM-5. Diagnosis of “mental illness” has always been more an art than a science. DSM-based research has repeatedly shown very poor reliability and, therefore, questionable validity. In a 2005 interview, Robert Spitzer, an earlier architect of the DSM, confessed candidly: “To say that we’ve solved the reliability problem is just not true. . . It’s been improved. But if you’re in a situation with a general clinician it’s certainly not very good” (Spiegel, 2005, p. 63). Critics of DSM-5 would agree that this statement remains true, as there is general agreement among them that diagnostic loosening and expansion of diagnostic criteria has resulted in an even greater decline in reliability and validity while at the same time medicalizing many normal behaviors. Unfortunately, psychiatric labeling has been developed and applied in biased ways and will most likely continue to result in more harm than good.
- The DSM is more a political document than a scientific one. Decisions regarding inclusion or exclusion of disorders are made by majority vote rather than by indisputable scientific data.
- One telling example is the declassification of homosexuality as a mental disorder. Homosexuality was listed as a mental disorder in the DSM until 1974, when gay activists demonstrated in front of the American Psychiatric Association Convention. The APA’s 1974 vote showed 5,854 members supporting and 3,810 opposing the disorder’s removal from the manual. At that time, the American Psychiatric Association made headlines by announcing that it had decided homosexuality was no longer a mental illness. Voting on what constitutes mental illness is truly bizarre and, needless to say, is political and unscientific.
- External political pressure can result, apparently, in the inclusion of a diagnostic category. For example, PTSD was included in the DSM-III as a result of massive lobbying on its behalf by Vietnam vets and their supporters. Prior to that, PTSD sufferers were routinely diagnosed with character disorders.
- Due to a deadlock in gender politics, Premenstrual Dysphoric Disorder (PMDD) was placed in the Appendix of DSM-IV. It has since been included as a diagnosis in DSM-5. Many believe this is due to public manipulation by pharmaceutical companies marketing directly to consumers, and subsequent consumer requests to treating professionals. America is the only country in the world that allows this.
- Unlike medical diagnoses of broken bones, lung infection or cancer, psychiatric diagnoses are not precise, accurate or objective. While different X-ray machines, blood tests or scanning devices are likely to yield similar results for the same person, different therapists are less likely to come up with the same diagnosis for the same person. Psychiatric diagnosis is not an exact science. The differences reflect different theoretical orientations of therapists. Diagnosis, in psychotherapy, often depends on the eye of the beholder.
- The DSM is a powerful tool of social control, as its criteria is a primary tool used to judge who is normal or abnormal, sane or insane, who should remain free or be hospitalized against their will, who might get a death sentence rather than life without parole, who will receive mental health services.
- Diagnostic inclusion in the DSM is influenced more significantly by the faction currently holding professional political power than by what science reveals.
- Psychoanalysts and psychiatrists, for example, predominantly influenced DSM-I and, thus, neuroticism was included.
- When medicating psychiatrists and pharmacological companies gained the upper hand, neuroticism and neurosis lost attention and anxiety became a primary focus.
- A concerning modern trend involves “early intervention” with treating younger and younger children with medications known to have very serious side effects. Adding to the concern is the fact that many of these medications have not been tested on children in longitudinal clinical trials, so there is no way of knowing what the long term side effects may be to these children.
- The DSM perpetuates the myth that the medical-mechanistic model can simply be applied to psychology and that by precisely identifying and naming the problem, treatment and cure will follow.
- The DSM gives the illusion that mental illness is a clearly identifiable brain disease. Unlike diseases such as coronary heart or cancer, or medical conditions, such as broken bones, there are no blood tests, X-rays or brain imaging techniques to identify the presence of any of the DSM diagnostic categories.
- Each diagnostic criterion in the DSM is part of an ever-changing and expanding list of symptoms compiled by “experts”. Some experts often represent special interests, such as pharmaceutical companies or certain brands of treatment modalities. It is not based on medical science, blood or other biological tests. The rationale seems to be: If you can describe a set of symptoms, then you can name a disease; and if you can name the disease, then you can claim it exists as a distinct “entity” with, eventually, a specific treatment tied to it.
- Designing treatments only according to symptoms (i.e., those who experience a certain constellation of symptoms of depression or anxiety should be prescribed a pharmaceutical agent) is often ineffective, at best, but can also be dangerous. Medical science does not operate in such a manner. For example, the mere manifested symptoms of pneumonia do not differentiate between bacterial, viral, mychocardial and inhalation pneumonias. Choosing a treatment based only on a mere set of universal symptoms might lead one to prescribe antibiotics for viral pneumonia, or anti-viral agents for bacterial pneumonia, leading to the erroneous conclusion that neither medication works. The same is true for mental illness, as the sheer presence of anxiety does not tell us if this anxiety is healthy as in response to real threat, normal as in response to existential concern around issues of death or meaning, psychotic as in response to voices telling the person to kill himself, or neurotic as in response to self perpetuated irrational drama. Obviously, each condition requires a different intervention, or combination of interventions, which may include medications and/or existential, behavioral, cognitive therapy, relaxation training, etc. Just as medicine goes beyond a set of symptoms by looking at lab results, X-rays, sputum, scans, etc., the field of mental health needs to find more viable forms of diagnostic criteria in relationship to treatment.
- Over the years, as psychology, psychotherapy, psychopharmacology, the DSM, and the culture at large have co-evolved, varying diagnoses have taken center stage. Prior to and during the 1940s, the pre-DSM era, most patients were characterized as hysterics. In the ’50s and ’60s, the most popular diagnoses tended to be neuroses and anxiety. During the 1980s, Borderline Personality Disorder became one of the most frequently diagnosed disorders, while in the ’90s, childhood abuse, eating disorders, Multiple Personality Disorder and PTSD became a predominant focus. Towards the end of the 20th century and the beginning of the 21st century, Attention Deficit Hyperactivity Disorder, PTSD, Bipolar Disorder, Borderline Personality Disorder and Autism occupied center stage. The question then becomes, to what degree do these historical shifts in diagnostic focus reflect deep evolutionary structural changes in the nature of the psyche, and to what degree do these shifts reflect the ways in which diagnosis in general, and how the changes in the DSM, are determined by cultural and professional fads, driven by professional self-interest and the business economics of the psychotherapeutic and psychiatric treatment market, rather than by scientific process? While some of the changes are clearly driven by professional and economic forces, such as the increase in the number of available diagnostic labels from 297 in 1994 to 374 in 2000, that evolved in response to insurance companies’ need for increased labels during that period, others clearly reflect the evolution of the culture at large. Hysteria, for example, was a phenomenon that, not surprisingly, appeared frequently in the repressed climate of Freudian times. Along the same lines, the proliferation of visual marketing media and the “thin industry” can explain the exponential increase in the number of patients diagnosed with anorexia in the last two decades. We will see what trends emerge out of the new DSM-5 Binge Eating Disorder diagnosis.
- The DSM tends to pathologize normal behaviors. Existential anxieties, for example, are labeled “Anxiety Disorder”. As a result, some kinds of normal and rather healthy anxieties are viewed and treated as mental illness. Similarly, shyness can too easily be seen and treated as “Social Phobia”, lasting grief as “Major Depressive Disorder”, spirited and strong willed children as “Oppositional Disorder”, fearful minorities as “Paranoid” and those who experience spiritual events as “Delusional”. Consequently, many psychotherapists, regardless of their theoretical orientations, tend to follow the DSM as it is in their professional best interest. Although the DSM-5 does not radically increase the overall number of disorders, with its loosened criteria (that is, if it takes fewer symptoms or less severity to meet the criteria for diagnosis), then more people qualify for a disorder. This increases the number of people who have a diagnosis of mental disorder.
- The DSM, especially the last two versions, is primarily driven and controlled by psychiatrists, insurance companies and the psychopharmacological industry. Each group has a direct financial interest in focusing on individual pathology (rather than familial or societal), inevitably leading to medication-based solutions and shorter periods of treatment. The DSM has been referred to as the pharmaceutical companies’ “bible,” because without its coded diseases there would be no drug trials. Without medications psychiatrists stand to lose their place in the treatment hierarchy, and the DSM would lose its legitimacy as a necessary biological-medical tool.
- The American Psychiatric Association is the most powerful mental health enterprise in the world, and the DSM constitutes a lucrative business for their organization, garnering millions of dollars in revenue (including sales of tapes, videos, study guides, etc.). The APA claims that the panel recommending new APA definitions was carefully vetted and lacked conflict of interest. However, the amount they could receive from drug companies was set at $10,000 a year and stock holdings to $50,000, excluding research grants, were allowed. Their marketing agents enjoy a captive consumer base. The DSM is translated into multiple languages and is the key volume on mental illness that all trainees must learn from, including psychiatrists, other physicians, social workers, psychologists, psychiatric nurses, marriage and family therapists, addiction specialists and psychologists.
- The DSM tends to ignore contextual factors in the development of symptoms and disorders. Some professionals have suggested a replacement of current diagnostic labels with descriptors such as “the consequences of poverty,” “the consequences of violence,” “the effects of homelessness and racism” or “the damage done by interpersonal discriminatory treatment.”
- The DSM focuses almost exclusively on individual pathology to the dangerous minimization of social, historical and environmental factors such as poverty, racism, sexism, classism, heterosexism, gender biases, ageism, violence, etc. This limiting focus has serious ramifications.
- Therapists, who uncritically follow the DSM medical model, are likely to place undue emphasis on individual emotional problems as causal factors rather than opening to the larger possibility that the individual is symptomatic due to familial, political or societal system dysfunctions.
- Social psychologists call such exclusion of social factors and excessive focus on individual pathology the “fundamental attribution error.”
- The focus on individual pathology leads to individual-based treatment, suggesting that the DSM markets the concept of individually and biologically based social discomfort.
- Drug companies fund, and reap the benefits of, a significant amount of research that is used to advocate new DSM diagnostic categories. Each of these new disorders corresponds to a drug (often new) that the company alleges can cure the symptoms of the diagnosis.
- Many labels in the DSM (e.g., neuroticism, paranoia) have not been supported by valid and reliable research to represent real entities.
- The DSM tends to pathologize several groups whose civil rights have historically been marginalized in the culture at large. The bias is clear in regard to race, social class, age, physical disability, gender and sexual orientation. Symptoms are a call for corrected balance. Rather than labeling the symptoms of a sick society, when appropriate, the client is too often diagnosed and medicated to adapt to the disease of the system.
Labeling normal behaviors as mental disorders financially and professionally serve psychotherapists of all theoretic orientations. Following are some examples of how the DSM turns normal behaviors and temperaments into mental illness.
- Shyness or normal introversion can be diagnosed as “Social Phobia.”
- The individual process of healthy grief might be diagnosed as “Major Depressive Disorder.”
- Healthy, strong willed or active children are often diagnosed as having “Oppositional Disorder.”
- Children who are restless, non-compliant or not academically oriented are diagnosed with “ADHD.”
- Meaningful and healthy existential angst might be diagnosed as “General Anxiety Disorder” and medicated away.
- Those with feelings of hopelessness and despair related to the burden of social injustice and poverty might be diagnosed with “Depression.”
- A person who attributes spiritual meaning to a powerful insight could be diagnosed as “Delusional.”
- A woman who is not sexually aroused in relationship to an emotionally disconnected partner could be diagnosed as having “Female Arousal Disorder.”
- Feeling jittery and agitated from drinking too much coffee can be diagnosed as “Caffeine Intoxication.”
- People, who for reasons of being abused, stressed, uninspired or who simply choose not to engage in sexual activity, are diagnosed as having “Female Sexual Interest/Arousal Disorder. The criteria might easily apply to many ‘normal’ working mothers, with young children and multiple responsibilities.
- The normal temper tantrums of childhood could be diagnosed as Disruptive Mood Dysregulation disorder.
- Pathologizing Women:
- White males have consistently and primarily constituted the dominant group responsible for the development of DSM nosology, deciding which behaviors are to be considered healthy and which unhealthy. Many have pointed out the following specific gender biases: attributes traditionally classified as feminine, such as the tendency to value emotional attachment and interdependence and the tendency to be cautious in expressing disagreement with others, have been codified as personality or other disorders. Conversely, traditional male gender role behaviors, such as autonomy and individualism, are seen as healthy and other behaviors, such as a tendency to view work as more important than relationships, is not codified as a disorder.
- In a clear gender biased approach, which socially stigmatizes women, natural changes in cognition and emotions resulting from normal hormonal variations were originally codified as Premenstrual Dysphoric Disorder (PMDD) in the DSM-IV. PMDD was invented as a diagnostic category even though there is no compelling empirically identified cluster of symptoms identifiable as PMDD, there is no link between symptoms attributed to PMDD and hormonal levels, nor does adjustment of hormonal levels affect the symptoms of PMDD. As with homosexuality, the inclusion of PMDD was decided by political process when its inclusion was decided by vote of the Legislative Assembly of the APA. Interestingly, just as the patent protections were about to run out, Eli Lilly introduced a new trade name, “Sarafem,” for the antidepressant Prozac and markets it for treatment of PMDD. PMDD has now been elevated to full diagnosis status in the DSM-5.
- There are no parallel diagnoses of PMDD for men (e.g., TDDD for “Testosterone Deficiency Dysphoric Disorder”), nor are there gender-neutral categories for dysphoria related to hormonal imbalance.
- Research has shown that clinicians take what male patients say more readily, at face value, than what female patients say; more readily judge a female patient as being mentally ill than they would a male with the same symptoms; more readily judge women than men to be overly emotional; more readily prescribe mood-altering medication for women than for men; and more readily assume that women are more likely to require ongoing monitoring and treatment than are men.
- Pathologizing Lower Socio-Economic Class:
- The DSM ignores the real and valid concerns of lower class members, such as poverty and lack of social power. Reactions to these essential injustices tend to be pathologized and labeled as antisocial, psychotic or paranoid.
- Research has demonstrated that even given similar symptoms, members of the dominant class are more likely to receive a diagnosis of “Bi-polar disorder,” while those of certain racial minorities and lower socio-economic classes are diagnosed as “schizophrenic.” The poor almost always carry the greatest burden of sociopolitical deprivation while receiving the least of what the social system has to offer with regard to treatment. It is likely that the loosening of diagnostic criteria in the DSM-5 will significantly burden already overwhelmed mental health systems with people experiencing “symptoms” which instantly qualify them as mentally ill, thereby decreasing the availability of services to the those with more serious symptomology.
- Research has shown that psychotherapists are more likely to give a DSM diagnosis (i.e., to claim that the person is suffering from a mental disorder) to clients who have mental health insurance coverage, than to those who pay for services “out-of-pocket” and are more likely to be financially affluent.
- Pathologizing Geriatric Populations:
- The elderly are often isolated and disempowered in our culture. As a result, their understandable reactions of low self-esteem, feelings of hopelessness, helplessness, etc., are often routinely diagnosed as a mental disorder (e.g., depression or organicity). They are medicated rather than viewed as experiencing a normal reaction to social isolation and stress due to valid concerns regarding lack of available basic necessities such as food, shelter and health care. The new DSM-5 diagnosis, Minor Neurocognitive Disorder, burdens a large false positive population of normal people, who experience natural minor decline in cognitive function, with a label of mental illness. As this group is not necessarily at special risk for developing dementia, an unnecessary diagnosis can engender fear, humiliation and anxiety about the future. Since there is no treatment for this “condition” it creates a true lose-lose situation and can only cause suffering.
- Pathologizing Ethnic Minorities:
- The relationship between power and dominance relative to psychopathology has not been considered in the development of the DSM.
- The emotional impact of social injustice and racial prejudice often results in stress related illness such as the increase in hypertension among African American males, as well as powerful emotional reactions. Yet, those who express appropriate rage and realistic fears due to experiences of chronic de-valuing, harassment and injustice at the hands of police and other authority institutions, are labeled as being paranoid or suffering from impulse control disorders.
- Depression, alcoholism and suicide are rampant in the Native American culture, whose members have experienced violent occupation and colonization by the now dominant society that diagnoses them.
- Characteristics that are normal to ethnic minority cultures have been pathologically viewed through the lenses of the upper class driven DSM.
- Members of many ethnic minority groups avoid contact with mental health systems because they expect their normal cultural conduct to be pathologized.
- Pathologizing Children:
- The psychobiological perspective prevalent in DSM diagnosis, coupled with managed care driven pressure for short-term biological based treatment, has had a profound influence on the diagnosis and treatment of children. Results of multiple studies indicate that in the last two decades, there has been a tripling of Attention Deficit Disorder diagnosis, a more than twenty-times increase in Autistic Disorder diagnosis, and a forty-times increase in childhood Bipolar Disorder diagnosis. The use of Ritalin has tripled and the use of anti-depressants has doubled in the treatment of pre-school children during the last decade. The use of psychotropic medications, combined, has tripled in the treatment of all children less than eighteen years of age, during that same period. There is, of course, concern for the self-concept of a person who has been labeled as abnormal before he or she has even entered kindergarten, as is the case with an increasing number of children.
- Few studies have been done to show the effectiveness of anti-depressants in children, nor longitudinal studies monitoring side effects, and none of the SSRIs has been approved by the FDA for use in the treatment of childhood depression. The FDA, in fact, issued a warning in 2004 cautioning treatment professionals and parents to watch children closely for signs of increased depression and suicidality while on SSRI medications.
- As stated, diagnosis and treatment reflects the changing tides of political, economic and social trends. There is considerable controversy regarding the DSM criteria for ADHD which some refer to as a well-defined condition that lends itself to short-term biological intervention, while others express concerns that the diagnostic evolution of criteria resulted from committee consensus rather than as the result of basic scientific process. Some have called ADHD the fad diagnosis of these times, and many consider the great expansion in the population diagnosed to be a function of a cultural and economic phenomenon that goes beyond the objective reality of the diagnosis. Attention Deficit with Hyperactivity, or ADHD, diagnosis is often given without any regard to familial dysfunction and other environmental factors. Stimulant medications for the treatment of ADHD constitutes, by far, the most prescribed medication for pre-schoolers and children under eighteen years of age, who are currently being treated with psychotropic medications.
- Pathologizing Members of the LGB Community:
- Homosexuality is no longer listed by name in the DSM, but was listed as a mental disorder in the DSM until 1974 when the American Psychiatric Association made headlines by announcing that, as a result of legislative vote by the APA, it had decided homosexuality was no longer a mental illness. The claim that it would be deleted was functionally false because the next DSM included homosexuality with which the patient was not fully comfortable. Now, with DSM-5, we have the diagnosis of Gender Dysphoria. This dysphoria could easily be considered a reality based “normal” discomfort for people growing up in a GLTB phobic culture known for hate crimes against their population.
- Pathologizing Autistic People:
- Autism is a neurological makeup, an instance of neurological diversity, listed in the DSM as Autism Spectrum Disorder. Autistics are sometimes described as “people with autism” despite the autism being how their minds are constructed, rather than a defect or disease. (We don’t describe Mexicans as “people with Mexican.”) As befits the DSM culture, there is a great deal of attention placed on “curing” autism. This could be seen as part of the same genre of unhelpful help that pathologizes women, ethnic minorities, gays, lesbians, and transgender people.
- Some may ask, “But autistic children act out a great deal, isn’t that a problem? And how can we help?” Autistic children who are “difficult” are responding to the difficult situation of growing up in a world designed for non-autistics. For most of them, this non-autistic world is too bright, too crowded, and too noisy. The sensory overload can sometimes lead to ‘symptoms’. A good non-autistic empathy experiment is to imagine growing up under a bright spotlight, with the constant sound of fingernails on a chalkboard. Does the exercise stress you system, somewhat? If the presenting problem is the result of sensory overload, the first goal of a humanistic intervention might be to assist the person to manage sensory input in the way that can be most effective for them. Too often, the intervention is to start or to increase medication. If the presenting problem were depression, we would first explore the sources of depression. As with gay, lesbian, and transgender, the poor and disenfranchised and many others, autistics have an uphill road living “against the grain.” Rather than framing clinical interventions primarily as “treating Autism” it might be more helpful to frame our interventions as helping autistic clients become healthy autistic people. As always, it is essential to remember that we are treating a person not just a symptom or a disorder.
- The DSM has become a tool with which therapists can irresponsibly use their position of authority to distance themselves from their clients by labeling them as having specific mental disorders. As a result, therapists can hide behind a professional façade, avoiding the reality that many clients are simply fellow human beings who are normally suffering from anxieties, sorrows and despairs, primarily related to the multiple imbalances of our modern culture and our endangered and endangering environment. Accordingly, the DSM perpetuates the myth of professionalism and superiority so prevalent among psychotherapists at the expense of those who seek therapists’ help.
Most undergraduate, graduate and postgraduate education neglects critical aspects of training in regard to the complex process of diagnosis. Few programs inform students that DSM diagnostic criteria generally lacks empirical support, that some criteria is the result of political or popularity “voting,” that scientific method and evidence has been largely disregarded in its development, and that issues such as gender and cultural sensitivity are grossly underrepresented. Ethical diagnosis is dependent upon a contextual understanding of the DSM as well as an individual therapist’s values and biases. The current limitations in most training programs make it difficult, if not impossible, for the student or clinician to approach the DSM from a balanced perspective or to employ critical thinking in assessing the impact and utility of the tool.
In Summary: Diagnostic tools can be very helpful in assisting people in healing and becoming healthier. The DSM is more of a political document then a scientifically based text. The very frame of the DSM is distorted by a primarily intra-psychic-individual focus paired with the relative exclusion of environmental, societal, political and familial concerns. Most clinicians are inadequately trained in its use, and used without the benefit of critical thinking, it can harm more than help. More specifically, the DSM discriminates against women, minorities, the lower class, the elderly, gays and lesbians or anyone who deviates from the values of the, perhaps well-meaning but biased, dominantly upper class white male political contingency that created it. The DSM is constructed predominantly by biological psychiatrists with strong influences from pharmaceutical and managed care companies. As a result, the DSM focuses on individual pathologies that are supposedly “cured” by psychotropic drugs.
The DSM is basically a tool that is designed to differentiate those who are considered healthy or normal from those who are labeled as sick or mentally ill, and there is a behavioral emphasis related to the clients’ level of functioning in society. The construction of mental illness is a western cultural artifact, which can be viewed, in contrast, to the more organic and inclusive systems existing in many indigenous cultures.Following is an example of a culture in which members who characteristically exhibit different and unique (not within the bell curve) behavior are treated in a respectful, holistic manner by the community system.
Here is an alternate view taken from Dr. Zur’s experience.
“As a young scientist-limnologist, I spent some time in East Africa in the 70s. While my stated mission was to help several remote villages develop fishponds, I was more fascinated with the sense and structure of the villages. My mission to promote fish soon took second place to my interest in the psychological, sociological and spiritual dynamics of the village. I was swept up by the strong current that flowed through and around this collection of families, joining them in a circle of interdependence, acceptance and mutual support. This current embraced the strong and the weak, the good and the not so good, the healthy and the frail and the so-called normal and the different. And what a plethora of roles were to be found in this small village: the Grouch, grumbling and complaining and annoying everyone; the Clown who joked and mocked and brought laughter to every face, finding the ridiculous in any circumstance, teasing me mercilessly about my odd accent; the Witchdoctor who allowed me to observe him for days on end as he administered to the villagers and conducted the rituals; the Man-who-Talked-to-Trees; the Medium who communicated and interceded with the villagers’ ancestors; and the young warriors, self-consciously leaning on their new spears, spending hours beautifying their hair and skin with red mud. Each was a treasured and colorful piece of the mosaic that made up this vital community. And to be sure, there were those who also occupied common basic roles, equivalent to our butcher, baker and candlestick maker. There were villagers who needed to be carried everywhere. There were villagers who needed to be constantly protected from harming themselves. Yet, the traditional village not only tolerated such diversity, they also, in fact, truly embraced and often celebrated the differences, offering a wide network of support for all. The village respected the roles and functions of the village shaman, the fool, the warrior and others who varied from the norm, providing them with food and shelter. Whether strong or frail, healthy or handicapped, each community member was supported physically, emotionally and spiritually. When necessary, special healing rituals focused on the mentally or physically frail.”
It is likely that most clinicians entering a village, such as the one described above, with the DSM and a prescription pad under their arm might prescribe anti-depressants and cognitive therapy to the Grouch, calm the Clown down with a little mood stabilizing medication, and relieve the Witchdoctor of his ritualistic behavior with a cocktail of treatments for OCD. The Man-who-Talked-to Trees and the Medium could clearly benefit from an anti-psychotic medication and probably psychiatric hospital incarceration, while the young Warriors, depending on their age, would probably label them with Disruptive Mood Dysregulation Disorder.
Some would say they might benefit from these interventions, and then again perhaps a combination of approaches would be the ideal. That which may be considered as the most healing aspect of “village treatment” is the way in which the culture supports its different or “abnormal” members in finding their place and role in the village and identity and meaning in their experience. This is central to the definition of therapy and it is what we are most likely to lose if we allow it to be legislated away in favor of cost cutting procedures and an over emphasis on biological intervention.
Many clinicians have found artful ways in which to use the DSM as a tool of communication in service of the clients’ ultimate well being. One must maintain caution, however, so that the distilled, conceptual jargon developed, in part, as a response to political, economic and social pressures does not confuse the larger contextual elements of truly helpful diagnosis. Used without benefit of critical, contextual thinking, the DSM can be unwittingly used as a weapon, perpetrating the violence of intolerance upon individuals and groups expressing diversity of many kinds. Diagnosis involves judgment. In the case of the DSM, a largely political piece of work, those holding power judge those who come to the attention of mental health professionals because they seem “different” than others. This document can be seen as a reflection of the “voters” values, biases, social status, privilege and power and as an agent of injustice rather than an empirically supported professional tool used in service of healing.
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- Online CE Course: DSM-5: Friend of Foe? – 6 CE Credit Hours
- Resources on DSM-5 and its critique
- DSM-5 – Friend or Foe?
- DSM: Diagnosing for Status & Money
- DSM: Diagnoses Seen in Movies
- Dr. Thomas Szasz and The Myth of Mental Illness