DSM-5: Diagnosing for Status and Money
Summary Critique of the DSM-5

Introduction

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.

Overview of Critique of the DSM-5

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)

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Critique of DSM-5 Diagnostic Categories

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.

1. 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.
2. Grief:
   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.
3. 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.
4. PTSD:
   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.
5. 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.
6. Autism:
   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.
7. 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.
8. Addiction:
   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?
9. 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.
10. 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.
11. 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.

What Did Not Make It into the DSM-5?

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.

Some Potential Redeeming Qualities of the DSM:

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.

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The Major Concerns Regarding the DSM as a Diagnostic System:

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.

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DSM Tends to Pathologize Normal Behaviors and Temperaments:

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: