The DSM

First published in 1952, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the diagnostic reference manual used by psychologists, psychiatrists, and other mental health clinicians in North America. The manual lists all the different depressive disorders, anxiety disorders, substance-related disorders, psychotic disorders, eating disorders, impulse control disorders, sexual and gender identity disorders, and personality disorders, among others. Each disorder is described by a set of diagnostic criteria.

What’s good and bad about the DSM?

Let's start with the good. First, the manual creates a common language for professionals. If I tell my client’s GP that the client has panic disorder, the doctor knows what I’m talking about. Second, a DSM diagnosis provides validation for clients; if you think you’re going crazy, it can be a relief to hear that your problem is a documented phenomenon. Third, DSM criteria are helpful in recruiting participants for psychiatric research. When you read an ad for individuals who experience recurrent and persistent intrusive thoughts or impulses and repetitive behaviours that they perform in response to an obsession, you’re reading the DSM criteria for obsessive-compulsive disorder.

What are the problems with the DSM? One of the biggest criticisms is that a DSM diagnosis is stigmatizing--a valid point. For example, if you have a major depressive episode documented in your medical file, your insurance carrier might consider you a suicide risk and raise your life insurance rate. If your file says that you have a personality disorder, some therapists may hesitate to accept you as a client. For this reason, as psychology interns, we are taught to be very careful what we write in client files.

A second criticism of the DSM is that it’s categorical and the diagnostic thresholds are arbitrary. I’ll use the diagnostic criteria for post-traumatic stress disorder (PTSD) as an example. You might have experienced a traumatic event and responded with intense fear, helplessness, or horror (criterion A). You may re-experience the event through flashbacks, nightmares, or memories (criterion B) and avoid people or places associated with the trauma (criterion C). But if you don’t experience arousal symptoms such as angry outbursts and sleep disturbances (criterion D), according to the DSM, you don't have PTSD. Without a DSM diagnosis, you may be denied access to specialized treatment, and your insurance company may decline to reimburse your therapy fees.

A final point to consider about the DSM is that the inclusion of a given condition constitutes an indicator of how that condition is viewed by society. Infamously, homosexuality was included in the DSM up until the 1980s. Today, there is heated debate about whether or not Gender Identity Disorder (the feeling that your physical gender does not match your true gender) is a real disorder and if so, whether or not the DSM should change the name to the less pejorative “Gender Incongruence.”

The edition in current use is DSM-IV-TR (text revision), published in 2000, but DSM-V is to be published in 2012. In preparation, working groups at the American Psychiatric Association are making decisions about such proposed additions as binge eating disorder, Internet addiction, and premenstrual dysphoric disorder.

Stay tuned.