What Is the DSM?

Although a number of classification systems have been developed over time for the diagnosis of mental disorders, the one that is used by most mental health professionals in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published most recently in its 5th edition (known as the "DSM-5") by the American Psychiatric Association in 2013. 

The DSM is the standard classification manual of mental disorders and contains a hierarchy of diagnostic criteria for every mental-health disorder recognized by the American Psychiatric Association. The DSM is used by psychiatrists and psychologists, doctors and nurses, and therapists and counselors. It is used for individual clinical diagnoses, but its codes and criteria are also used in the collection of data about the incidence of different disorders.

The DSM is often considered a "necessary evil"—it has many flaws, but it is also the only widely accepted method of diagnosing mental disorders.

History of the DSM

The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. Research and changing cultural norms have contributed to the DSM's evolution over time.

DSM-I (1952)

The first version of the DSM was created in response to the large-scale involvement of psychiatrists in the treatment, processing, and assessment of World War II soldiers. The DSM-I was 130 pages long and listed 106 mental disorders, many of which have since been abandoned.

DSM-II (1968)

The DSM-I and the DSM-II are clear reflections of the strongly psychodynamic slant the field of psychology had at the time of their publication. Symptoms were not specified in detail for specific disorders, and many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was incorporated in a model that did not emphasize a clear boundary between normality and abnormality.

DSM-III (1980)

Around this time, a controversy emerged regarding the deletion of the concept of neurosis. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the American Psychological Association's (APA's) board of trustees unless "neurosis" was included in some capacity; a political compromise reinserted the term in parentheses after the word "disorder," in some cases. The DSM-III included more than twice as many diagnoses (265) as the original DSM-1 and was nearly seven times its size (886 total pages).

DSM-IV (1994)

In this version, a clinical significance criterion was added to almost half of all the categories. This criterion required that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning."

A "text revision" of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The DSM-IV-TR was organized into a five-part axial system.

• Axis I: Clinical disorders, such as depression and anxiety.
• Axis II: Personality disorders and/or developmental disorders (such as intellectual disabilities, formerly called mental retardation).
• Axis III: Physical issues that may impact mental health, such as diabetes.
• Axis IV: Psychosocial stressors, such as occupational problems.
• Axis V: A global assessment of functioning score (GAF), which provides a score of the person's overall functioning from 1 to 100.

DSM-5 (2013)

Perhaps the most controversial version yet, the DSM-5 contains extensively revised diagnoses; it broadens diagnostic definitions in some cases while narrowing definitions in other cases. Notable changes include the change from autism and Asperger syndrome to a combined autism spectrum disorder; dropping the subtype classifications for variant forms of schizophrenia; dropping the "bereavement exclusion" for depressive disorders; a revised treatment and naming of gender-identity disorder to gender dysphoria; and changes to the criterion for post-traumatic stress disorder (PTSD). The DSM-5 has discarded the multiaxial system of diagnosis of the DSM-IV, listing all disorders on a single axis. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (the GAF) entirely. Although DSM-5 is longer than DSM-IV, the volume includes only 237 disorders, a decrease from the 297 disorders that were listed in DSM-IV.

DSM-5

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, published in 2013.

Strengths of the DSM

Evidence-Based Treatment

One of the strengths of the DSM is its use in researching and developing evidence-based treatments. Researchers use the DSM diagnoses to conduct studies and trials on patients, and this research determines which treatment approaches provide the most effective results. As studies get published, mental-health service providers learn how to incorporate the most evidence-based treatments into their practice.

Consistency and Insurance Coverage

The DSM also provides a common language for physicians, social workers, nurses, psychologists, marriage and family therapists, and psychiatrists to communicate about mental illness. In addition to providing a common language among practitioners, hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. Providers must often use the DSM in order to get coverage for their clients from insurance companies, which require certain DSM diagnoses for treatment.

Weaknesses of the DSM

Reliability and Validity Concerns

The revisions of the DSM from the 3rd edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. Many diagnoses are so similar that there is a high rate of comorbidity between disorders.

Diagnoses Based on Superficial Symptoms 

The DSM is primarily concerned with the signs and symptoms of mental disorders, rather than their underlying causes. It claims to collect them together based on statistical or clinical patterns. Furthermore, diagnostic labels can be stigmatizing for patients by creating stereotypes about certain diagnoses.

Cultural Bias 

Current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Common criticisms include both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included are often misinterpreted or misrepresented.

Medicalization and Financial Conflicts of Interest 

It has been alleged that the way the categories of the DSM are structured and the substantial expansion of the number of categories are representative of an increasing medicalization of human nature. This has been attributed by many to the expanding power and influence of pharmaceutical companies over the last several decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. 

Stigma

Because the DSM is a system of labeling, it is often criticized for contributing to the creation of social stigma against those with mental illnesses. In the context of mental illness, social stigma is characterized as prejudiced attitudes and discriminating behavior directed toward individuals with mental illness as a result of the label they have been given. Stigma and discrimination can add to the suffering and disability of those who are diagnosed with a mental disorder.