The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system used throughout mental health to standardize the way mental disorders are defined and categorized. Although the DSM provides those of us working in the field with a language that makes treating our patients much easier, there are many valid arguments against the use of this system. As a career helping professional, I can see and understand the ways in which this system is helpful to us. However, when valid arguments are raised about the integrity of the DSM, the question must be asked, does the benefit to us truly outweigh the potential risks to the patient?

A recent study published in the journal,  Psychiatry Research involved a detailed analysis of five diagnosis as they are written in DSM 5, the most current version of the DSM. The study’s authors looked at “schizophrenia,” “bipolar disorder,” “depressive disorders,” “anxiety disorders,” and “trauma and trauma related disorders.” Lead researcher Dr. Kate Allsopp, from the University of Liverpool, concluded that DSM labels are “scientifically meaningless,” criticizing the DSM as “a disingenuous categorical system.” They concluded the following:

1. Psychiatric diagnoses (within the DSM) all use different decision-making rules

2. There is a huge amount of overlap in symptoms between diagnoses

3. Almost all diagnoses mask the role of trauma

4. Diagnoses tell us little about the individual patient and what treatment they actually need

These types of criticisms of the DSM are not at all new. In fact I was reminded when I read this article of a rather zealous professor I had in grad school who wanted to make it very clear to us what the DSM was, and was not. I was inspired to take a look back at some of my old notes from his abnormal psychology class. That’s where I stumbled upon what I was in search of, the works of Dr. Thomas Sasz and his contemporaries.  The most famous of the opponents of mental illness altogether, Dr. Sasz authored over 600 articles, and 26 books, arguing that mental illness itself is a myth. In what is considered his most famous publication, The Myth of Mental Illness, Dr Sasz argues that mental illness does not actually exist at all – in the material sense. He argued that there is no biological basis for mental illness, and that these diagnoses are entirely arbitrary, made up, not at all analogous to medical illnesses such as cancer or blindness. He argued that mental illness is really nothing more than a concept – an idea, which he likened to communism, or witchcraft. As I revisited some of Dr Sasz material, not through the eyes of a graduate student, but from the perspective of seasoned mental health professional, I realized just how serious of a dilemma this really is. As a professional working on the front lines in the field it is easy to confuse physiological activity with biological causality, but they are undeniably different matters. At MYND MVMT we are constantly talking about the interplay between the mind and body. The DSM however was not designed with this relationship in mind. Remember every thought, every move the body makes, is physiological, or creating activity in the brain. The system was designed based on observations of behavior. Even the most recent version was not updated using objective scientific measurement tools, where CAT scans were used to find bipolar disorder, or MRIs to find substance use disorders. The DSM 5 was updated using the personal experience of a “Task Force” and their “13 Work Groups” according to the APA (American Psychiatric Association), who sponsored the changes. This included more than 160 mental health professionals, the majority of who were psychiatrists, considered “leaders in their respective fields”. The challenges the field itself faces in making the necessary changes are extensive and could come with serious consequences. Anyone who has worked in mental health for any length of time can attest to the use of the DSM, currently in its fifth edition, as a conclusive diagnostic tool used to routinely categorize patients. Insurance companies require a diagnosis be given in order to pay for services, and a diagnosis is required at all levels of treatment from weekly one to one therapy, to full psychiatric hospitalization. The patient’s diagnosis is typically made within one or two initial assessment conversations, and then informs all treatment planning, medication or behavioral interventions, all referrals and all recommendations there to follow. For mental health professionals, social workers, psychiatrists, therapists, and counselors, the DSM is used in practice like the holy bible of mental health treatment. We use the DSM to communicate with other clinical professionals, to the patient, and to any other agency, family member, or interested/important parties within arms reach of the patient. Most importantly however, the diagnostic label is given to the patient, and never with any explanation of what it really means, or of its arbitrary nature, and lack of any real significance. The diagnosis is then forever placed into the patient’s medical records and remains a part of their permanent record – whether or not the label turns out to be accurate.

Working in the field for 18 years I have never once heard any other mental health professional mention, or make reference to, the arbitrary nature of the DSM, or the potential risks of the use of the diagnosis to the patient. It is impossible to tell whether that is because these professionals are not taught the reality of its nature, or if they have just accepted this is the way the system is. I speculate it is the former rather than the latter based on the way these professionals use the DSM in their day-to-day work. Clinical supervisors, most of all, seem to cling to DSM labeling as though it is a scientifically meaningful diagnostic tool with its roots in biology. This leads me to conclude that those who embrace the system most, are rewarded for doing so by being placed in a position of power. It begs the question, do these professionals not know of its roots, or not care? Maybe most distressing is the standard practice of professionals telling patients and their loved ones that the presence of the diagnosis is enough for them to conclude “this is the best it is going to get” for them. This implies the diagnosis itself means it is a permanent condition with a long-term predictable path based on scientific evidence, not conjecture. Although it is the case that many disorders, such as substance use disorders, do have a predictable path, if I have learned anything in my time as a clinical professional it is to avoid statements of absolute certainty! They are dangerous, and incorrect much of time. The truth is we all love to be able to put things in nice little boxes with clear labels. It makes things look nice and neat and organized. We also love to be right! One of the attractive components of being a mental health professional is being able to exert expertise. However, the problem is human beings rarely fit into the boxes we try and put them it, and true healing must be a two-way collaboration. It is also worth noting that when an “expert” makes a claim of absolute certainty to a patient, the claim itself has the ability to negatively impact outcomes. Once a patient believes they are incapable, they become incapable.

Additional Criticisms of The DSM Classification System 

There are many arguments against the use of a categorical system such as the DSM, as it stands today. Here are 10 of them.

1. The DSM is an arbitrary diagnostic system. Much like Dr. Sasz argued, mental illness is a concept – an experience, an emotional and psychological pain, not a condition caused by a neurological abnormality, or dysfunction. Although in daily practice we treat the DSM like it is the law of the land, classifications are based on the experiences of mental health professionals over time.

2. Mental disorders do not have a biological basis. Probably the most famous argument against mental illness. Unlike neurologists, those who treat brain abnormalities, mental health professionals are not curing structural anomalies. Mental disorders do not have their roots in the physical. Further in daily practice the matter of physiological effect is confused with biological causality.

3. The diagnosis is often in the eye of the beholder. Just like with anything, people see the world in accordance with their personal beliefs, experiences, thoughts, and expectations. As we have already learned from the University of Liverpool research study, there is tremendous cross over in symptoms from one diagnosis to the next. It’s extremely common for clinicians to “read” behavioral symptoms, through the lens of their areas of expertise. Misdiagnosis for this reason is extremely common in mental health.

4. Psychiatric medications have serious effects. Although psychiatric medication is increasingly common amongst the general population, psych medications are a very serious matter. Not only are most not warned of how serious they are, diagnosing a patient with a mental disorder is typically done in one visit and the medication prescribed is based on the diagnosis being given. As a result the chances of mis-medication are high. Moreover, it is common for it to take patients several years to find the “right” medications.

5. There are no objectively measurable ways to test for a mental disorder There is no CAT scan or MRI you can take to see Bipolar disorder.

6. What we call “mental illness” may be those who don’t or can’t conform to a limiting definition of “normal.” Mental illness may be a byproduct of our modern, “achievement” driven culture. In that case it’s our limiting definition of “normal”, that is then responsible for our definition of mental illness – those whose behavior falls outside of the norm.

7. Mental Illness is a luxury of a modern society. Prior to modern civilization, happiness was not assumed to be a birthright. You have to assume that happiness is a normal part of life in order to assume suffering, in its various manifestations, is an “illness.”

8. The shaming effects. In my experience of working with hundreds of clients, each and every one has shared one symptom in particular: very low self-esteem. It begs the question whether or not labeling someone as mentally ill, due to the stigma attached, isn’t doing more harm than it is good.

9. Labeling someone with a mental illness is misleading and confusing. Labeling someone with a mental illness can be very misleading to the person being given the diagnosis. Without explanation to the contrary most assume this means causality, permanence, and limitation.

10. There is evidence the diagnosis solidifies the behavior. Some have argued that it is not until after a diagnosis is given that the symptoms of the diagnosis fully express. Citing the power of human belief, and our subconscious tendency to stay consistent with who we believe we are, some argue the label sharpens the problem.

Helpful Links & References

Sasz, T.S. The Myth of Mental Illness

Who Is Behind the DSM

The New Atlantis : A Journal of Technology & Society

Neuroscience News: New Study Finds DSM Scientifically Meaningless

Wyatt, R. C. Thomas Sasz: Liberty & The Practice of Psychotherapy, Journal of Humanistic Psychology, Vol. 44 No. 1, Winter 2004 71-85.

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