Mental Health Diagnosis: Just Say No!
Part 1: The DSM is unfit for purpose.
Posted August 5, 2019
This is the first article in a 5-part series discussing different aspects of the current mainstream, biomedical approach to mental health diagnosis. Earlier versions of these 5 articles were part of an online forum called the “Global Summit on Diagnostic Alternatives” which ceased operating in 2015 and is no longer accessible.
[For the sake of brevity, I’m assuming readers already have some understanding of things like: what the DSM is; the massive influence it has on the way we think about and address mental health; the industry it has become; and the extraordinary amounts of revenue it generates for the American Psychiatric Association.]
In some ways, it is hard to understand what the hullabaloo with the DSM (Diagnostic and Statistical Manual of Mental Disorders) is all about. Let me explain. Prior to the publication of the DSM-5 (American Psychiatric Association, 2013) there was spirited debate about different aspects of the DSM’s diagnostic approach. That debate continued once the DSM-5 was published.
Despite the extent of the debate, one perspective that is seldom considered is whether or not the DSM can fulfill the purpose for which it was designed. The query about whether we should diagnose is separate to the matter of whether it is possible to diagnose using the DSM. The inescapable conclusion, from a consideration of the available evidence, is that, even if diagnosis is important and useful, the DSM is not up to the task.
The DSM, published by the American Psychiatric Association (APA), purports to be, as the title suggests, a diagnostic manual. Diagnosis, as it is defined in Wikipedia, “is the identification of the nature and cause of a certain phenomenon” (http://en.wikipedia.org/wiki/Diagnosis). It would be reasonable to assume, therefore, that, within the DSM, mental disorder would be regarded as a phenomenon, and the DSM would assist in identifying the nature and cause of this phenomenon. Quite apart from whether or not it is appropriate to diagnose mental disorder, is the issue of the DSM’s ability to deliver on what it says it is.
The introduction to the previous edition of the DSM, the DSM-IV TR, explained that “important methodological innovations” (APA, 2000, p. xxvi) were introduced with the DSM-III. One of these innovations was that the new DSM was “a descriptive approach that attempted to be neutral with respect to theories of etiology” (p. xxvi). So, even though diagnosis is the identification of the nature and cause of a phenomenon, the APA somehow reconciled publishing a diagnostic manual that made no reference to the cause of that which was being diagnosed.
Perhaps it could be argued that despite not being able to offer comment on the causes of the various mental disorders, the DSM still provides a useful guide to the categorization of mental disorders. Here, advice from the DSM is instructive.
“In DSM-IV, there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or no mental disorder.” (APA, 2000, p. xxxi). So, the categories that DSM offers us do not have boundaries demarcating one disorder from another or, indeed, one disorder from no disorder. This is an extraordinary revelation. This means, according to the DSM, there is no assumption that the category “schizophrenia” has boundaries that separate it from other mental disorders or from not having schizophrenia.
The DSM goes on, “There is also no assumption that all individuals described as having the same mental disorder are alike in all important ways.” (APA, 2000, p. xxxi). It is certainly reasonable to expect some degree of variability in people having the same disorder, but surely it is also reasonable to expect that people with the same disorder would be alike in “all important ways”. All the people who ever receive a diagnosis of basal cell carcinoma, for example, will be different in many ways. Despite their differences, however, there will be at least one “all important way” in which they are the same (the presence of a basal cell carcinoma for instance!).
Some of the wording in the preface of the DSM-5 (APA, 2013) has changed from the DSM-IV (APA, 2000) although no scientific evidence is provided for justifying the change of wording. Perhaps that is because the prevailing sentiment remains. For example, while the words that categories are not assumed to be completely discrete entities have been removed, there are statements such as “Although DSM-5 remains a categorical classification of separate disorders, we recognize that mental disorders do not always fit completely within the boundaries of a single disorder.” (p. 30); “the boundaries between many disorder “categories” are more fluid over the life course than the DSM-IV recognized” (p. 37); “we have come to recognize that the boundaries between disorders are more porous than originally perceived.” (p. 38); “it is well recognized that this set of categorical diagnoses does not fully describe the full range of mental disorders that individuals experience” (p. 56); and “In DSM-5, we recognize that the current diagnostic criteria for any single disorder will not necessarily identify a homogeneous group of patients” (p. 56).
Remarkably, although the authors of the DSM-5 (APA, 2013) appear to appreciate the problems created by the DSM’s categorical system, their stance is that “Despite the problem posed by categorical diagnoses, the DSM-5 Task Force recognized that it is premature to propose alternative definitions for most disorders.” (p. 49). Perhaps it is premature because biological markers have still not been discovered for any of the DSM categories. Essentially, no underlying pathology has been identified for the DSM disorders.
In the preface of the DSM-5 it is reported that “a complete description of the underlying pathological process is not possible for most mental disorders” (p. 29). This is somewhat of an understatement. According to the best available evidence, the alleged dysfunctions in underlying mental processes are still waiting to be found. As Timimi (2014) points out in his excellent critique of the DSM system, “The failure of decades of basic science research to reveal any specific biological or psychological marker that identifies a psychiatric diagnosis is well recognized.” (p. 209). In apparent oblivion to this body of work, the first sentence in the DSM-5 definition of a mental disorder states “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” (p. 56). How can the DSM authors assert that mental disorder reflects underlying dysfunction when no underlying dysfunction has ever been identified? A statement such as this is based on hope rather than science. The above definitional statement, when juxtaposed with other statements in the DSM-5 such as, “The symptoms contained in the respective diagnostic criteria sets do not constitute comprehensive definitions of underlying disorders” (p. 55), illustrates the conceptual confusion that runs rampant throughout the introductory information of the DSM-5.
Despite the claims in the DSM that its categories are just “like other medical disease classifications”, there are at least two fundamental differences between the DSM categories and legitimate medical diagnoses. Firstly the “fact that a value judgement is necessary to instantiate any definition of mental disorder” (Blashfield, Keeley, Flanagan, & Miles, 2014, p. 35) makes DSM categories quite unlike any diagnostic grouping in medicine. Secondly, decisions regarding the DSM diagnostic categories are made by committees and, on some occasions, “important decisions that affected the final outcome of a DSM categorization system were made at the level of the Board of Trustees of the APA.” (Blashfield et al., 2014, p. 43). A diagnostic system that is developed through committee voting processes can hardly be considered a scientific system.
The DSM does not explain causes and does not separate those with a disorder from those without. Moreover, Timimi (2014) reports that “there is little evidence to show that using psychiatric diagnostic categories as a guide for treatment significantly impacts on outcomes.” (p. 209).
What is the utility, clinical or otherwise, of a diagnostic manual that cannot separate – by its own admission – those with a disorder from those without one? If the DSM will not distinguish between the “haves” and the “have nots”, of what purpose is it? If it does not aid in providing more effective treatment, what possible reason can there be for using it?
The DSM is all tip and no iceberg. If diagnosis is “the identification of the nature and cause of a certain phenomenon”, the fundamental problem might be that the DSM is devoid of phenomena to explain.
Perhaps the most useful thing the DSM does, from time to time, is to remind us that it is the interference with a person’s daily functioning that is important. Even here, though, there is no indication of an appreciation within the DSM of what daily functioning entails. To function is to control. Control is a phenomenon. It is, in fact, one of nature’s most remarkable phenomena being responsible for life on this planet. Only when an understanding of control informs our research and practice enterprises, will we finally begin to develop sensible and effective ways of figuring out why daily functioning is interrupted, and how we might best be able to assist.
Understanding people and helping them with the problems they experience will not arise by allocating them to one or more DSM categories. Useful insights will emerge when efforts are made to learn about people as controllers and, as controllers, the problems they encounter pursuing the lives they wish to live. What are the problems being experienced and how do these problems prevent people living a life of their own design? Questions of this ilk are probably explored in many mental health services currently, however, all too frequently the questioning occurs under the shadow of the DSM. Stepping out of this shadow and affording questions such as these a central role in mental health service provision will, when informed by an understanding of control, promote more nuanced and more effective ways of helping more people more of the time, and harming people much less of the time.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorder. Fifth edition. Arlington, VA: American Psychiatric Association.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders. Fourth edition. Text revision. Arlington, VA: American Psychiatric Association.
Blashfield, R. K., Keeley, J. W., Flanagan, E. H., & Miles, S. R. (2014). The cycle of classification: DSM-I through DSM-5. Annual Review of Clinical Psychology, 10, 25-51.
Perepletchikova, F., & Kazdin, A. E. (2005). Oppositional defiant disorder and conduct disorder. In K. Cheng and K. M. Myers (Eds.), Child and adolescent psychiatry the essentials (pp. 73-88). Philadelphia, PA: Lippincott Williams & Wilkins.
Timimi, S. (2014). No more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished. International Journal of Clinical and Health Psychology, 14(3), 208-215.