Limitations of the DSM-5

Limitations of the Diagnostic and Statistical Manual of Mental Disorders — also known as the DSM – Medium Feb 2017 – by Jeffrey Guterman

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) may be among the most controversial and polarizing books in the world.

Informed by the medical model, the DSM-5 is the official diagnostic manual of mental disorders authorized by the American Psychiatric Association (APA, 2013).

It has engendered debate in the public arena as well as professional circles. At the same time, it has been a best-seller on The New York Times, Amazon, and other book lists.  

Often referred to as the “bible of psychiatry,” it is required reading for mental health clinicians who seek insurance reimbursement and for students in graduate courses for the mental health professions.

Yet the DSM-5 is at odds with many core values that therapists hold about clients and therapy, including an emphasis on the role of the therapeutic alliance and a wellness perspective.

Meanwhile, much of what talk therapy offers has been be lost to the field’s emphasis on the medical model.

Many therapists have also noticed that while their caseloads and paperwork have increased, their reimbursements have decreased, and they have lost control to insurance companies of making some of the key decisions in their clinical practices.

Like many therapists, I was initially struck by the idealism of being a professional helper. In the 1980s, after working in various mental health settings including psychiatric hospitals, community mental health centers, and private practice, I became disillusioned by the field’s emphasis on diagnosis and psychopathology.

In the 1990s, I shifted from a rational emotive behavior therapy (REBT) approach to a solution-focused model because I had sought alternative ways of conceptualizing clients, problems, and change.

Signs of Struggle for the DSM

The medical model holds that through scientific knowledge a physician can know the true cause of a disease, formulate an accurate diagnosis, and prescribe the appropriate treatment.

A closer examination of the DSM-5, however, reveals that its diagnoses are not accurate representations of mental disorders and they are not necessarily effective in determining what treatment approaches are best for particular disorders.

Although the DSM-5 often conflicts with therapists’ values, it is important to learn the language of diagnosis to communicate with colleagues.

At the same time, the DSM-5 lacks scientific validity and reliability and does not adequately inform treatment.

Nevertheless, insurance companies and funding agencies will not reimburse clinicians unless there is a DSM-5 diagnosis and treatment is organized around such diagnoses.

This is a catch-22 for many clinicians.

The DSM-5 lacks validity and reliability

Inhumane “treatments” based on bad science were widespread in the U.S. during the 20th century, including involuntary sterilization (Largent, 2008) and lobotomy (El-Hai, 2005)

Since psychiatric drugs were developed by the middle of the 20th century, they have become the most common form of psychiatric treatment and are also considered by some to be based on dubious scientific findings

DSM-5 diagnoses do not reflect objective brain diseases which, in turn, inform the prescribing of drugs that can ameliorate such brain diseases. Pharmacology is to a large extent a trial and error process.

A medical diagnosis is considered valid when it is an accurate understanding of a client’s condition or disorder. However, the diagnoses set forth in the DSM-5 are not objective medical conditions similar to how diabetes and heart disease are independently verifiable through objective tests

What is and is not observed by a clinician depends on many factors, especially the clinician’s tendency to look for, find, and interpret information so that it confirms their preconceptions, or confirmation bias about so-called psychopathology.

A careful review of the DSM-5 suggests it does not hold that its diagnoses are valid (APA, 2013, p. 5). The DSM-5 has stated that the APA recognizes past science did not produce valid diagnoses for mental disorders (APA, p. 5).

However, clinicians may still think of the DSM-5 as a valid diagnostic system for various reasons, including because it corresponds to the medical model which is based on a scientific view.

Confusions and seeming contradictions arise because the DSM-5 is a descriptive nosology (excluding substance-induced and medically caused conditions), yet it claims to be based on the medical model.

Field trials have also showed that the DSM-5 has poor reliability

For the DSM-5 this means that the same diagnosis will be formulated by different clinicians based on the same clinical presentations. Lack of reliability for the DSM is not new.

Based on the lack of scientific validity and reliability for the DSM-5, the National Institute of Mental Health (NIMH) largely abandoned the DSM for research purposes in 2013 because it held it does not lead to useful research.

The DSM-5 does not inform treatment

In recent years evidence-based practice has emerged as a significant trend in psychiatry and the field of mental health

However, a significant limitation of evidence-based practice is that it tends to match diagnoses to interventions in a decontextualized manner (Duncan, 2014).

Effectiveness in therapy depends less on the type of treatment selected and more on the resources and strengths of the client and the therapeutic alliance (Duncan, Miller, Wampold, & Hubble, 2009).

Research has found that client factors and therapeutic alliance factors account for 40% and 30% of improvement in therapy, respectively — the highest percentage among common change factors.

Model factors, on the other hand, only account for 15% of improvement.

There are at least two reasons the field may be obsessed with developing new therapy models despite the finding that the models used by therapists play the smallest role among common factors in bringing about change

The first reason may be that the field of mental health continues to search for the ultimate therapy model — the panacea, if you will — for all ills

In recent years, mindfulness has been lauded as the new panacea despite recognitions of its limitations.

A second reason why some therapists may remain loyal to particular therapy models is political. Powerful institutions such as universities and professional associations hold privileged knowledge and impose the prevailing therapy models in our field.

The entire profession, including clinicians, educators, researchers, and students are indoctrinated to the prevailing models, and the pressure is on to align with those models to advance in academic programs, obtain licensure and certification, and attain employment

The trend toward medicalization and evidence-based practice has often sacrificed the integrity of core values of many clinicians.

The DSM-5 engenders stigma

DSM-5 diagnoses are limited descriptions which highlight deficits, weaknesses, and problems and overlook capabilities, resources, and strengths

For many clients, however, the stigma of a diagnosis may be oppressive and in some instances worse than the mental illness.

stigma of mental illness persists and is often reinforced by the pathologizing focus of the DSM-5.

In a cautionary statement, the DSM-IV-TR stated that any given diagnosis is intended to diagnose conditions, not individuals (APA, 2000, p. x). This salient warning is curiously absent from the DSM-5.

Perhaps most important, therapists have unique opportunities to help fight stigma in their clinical relationships with clients.

Therapists can promote social justice in the fight against stigma one case at a time. This can be achieved by viewing clients as individuals with their own unique potentials rather than limited by a DSM-5 diagnosis.

Stigma of mental illness has also been perpetuated by the DSM-5 due to its lack of emphasis on the critical role of culture and diversity in understanding human problems and the phenomena otherwise associated with mental illness

The DSM-5 rightly cautions that the boundaries between normality and abnormality differ across cultures (APA, p. 14). This acknowledgment suggests that mental illness is largely culture-bound.

The pathologizing focus of the DSM-5 also distracts from many if not most of the problems of which most clients seek therapy. Research has found that the majority of problems that clients seek therapy for are relational in nature (Gottman, 1999).

But a client will rarely be covered for these unless they are given an individual DSM-5 diagnosis — a mental disorder. To be covered by insurance, you have to be sick to receive mental health care.

More-of-the-same from the DSM

While efforts to improve the DSM appear to reflect the spirit of scientific inquiry, closer examination indicates most, not all, of the changes amount to a more-of-the-same solution for the problems I have thus far identified regarding this diagnostic system.

Revisions of the DSM are sometimes made due to political and social pressure to remove archaic diagnoses.

Rather than provide an exhaustive review of changes in the DSM-5, I provide a brief review of the shift from a multiaxial system to a nonaxial system because unlike other changes, this significantly impacts use of the manual in daily practice.

What was separated on Axis I, II, and III in the DSM-IV-TR are now combined in the DSM-5 because no distinction is drawn for purposes of listing diagnoses between medical disorders and mental health conditions.

Whereas psychosocial problems were listed on Axis IV in the DSM-IV-R, these are now listed as V codes or 900 codes.

The Global Assessment of Functioning (GAF), which was used on Axis V of the DSM-IV-TR, was removed due to a lack of conceptual clarity, lack of clinical utility, and poor reliability.

The DSM-5 has introduced the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0; WHO, 2010) for “further study.” Information on the validity or reliability of the WHODAS 2.0 is not available in the DSM-5.

A potential advantage of the nonaxial system is that it may reinforce the holistic perspective held by some therapists by no longer distinguishing between medical, emotional, and psychosocial factors.

The nonaxial system also resolves some limitations and drawbacks of the multiaxial system

Concluding Remarks

The DSM-5 has made numerous diagnostic changes, structural modifications, and has revised its organization.

Multiple online enhancements for the DSM-5 are provided at www.psychiatry.org/dsm5.

I suggest therapists access this online resource due to anticipated changes in the DSM-5.

To date, however, the DSM-5 has significant limitations, including that its diagnostic system

  • lacks validity and reliability,
  • does not inform treatment, and
  • tends to engender stigma.

This last sentence implies that the DSM is fatally flawed and almost useless.

That is, useless for everything but insurance reimbursement.

Author: Jeffrey Guterman – Counselor, educator, author. Also follow @SolutionsBook about my book for helping professionals and the solution-focused approach.

Original article: Limitations of the Diagnostic and Statistical Manual of Mental Disorders — also known as the DSM – Medium

1 thought on “Limitations of the DSM-5

  1. Kathy C

    It is kind of scary how they approved the DSMV-5. A the tie I asked a “Therapist” about the changes to the DSMV-5. He insisted that Psychologists would know the difference. These changes were done for a reason, one of them being to add more confusion, and stigma. The changes also benefit the Pharma Industry, since now there are no wrong treatments, anything goes. No matter how much worse the client gets, or how much damages the Stigma and medication do to anyone, there is no wrong way to provide care. If the patient gets worse after “Treatment” or turns to suicide, it is not the fault of the Industry, it is the patients fault.

    I have a cousin with Schizophrenia, he is no better off today than he was 40 years ago. His teeth have fallen out due to the Medications, and he is Institutionalized. I have acquaintances with Bi Polar Disorder, they are worse now than when they were initially diagnosed. Even worse, one has children. Never even once did her treatment provider, even consider the children. They have problems due to the not only the disorder but how it was treated. One of her sons has been diagnosed with Bi Polar Disorder, he was young, but the Diagnosis, removed any incentive to even behave normally, or get along in life. Even worse is that the “Provider” is religious non profit, contracted by the state. There is no expectation of performance or even basic oversight. One of their “Clients” was shot 17 times by the police. Not one person asked what happened.
    After the shooting I contacted NAMI. I received a call the next day from a lovely older gentleman. He had not even heard about the shooting. He was a volunteer, with no background at all. He just repeated talking points, with no grasp of what had occurred. I realized years ago, that NAMI has been effectively useless. They rely on funding from Pharma, and the same Institutions, they are supposed to be advocating against. In my area, the same hospital a religious non profit, which released the Schizophrenic, after the police had brought him in. The hospital has a history of mistreating the Mentally ill. So of course there was no change to procedures after the young man was shot 17 times. Perhaps the police officer who shot him 16 times had seen the movie “Split” and used that to explain Schizophrenia.

    The thing that occurred to me was that nothing has improved. The public seems content with the number of Mentally ill in our jails. The local Media constantly demonizes the Mentally ill, while running thoughtful appearing Articles bemoaning the lack of services. Our Governor, cut funding to Behavioral Health a few years ago, which put a lot of providers out of business. They had been undermining the System for years, and no one cared. The Local News does not cover the Facts, only anecdotal stories, that are designed to mislead the public. Instead of acknowledging problems and fixing them, the Industry chose to continue on with this failure. It is out of sight, out of mind.

    When they say Behavioral health, they think people are getting “Treatment” instead they are just handed a bunch of Medications. The new generation of Anti Psychotics, are now prescribed for everything, from situational depression, and Anxiety to Schizophrenia. The VA is giving them out for everything, from pain, to lack of sleep and PTSD. They don’t “treat” anything, they are prescribed after 5 minute “Consultations.” The VA diagnosed women with sexual trauma who served in the Military, with “Personality Disorders,” they did the same with the Veterans who were exposed to toxic wastes and developed Gulf War Syndrome. The DSMV-5 facilitated Diagnosis of Convenience, for both the Military and Civilian Providers.

    The DSMV-5 was designed to allow the Industry to not only dispense drugs with no real purpose, but to Pathologize anyone. This way there could be two levels of care, the Institutional Model for the people who can’t afford care, and one for the people who can. The wording also allowed them to describe people with Medial issues as “Mentally Ill.” They created grey area, where people with Chronic Pain could be described as mentally ill. This also allowed them to describe people with heart Conditions too. The Healthcare System is not a source of distress, it is the patient “Disorder’ that makes it appear the Healthcare Industry is failing them. Distress can be described as Catastrophizing, The media recently ran articles about a “Study” that showed that people with Chronic Pain have a Mental Disorder. Once they Framed it that way, it was alright to ignore them. The DSMV-5 was designed to dehumanize the poor, the sick, anyone in distress.

    Years ago I had a Conversation with one of the Directors at that Religious Non Profit Behavioral Health Clinic. She stated that she did not know why people were poor. She ran Clinic for people who could not afford Mental Health Services, which was more than half of our town. She said “They can make thousand of dollars stuffing envelopes.” That was in the nineties when there was a Scam that ran ads in local papers. “Make 1500 dollars a week, stuffing envelopes.” That comment stuck with me. I realized the same thing is going on now. The media broadcasts a “Prosperity Ideology” where poverty is the fault of the people who are living in it. They weaponized Positive Psychology, Mindfulness, and “Alternative Medicine. Beliefs are more important than facts. Something taken from marketing psychology, and hoisted on all of us.
    Now we have 20% of the population on some kind of Anti Depressant. The Addiction and Suicide Rates are climbing. Teenagers are hooked on their devices,. so much that they are not even having sex. They created a Mindfulness App for that. The very idea of a Mindfulness App for kids so disengaged from reality, marketed with Positive Psychology terms, is terrifying. This has been so ingrained that no one questions it. In my state with one of the highest rates of suicide in the nation, they are advertising a “Suicide App.” for teens. It is like the Invasion of the Pod People. Every screen device is designed to keep your attention, and it is more powerful for the kids exposed to it. Even toddlers are not off limits.

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