DSM, Diagnoses, and Debate: The Many Dimensions of Mental Health

One of the biggest debates surrounding the field of psychology and its practitioners today is the debate concerning how exactly mental health diagnoses should be made. What defines a mental illness? Who determines what constitutes each specific illness and what gives them the credentials to do so?  In the early years of psychology, this very issue contributed to the struggle psychologists faced in legitimizing their field as a science.  Poor diagnostic techniques and lack of standardization of diagnoses made early psychological ventures appear more philosophically-based than factual and scientific.  Today, however, we have the Diagnostic and Statistical Manual of Mental disorders (DSM for short), first created in 1952 as a collective effort by the American Psychiatric Association to standardize psychological diagnoses and further legitimize the field of psychological study.  While the original DSM was a breakthrough in psychological study and treatment for the mentally ill, specifics on the diagnoses are still fiercely debated, and definitions are continually being revised and reworded to include and exclude certain elements of specific disorders.  These specific diagnostic criteria affect not only the psychologists doing the diagnosing — they also greatly impact the people themselves who are being diagnosed.

The debate over how exactly to diagnose patients and what constitutes each individual illness has become particularly relevant again recently, as the fifth version of the DSM was released just a few short years ago in 2013.  It was released to many mixed emotions over the changes that had been made from the previous version. Many psychologists are concerned with the fact that the DSM-V still emphasizes categorical diagnosis, maintaining the need for patients to meet specific criteria for disease diagnosis, which critics believe is outdated and less clinically relevant. Some have even begun working on an entirely new classification system that relies solely on dimensional diagnosis or diagnosing patients according to a spectrum of impairment or disability.  Proponents of this method argue that someone should not have to merely meet a certain “list” of symptoms, but that the severity of their symptoms should also be weighed heavily in their diagnosis.  

Not all of the updates should be criticized, however; the category for bipolar disorders, for example, has also been changed, expanded to include “an emphasis on changes in activity and energy — not just mood.” The phrase “mixed episode specifiers” has also been included in describing manic, hypomanic, and depressive episodes, allowing for more freedom in how patients describe the highs and lows related to their bipolar disorder.  Categories have also been added that describe episodes of short duration and anxiety-related specifications of bipolar disorder.  Thus, as it relates to bipolar disorder, the changes brought about in the DSM-V actually make diagnosis easier for patients struggling with a wide variety of symptoms, for the most part, and include categories and intricacies of the disease that may have been ignored by previous versions of the DSM.

While the clinical relevance of the DSM diagnostic criteria cannot be ignored, the changes in the definition of these diagnoses and the debate surrounding them impact more than just the list of signs and symptoms needed for a specific diagnosis. What about the patients behind the disorders?  How are these changes in diagnostic criteria affecting patients of specific diseases?  When categories are expanded or done away with, it can have a significant influence of the patients, whose diagnoses often become an integral part of their identity.  Melissa Miles McCarter, an author, academic, and publisher, reflects on her experience with bipolar and how it relates to her career and her everyday life, even becoming intertwined in the two.  She says, “Without medication, I deteriorate and become dysfunctional or am thrust into a deep depression followed by manic psychosis. However, if I had never had these challenges, even the bouts with severe mental illness, would I still be the same person — and would I want to be?” Another example of the effects diagnostic criteria can have on mental health patients is in the removal of Asperger’s Syndrome, placing patients that previously met that criteria into a new broadened category renamed “Autism Spectrum Disorder,” which sparked much debate among the Asperger’s community.  

While criteria specific to bipolar disorder and those diagnosed with this disease may have been benefitted from the DSM-V, many categories of illnesses are still under continuous debate.  Re-wording, rewriting, and recombining signs and symptoms of disorders affect not only the psychologists who must be familiar with diagnostic criteria — they also affect the patients whose identities are oftentimes tied quite closely with a disorder they have come to embrace as their “own.”  Unfortunately, no system is without its flaws, and this fact speaks to the current debates facing psychological diagnoses.  While psychologists continue to strive to make improvements to classifications of mental disorders, the interests of the ones who are actually suffering from the mental disorders must be balanced with the need for better classification systems and criteria.


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The DSM and Depression: Flawed Labeling Leads to Misdiagnoses and Increased Stigma

The DSM has long been hailed as psychiatry’s “bible”; clinicians across the country have used the Diagnostic and Statistical Manual as their guide to identifying mental illness. However, in recent years, the reliability of the DSM has been called into question by psychiatrists and doctors alike. For depression, specifically, the DSM falls short in field tests, with test-retest reliability being extremely questionable. Depression screening and treatment is currently based on an extremely flawed set of standards, and this is providing a basis for misdiagnoses and false positives (Nemeroff et. al., 2013). Furthermore, although the compartmentalization of mental illnesses into specific categories may be necessary for treatment, strict categorization is contributing to an increased number of diagnoses per patient, which is creating labels and causing negative stigma (Szalavitz, 2013).

The DSM V lists nine criterion for depression, and goes on to put these symptoms under one of two categories: 1) depressed mood and 2) loss of interest or pleasure. It states that five (5) of these nine criterion must be met in order for a patient to have depression. The manual goes on to list 4 more categories that specify conditions that must be met in order to make sure the patient has depression (APA, 2013). There are two main issues with this approach. Firstly, the symptoms proposed by the DSM vary widely, but the treatment options for varying degrees of depression are very similar. This can be highly detrimental to the patient because the treatment is not specialized enough (Szalavitz, 2013).  Additionally, a lot of the symptoms for depression can be indicators for symptoms of other mental illnesses such as anxiety. This leads to false positives and diagnostic inflation, which is when a patient is over diagnosed with a multitude of mental illnesses, and perceived comorbidity, which is when two chronic illnesses are present simultaneously.

For a lot of patients, diagnostic inflation and false positives can lead to feelings of hopelessness and despair, as in the case of Maia Szalavitz. In her 2013 article for TIME magazine, Szalavitz states that she has been diagnosed with no fewer than six mental illnesses over the course of her lifetime. Szalavitz goes on to say:

My multiple diagnoses are the rule, not the exception, and one criticism of the DSM structure is that if you qualify for one diagnosis, you typically also qualify for others. Which one should be treated? Or do they all require interventions? And what if the therapies conflict with each other? You see the problem” (Szalavitz, 2013).

Although diagnostic labels are sometimes needed for treatment, over diagnosing patients can lead to risky medication combinations and incorrect labeling (Szalavitz, 2013). An increased number of diagnoses can understandably lead to more despair in the patient without providing a concrete solution to the patient’s problems (Batstra et. al., 2012).

Diagnoses are not at all an exact science, and the DSM tries to treat them as such. Overall, not enough is known about mental illnesses such as depression to narrow symptoms down to a precise list of categories. Labels for mental illnesses are far from perfect, and over labeling adds to stigma and only increases patient distress. To some extent, we do need labels, but mental health professionals should realize that these labels are not set in stone.


Special thanks to Dr. Nicholas Eaton for providing information for this article

Batstra, L., & Frances, A. (2012). Holding the Line against Diagnostic Inflation in Psychiatry. Psychotherapy and Psychosomatics, 81(1), 5-10. doi:10.1159/000331565

Hunt, C., Slade, T., & Andrews, G. (2004). Generalized Anxiety Disorder and Major Depressive Disorder comorbidity in the National Survey of Mental Health and Well-Being. Depression and Anxiety, 20(1), 23-31. doi:10.1002/da.20019

Nemeroff, C. B., Weinberger, D., Rutter, M., MacMillan, H. L., Bryant, R. A., Wessely, S., … Lysaker, P. (2013). DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions. BMC Medicine, 11(1). doi:10.1186/1741-7015-11-202

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TIME. (2013, May 17). Viewpoint: My Case Shows What’s Right — and Wrong — With Psychiatric Diagnoses. TIME Magazine.