Overview
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered an authoritative set of standards for classifying mental health conditions.
History and Etymology
In 1952, the DSM-I was published as a 32-page booklet with 106 disorders that was heavily influenced by the psychodynamic ideas proposed by Adolf Meyer and Sigmund Freud, where mental health disorders were seen as underlying conflicts within the drives of one’s personality.
The DSM-II was published in 1968 with the intention of aligning descriptions and definitions better with the International Classification of Diseases (ICD) proposed by the World Health Organization (WHO). By this point, 182 diagnoses appeared in the manual.
The DSM-III, created in 1980, sought to push back on psychoanalytic formulations of mental health disorders that were difficult to test and generate evidence for. For instance, scientific evidence failed to substantiate homosexuality as a mental health disorder resulting from latent unconscious conflicts rather than sexual preferences and inclinations. Instead, it included diagnostic checklists and increased the total number of recognized disorders to 265. A 1987 revision (DSM-III-R) bumped it to 292 diagnoses.
The DSM-IV was published in 1994 as an expansion of the DSM-III’s shift towards empirical validation of diagnoses, pushing the book’s diagnoses to 297. The DSM-IV-TR (Text Revision) included 365 diagnoses by 2000.
The current edition, the DSM-5, first came out in 2013 before a revised edition (DSM-5-TR) came out in 2022. The number of diagnoses dropped to ~300 as some conditions were grouped together under larger categories, such as Autistic Disorder and Asperger’s Disorder being grouped under Autism Spectrum Disorder to recognize the complexity and nuance in the presentations of autism.
The DSM-5 was also incredibly controversial across multiple points of contention:
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Excessive Pathologizing: The DSM-IV task force chair Allen Frances argued that the DSM-5 was lowering the standards for what constitutes a mental health disorder such that ordinary suffering was medicalized. For instance, the DSM-5 tossed out the guideline that someone should not be diagnosed with Major Depressive Disorder if their symptoms present within two months of the loss of a loved one to avoid conflating grief with depression, even if the two might be related.
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Discarding the Multiaxial System: From the 1980 DSM-III through the 2000 DSM-IV-TR, clinicians evaluated patients across five axes - clinical disorders, personality disorders and intellectual disability, general medical conditions, psychosocial and environmental problems, global assessment of functioning (GAF). The DSM-5 discarded it on the basis that the distinctions between axes weren’t grounded in scientific evidence, the GAF was highly subjective, and the ICD used a single axis so the multiaxial system was just introducing complications.
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Lack of transparency: the American Psychiatric Association (APA) had required members of its DSM-5 task force to sign non-disclosure agreements (NDAs) against the traditions of open debate in science, and many of the members had ties to the pharmaceutical industry which has conflicts of interest towards expanding the number of diagnostic categories that someone can qualify and receive medication for.
The National Institute of Mental Health (NIMH) had announced in 2013 that it would be distancing itself from the DSM-5. From then-director Thomas Insel:
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”
Another big controversy concerning the DSM-5 was the exclusion of Complex PTSD (C-PTSD). Bessel van der Kolk is perhaps one of the most well-known advocates for exploring the bodily physiological aftermath of trauma in his book The Body Keeps the Score, and those inspired by his work argued that C-PTSD was a distinct enough phenomenon from PTSD to warrant a separate diagnosis rather than an expansion of the criteria for PTSD. Historically, PTSD was associated with singular traumatic events like accidents or violence rather than a constant stream of recurring traumas in childhood that have impacts on development. Many clinicians argued that C-PTSD treatment has to involve a much longer stabilization period than standard PTSD to help the nervous system feel safe and regulate itself before discussing the memories of trauma. Also, proponents for the existing DSM-5 also claimed that the symptoms of emotional instability and relationship volatility could be adequately accounted for through Borderline Personality Disorder (BPD), though critics argued that this encouraged institutions to ignore the sources of these symptoms and fed into the stigmatized stereotypes around BPD.