What is the DSM 4 - TR?

by Greg Nooney ©2006

What is this document called the Diagnostic and Statistical Manual of Mental Disorders, Text Revision published by the American Psychiatric Association in 2000? The DSM IV is a research-stimulated, politically influenced, pathologically based categorical classification system that divides mental disorders into types based on criteria sets with defining features.

Arranging observable data into categories works best when there are few differences among the items within each category, and many important differences among items in different categories. It is clear, however, that neither is true when organizing diagnoses. Rather, the differences among cases within specific categories is large, and it is often the case that persons who are diagnosed with distinctly different disorders may be quite similar to one another in terms of their symptoms or etiology. While the DSM makes no claim to embrace the medical model, it is frequently so perceived in every day usage. Consequently, persons who are diagnosed with specific disorders based on DSM criteria often assume that their diagnosis is correct and mostly unchangeable.

If someone is diagnosed with cancer, they do not expect that this diagnosis will later be changed to irritable bowel syndrome. If it is, they suspect malpractice of some kind. However someone diagnosed with Schizophrenia might in fact discover that a new psychiatrist has changed that diagnosis to Schizoaffective Disorder or Bipolar Disorder. Such a person might also suspect some kind of malpractice, that one or the other doctor must have made an error. However, it is entirely possibe that no error was made and that the person met the criteria for Schizophrenia at one time and no longer does so, but does in fact later meet the crieteria for Bipolar Disorder or Schizoaffective Disorder.

I am suggesting that the problem may lie with the manual itself, with its poorly understood limitations. The culture wants certainty and clarity in regard to personal suffering and diffiuclties. Even though the DSM does not lay claim to such clarity or certainty, its existance fills such a void and it is so embraced. It has even been called the "Bible" of mental health services. This is, in my view, a dangerous road on which to embark. I would encourage the reader to familiarize themselves with the Introduction and Cautionary Statement, pp.xxii-xxxvii, where the following limitations and uncertainties of the document are clearly set forth:

  1. Ultimately, DSM is a series of guidelines, that “reflect a consensus of current formulations of evolving knowledge.”
  2. Problems with the DSM's usage of a categorical classification system:
    a. No absolute boundaries between mental disorder and no mental disorder
    b. No absolute boundaries between mental disorders
    c. There are other completely different ways in which the data could be organized, such as through a “dimensional model,” which would have no categories at all.
  3. Limits of understanding what “mental disorder” actually is.
    a. We cannot actually separate mind and body. Such a suggestion is a “reductionistic anachronism of mind/body dualism”
    b. There are many completey different ways of defining mental disorder: distress, dyscontrol, disadvantage, disability, inflexibility, irrationality, syndronal pattern, etiology, statistical deviation from a norm
  4. Ethnic and cultural biases will be present
  5. Diagnosis will never be sufficient to decide on treatment
  6. No fundamental distinction can be established between mental disorders and general medical conditions
  7. Diagnosis says nothing conclusive about disability, legal understandings, competency, individual responsibility.

Another issue that is important in considering the DSM is its pathological basis. By definition, one must identify "a clinically significant behavioral or psychological syndrome or patterm that occurs in an individual" and which is a "manifestation of a behavioral, psychological, or biological dysfunction in the individual," (p.xxxi) in order to make a DSM diagnosis. In other words, there must be a judgment that there is an identifiable dysfunction existing within the individual being diagnosed. This dysfuction is unwanted; it causes suffering; it is pathological. The DSM sorts and organizes the symptoms that are the fruit of this pathology. Making such a judgment is not a neutral act. It has real effects in the lives of those who are so diagnosed. Sometimes there are both positive and negative effects. One of the positive effects has to do with the fact that there are few places in our society where we can stand outside of shame when viewed as deviant or not measuring up. One such place is in the realm of illness. To be diagnosed with a mental disorder often provides some limited shelter from such shame. Some of the potential negative effects are how one's identity can be shaped by being diagnosed. One can perceive oneself as a "Schizophrenic" or a "borderline," and such an identity description can be quite limiting to ones' sense of self. Those who have been diagnosed can also be subject to ridicule and discrimination.

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