The reception to the new DSM-5 has been mixed. The British Psychological Society (BPS) published a largely critical response in which it attacked the whole concept of the DSM. It stated that a “top-down” approach to mental health, where patients are made to “fit” a diagnosis is not useful for the people who matter most – the patients.
The BPS said: “We believe that any classification system should begin from the bottom up – starting with specific experiences, problems, symptoms or complaints.
“Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice.”
The UK mental health charity Mind took a more positive approach. The charity’s chief executive, Paul Farmer, said: “Mind knows that for many people affected by a mental health problem, receiving a diagnosis enabled by diagnostic documents like the DSM-5 can be extremely helpful. A diagnosis can provide people with appropriate treatments, and it could give the person access to other support and services, including benefits.”
In defence of the DSM-5
Given the criticism listed above you could be forgiven for thinking that the DSM in general and the DSM-5 in particular has no supporters in the world of mental health. This is not the case. Many mental health professionals are proud to defend the DSM-5 and its principles.
Some may cite the fact that given our uncertain knowledge of mental health, having a diagnostic guide is invaluable for doctors to refer to. While the DSM (and the related ICD system) may be a flawed classification system – subject to biases and lacking empirical proof – it is likely to be better than anything else currently available.
Other attempts to classify mental health conditions, have included:
- systems based on brain biology – such as assessing unusual levels of neurotransmitters
- systems based on measuring the psychological dimensions of personality (such as extraversion, agreeableness, conscientiousness, neuroticism, openness)
- systems based on the development of the mind
While these systems are often elegantly expressed in textbooks, none has succeeded in being robust enough to withstand real-world conditions.
As Prof Frances puts it in an essay on the topic called Psychiatric Diagnosis: “Our classification of mental disorders is no more than a collection of fallible and limited constructs that seek but never find an elusive truth. Nevertheless, this is our best current way of defining and communicating about mental disorders.
“Despite all its epistemological, scientific and even clinical failings, the DSM incorporates a great deal of practical knowledge in a convenient and useful format. It does its job reasonably well when it is applied properly and when its limitations are understood. One must strike a proper balance.”
Many people may have sympathy with the British Psychological Society’s response – which could be briefly summarised as “treat the person not the disease”.
But what happens when it comes to research? If you were running a large randomised controlled trial on hundreds of people with schizophrenia you would need some sort of pre-determined criteria of what constitutes schizophrenia. It would be unfeasible to carry out a full psychological assessment of every individual in that trial.
It is also easy to forget how open to doubt psychiatric diagnoses were in the past. In a landmark 1973 paper by David Rosenhan (On Being Sane in Insane Places), eight people with no history of mental illness feigned symptoms in order to gain admission to mental health facilities. As soon as they did gain entry they then stopped feigning any symptoms, yet none of the staff noticed any change in their behaviour. Embarrassingly enough, many other patients did suspect that these people were “not crazy”.
Another study from 1971 found that psychiatrists were unable to come to a shared diagnostic conclusion when studying the same patients on videotape.
Therefore any improvement in the diagnostic framework for mental health, however imprecise it may be, should never be taken for granted.