Strengths and Limitations of the DSM-5

The Diagnostics and Statistical Manual is currently in its fifth edition, published in 2013. Informed by the medical model, it is the official diagnostic manual of mental disorders authorized by the American Psychiatric Association (APA, 2013). It honors and references the International Classification of Diseases, making it amongst the most controversial and polarizing books of the world; a definitive resource in psychology for the United States, Europe, and Asia; however, no version of the DSM is without problems.

It has engendered debate in the public arena as well as professional circles, 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 mental health professions. However, the DSM-5 is at odds with the core values some clinicians hold about clients and therapy, including the emphasis on the role of the therapeutic alliance and a wellness perspective.

The strengths which brought the DSM to international prominence continue to promote its role as the standard for diagnosis, treatment, research, and teaching in psychology. It does this despite widespread acknowledgment of its shortcomings.

By creating a standard terminology for mental health, it removes ambiguity in patients' records for treatments as well as allows researchers to convey their findings in a realm of clearly defined concepts. This also makes the information presented in the DSM applicable to many settings, from the research facility to the outpatient clinic.

It also categorizes disorders based on similar symptoms, causes, and behaviors. This helps clinicians and researchers diagnose patients easily by identifying the category of applicable disorders, then narrowing down the diagnosis to a specific disorder. Finally, the aim of the DSM and the directive for each new edition is to create the material from a large base of empirical evidence. This would indicate that each new edition, given the addition of new data in the intervening years, has a stronger empirical foundation than the last.

Struggles for the DSM

Unfortunately, no edition of the DSM is without its weaknesses. The most cited problem is that the categorization and typing of disorders by symptoms places a stronger emphasis on the most obvious or outwardly visible symptoms, neglecting potential underlying causes or less visible symptoms. In many ways, this can also lead professionals into the false belief that people with the same disorder must conform to the manual's description of the disorder.

As such, mental health treatment has become increasingly integrated with medicine. Surveys have found that many primary care physician visits are related to psychological issues. Drug companies run advertising campaigns marketed directly to consumers using DSM-5 diagnoses. And prescription drug addiction has become an epidemic. A comprehensive research program also found that patients with schizophrenia who received low dosages of medication with individual talk therapy made greater progress over a two-year period than patients with schizophrenia who only got medication (Kane et al., 2015). Despite this landmark finding, we can expect the trend toward medicalization in our field will persist. Meanwhile, much of what talk therapy offers have been lost to the field’s emphasis on the medical model.

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 disorders. I am not negating that there is a phenomenon of mental illness, that people experience distress, or that there are deviations from norms, although the latter is based largely on cultural norms that we have created in the first place. Clinicians often overlook that the DSM-5, itself, provides a disclaimer that its manual should not be used as the sole basis for treatment planning and, instead, recommends a comprehensive evaluation be conducted for this purpose (APA, 2013, p. 19).

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 are organized around such diagnoses. This is a catch-22 for many clinicians.

Lacking validity and reliability

Evidence-based practice refers to those treatments that have been shown through randomized clinical trials to be effective over placebo or no treatment groups. This trend reflects an effort to develop rigorous research methodologies aimed at evaluating best practices and establishing improved accountability. 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).

It has been over a century since the first therapy models were developed and the field has still not come close to discovering a cure for mental illness. Yet new approaches are continually being developed to find The Holy Grail. In recent years, mindfulness has been lauded as the new panacea despite recognition of its limitations. Granted, neuroscience may fundamentally transform mental health in the future in ways that are unimaginable today (Martin, Guterman, & Kopp. 2012). But for now, such solutions are out of reach.

Resources

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). Arlington, VA. Author. Print.

Duncan, B.L., Miller, S.D., Wampold, B.E., & Hubble, M.A. (2009). The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, D.C.: American Psychological Association.\

Kane, J.M, Robinson, D.G., Schooler, N.R., Mueser, K.T., Penn, D.L, Rosenheck, R.A., Addington, J., Brunette, M.F., Correll, C.U., Estroff, S.C., Marcy, P., Robinson, J., Meyer-Kalos, P.S., Gottlieb, J.S., Glynn, S.M., Lynde, D.W., Pipes, R., Kurian, B.T., Miller, A.L., Azrin, S.T., Goldstein, A.B., Severe, J.B., Lin, H., Sint, K.J., John, M.J., & Heinssen, R.K. (2015). Comprehensive versus usual community care for first-episode psychosis: 2-Year Outcomes from the NIMH RAISE early treatment program. The American Journal of Psychiatry, 174, 362- 372.

Martin, C.V., Guterman, J.T., & Kopp, D.M. (2012). Extending the dialogue about science and humanities: A reply to Hansen. Journal of Humanistic Counseling, 51, 161–163.

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