DO YOU DIAGNOSE USING THE DSM?
The short answer to the above question is a qualified "no". While I admit that this is somewhat of an unpopular position for a psychologist to hold these days, I will try to explain my reasoning. First, let's define the term "diagnosis," which roughly translates from its Greek origins to mean discernment, or the identification of the nature and cause of anything. This is clearly important as it relates to therapy. Most clients are indeed looking for their clinician to identify and/or understand the issues that they want to resolve in therapy. In my own work, I will tend to assess and diagnose according to my theoretical commitments (e.g. attachment, psychodynamic, family-systems, and existential theories). The broader goal of diagnosis is to arrive at a theoretically-coherent conceptualization of the presenting problems, concerns, or symptoms that a client wants to address in therapy. It is important to note that this is a theoretically-dependent diagnosis or assessment process, and that it is used primarily by me, for the specific purpose of planning and negotiating a fruitful course of therapy for my clients. In other words, I tend to be relatively unconcerned about using short diagnostic-labels, such as "Major Depressive Disorder," "Generalized Anxiety Disorder," "Adjustment Disorder," and so on.
While I tend to avoid labeling people according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), I will occasionally do so if a client meets criteria, and if the situation falls under one of these circumstances:
- If a client asks for a DSM diagnosis.
- If it is required by a third-party for a client to access services.
- If I am consulting with another professional who may not share my theoretical commitments, I may use a DSM diagnostic label as a way to quickly describe a set of symptoms - as long as it is appropriate and does not oversimplify the core therapeutic issues.
Why don't you diagnose using the DSM?
It is important for people to understand that a DSM diagnosis is nothing but a labeldescribing a particular list of psychological symptoms. It does not claim to offer any explanation for those symptoms, even though most of us are led to believe that it can. The term "mental disorder" implies a disease model of psychopathology that attempts to parallel the kinds of diseases and disorders discovered within the medical profession and the natural sciences. The problem is that we are likely talking about two different classes of things: one related to the physical body, the other related to the mind. This is not to say that the mind is somehow separate from the body. On the contrary, I think most would say that they must be intrinsically linked, as the DSM editors themselves suggest:
the term mental disorder unfortunately implies a distinction between "mental" disorders and "physical" disorders that is a reductionistic anachronism of mind/body dualism? (American Psychiatric Association, 1994, p. xxi).
The problem is not agreeing on whether the mind and body are linked, but in understanding exactly how they are linked. What is "mental," for example, is clearly a product of the mind, however, we do not yet understand its relation to the body (Duffy et al., 2002). This is an important philosophical question that the DSM avoids answering. So while the DSM implicitly endorses a categorical system of mental illness loosely modelled after a physical and disease-based medical model, it makes no attempt to explain how or why this model should work.
Sometimes people will ask me during a course of therapy if they meet criteria for a DSM diagnosis. I almost always ask the question "what would it mean if you did"? I am still surprised by the number of people who respond: " because if I have a diagnosis of 'Depression,' then maybe there is some medication that can help me." Again, the assumption or belief is that "depression" in this case is caused by some underlying biological problem, and that it is best resolved by means of a biological intervention (e.g. medication). The disease-based assumptions of the DSM have become a dominant cultural narrative in how we think about mental health and illness. But these narratives are not based on science or factual knowledge. There is no blood-test, brain scan, or physical examination capable of determining who is depressed versus not. In this way, having a diagnosis of depression is qualitatively different than having a diagnosis of cancer or liver disease.
Many people are surprised to learn that the DSM is an atheoretical method of categorization - meaning that its classification system does not claim to be supported by any particular theory of psychopathology, by scientific research, or by psychobiological evidence of any kind. One would also think that in order to determine what is "abnormal," you would first need to define "normal." However you will find no such definition in the DSM. The diagnostic categories of the DSM are instead determined by the professional consensus of a comparatively small group of psychologists and psychiatrists that essentially "vote" on which labels will be included in the most current version of the DSM. This process can be influenced significantly by mainstream cultural assumptions, generational and historical differences, and sociopolitical attitudes. It may shock many people to know, for example, that until 1973 homosexuality was considered a mental disorder.
The current DSM committee is getting ready to release the newest version of the DSM (the DSM-V), and there has been much talk about adding or removing various disorders from the book. Can you imagine a small group of physicians having enough power that they could "remove" cancer from the face of the earth, simply by coming up with a unanimous decision to do so? Cancer could be erased through sheer will! Just think of how many lives could be saved, and much money we would save in cancer research and treatment!
So unlike medical diseases, which are discovered, DSM diagnoses are rather invented, based on a host of factors that have very little to do with science. And remember that a DSM diagnosis only describes symptoms, not causes: it can never offer an explanation for psychopathology. For example, someone might meet criteria for "Generalized Anxiety Disorder" as a result of very different underlying causes - it makes little sense to lump them together under the same diagnostic label and pretend that they mean the same thing. In support of this argument, researchers have found that the reliability of these diagnostic labels, and their distinction from one another, to be in fact quite poor (e.g. Gordon, 2011; Lux, 2010).
Another critique of the DSM, is that in assuming that mental disorders are biological realities housed within the physical body, it claims that psychopathology is something that occurs within the individual person. This implies that psychological problems are the result of faulty individual functioning, which excludes or minimizes the influence of our sociocultural environments, life events, and subjective experiences within interpersonal relationships (Crowe, 2000).
Since all of my work involves therapeutic treatment, I prefer to use an assessment or diagnostic approach that conceptualizes the issues in a way that directly points to a logical form of treatment. The DSM is atheoretical, makes no claims about causation, and is built upon some very flawed logic. It is therefore of limited use to both client and clinician, though its diagnostic labels have admittedly become part of our dominant cultural narrative. I believe that if a clinician is overly committed to the DSM, it may restrict their capacity to think flexibly, appreciate individual differences, sociocultural influences, developmental factors, attachment history, and how they all fit within the larger context of an individual's life. In short, I believe that by using the DSM, it puts clients at increased risk of becoming pigeonholed into categorical boxes that may not reflect the reality of their personal situations. In addition, if "diagnostic realism" takes hold - that is, if DSM disorders are treated as though they are somehow caused by real biological things, rather than as convenient labels describing a loose set of symptoms, then clients are at additional risk of believing that they should be taking medication, when there might not be any need to.
If the reader understands and agrees with some of the problems that I have outlined, they might then be inclined to ask, "Why doesn't anyone else seem to be talking about these issues?" I think the short answer is that most people, including most psychologists, simply fail to recognize them. To be clear: the problems of the DSM are problems of human reasoning and sloppy thinking. They are, in a sense, philosophical problems more than they are scientific ones. The field of psychology, in my opinion, makes a lot of assumptions. But to assume is to take something as true, without questioning or critically examining the reasoning on which it is based. Despite our rigorous training, few psychologists will ever take a course in basic logic, critical reasoning, or theory construction. As a result, my profession is at increased risk of making severe errors in logic, though there are a small number of very intelligent psychologists who are willing to critique mainstream views that appear problematic or potentially dangerous. I hope that our field will begin to explore these problems more earnestly in the future. Until then, I think it is reasonable for the general public to be weary of psychologists who put too much emphasis on diagnostic labels.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Crowe, M. (2000). Constructing normality: a discourse analysis of the DSM-IV. Journal of Psychiatric Mental Health Nursing, 7(1), 69-77.
Duffy, M., Gillig, S., Tureen, R. & Ybarra, M. (2002). A critical look at the DSM-IV. The Journal of Individual Psychology, 58(4), 363-373.
Gordon, D. (2011). Reliability and validity of the DSM-IV generalized anxiety disorder features. Journal of Anxiety Disorders, 25(6), 813-821.
Lux, V. (2010). Deconstructing major depression: A validation study of the DSM-IV symptomatic criteria. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 40(10), 1679-1690.
Mitchell, R. (2003). Ideological reflections on the DSM-IV-R (or pay no attention to that man behind the curtain, Dorothy!). Child & Youth Care Forum, 32(5), 281-298.
Warelow, P. (2011). Deconstructing the DSM-IV-TR: A critical perspective. International Journal of Mental Health Nursing, 20(6), 383-391.