by Chase Love
Illustration: ‘D(diagnosis)SM’ by Leana King
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has served as the premier diagnostic tool in psychology and psychiatry for the past four decades. Published in 2013, the most recent edition attempts to bring a sense of cohesion to the diagnostic criteria that govern caretaker-patient interactions within the mental health fields.18 In doing so, the DSM strays away from the tenets of psychology as it transforms psychiatry into a branch of medicine that is more technical, rather than personable, in nature. Recently, the manual has received noteworthy praise due to its allusion to medical prestige and new branding of “modern” psychology, which has slowly begun to make psychiatry indistinguishable from other types of medicine.9 Although the DSM is widely considered to be the best categorization of mental disorders that exists to date, it is a flawed guideline that generalizes psychological ailments.9,17,18 Its greatest shortcomings lie in the apparent integration of marketing strategy and decreased reliance on traditional psychology.
The goal of the DSM is to categorize mental disorders and describe the diagnostic criteria for each disorder to the best of its ability. 15 The book borrows aspects of these criteria from prominent psychological diagnostic encyclopedias and introduces them to the world of medical diagnostics.12 However, unlike general medicine, psychology is anything but uniform. The DSM categorizes “diseases” and presents criteria that are not altogether supported by hard scientific fact.19 For instance, a basic bacterial disease such as Legionnaires’ disease differs from depression in that it has definitive symptoms. Legionnaires’, caused by the legionella bacterium, is “a severe form of pneumonia — lung inflammation usually caused by infection.”11 Depression, however, is not so clear-cut. It divides into multiple levels and subcategories that can be ambiguous. Various types of depression, such as those labeled “severe”, “major”, or “substance-induced”, differ in severity, symptoms, and age-range occurrence, but are all attributed to a broad range of overlapping causes.6 These subcategories complicate depression diagnoses as they leave behind uncharted territory. It is almost impossible to categorize the disorders to fit everyone’s physiological and psychological needs. This is due to the complexity of each individual human and the lack of technology needed to prove definitive psychological diagnostic patterns for developing criteria. The categorization in the DSM is thus better geared towards creating a concrete name rather than serving a practical function.
The naming and categorizing of a disease allows for a generalized treatment plan that usually involves the use of pharmaceuticals. The medications synthesized by scientists and marketed by companies target different disorders. As that list of disorders expands, so does medication marketing towards any specific disease. For example, the DSM intentionally separates bipolar disorders into its own category and eliminates the bereavement period after a death as a time frame to gauge when grief becomes depression.17 It is therefore responsible for helping expand the market for medications and making diagnosis more reliant on health-provider opinion. This outcome is beneficial for pharmaceutical companies because they can now sell a greater variety of medications that have the backing of the DSM. However, it becomes dangerous when doctors disagree on which categories serve as a diagnosis for a particular disorder because it can lead to faulty or unnecessary treatment. This underlying disagreement usually sparks debate over what constitutes a specific disorder, which should be answered by the DSM since it establishes the diagnostic norm. The dialogue over biological versus therapeutic treatment plans also comes into play and further widens the gap between psychology and psychiatry. The DSM’s favoritism towards psychiatry is exposed by the pharmaceutical and financial influences that essentially filter the DSM’s content.
To make the DSM-5 appear free of bias, the APA implemented a conflict-of-interest disclosure policy.19 Though the policy itself reflects a step in the right direction, it was not installed effectively. To the naked eye, the policy diminished much of the bias that had plagued the DSM’s reputation for years, but in reality, the policy was implemented merely for show. The bias that was once kept a “secret” was exposed to the public, and so any outside influences were presumed to have “disappeared”. Transparency on its own cannot stop special interest collaborations without explicit enforcement against the perpetrators. In March 2012, Dr. Lisa Grove and Dr. Sheldon Krimsky conducted a study of the DSM’s new disclosure policies and the special interest relationships that the DSM-V panel fostered.3,5 About 69% of DSM-5 task force members disclosed having pharmaceutical relationships, which is a proportional increase of over 21% from the DSM-IV.5 The panels of writers and reviewers that use medications as the best and first option for treatment for that disorder consequently have the biggest medical bias in those categories while psychotic disorders and sleep/wake disorders have 83% and 100% of members with a conflict of interest, respectively.5 The APA has heavily decreased pharmaceutical bias among writers, which on the surface seems like the key to a decrease in overall bias. Instead, it has been another way to mask their involvement with pharmaceutical companies. The editors, who have ultimate power over final revisions and facts included in the DSM, also contain the largest proportion of members with pharmaceutical ties ranging from honorarias to conditional research grants.5 If DSM contributors have unconditional grants and/or past profits from industry ties, they do not have to disclose information regarding their profits and research. Contributors to the book could continue to be funded by pharmaceutical companies without being accused of a conflict of interest.
The pharmaceutical influence is only amplified by the major backing the DSM has received from insurance companies. Insurance companies require a DSM diagnosis by a medical doctor before they can compensate clients for their medications. The insurance companies use the DSM as a baseline to fit ICD-10-CM, Z codes which are the criteria for the relationship between the diagnosis and corresponding treatment.10 In turn, this allows for the reimbursement of psychotic medications ranging from anti-depressants to SNRIs, therefore encouraging pharmaceutical production and medication prescription to patients.10 It also encourages patients to rely on drugs because they can be refunded by their insurance companies for their medications and do not have to worry about the prices associated with them. These inextricable ties make the DSM a crucial tool in psychiatrists’ treatment of mental disorders. The DSM’s impact is far-reaching, which can be seen when examining disorders like depression, which is the second leading cause of disability in America.2 It is of little surprise that the second biggest selling drug in America was the depression drug Abilify.4 It is also important to note that the amount of depression pills prescribed by a non-psychological related doctor is about 85% of all depression pills. 16 Doctors without a specialization in treating depression are subsequently prescribing at an alarming rate that far surpasses the proportion at which psychiatrists prescribe the same medications. This illuminates the major discrepancy in the treatments between psychologically affiliated doctors and MDs that is directly caused by the allusion of the DSM’s criteria as a supplement for specialization.
To maintain its prestigious reputation, the DSM manages to mask its inaccuracy. The DSM-5 introduces vague disorder categories such as “Unspecified Neurodevelopment Disorder” and “Depressive Disorder Not Otherwise Specified” in order to clump diagnostically similar disorders together that do not fit in anywhere else.1 It features loose and imperfect categorization that cannot always hide its uncertainty from the public. In an attempt to improve accuracy, the DSM installed a two-stage process: Stage One involved pinpointing inaccurate diagnoses, while Stage Two involved weeding out inadequate sets of criteria and redrafting them.9 This process ensured that the DSM would be thoroughly analyzed and that its mistakes would be minimized at an unmatched rate. However, due to the late completion of the first stage, the second stage could not be finished in time.9 Instead of delaying the release of the publication and potentially losing profits, the DSM terminated the crucial second stage, which could have allowed for the needed development of unspecified disorders.9 This brand of carelessness can also be seen in the actions that the APA has taken in the past. The APA’s calculated stances can be seen through the outcomes of their votes on controversial categorizations. The most famous vote was on the removal of homosexuality from the DSM, even though it was known that it was not a mental disorder at the time and thus should not have been included in the manual.17 Although the DSM has progressed in its accuracy of diagnostics, it has not reached the definitive nature necessary for the amount of influence it has.
A notion that has stumped people time and time again, psychological disorders have no defined cure. The brain and its functions are not fully understood, and psychological disorders are not automatically fixed with pills, technological advances, or therapy. The DSM’s main pitfall does not lie in its diagnostics platform or in its gross generalizations, but rather in its marketing. The DSM is part of a large, wealthy, interconnected network that is highly dependent on concrete diagnostics. Diagnostic criteria that are unspecified and contain over-generalized symptoms should not be at the helm of this system. If the DSM was viewed as more of a reference and stepping stone in the development in psychological studies, its purpose and influence could lead to the development of a more accurate diagnostic book and a revitalized psychology industry.14
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2 Briggs H. Depression: ‘Second biggest cause of disability’ in world. BBC News. Published November 6, 2013. http://www.bbc.com/news/health-24818048. Accessed October 9, 2016.
3. Brooks M. APA Criticized Over DSM-5 Panel Members’ Industry Ties. Medscape. Published March 20, 2012. http://www.medscape.com/viewarticle/760542#vp_1. Accessed October 20, 2016.
4. Brown T. The 10 Most-Prescribed and Top-Selling Medications. WebMD. Published May 8, 2015. http://www.webmd.com/news/20150508/most-prescribed-top-selling-drugs. Accessed October 9, 2016.
5. Cosgrove L, Krimsky S. A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med PLoS Medicine. March 13, 2012; 9(3). doi:10.1371/journal.pmed.1001190. Accessed October 1, 2016.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: American Psychiatric Association; 2013.
6. Drug industry ties to doctors weaken as disclosure, gift rules spread. amednews.com. Published November 29, 2010. http://www.amednews.com/article/20101129/profession/311299964/1/. Accessed October 1, 2016.
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9. Mayo Clinic Staff Print. Legionnaires’ disease. Mayo Clinic. Published 2016. http://www.mayoclinic.org/home/ovc-20242041. Accessed October 9, 2016.
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12. Pickersgill MD. Debating DSM-5: diagnosis and the sociology of critique. Journal of Medical Ethics. Published August 7, 2013. Revised November 15, 2013. http://jme.bmj.com/content/early/2013/12/10/medethics-2013-101762.full. Accessed October 1, 2016.
13. Poland J, Eckardt BV, Spaulding W. Problems with the DSM Approach to Classifying Psychopathology. Academia.edu. https://www.academia.edu/237138/problems_with_the_dsm_approach_to_classifying_psychopathology. Accessed October 1, 2016.
14. Preston J, O’Neal JH, Talaga MC. Handbook of Clinical Psychopharmacology for Therapists.Oakland, CA. New Harbinger Publications; 2013.
15. Reese H. The Real Problems With Psychiatry. The Atlantic. Published May 2, 2013. http://www.theatlantic.com/health/archive/2013/05/the-real-problems-with-psychiatry/275371/. Accessed October 1, 2016.
16. Sterbenz C. The Way We Diagnose Mental Illness Might Be A ‘Mistake’. Business Insider.Published August 2013. http://www.businessinsider.com/problems-with-the-dsm-2013-10. Accessed October 1, 2016.
17. The DSM: Psychiatry’s Billing (Fraud) Bible. CCHR Orange County RSS. Published 2012. http://cchroc.org/the-dsm-psychiatrys-billing-fraud-bible/. Accessed October 1, 2016.