Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs (review)

The Diagnostic and Statistical Manual of Mental Disorders, or DSM (American Psychiatric Association 1994), is something we can't live with and can't live without. We can't live with it because of diagnoses that shouldn't be or aren't there, or because of criteria that seem too subjective, behavioral, broad, or exclusive. It is chock full of unwieldy webs of diagnostic specifiers for disorders without a known biological basis. (For non-psychiatrist readers: unlike most medical diagnoses, which point ultimately to biological mechanisms or causes, psychiatric diagnoses are based on matching a patient's symptoms, behaviors, and psychological predispositions to operational criteria written by committees.) Thus nearly everyone has reason to complain that the DSM inadequately captures his or her ideas about mental illness. Some writers are frankly suspicious of the DSM's ambition to provide diagnostic criteria for any problem for which anyone might consult (or be forced to see) a psychiatrist. When critics of psychiatry attack the DSM's broad definition of mental disorder as documentary evidence of psychiatry's hegemonic intention to deem all social deviation as mental illness, it is hard to offer a vigorous defense.

The DSM is, by design, not a theory of mental illness about which one can debate assumptions, and not an encyclopedia containing evidence to be weighed, and not really a systematic taxonomy based on a set of objective organizational principles, but rather a tool to ensure diagnostic reliability in the field (Sadler et al. 1994). Criticism of the DSM by non-psychiatrists seems a bit absurd, like criticism of a French cookbook by vegans. Although the DSM is informed by science and the values of objectivity science implies, the overriding aim to produce a universally useful diagnostic manual ensures that pragmatic considerations win out over scientific ones.Thus, according to contributors to Descriptions and Prescriptions:Values, Mental Disorders, and the DSMs, the principal reason we can't live with the DSM is not because we disagree with it on the definition of particular disorders, but because of the contradiction of scientific versus pragmatic values at its foundation.

If the DSM has fundamental flaws, why can't we simply live without it? Because the DSM is a useful tool. There is great value in having reliable diagnostic criteria, in being confident that a drug that worked in a clinical trial on the other side of the country will probably work in the same kind of patient in your practice. And the ability to assign to a disorder a five-digit code no doubt enhances the enterprises of government record-keeping, medical billing, and insurance company oversight. Because of this centrality to psychiatric practice, the DSM is often referred to as the bible of American psychiatry.

The DSM is also a bible in another unintended sense: it is a framework for psychiatric teaching and thought. Psychiatric textbooks are routinely organized in parallel with DSM and quote DSM criteria for every disorder they discuss. One handbook I perused recently had a chapter entitled "How to Memorize the DSM-IV." I have known medical students to purchase a DSM to study for exams and have seen psychiatric boards examinees cramming from pocket versions prior to their orals. The DSM has thus changed the way psychiatrists think about mental disorder. Students of psychiatry feel that they know what they know about a patient because the patient's symptoms and behaviors tend to conform to diagnostic categories specified in the DSM.This, a reader of Descriptions and Prescriptions would conclude, creates a problem. In accepting the DSM as the authority on what is and is not mental disorder, students and practitioners of psychiatry risk adopting values they may have mistaken as objective (or "scientific") truths because of the value-neutral way in which the DSM presents them. An example...