The Poor DSM: Atheoretical, Overpathologizing, and Friendless?

If you know anything about clinical or counseling psychology, chances are you’ve heard of the Diagnostics and Statistics Manual of Mental Disorders, currently in its fourth edition. It’s the standard for the identification and diagnosis of mental illness.The fifth edition is slated to come out next year, and has been anticipated almost as breathlessly as the next Song of Ice and Fire book (come to think of it, DSM revisions come out more frequently).

The DSM is written by a committee—some would say “shadowy cabal,” but I’m not that flip—of expert psychiatrists.  While it’s an enormously important book, it has attracted its share of critics of all different theoretical orientations. What’s interesting about these critics is that they all seem to dislike the same things about the DSM, all for different reasons.

Take the recent open letter to the DSM-5 crew, written by the Society for Humanistic Psychology. Since the DSM-5 committee’s proceedings are available for preview, it is possible for fanboys everywhere to sign a petition which says, essentially “I see what you’re doing, and it’s going to suck.” (Incidentally, this is how the world was saved from a Superman movie starring Nicholas Cage, excuses about “budget issues” aside.)

The letter expresses concern that the DSM-5 appears to be lowering diagnostic thresholds, which would make it easier to get a mental illness diagnosis and thus, perhaps, some little pink pills. Remember how people are always talking about how America has underpathologized human behavior, and we need to diagnose more people with mental disorders? Yeah, me neither.

Similarly, the letter also chides the committee for the addition of more mental illness labels such as Disruptive Mood Dysregulation Disorder for children. The existence of this diagnosis implies that some kids get riotously upset not because at least 60% of the adults they encounter on a daily basis are patronizing, domineering jagoffs who try to force them into unnaturally structured and stultifying environments, but because these youngsters have had as-yet-unrecognized mental disorders.

The list goes on…for example, the DSM-5’s wording might not guard well enough against the eventuality of a person being called “disordered” because s/he doesn’t fit the particular sociocultural context in which s/he might reside.

Let me reiterate that this is the Society for Humanistic Psychology pointing out these claims. Psychologists with this orientation are not known for their evolutionarily informed thinking…these professionals are concerned with the implications of slapping a label on someone and pointing, as validation, to a book which supposedly reifies the “mental illness” diagnosis. But evolutionary clinical psychology proponents (the twenty or so of us who are out there, anyway) who have been shaking their heads at the DSM for years and holding out anxious, unrealistic hope for the next release (“Please don’t put rubber nipples on the batsuit, please don’t put rubber nipples on the batsuit!”) are likely to be as disappointed by the DSM-5 as the humanist psychologists, at the same problems brought up in the letter (but for different reasons).

The DSM is admittedly and proudly “atheoretical.” That means it remains neutral to all those pesky quibbling theories of why disorder exists, and instead classifies and defines disorder by symptoms and syndromes, i.e., what the disorders look like. So far, so benign.

“But a diagnostic manual needs a guiding metatheory!” the evolutionary people say (I’ll give you a spoiler–they’re referring to biological evolution). Evolutionary perspectives can help us understand the natural function of the brain, so we can better understand what disorder looks like. Who’s to say that a child who can’t sit silently in a wooden desk from 8am to 3pm with no recess and and a wordless 30 minute lunch break has a mental disorder? Miss Farley? Principal Jenkins? Superintendent Blattenfarb? Maybe they’re the ones who have disorders, those sadists.

If nobody supports the new DSM when it comes out, what happens? Along with the ICD, with which it roughly corresponds, the DSM has been the structural basis of mental disorder diagnosis since 1980 when the third version came out (essentially a successful reboot of the feeble DSM franchise…the first one wasn’t too bad, but Part II completely jumped the shark). Suppose everybody just turns walks away, like rats from an increasingly unpopular ship. Suppose every theoretical orientation writes their own diagnostic manual (like this psychodynamic alternative, the PDM, already in print, that my friend Nick Armenti showed me)…would that be such a bad thing?

Many feel like it wouldn’t. Power to the people! A Balkanized bunch of diagnostic manuals to bust up the monopoly and win adherents via their own merits, rather than just by riding the dynasty. There are whispered rumors of a newly conceived project to complete an evolutionarily informed alternative to the DSM. We all complain about the DSM, but can we do better?