You really knocked this one out of the park. Thank you for such a well-researched and thoughtful article. So often these critiques of DSM fall into anti-psychiatry nihilism "we can't find the lesion, therefore psychiatric diagnoses are all social constructs" or we fall into identity-tribalism "you have no right to tell me that I don't have social anxiety!" It's rare to find one where the perfect doesn't become the enemy of good patient care.
Those last few paragraphs should be required reading of all clinicians in training. They acknowledge the experience of the person without making it into an identity.
I sometimes say to patients regarding dx: "I don't care if we call it 'french toast' so long as the label helps us to identify an appropriate and useful treatment that helps you feel better and more able to live your life, then it will have served its purpose. It's just a descriptor - like having brown hair. It's not an identity."
This is really a wonderful and wonderfully-written article. I too find myself downplaying diagnosis in some cases, just as I sometimes lower expectations for medications What does this mean, that we both don't know how to define what is wrong and also don't know how medications work and why they don't work? Ugh. After years of training, I feel a little fraudulent.
Sometimes the process feels bleak. In an outpatient practice, I often have to put a diagnosis code that doesn't really fit someone because otherwise I don't get paid. I don't like having one diagnosis for the insurance and, as you say in terms of the DSM being for clinicians, a more nuanced version of this for our purposes.
Inevitably you get into trouble that way. I'm sure there are lots of medical issues not captured by the ICD, or captured only belatedly, and it is true that people also describe themselves in terms of a medical diagnosis (my diabetes, my heart condition), but psychological labels are more personally-resonant, as you describe beautifully. Thank you.
what is also interesting is that the insurance companies are not incentivized to fix this because the discipline itself (WHO,AMA,CMS) is not willing to provide practitioners and insurers mechanism-aware, intervention-aware, outcome-sensitive bridges on the billing system that rightfully connect intervention to diagnosis.
Thank you for all the historical context. I haven't seen much written about how access to supports and services also drives diagnoses. Here I am thinking especially of the rise in the prevalence of autism. Often a diagnosis of autism allows access to critical supports across education, health, respite etc., while those with similar functional needs (e.g., genetic disorder, other neurodevelopmental disorder) or those that don't quite meet criteria but would benefit from additional supports get near to nothing. Thus, clinicians are often torn as to what to do in these circumstances and often offer the diagnosis so that the families can receive the necessary supports and services. Until eligibility is based on function rather than category, prevalence numbers will remain artifacts of policy as much as epidemiology. But of course providing adequate supports will require much more investment.
I agree, prevalence numbers are heavily confounded by service and treatment access issues on the ground, and clinicians are basically using whatever diagnosis will get the service/treatment covered for the patient. It's a mess.
Thank you for this brilliant and well researched article. Currently, my DSM-5 serves as a paperweight when compressing artworks or a stand when using my EMDR machine, certainly not its intent. In the past, I, taught the DSM III, IV, IV-R and DSM-5 to my students. But in my forthcoming book (the 4th edition of The Art Therapists’ Primer ), I suggested diagnosis could use a more embodied approach, bottom up as opposed to the overuse of top-down. Over pathologizing seems to rule the day, and like Sisyphus, I await the day when this isn’t such an uphill battle.
The budgetary priorities of NIMH and Tom Insel's latter day pessimism are both evidence that biological reductionism in psychiatric nosology is both prevalent and misguided. While the DSM obviously isn't a manual of biological diagnosis (e.g., "A blood level of X diagnoses schizophrenia"), the system of classification coupled the brevity of most mental health visits (in primary care or community psychiatry) results in psychopharmacologic interventions being offered most of the time (https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1784344). The diagnostic reductionism of the DSM, given our current therapeutic milieu, results in biological reductionism in the clinic and in the hospital. Although you've written about the Rumpelstiltskin effect (great paper, by the way), most patients and clinicians, once a patient is diagnosed, will obviously ask, "Now what?" and expect a pill. Hope is in the pills, or that's what our practice patterns suggest anyway.
I don't think this is true for people with mild problems (e.g., mild anxiety, mild depression), and it's desperately incomplete for people with severe problems (e.g., severe anxiety, severe depression, schizophrenia, anorexia), where medication is only a piece, and perhaps not even the most substantial piece, of a much more comprehensive set of interventions, some of which may not even be medical.
You could say maybe the DSM is better than nothing, and maybe RDoC or HiTOP will lead us somewhere better, but regardless of what diagnostic systemic we use, the culture in which we practice still engenders reductionism of one kind or another. In the world of mental health, that means responses will always be at best incomplete and at worst dehumanizing and harmful.
Not that I feel entitled to such, but I'd be curious to hear your thoughts on the PDM (the psychodynamic equivalent of the DSM) which McWilliams had a significant role in authoring. In my admittedly insular corner of the mental health world, I've found this to be as good an attempt as any at a thoughtful attempt to integrate constitutional/maturational traits and defences with psychopathology and it is what I used for the bulk of my diagnostic work. I'd like to write about this sometime, but I think I'm simply too lacking in knowledge around the comparative usefulness of the two texts.
I think PDM is pretty decent for psychodynamically oriented clinicians (and I'm a bigger fan of Nancy McWilliam's Psychoanalytic Diagnosis). I am planning to write about PDM in 2-3 months after PDM-3 comes out :)
"Hosts to diagnostic entities" is about as perfect an analogy as any I've found to capture the tension I feel between the usefulness of ADHD as a framework for understanding a particular way of functioning (the Rumpelstiltskin effect) and growing discomfort with the way it's increasingly framed as "essence of self".
It's the most curious mix of both completely personal (as identity), and yet completely impersonal (as something that inhabits me and therefore has nothing really to do with me).
This is a masterful exploration of the DSM’s limits and its impact on self-perception. I especially appreciate the emphasis on using diagnoses as tools for treatment rather than identity. It reminds clinicians and patients alike that labels describe patterns—they don’t define a person.
This is one of the clearest, most balanced articulations I’ve seen of what the DSM is and what it absolutely is not. As a psychologist, I’m constantly navigating that gap between “useful shared language for clinicians/insurers/researchers” and the way people absorb diagnoses as essences that define who they are.
I especially appreciated the point that all it means to “have” a DSM disorder is to meet threshold criteria for a pattern of symptoms over some period of time and that what that means for biology or self-understanding is still unsettled. That nuance gets almost completely lost in public discourse and, honestly, in a lot of clinical settings too.
Great read, thank you! I’m a child and adolescent psychiatrist in the UK, and something I’m often struck by is the ‘pressure’ my group seem to experience- to define themselves. Not necessarily in medical or psychiatric terms, but just generally in life. You've given me an idea that I need to write about!
No-one ever says the international classification of diseases is psychiatry’s ‘bible’, partly because it hasn’t entered the public’s consciousness, partly because it is more technical / less expansive but also because it assigns codes to both mental and physical disorders
This is very well written. I'd like to propose a much simpler explanation, what if the DSM is not serviceable? What if it simply suck? What if the reasons for that are entirely mundane and unremarkable? Groups of people produce bad work all the time, it doesn't require special explanation, nor does does require any feat of intellect to recognise a bad product.
Committees in particular are notorious for producing crap. It's a near universal experience. All of us at some point of our lives have had the experience of sitting on a committee and listening to the dumbest voices in the room shout down the only two people who know what they are talking about.
The DSM working groups function exactly the same way. They are usually made up of one or two noteworthy thinkers and the rest are there for political reasons. It's no great mystery as to why the result is a turd sandwich. Who was it that said "how many troops does the pope have?".
Kraepelin's textbook is "serviceable", the DSM is a shitshow. Call a spade a spade.
Thanks for introducing me to Ian Hacking's formulation of looping theory. It's something that repulses me about the neuro diversity movement. People seem to find their identity in, and structure it around, DSM diagnoses. Ironically, I can see that diagnosis plays a crucial role in my own self understanding, I'm just committed to being indistinguishable from "normal" people and don't tell anyone about my label. We were taught "don't treat the dsm like a cookbook" - but laypeople presume it's a collection of recipes and read it as such.
Contrary to the lead in to this blog, the DSM is, in fact, explicit that mental disorders are internal, individual, and biologically (as well as psychologically/developmentally) determined when it says they reflect a “dysfunction in the biological, psychological, or developmental processes underlying mental functioning…” and that “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”(p. 20)
As Steven Hyman said years ago, the DSM is a “fool's errand” as it has unsuccessfully struggled for decades to classify experiences and decisions that allegedly reflect underlying dysfunctions in individuals, but that have yet to be found. If such dysfunctions were found, the problem would necessarily fall within the bailiwick of neurology, immunology, or other medical specialties that have internal systems as their targets - systems that can become dysfunctional. And, as those internal dysfunctions are found (e.g., neurosyphilis), psychiatry is left with fewer and fewer targets, eventually with nothing but moral judgments about experiences and decisions, as well as their social consequences.
The fundamental and most important issue to be discussed about so-called mental disorders is whether the problems they describe are matters of pathology (not just biology). How they are classified is a different issue altogether.
You are misunderstanding the DSM reference to dysfunction as mental disorders being internal, individual, and biologically determined. Mental disorders are problems an individual is experiencing, but it is not a statement about their causes (which are both internal and external). And while DSM doesn't formally define dysfunction, in execution, it is apparent that the DSM notion of dysfunction is a very common-sensical and folk-psychological one. Dysfunction here is not a hypothesis about the existence of an unobserved brain abnormality.
I disagree. The DSM definition clearly implicates a causal dysfunction (dys = abnormal/impaired/bad) in the individual's underlying processes, not just dysfunction in terms of outward mental or social functioning or an individual sense of distress. And I'm not claiming the DSM limits it to a brain dysfunction - that is just one possibility. It also includes psychological and developmental dysfunction (whatever that is). Also, in practice, professionals and consumers readily adopt this mindset. I realize some, perhaps the two of us included, think otherwise. I agree with you that the mental disorder descriptions in the DSM are purely about "problems an individual is experiencing." But why in the world would those experiences need to be assessed, diagnosed, and treated as if they were illnesses when there is nothing to treat and the best case scenario is only palliative?
This exchange shows why the DSM problem cannot be solved at the level of classification alone. Before asking how mental disorders should be classified, the discipline has to clarify what authorizes a condition to count as pathology, what kind of dysfunction is being claimed, where that dysfunction is located, and what intervention is supposed to change. Without that prior clarification, “mental disorder” remains a classification category doing pathology work it has not earned.
Is the DSM this… “Diagnostic and Statistical Manual of Mental Disorders?” Sorry, I’m just a layman reader and the acronym isn’t clearly defined. But I’m pretty sure I’m correct.
Just posted this on the DSM-5, in particular how it's been elevated to a source of truth in asylum law. It's being (mis)used to define persecuted groups.
It’s safe to say that few persecutors are motivated by DSM-5-delineated distinctions. One imagines a bully releasing a classmate and saying “I’m so sorry! I didn’t realize that you had developmental coordination disorder! I only meant to beat up kids with stereotypic movement disorder.”
You really knocked this one out of the park. Thank you for such a well-researched and thoughtful article. So often these critiques of DSM fall into anti-psychiatry nihilism "we can't find the lesion, therefore psychiatric diagnoses are all social constructs" or we fall into identity-tribalism "you have no right to tell me that I don't have social anxiety!" It's rare to find one where the perfect doesn't become the enemy of good patient care.
Those last few paragraphs should be required reading of all clinicians in training. They acknowledge the experience of the person without making it into an identity.
I sometimes say to patients regarding dx: "I don't care if we call it 'french toast' so long as the label helps us to identify an appropriate and useful treatment that helps you feel better and more able to live your life, then it will have served its purpose. It's just a descriptor - like having brown hair. It's not an identity."
This is really a wonderful and wonderfully-written article. I too find myself downplaying diagnosis in some cases, just as I sometimes lower expectations for medications What does this mean, that we both don't know how to define what is wrong and also don't know how medications work and why they don't work? Ugh. After years of training, I feel a little fraudulent.
Sometimes the process feels bleak. In an outpatient practice, I often have to put a diagnosis code that doesn't really fit someone because otherwise I don't get paid. I don't like having one diagnosis for the insurance and, as you say in terms of the DSM being for clinicians, a more nuanced version of this for our purposes.
Inevitably you get into trouble that way. I'm sure there are lots of medical issues not captured by the ICD, or captured only belatedly, and it is true that people also describe themselves in terms of a medical diagnosis (my diabetes, my heart condition), but psychological labels are more personally-resonant, as you describe beautifully. Thank you.
what is also interesting is that the insurance companies are not incentivized to fix this because the discipline itself (WHO,AMA,CMS) is not willing to provide practitioners and insurers mechanism-aware, intervention-aware, outcome-sensitive bridges on the billing system that rightfully connect intervention to diagnosis.
Thank you for all the historical context. I haven't seen much written about how access to supports and services also drives diagnoses. Here I am thinking especially of the rise in the prevalence of autism. Often a diagnosis of autism allows access to critical supports across education, health, respite etc., while those with similar functional needs (e.g., genetic disorder, other neurodevelopmental disorder) or those that don't quite meet criteria but would benefit from additional supports get near to nothing. Thus, clinicians are often torn as to what to do in these circumstances and often offer the diagnosis so that the families can receive the necessary supports and services. Until eligibility is based on function rather than category, prevalence numbers will remain artifacts of policy as much as epidemiology. But of course providing adequate supports will require much more investment.
I agree, prevalence numbers are heavily confounded by service and treatment access issues on the ground, and clinicians are basically using whatever diagnosis will get the service/treatment covered for the patient. It's a mess.
Thank you for this brilliant and well researched article. Currently, my DSM-5 serves as a paperweight when compressing artworks or a stand when using my EMDR machine, certainly not its intent. In the past, I, taught the DSM III, IV, IV-R and DSM-5 to my students. But in my forthcoming book (the 4th edition of The Art Therapists’ Primer ), I suggested diagnosis could use a more embodied approach, bottom up as opposed to the overuse of top-down. Over pathologizing seems to rule the day, and like Sisyphus, I await the day when this isn’t such an uphill battle.
I wonder how many DSMs are used as monitor stands...
😂
The budgetary priorities of NIMH and Tom Insel's latter day pessimism are both evidence that biological reductionism in psychiatric nosology is both prevalent and misguided. While the DSM obviously isn't a manual of biological diagnosis (e.g., "A blood level of X diagnoses schizophrenia"), the system of classification coupled the brevity of most mental health visits (in primary care or community psychiatry) results in psychopharmacologic interventions being offered most of the time (https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1784344). The diagnostic reductionism of the DSM, given our current therapeutic milieu, results in biological reductionism in the clinic and in the hospital. Although you've written about the Rumpelstiltskin effect (great paper, by the way), most patients and clinicians, once a patient is diagnosed, will obviously ask, "Now what?" and expect a pill. Hope is in the pills, or that's what our practice patterns suggest anyway.
I don't think this is true for people with mild problems (e.g., mild anxiety, mild depression), and it's desperately incomplete for people with severe problems (e.g., severe anxiety, severe depression, schizophrenia, anorexia), where medication is only a piece, and perhaps not even the most substantial piece, of a much more comprehensive set of interventions, some of which may not even be medical.
You could say maybe the DSM is better than nothing, and maybe RDoC or HiTOP will lead us somewhere better, but regardless of what diagnostic systemic we use, the culture in which we practice still engenders reductionism of one kind or another. In the world of mental health, that means responses will always be at best incomplete and at worst dehumanizing and harmful.
Not that I feel entitled to such, but I'd be curious to hear your thoughts on the PDM (the psychodynamic equivalent of the DSM) which McWilliams had a significant role in authoring. In my admittedly insular corner of the mental health world, I've found this to be as good an attempt as any at a thoughtful attempt to integrate constitutional/maturational traits and defences with psychopathology and it is what I used for the bulk of my diagnostic work. I'd like to write about this sometime, but I think I'm simply too lacking in knowledge around the comparative usefulness of the two texts.
https://eclass.edc.uoc.gr/modules/document/file.php/DEA101/Psychodynamic%20Diagnostic%20Manual_%20PDM-2-The%20Guilford%20Press%20%282017%29.pdf
I think PDM is pretty decent for psychodynamically oriented clinicians (and I'm a bigger fan of Nancy McWilliam's Psychoanalytic Diagnosis). I am planning to write about PDM in 2-3 months after PDM-3 comes out :)
"Hosts to diagnostic entities" is about as perfect an analogy as any I've found to capture the tension I feel between the usefulness of ADHD as a framework for understanding a particular way of functioning (the Rumpelstiltskin effect) and growing discomfort with the way it's increasingly framed as "essence of self".
It's the most curious mix of both completely personal (as identity), and yet completely impersonal (as something that inhabits me and therefore has nothing really to do with me).
This is a masterful exploration of the DSM’s limits and its impact on self-perception. I especially appreciate the emphasis on using diagnoses as tools for treatment rather than identity. It reminds clinicians and patients alike that labels describe patterns—they don’t define a person.
This is one of the clearest, most balanced articulations I’ve seen of what the DSM is and what it absolutely is not. As a psychologist, I’m constantly navigating that gap between “useful shared language for clinicians/insurers/researchers” and the way people absorb diagnoses as essences that define who they are.
I especially appreciated the point that all it means to “have” a DSM disorder is to meet threshold criteria for a pattern of symptoms over some period of time and that what that means for biology or self-understanding is still unsettled. That nuance gets almost completely lost in public discourse and, honestly, in a lot of clinical settings too.
Thank you so much for this article. It’s a great overview of a crucial topic.
Great read, thank you! I’m a child and adolescent psychiatrist in the UK, and something I’m often struck by is the ‘pressure’ my group seem to experience- to define themselves. Not necessarily in medical or psychiatric terms, but just generally in life. You've given me an idea that I need to write about!
Good point of comparison with ICD
No-one ever says the international classification of diseases is psychiatry’s ‘bible’, partly because it hasn’t entered the public’s consciousness, partly because it is more technical / less expansive but also because it assigns codes to both mental and physical disorders
This is very well written. I'd like to propose a much simpler explanation, what if the DSM is not serviceable? What if it simply suck? What if the reasons for that are entirely mundane and unremarkable? Groups of people produce bad work all the time, it doesn't require special explanation, nor does does require any feat of intellect to recognise a bad product.
Committees in particular are notorious for producing crap. It's a near universal experience. All of us at some point of our lives have had the experience of sitting on a committee and listening to the dumbest voices in the room shout down the only two people who know what they are talking about.
The DSM working groups function exactly the same way. They are usually made up of one or two noteworthy thinkers and the rest are there for political reasons. It's no great mystery as to why the result is a turd sandwich. Who was it that said "how many troops does the pope have?".
Kraepelin's textbook is "serviceable", the DSM is a shitshow. Call a spade a spade.
Thanks for introducing me to Ian Hacking's formulation of looping theory. It's something that repulses me about the neuro diversity movement. People seem to find their identity in, and structure it around, DSM diagnoses. Ironically, I can see that diagnosis plays a crucial role in my own self understanding, I'm just committed to being indistinguishable from "normal" people and don't tell anyone about my label. We were taught "don't treat the dsm like a cookbook" - but laypeople presume it's a collection of recipes and read it as such.
Contrary to the lead in to this blog, the DSM is, in fact, explicit that mental disorders are internal, individual, and biologically (as well as psychologically/developmentally) determined when it says they reflect a “dysfunction in the biological, psychological, or developmental processes underlying mental functioning…” and that “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”(p. 20)
As Steven Hyman said years ago, the DSM is a “fool's errand” as it has unsuccessfully struggled for decades to classify experiences and decisions that allegedly reflect underlying dysfunctions in individuals, but that have yet to be found. If such dysfunctions were found, the problem would necessarily fall within the bailiwick of neurology, immunology, or other medical specialties that have internal systems as their targets - systems that can become dysfunctional. And, as those internal dysfunctions are found (e.g., neurosyphilis), psychiatry is left with fewer and fewer targets, eventually with nothing but moral judgments about experiences and decisions, as well as their social consequences.
The fundamental and most important issue to be discussed about so-called mental disorders is whether the problems they describe are matters of pathology (not just biology). How they are classified is a different issue altogether.
You are misunderstanding the DSM reference to dysfunction as mental disorders being internal, individual, and biologically determined. Mental disorders are problems an individual is experiencing, but it is not a statement about their causes (which are both internal and external). And while DSM doesn't formally define dysfunction, in execution, it is apparent that the DSM notion of dysfunction is a very common-sensical and folk-psychological one. Dysfunction here is not a hypothesis about the existence of an unobserved brain abnormality.
I disagree. The DSM definition clearly implicates a causal dysfunction (dys = abnormal/impaired/bad) in the individual's underlying processes, not just dysfunction in terms of outward mental or social functioning or an individual sense of distress. And I'm not claiming the DSM limits it to a brain dysfunction - that is just one possibility. It also includes psychological and developmental dysfunction (whatever that is). Also, in practice, professionals and consumers readily adopt this mindset. I realize some, perhaps the two of us included, think otherwise. I agree with you that the mental disorder descriptions in the DSM are purely about "problems an individual is experiencing." But why in the world would those experiences need to be assessed, diagnosed, and treated as if they were illnesses when there is nothing to treat and the best case scenario is only palliative?
This exchange shows why the DSM problem cannot be solved at the level of classification alone. Before asking how mental disorders should be classified, the discipline has to clarify what authorizes a condition to count as pathology, what kind of dysfunction is being claimed, where that dysfunction is located, and what intervention is supposed to change. Without that prior clarification, “mental disorder” remains a classification category doing pathology work it has not earned.
Is the DSM this… “Diagnostic and Statistical Manual of Mental Disorders?” Sorry, I’m just a layman reader and the acronym isn’t clearly defined. But I’m pretty sure I’m correct.
Yes. The full name is in the opening line of the article.
Just posted this on the DSM-5, in particular how it's been elevated to a source of truth in asylum law. It's being (mis)used to define persecuted groups.
It’s safe to say that few persecutors are motivated by DSM-5-delineated distinctions. One imagines a bully releasing a classmate and saying “I’m so sorry! I didn’t realize that you had developmental coordination disorder! I only meant to beat up kids with stereotypic movement disorder.”
https://samsramblingss.substack.com/p/we-dont-need-no-stinkin-dsm-5