Written by: Caitlin Saliba
Edited by: Holly Paik
The classification of psychopathology, or mental disorders, is a field that is highly convoluted, complicated, and without an exact answer. The current nosological (i.e., classification) system used by the field of psychology in the United States is the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The field currently uses the fifth edition of the manual which was published in 2013, with the book’s history stretching all the way back to 1952 when the American Psychiatric Association published the first DSM as a variant of the sixth International Classification of Diseases Manual (ICD-6; “DSM History,” n.d.). Despite the praise it receives for being an “essential educational resource” that is “accurate” for diagnosis and treatment (American Psychiatric Association, 2013), there are a number of issues that underlie both the approach to the DSM’s conception as well as its reliability and validity in the diagnostic field. More specifically, the DSM’s rather subjective approach combined with its use of categorical diagnosis over that of the dimensional type are factors that greatly hinder its nosological accuracy and reliability within the field of psychology, along with the striking lack of diversity seen in the manual’s creation.
The DSM was originally created in 1952 by the American Psychiatric Association, with the original goal to make a unified, cohesive system for the diagnosis and treatment of psychopathology. This unified approach was based on the classification systems used throughout the United States: the Insane Asylum System, the systems of the Army, the Navy, the Department of Veterans Affairs (VA), and the American Prison Association’s classification system (Surís, 2016). Since the first publication of the manual, the DSM has grown in reputation and topical coverage, with the DSM-5 including 541 mental disorders as compared to the 128 covered in the first edition (McDanal, 2022). Despite this apparent growth, the issues that are sewn into the DSM’s creation still persist today in the newest edition, causing an upsurge of new nosological approaches such as the RDoC, HiTOP, and Network Analysis Approach in an attempt to fix these issues.
Perhaps the biggest challenge for the DSM is its categorical conceptualization of mental disorders. In other words, the DSM conceptualizes psychopathology as being either present or not present– one cannot have a “mild” or “severe” version of a given disorder, only the disorder itself. Despite this conceptualization being the only one utilized by currently implemented nosological manuals (ICD & DSM), the categorical approach is quite a poor fit to the actual nature of mental disorders. During the diagnostic process, patients are screened for endorsing specific criteria that are known to be symptoms of a certain disorder. Based on the number and kinds of symptoms endorsed by a patient, a diagnosis is either made or not made. The issue with the categorical system arises from the fact that there are no concrete or existing cutoff points for any disorder, and that threshold between non-disordered and disordered behavior is, at best, arbitrary. This being the case, such cutoffs are decided by the expert clinicians behind the manual itself, making this vitally important threshold based entirely on subjective personal opinion. These arbitrary cutoff points not only make treatment more difficult, but also call into question the validity of the disorders defined by the DSM (Hofmann, 2014). Many proponents of systems such as the HiTOP emphasize the shortcomings of the categorical system, instead advocating for the use of statistical measures and objective data to create less restrictive, dimensional categories.
While there are attempts by proponents of the manual to point out strengths of the DSM, with just a bit of research it doesn’t take one long to realize that these “strengths” aren’t as positive as they may seem. Perhaps the best example of this is the claim by supporters of the DSM that its extensive use of clinical field work and input from experts is something that makes it highly reliable and free of bias. In particular, many often cite that the DSM III had the combined work of over 800 clinicians (Spitzer et al., 1980). However, there are considerable issues that interfere with this claim. While it is entirely true that the DSM utilized high numbers of clinicians in the creation of the third edition of the manual, it is equally true that a vast majority of these clinicians were white males. Although the sheer number of contributors certainly makes for a manual with high inter-rater reliability, it does nothing to eliminate the bias that comes with the background of the researchers. This is not a fact that is hidden by the current field of psychology, either– many researchers from prestigious organizations such as Stanford aren’t shy to speak out on the massive racial bias issue that underlies the field of psychology (DeWitte, 2020).
Although many don’t realize just how new the established field of psychology may be in comparison to other disciplines, it remains true that there is much to be learned and improved upon for the way that we classify and diagnose psychological disorders. With the development and rigorous testing of new classification systems such as the HiTOP and RDoC, we are growing closer to a more objective, accurate, and overall reliable method of diagnosis that would benefit patients across the world. By looking at psychopathology as objectively as possible (where logical to do so), we are able to eliminate personal or cultural biases, the arbitrary cutoff points all too common in categorical classification, and improve the diagnostic accuracy of disorders. Furthermore, there are a plethora of programs and incentives that help people from a wide variety of backgrounds to enter more easily into the field of psychology in an effort to mitigate the lack of researcher representation skewing the literature. The DSM, while useful in many lights, has many shortcomings in the fields of objectivity and dimensionality, and with the further development of other organizational or classification systems– to then be combined with and used in tandem with more subjective DSM measures– we are able to best capture the true nature of psychopathology.
References:
American Psychiatric Association. (2013). Preface. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
De Witte, M. Stanford University. (2020, June 25). Psychological research has a racism problem, Stanford scholar says | Stanford News. Stanford News. https://news.stanford.edu/2020/06/24/psychological-research-racism-problem-stanford-scholar-says/
DSM History. (n.d.). https://www.psychiatry.org/psychiatrists/practice/dsm/about-dsm/history-of-the-dsm#:~:text=The%20APA%20Committee%20on%20Nomenclature,to%20focus%20on%20clinical%20use.
Hofmann, S. (2014). Toward a Cognitive-Behavioral classification system for mental disorders. Behavior Therapy, 45(4), 576–587. https://doi.org/10.1016/j.beth.2014.03.001
McDanal, R. (2022). DSM and its Benefits [3-9]. Psychology Department, Stony Brook University.
Surís, A., Holliday, R., & North, C. S. (2016). The evolution of the classification of psychiatric disorders. Behavioral Sciences, 6(1), 5. https://doi.org/10.3390/bs6010005
Spitzer, R. L., Williams, J. B.W, & Skodol, A. E. (1980). DSM-III: The Major Achievements and an Overview. Am J Psychiatry, volume 137 (issue 2), 2.
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