The DSM has undergone a sociopolitical, economically driven evolution since its inception in 1952 when it emerged as a diagnostic tool for physicians who framed it in the medical model. Emerging from a psychoanalytic perspective, pathology was seen to reside within the individual, resulting in expression through neurotic conflict. Subsequent revisions in 1980 and 1987 evolved toward a more firmly biopsychological perspective. In a response to insurance companies' need for increasing specificity in diagnosis, we saw an increase in the number of available diagnostic labels from 297 in 1994 to 374 in 2000. The current criterion focuses on medication management of behavioral symptomology over psychotherapy. The primary elements that have survived all revisions are the intrapsychic focus and the power of political and economic agendas. Many clinicians are unaware that the DSM is more political than scientific, that there is little agreement among professionals regarding the meaning of vaguely defined terms and that it includes only scant empirical data.

The constructors of the DSM point to the following positive uses for its system of psychiatric diagnostic codes: It can be helpful for clinicians and mental health practitioners as they construct treatment plans, especially evidence based treatment plans. It provides a consistent structure and vocabulary for professionals, which helps with communication and collaboration. It can facilitate continuity of medical care and collaboration between professionals of varying treatment modalities. It is consistent with many forms of current medical record keeping. It can facilitate unified data collection for survey, pharmacological and other research purposes. It can be instrumental for the compilation and retrieval of statistical health information. It simplifies the reporting of unified data to interested third parties, such as the World Health Organization and insurance companies.

Diagnosis of physical problems is obviously extremely helpful. In principle, psychiatric diagnosis can be helpful as well. Unfortunately, psychiatric labeling has been developed and applied in biased ways and has resulted in more harm than good.

[Since the article is copyrighted, I'll stop there. The best part of the article is the next part, though: a list of concerns about DSM diagnoses!]

Here are some thoughts...

He seems like to me that he is not really criticizing the DSM model itself, rather than it's abuse and power an untrained psychologist or therapist may give it.

Things like his list of traits that MAY be translated to a certain disorder incorrectly is an example of this. It was said a few times that psychology is not an exact science, and anyone who has done any amount of research into psychology can attest to this. I think this is why there are "good" therapists and "bad" therapists. If you see someone for the first time and walk away with a diagnosis, that's not a good thing.

I think the DSM has some good information in it, but providers should understand that it is a guide, a TOOL, not a crystal ball with all the answers. It is up to the clinician at that point to pull out the relevant data, and based on their education create care plans that would best serve that particular client. A psychologist who uses only one method of treatment for any patient diagnosed with any one disorder has no business practicing. I would like to think this is the industries perception as well.

I think the list of pro's seemed pretty accurate. I would like to see a pharmaceutical company treat anxiety related to compulsive habits. Not to cure, but to help the body coincide more with what the mind wants and is resistant to. I don't think it's a bad thing, and I would trust a trained physician to make the call with me whether or not, in MY case, it would be appropriate. I think it's true that if pharmaceutical companies were able to claim that a drug would "cure" any ailment or disorder based on symptoms alone, we'd be in trouble.

As for the politics, I think that goes with anything in life. Any governing agency that sets parameters and standards are going to be subject to influences. I believe that is just the way it is due to the fact we are human. If a removal of the disorder of homosexuality was influenced by a protest, I think the homosexual community may revel in that as a victory; as their voices being heard. I for one feel it's a shame it was ever in the DSM, and maybe that's the original intent, but again... we are human and at one point, the ruling was in the majority that it was. Hopefully what we can learn from that is when he know more, we do better, and we can listen to progress as it comes marching to our door.

I think the comparison in medical diagnosis may be a little over exaggerated. Far too many times, even medical diagnosis is not accurate despite the blood work, x-rays, and CT scans. Again, those are just tools for a trained provider to use in assisting treatment. A scalpel, like the DSM can do just as much damage to the untrained person. Nothing is guaranteed when we turn over much of our health, mental or physical to trusted people who we rely upon to make decisions based on information that we may not have.

I applaud his outlook on how it can be abuse, when used inappropriately, and why other factors need to be considered, but I'm not sure if it deserves criticism. Modification, education on it's use, and people giving it it's fair weight in salt sound like better alternatives to me.

I know this will sound weird, but I like having the label. It gives me something to focus on, as a real issue and not being a "psychological anomaly." It normalizes me, despite a label being thought of as generally bad because it excludes, but for me I find comfort in that I am so not alone, it is worldly recognized.

I do like his principles, and I really love his attention to detail and client centered therapy though :)

some personal feelings about diagnosising:

As the diagnosises and the perscriptions came in for my niece I mentioned my concerns and observations of a type of Maunchousen syndrom possible in my sister. My brother in law affirmed that when they went to the pychyitrist the primary thing they went on was what the parents were saying.

So for instance when I saw my neice start to lose it as the clutter took over her house and she had no clear surface to study on she was so articulate and caring and personable in those days (and when she was hosptalized - she said it was two things; her parents fighting and the house clutter) so nothing happened on those fronts and my sister began to get very loud about my niece having ADHD and since it was genetic no cure, she bought tons of books said she was champaning for disabled childrens rights, even though her teachers were insisting that she was alright. (one day I was over she had my niece on the bed doing homework and it was like my sister was taking over ... I knew it wasn't good for my niece) I watched it all happen -- my sister fought for diagnosis and then the diagnosises started to happen ADHD, possible (the social skills one) then bi - polar and that came with all the medicines. One heart breaking evening was when I was with my niece and she told me the names of her diagnosises. I wanted to get involved but who could I talk to.

If someone had just listened and got her into a clutter free zone and away from the fighting when she articultated that that was what she needed by focusing on the parents' problems... How healthy would she be today?

maybe it's not this easy of course it's not but I really believe there is something to this.

Good points. The problem I see--for example--are when any patient who becomes quarrelsome or resistant is punitively called "a Borderline." This is especially prone to happen to women. I also saw the hospital where I used to work manipulate diagnoses specifically to correspond to insurance payout rates. If a company would pay for Major Depression but would deny PTSD, guess which diagnosis the patient got? I have a friend whose son has Reactive Attachment Disorder in every possible obvious criteria, but his psychometrist ran tests and even though the tests supported this she ruled out RAD in favor of "adjustment disorder" because she could get paid for a longer period of treatment.

No doubt it can go awry. But what about those who are genuinely diagnosed with ADHD? They are probably glad to have a "label" only because it may allow for medication to be more accepted for them and others. Say for instance you had a child who was in fact ADHD and exhibiting all the classic signs and symptoms. The diagnosis is made and the child received treatment and medication to help him/her study better and make better connections with others. Now say there is another child who is exhibiting the same symptoms, but there is no diagnosis. So the child is not treated with medication because no physician will medicate a child for "out of control" behavior. The only one that is hurt in that situation is the child.

I feel for your niece. It also sounds like your sister rallied enough support to convince people. Yes, parents are often times consulted more than the kids which can be a problem, but often times kids don't have the maturity or life skills to step back and realize what they are experiencing is abnormal, or the other way around. Sometimes things that aren't "fair" in life is just life and can't be fixed. Not that this is what happened to your niece, but it leans credence to why some providers listen to parents for a large portion of it.

Again, it seems like to me it wasn't the diagnosis fault, rather than the providers who issued them willy nilly!!!!

Ethical question:

Would you rather be diagnosed with PTSD and not receive treatment or be diagnosed with Major Depression and have all visits covered. I vote for the MD. It's not right to lie, but then again, it's not right for insurance companies to make those calls either. If what one diagnosis vs another says about me on paper doesn't change the way my T focuses our treatments, I could care less. Now... if he told me I had MD, and I didn't, that isn't right. And if both are covered, but he gets paid more for one vs another, again... NOT COOL.

But in this crazy insurance driven world, I'll take treatment over non-treatment if it's a matter of paperwork.
Either way you slice it, there's always the potential for injustice and fraud.

From the start of the link:
-- Because most undergraduate, graduate and postgraduate courses uncritically present the DSM as an objective scientific document, this summary focuses exclusively on the rarely acknowledged critical view. ---

It seems to me this is the heart of the problem: that courses _uncritically present_ .... How can you really use any tool properly if you don't know its limitations?

Sadly, for all the training in cognitive therapy, if large numbers of therapists are in fact taking DSM at face value, apparently therapists are not being taught to .... think. Sigh.

I remember in college reading several articles about the limitations of DSM III, I think, as part of the reading in my Abnormal Psych class (c. 1995). They touched on many of the issues raised by Dr. Zur, although I think they were a bit less cynical about the reasons for wanting reliable diagnosis. Academics and researchers need reliable categories too, not just pharmaceuticals looking for the next big drug hit.

This approach was the norm for my school. In course after course we were taught to think about and deconstruct information, not swallow it. I really wish more people were exposed to that sort of education.

I wish this not just because it is good academically, but because I think it is actually a critical element in good counseling. The ability to listen, question, and not take things at face value would surely lead to better diagnosis. It would also lead to better treatment. Few people are neatly textbook.

Given those two choices, then of course--cover me. But the larger ethical question applies not to the psychiatrist, but to the insurance company: it ought to be unethical to selectively discriminate against some diagnoses out of profit consideration. Since profit drives the process, both the insurance provider and the treatment agency have to tapdance, while pretending this is all on the up-and-up.

Here's another scenario: some treatment programs discovered that certain diagnostic codes paid so well that they were given to patients who didn't need them, purely to earn money for the treatment company. When a patient requires a psychiatrist's discharge note to return to work, she is hostage to that doctor's sole discretion. I once saw a woman sit in treatment for four months, with NO mental health needs, because her doctor found she could collect continued payments as long as the patient was still in treatment. So she sat, bored, day after day so the company could collect the insurance payment. (anyone wanna guess which former employer of mine this was? come on--betcha can't!)

Then there was the other side: patients who were clearly in crisis were denied coverage by their insurance companies, and promptly discharged. Since this is absolutely unethical, the summary on the discharge paper was contrived to state: "Patient has competed treatment plan goals and is sufficiently stable to continue treatment in a less-restrictive setting." By linking discharge to stability (even though it was a lie) rather than economics, the whole thing became perfectly ethical! (Anyone want to guess which former employer of mine did this?)

Oh, how I wish I could have practiced in Canada, where a client can get as much or as little therapy as she needs, without having to dance through diagnoses to get it!

-- Would you rather be diagnosed with PTSD and not receive treatment or be diagnosed with Major Depression and have all visits covered. --

From a pragmatic point, I think most people would just want whatever diagnosis was covered. But honestly, I think such diagnosis fudging trades short term gain for the people directly involved (patients, providers) for long term loss of general good.

Those categories are also used to select sample populations for research. It really messes up research when a sample population that is supposed to be homogeneous is in fact heterogeneous. In the long run people who really have major depression suffer. Treatments that DO work for them look like they fail because half the sample was really PTSD and the treatment didn't work for them. If enough studies are muddied this way, the treatment doesn't get covered.

Agreed on the insurance. I think it's disgusting the power they get to discriminate against their CUSTOMERS, people who pay their premium to be covered in all aspects of health. I don't know how they have that power. I am completely ignorant in those matters, but I think they need to be governed better because in my opinion, when a company takes money for services, and fails to deliver those, it is theft.

The tap dance you mentioned sucks. On the other hand, when the client needs the coverage for treatment to be protected from the insurance companies, I say... dance your heart out, lol. When mental health providers are given the lee way for those variances, or take upon themselves, there will always be those out there who use their discretions for personal gain. It's just sad... and not right.

I think bottom line, I have to say I am glad that therapists have the discretion to mold and fit their treatment to their clients needs and not stick to the DSM (well... not those in OK), but it takes a good therapist to really know how to do that. I think it's not a bad idea to have DSM as a reference, but not as a bible.

One of the reasons I started the "social support group" for survivors was to continue continuity of care for those who had been "economically discharged" while still hurting, but the other was so that they could interact in positive ways that were deliberately off the "clinical books." That wasn't for the intent of being sneaky--heck, we had a newsletter!--but so they could converse openly without ever having to fear that what they were saying would wind up in a lifelong medical record accessible to reviewers in cubicles somewhere.

I do worry that the diagnosis-per-payment routine may backfire in the long-run by flagging a person as having a diagnosis that may not be wholly accurate. that might eventually divert her off into channels of care that aren't a fit to her needs. Sure, a MD replacement for PTSD pays in the short term, but when she needs real PTSD treatment later on her medical records no longer support the clinical evidence of need. She'll be referred to specialists in depression, while her trauma isn't addressed by qualified persons.

The other hindrance to care was that during weekly insurance reviews, we had to prove that the patient was in such critical need that insurance was obligated to pay for another week. That meant we couldn't demonstrate that her treatment was working...no, that was NOT what would convince a company to pay for next week's sessions. Rather, we had to make a convincing case for how BADLY she was doing, how terrible crucial it was to continue treatment OR ELSE. If therapy was working, as evidenced by any improvements in her crisis, that was grounds for discharge! So ironically, we were in a better financial position when our therapy seemed to be just terrible, producing no results. Any spectacular breakthroughs worked against us. And we wonder why it's so hard to find a great therapist! The financial incentive is to be poor, not effective.

One of the reasons I started the "social support group" for survivors was to continue continuity of care for those who had been "economically discharged" while still hurting, but the other was so that they could interact in positive ways that were deliberately off the "clinical books." That wasn't for the intent of being sneaky--heck, we had a newsletter!--but so they could converse openly without ever having to fear that what they were saying would wind up in a lifelong medical record accessible to reviewers in cubicles somewhere.

I do worry that the diagnosis-per-payment routine may backfire in the long-run by flagging a person as having a diagnosis that may not be wholly accurate. that might eventually divert her off into channels of care that aren't a fit to her needs. Sure, a MD replacement for PTSD pays in the short term, but when she needs real PTSD treatment later on her medical records no longer support the clinical evidence of need. She'll be referred to specialists in depression, while her trauma isn't addressed by qualified persons.

The other hindrance to care was that during weekly insurance reviews, we had to prove that the patient was in such critical need that insurance was obligated to pay for another week. That meant we couldn't demonstrate that her treatment was working...no, that was NOT what would convince a company to pay for next week's sessions. Rather, we had to make a convincing case for how BADLY she was doing, what mayhem she was suffering, how terribly crucial it was to continue treatment OR ELSE. If therapy was working, as evidenced by any improvements in her crisis, that was grounds for discharge! So ironically, we were in a better financial position when our therapy seemed to be just terrible, producing no results. Any spectacular breakthroughs worked against us. And we wonder why it's so hard to find a great therapist! The financial incentive is to be poor, not effective.

Insurance companies can sure make your life a living hell...

Can I just say that insurance companies in their wisdom can cause reinjury? I had issues with my insurance company. They really botched a hand-off to someone else who was now handling mental health. My therapist ended up out of network even though she kept trying to stay in the network. I wrote a complaint letter about the insurance companies services.

Next thing you know, someone is reviewing my case and questioning my therapist on her treatment of me.

They have so much power.

And what is it about that PTSD diagnosis? They truly do want to cover much less with that. Yet, you have a trauma to the brain. I just sat in tears about that one. What in 6 months.. I am supposed to get over a many, many years of many types of traumas? Yet, if I went in with an arm that was severely damaged the treatment would not be handled the same.

I don't get it.

<<<The DSM focuses almost exclusively on individual pathology to the dangerous minimization of social and environmental factors such as poverty, racism, sexism, classism, heterosexism, ageism, violence, etc. This limiting focus has serious ramifications:

* Therapists, who uncritically follow the DSM medical model, are likely to place undue emphasis on individual emotional problems as causal factors rather than opening to the larger possibility that the individual is symptomatic due to familial, political or societal system dysfunctions.
* Social psychologists call such exclusion of social factors and excessive focus on individual pathology the "fundamental attribution error."
* The focus on individual pathology leads to individual based treatment, suggesting that the DSM markets the concept of individually and biologically based social discomfort.>>>

This is important. This is what I was trying to say earlier. What's the difference in saying someone is ADHD and bi polar as opposed to this child who was perfectly capable of focusing is now having an increasingly difficult time focusing due to an increasing wall of clutter in her house that is frightening her not leaving a pathway in the house and no table surfaces. The environmental conditioning is causing the problem not something she was born with.