A Psychiatry Research paper describes how researchers found many inconsistencies and contradictions in the Diagnostic and Statistical Manual of Mental Disorders, which is now in its fifth edition (DSM-5).
Researchers from the University of Liverpool and the University of East London, both in the United Kingdom, examined the “heterogeneous nature of categories” in the DSM-5.
They conclude that the lack of uniformity that they found across key chapters of the DSM-5 “has important implications for research, clinical practice, and the provision of care that is specific to a person’s individual needs.”
“Although diagnostic labels create the illusion of an explanation,” says lead author Dr. Kate Allsopp, of the Institute of Psychology Health and Society at the University of Liverpool, “they are scientifically meaningless and can create stigma and prejudice.”
The DSM-5 is a widely used diagnostic bible of mental health. For example, in the United States, mental health professionals use the DSM-5 for the “standard classification of mental disorders,” according to the American Psychiatric Association, which publishes the volume.
Dr. Allsopp and colleagues analyzed five chapters of the manual, covering: “schizophrenia spectrum and other psychotic disorders; bipolar and related disorders; depressive disorders; anxiety disorders; and trauma- and stressor-related disorders.”
‘Subjective judgment of what is normal’
The team found a high degree of inconsistency and contradiction within and across the diagnostic categories of the DMS-5.
A key finding was that, while no two psychiatric diagnoses use the same decision-making rules, there is much overlap of symptoms between them.
The researchers also observed that diagnoses don’t say much about the individual and which treatment could be most helpful.
Furthermore, they found that nearly all diagnoses underplay the impact of trauma and distressing events.
“By making reference to trauma or stressors only in one dedicated chapter,” the authors point out, “the DSM-5 implies that other diagnostic categories are unrelated to trauma.”
Even in the chapter that relates to trauma and stressor disorders, it appears that, despite having a specific trauma component, the experiences assessed “are seen as symptomatic of a disordered or inappropriate response to that trauma.”
“The diagnostic system,” says study author Peter Kinderman, Ph.D., a professor of clinical psychology at the University of Liverpool, “wrongly assumes that all distress results from disorder and relies heavily on subjective judgments about what is normal.”
Contrast among specific and flexible criteria
The recent analysis is not the first to criticize the value of psychiatric diagnoses and the DSM-5.
The study authors write that other researchers have observed that the DSM-5 has “almost 24,000 possible symptom combinations for panic disorder,” compared with just one combination for social phobia.
There is a marked contrast between diagnostic criteria that are highly specific and those “with more flexibility around symptom presentation,” they note.
Other studies have also reported a considerable lack of uniformity “within the criteria of individual diagnoses” in both the DSM-5 and earlier editions.
Using these criteria, for instance, it is possible for two people to receive the same diagnosis without having any symptoms in common.
Need to ‘think beyond diagnoses’
It would seem that a key part of the researchers’ message is that, while diagnostic models can help psychiatrists exercise “clinical judgment,” they can also get in the way of understanding the causes of mental distress.
For instance, they write that “By focusing on diagnostic categories, individual experiences of distress and specific causal pathways may be obscured.”
This could lead to an emphasis on reducing symptoms “seen as inherently disordered, such as voice hearing, rather than on removing only the distress associated with the experiences.”
This also results in unhelpful diagnostic labeling, in that “labeling distress as abnormal may in itself create further distress.”
The authors call for a more “pragmatic approach to psychiatric assessment, which allows for recognition of individual experience,” as it could be “a more effective way of understanding distress than maintaining a commitment to a disingenuous categorical system.”
“I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.”
Dr. Kate Allsopp