Criticisms of the DSM Development Process

Another short piece written as a Focus Point for the second edition of my Psychopathology textbook (due to be published late 2013).

DSM regularly undergoes an intensive revision process to take account of new research on mental health problems and to refine the diagnostic categories from earlier versions of the system. One would assume that this would be a deliberate and objective process that could only further our understanding of psychopathology, and that is certainly the intention of the majority of those involved. However, at least some people argue that the process of developing a classification system such as DSM can never be entirely objective, free from bias, or free from corporate or political interests. Allen Frances and Thomas Widiger were two individuals who were prominent in the development of the fourth edition of the DSM, and they have written a fascinating account of the lessons they believe should be learned from previous attempts to revised and develop mental health classification systems (Frances & Widiger, 2012). They make the following points:

1.         Just as the number of mental health clinicians grows, so too will the number of life conditions that work their way into becoming disorders. This is because the proliferation of diagnostic categories tends to follow practice rather than guide it.

2.         Because we know very little about the true causes of mental health problems, it is easier and simpler to proliferate multiple categories of disorder based on relatively small differences in descriptions of symptoms.

3.         Most experts involved in developing DSM are primarily worried about false negatives (i.e. the missed diagnosis or patient who doesn’t fit neatly into the existing categorizations), and this leads to either more inclusive diagnostic criteria or even more diagnostic categories. Unfortunately, experts are relatively indifferent to false positives – patients who receive unnecessary diagnosis, treatment, and stigma – and so are less likely to be concerned about over-diagnosis.

4.         Political and economic factors have also shaped the ‘medical model’ view of psychopathology on which DSM is based, and also contributed to the establishment and proliferation of diagnostic categories. For example, the pharmaceutical industry benefits significantly from the sale of medications for mental health problems, and its profits will be dependent on both (1) conceptions of mental health based on a medical model that implies a medical solution, and (2) a diagnostic system that will err towards over-diagnosis rather than under-diagnosis (see Pilecki, Clegg & McKay, 2011).