A Critique of the DSM1

Karl Tomm, M.D.

As a psychiatrist, I have become increasingly concerned about the inadvertent

pathologizing influence in our culture of a major psychiatric document, namely, the
Diagnostic and Statistical Manual of Mental Disorders published by the American
Psychiatric Association (APA). The impact of this Diagnostic and Statistical Manual
(DSM) has been felt far beyond the United States and continues to grow. In my
opinion, more open criticism of the document is required to enable clinicians to reflect
upon the degree they wish to buy into its assumptions and to participate in extending
or in curtailing its influence. What follows are some background comments about the
DSM and a brief listing of some of the criticisms that have come to my attention.

Background

The first edition (DSM-I) was published in 1952. It was originally intended to stabilize
psychiatric nomenclature in American psychiatry and to clarify the description of
mental syndromes. The basis goal was to encourage consistency in communication
among clinicians by officially “approving” certain diagnostic terms. The impact of
DSM–I was modest but with each new edition, the manual progressively gained more
stature.

The key change in DSM-II the second edition which appeared in 1968, was a shift
from describing mental syndromes as “reactions” (as was the case in DSM-I) to
defining mental syndromes as “illnesses”. This move aligned American psychiatry
more closely with the rest of medicine. Another focus for DSM-II was to standardize the
American classification of mental disorders in relation to the World Health
Organization’s eighth revision of the International Classification of Diseases (ICD-8).
This provided a foundation for more international acceptability and potential influence.

The changes incorporated in the third edition, DSM-III, were extensive. They included
“such new features as diagnostic criteria, a multiaxial approach to evaluation, much
expanded descriptions of the disorders and many additional categories” (p.7). The
priority became one of precision and accuracy in making diagnoses. This was based
on the medical assumption that “planning a treatment program must begin with an
accurate diagnostic assessment”. (p.7) I wonder in what direction the manual might
have evolved if, instead, it was based on a humanistic assumption like “planning a
therapeutic response must begin with empathy and compassion”. But the authors of
the manual were much more interested in empirical science than humanism. DSM-III
was to be based on “research evidence” as far as possible. Thus, in preparing the third
edition, the influence of research investigators with “objective data” increased while
the influence of clinicians with therapeutic experience decreased.

1 Published in Dulwich Centre Newsletter 1990 No. 3

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When it was finally published in 1980, DSM-III was presented to the mental health
community as incorporating the best and most up-to-date scientific knowledge that
was available. This claim, together with the illusion of objective precision, proved
irresistible for most Western clinicians and researchers. As a result, DSM-III was
widely adopted and its influence soared. It even was taken up by governments and
third party insurance agents. The 1987 revised version, DSM-III-R, acknowledged that
“the impact of DSM-III has been remarkable” (p.xviii), and went on to note that it had
already been translated into 13 languages. DSM-III-R did not depart significantly from
the basic thrust of DSM-III, it simply extended the effort to be more rigorous and
precise.

Both DSM-III and DSM-III-R claimed to be based on a predominantly “descriptive

approach”. They were purported to be “generally atheoretical”. Yet, both explicitly
articulated a strong and unequivocal individualistic bias: “each of the mental disorders
is conceptualized as a clinically significant ... syndrome or pattern that occurs in an
individual” so that “conflict between the individual and society ... is not by itself a
mental disorder”. (p.6 in DSM-III and p.xxii in DSM-III-R) The authors seemed oblivious
to the theoretical significance of their individualistic presuppositions. There was no
mention of the possibility of another point of view. They simply ignored the body of
knowledge based on an alternative assumption, namely that the human behaviour, the
mind, and its disorders, may be more fundamentally grounded in social phenomena
than individual phenomena.

Interestingly, axes IV and V (severity of psychosocial stressors and highest level of

adaptive functioning) implicitly acknowledge the importance of a person’s social
environment but both axes remain solidly embedded in individualistic assumptions. An
important anomaly in DSM-III and DSM-III-R related to this theoretical issue is that
when a situation requires clinical attention or treatment, but the evidence of social
influence in generating the mental distress is too strong to be ignored, the condition is
defined as “not attributable to a mental disorder”. Yet the “V codes” are provided to
classify it. This contradiction is one manifestation of the inadequacy of the purely
individualistic orientation to describing and understanding mental problems.

However, one of my major concerns is that there is so little cognizance of the fact that
DSM has evolved to become such an authoritative document for classifying and
labelling persons with mental problems. It has virtually become “The Bible of
Psychiatry” and is being applied religiously by “the faithful”. Most mental health
systems in North America have adopted it and in many settings it is not possible to
receive payment without submitting a diagnosis. Yet, there seems to be so little
discussion of how pathologizing this practice of psychiatric labelling is for persons who
have already been socially and psychologically traumatized.

The DSM disclaimer, that classifying disorders does not classify individuals (p.6 in
DSM-III and p.xxiii in DSM-III-R) does not hold very much credibility in my view. In
actual practice, DSM diagnoses are almost always collapsed onto the persons so
diagnosed. For instance, “a person with schizophrenia” is referred to as “a
schizophrenic”, “a person with obsessive compulsive disorder” has come to be known
as “an O.C.D.” This is often first done by professionals, then by family members,

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friends, and the public at large, and eventually by “patients” themselves.

The labelling process initiates permanent stigmatizing patterns of social interaction in

the human network of relationships in which a person so labelled is embedded. A
person, once authoritatively labelled “a schizophrenic”, is never treated the same
again in his or her social network. People simply look at him or her differently. Nor
does such a person ever see himself or herself in the same way again. These identity-
defining practices follow logically from the theoretical framework out of which the
whole DSM system arises, namely, that the disorder is in the person. What is so
frightening to me is that the clinicians, researchers, politicians, and insurance agents
who use the manual are actively promoting such human classifying practices in our
present culture. The resultant damage being done to persons and to social
relationships is enormous.

I take the published disclaimer about classifying persons as a disavowal of any

deliberate intent to pathologize and stigmatize and, hence, I cite the pathologizing
effects of the document as inadvertent. However, the fact that these effects are
unintended renders them no less damaging. What is required to mitigate the
dehumanizing effects of the document, is the courage to challenge its formidable
authority and then to take a stand against the automatic practices that follow from that
authority. If one chooses to take such a position, one needs some arguments to
undermine the authority of the DSM. What follows are some specific criticisms that I
have used to limit its influence on my own habits of thought and clinical action:

Empirical Criticisms
1. The nature of the disorder, its diagnostic criteria, and the boundaries of categories
are determined in APA committees, not by the phenomena being described.
2. DSM is unable to encompass many clinical situations (i.e. the “V” codes are
inadequate).
3. There is no provision for interpersonal, familial, cultural, or institutional “diagnoses”.

Political Criticisms
1. Constitutive “power in defining the nature of persons can easily be abused.
2 In whose interest is it to label (professionals; patients; other parties such as family
members, insurance agents, government; etc.)?
3. DSM promotes the “medical mode” and psychiatric supremacy in the mental health
field.
4. Gender bias may be institutionalized (i.e. ”Pre-Menstrual Syndrome” is being
considered for DSM-IV), as a heterosexuality bias (i.e. “homosexuality” was
included in DSM-II) with reification of traditional stereo-typing.

Humanitarian Criticisms
1. Persons are dehumanized by transforming them into subjects under the scientific
“gaze”.
2. Persons are pathologized through labelling, totalizing, and segregating.
3. DSM promotes an “orientation towards inadequacies” by attending to tragedies
and personal failures rather than an orientation towards solutions” with attention to
resources and competence.

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Pragmatic Criticisms
1. There is an overemphasis on the general syndrome and a de-emphasis with
respect to the specific experiences and personal context of the client.
2. DSM promotes a static rather than a dynamic perspective by emphasizing
permanent traits rather than transient states.
3. DSM promotes blindness with respect to the interpersonal and cultural factors that
contribute to mental health problems.
4. DSM is seldom useful in the determination of a specific treatment plan.

Ontological Criticisms
1. The basic assumption about the nature of mental phenomena seems problematic
(i.e. that mental disorders are “in the person” vs “in the interaction between the
person and the context” vs “in the coordination of interaction among persons”).

Ironic Criticisms
1. DSM fails to include the diagnosis of the “DSM syndrome” - a spiritual psychosis
characterized by a compulsive desire to objectify persons and to label them
according to predetermined psychiatric categories.
2. These “victims” of modern psychiatric ideology give priority to knowledge about
precise descriptions - over knowledge about healing interactions - as manifest by
obsessive preoccupation with pejorative adjectives, inclusion and exclusion
criteria, etc.

Karl Tomm is Director, Family Therapy Program, The University of Calgary, 3350
Hospital Drive NW, Calgary, Alberta, Canada T2N 4N1. He and his colleagues in the
Family Therapy Program are currently working on an alternative approach to
assessment based on the distinction of pathologizing interpersonal patterns (PIPs) of
interaction in connection with specific mental problems.

A brief summary of this paper was previously published in “The Calgary

Participator”, A Family Therapy Newsletter, 1990, p.2-3.