I wrote another thingadoodle for my abnormal psych class. The prompt was “How is the DSM IV a vital tool in the diagnosis and treatment of mental disorders? How is it an obstacle to the diagnosis and treatment of mental disorders?”.
In the Biblical story of the Tower of Babel, the Judeo-Christian god interferes with the attempts of mankind to build a temple that reached to the sky (now believed to be a Babylonian ziggurat) by inflicting a curse upon the men building the temple. The curse was that of individual language; by causing each man to speak and understand only his own language, they were no longer able to collaborate and finish the complex task of constructing the temple, and it was abandoned. This story speaks to a basic truth of mankind: collaboration requires that we have a shared understanding of one another. The DSM-IV is our current best attempt at achieving this shared understanding in the field of mental health.
By standardizing the definition of known mental illnesses, the DSM IV allows doctors and mental health professionals to speak the same language. When a clinical psychologist says depression, a psychiatrist knows something meaningful and tangible about the mental state of that patient, allowing her to adjust her treatment strategy in a manner that will, more often than not, better address the issues at hand. The psychiatrist is not strictly bound to this diagnosis – a wise psychiatrist will understand that a patient’s entire past, present, and future cannot be summed up in a single diagnosis, that the diagnosis may change, or that the original diagnosis may not have been accurate. This is the challenge that all doctors face – how trustworthy was the analysis of this patient’s previous doctor? Were all of the appropriate tests performed? Did the nurse perform the tests accurately? Human error exists at every step of the way, and it is part of the job of men and women in the field of medicine to use good judgment, taking into account all of the available evidence.
Still, today there is no controversy in pointing out that the DSM IV is imperfect, and that its flaws have created, for some individuals, more problems than solutions. Temerlin (1968) illustrates this all too well: if told that an individual is psychotic, the majority of psychiatrists will then see that individual as psychotic, regardless of the individual’s actual behaviors. Similarly, Rosenhan (1973) demonstrated that individuals placed into institutions have vanishingly slim chances of being correctly identified as healthy, once inside. Clearly, we run a serious risk when we cease to consider patients as individuals, but seek only to compare their behaviors to symptoms. With one hand, the DSM resolves many problems, but with the other, it creates dangerous traps for doctors and mental health professionals to fall into.
Such is the way of progress. The DSM is necessary to ensure consistency and accuracy between diagnoses, and it also serves to bring legitimacy and recognition to disorders the surrounding culture may not be willing to accept as true disorders. Autism, for example, has historically often been lumped together with other disorders such as mental retardation and schizophrenia (even including in the DSM-I and DSM-II). Although it wasn’t until 1980 that autism was granted its own classification in the DSM-III, this marked a change in how the mental health fields would treat autism. No longer could it be placed incorrectly alongside fundamentally different conditions – it would now demand diagnosis on its own terms, and treatment could now be more accurately directed.
The DSM is a powerful tool. Like all tools, it can be misused, abused, and completely misunderstood. Despite this, it manages to create the potential for mental health professionals to communicate with a common vocabulary, to justify diagnoses using accepted criteria, and to identify unknown illnesses through the recognition of defined symptoms. Without this, psychology could never be a legitimate entry into the field of medicine, but would be relegated to postulation and pseudoscience.
Rosenhan DL (January 1973). On being sane in insane places. Science, 179(4070), 250–8.
Temerlin, M. (1968). Suggestion effects in psychiatric diagnosis. Journal of Nervous & Mental Disease, 147(4), 349-353.