THE DSM
The Diagnostic and Statistical manual of mental disorders (DSM) is published by the American Psychiatric Association. Its purpose is to enable those in the health sector to communicate using a common diagnostic language. Its predecessor, the Statistical Manual for the Use of Institutions for the Insane was published in 1917, which had the main aim of gathering statistics about mental disorders across mental hospitals. During WWII the U.S. Army developed a much broader classification system in order to treat outpatient servicemen and veterans. At this time the World Health Organisation was constructing the sixth version of ICD (International Statistical Classification of diseases) which was the first edition to include a section devoted to mental disorders. ICD-6 was largely influenced by the work of the U.S Army (and the Veterans Administration). In 1952 the APA committee on Nomenclature and Statistics developed a variant of the ICD-6 that was published in 1952 which was the first edition of the DSM. As research and studies have developed understanding of mental disorders newer versions of the DSM have added an increased number and updated list of mental disorders, and improved clarity and specificity through the development of a multi-axial diagnostic system.
The DSM currently has 5 axes. The 5 different axes relate to different aspects of the disorder. A patient is diagnosed by navigating the axes to categorise the patient using the symptoms they are experiencing. Axis 1 looks at clinical disorders which may be present, such as major mental disorders, developmental disorders and learning disorders. These would require some form of immediate attention from a psychiatrist. Axis 2 looks at underlying personality conditions which may affect treatment such as mental disorders. Axis 3 considers medical and physical conditions such as heart issues or diabetes, which may also have an influence on the treatment given. Axis 4 focuses on psychosocial and environmental factors which may be affecting the disorder and Axis 5 gives an assessment of global functioning which is a scale of 1-100 used to rate the social, occupational, and psychological functioning of adults.
The main benefit of the DSM is that it provides a detailed account of mental disorders offering information which can aid the treatment of patients, through supporting psychiatrists, and others who wish to help a person with a disorder. The DSM is also responsible for bringing conditions into the public eye and influencing clinical guidelines. Previous versions of the DSM were arguably responsible for making certain conditions better known in the UK, such as attention deficit hyperactivity disorder and borderline personality disorder. The manual is developed using current and widely accepted research, which can give patients confidence that their diagnosis is likely to be accurate rather than simply the subjective opinion of a healthcare professional. The UK mental health charity Mind, support the DSM, making the point that once a patient receives a diagnosis, as well as receiving appropriate treatment, they will have greater access to other support and services, including legal and financial benefits. In certain circumstances a DSM diagnosis can be crucial for a person with a disorder, to protect them in a legal court, for receiving health insurance, or financial support allocated by the government. For example many insurance carriers consider treatment of mental health disorders to be medically necessary and will provide coverage. Without a DSM-IV diagnosis, counselling and medication may not be considered by insurance companies for payment, as it can be considered an elective service. The British legal system protects those who suffer from certain mental disorders from certain crimes as a person may not be fully in control of their actions due to a disorder and should therefore be exempt from the sanctions that would be given, if they did not have a disorder. Although a valid DSM diagnosis enabling a patient to receive beneficial and deserved support in their country’s legal system and from their health insurance is clearly a positive outcome, there is room for ethical debate around the issues that can be caused by the power and perceived importance of a diagnosis. For instance a person could suffer from a mental disorder, but they may not fit well enough with the specific requirements of the DSM, and therefore may receive no deserved financial support or legal protection. There is also the possibility that these systems can be manipulated. Criminals may attempt to receive a more lenient sentence by playing up to characteristics of a disorder documented in the DSM. However this is not a direct criticism of the DSM itself, but rather challenging its role in certain societies. Another advantage of the DSM is its contribution to further research of mental health. Attempting to collate together all that is known about mental disorders exposes which areas we know the least about, or which areas need urgent research. The objectivity of the DSM also makes it easier to operationalise the independent variable in some studies, as generally patients will fit into a certain category.
A common accusation of the DSM is that it unhealthily “medicalises” "patterns of behaviour and mood that are not considered to be particularly extreme. Many who hold this view believe that the large pharmaceutical transnational corporations are responsible for this, as they will make more profit; the more medication is being prescribed and they are thought by critics to tailor the DSM to meet their needs during its revision process. A 2011 article in the Psychiatric Times pointed out that 67% of the task force (18 out of 27 members) had direct links to the pharmaceutical industry, however the DSM taskforce responded to this, stating that “not only is close co-operation between researchers and industry to be expected, it is also “vital to the current and future development of pharmacological treatments for mental disorders”. In the latest edition of the DSM (DSM V) many critics have been concerned by the lowering of diagnostic thresholds for certain disorders, and that these changes may result in inappropriate treatment of vulnerable populations. For example in previous versions of the DSM definitions for major depressive disorder have specifically excluded a diagnosis of Major Depressive Disorder if the person was recently bereaved. This exception has been removed in DSM-5 and organisations have argued that the DSM-5 is in danger of "medicalising grief". The argument expressed is that grief is a normal, if upsetting, human process that should not require treatment with drugs such as antidepressants. Some critics believe that the DSM’s approach to treating mental health is fundamentally wrong. “Splitting a disorder into a list of symptoms makes it reductionist; a holistic approach may be more valid” - “Not even death is so clear that we can definitively operationalize its definition. In the field of mental disorder, which is murky and uncertain at best, this is even more true.” However it is arguable that it is better than any other resource that is currently available, while general scientific understanding of mental health has a long way to develop. Other criticisms are that diagnoses lead to labelling, and can cause self-fulfilling prophecy. A patient may then see themselves as their diagnoses portrays them and act as they are expected to, meaning that they may not respond to treatment as they may continue to show symptoms as they believe it is how they are expected to act.
In the context of diagnoses reliability means that all clinicians would make the same diagnosis when presented with the same symptoms. If different clinicians would not give the same diagnosis then the diagnoses would not be reliable and this could compromise the treatment of a patient. In Goldstein’s 1998 study, DSM III was tested for reliability. Using DSM III, Goldstein re-diagnosed 199 patients who had been previously diagnosed using DSM II, by different clinicians. The study strongly supported the case that the DSM is reliable as the large majority of the 199 original diagnoses were confirmed by Goldstein’s re-diagnosis. A few differences were to be expected due to the changes made from the DSM II to the DSM III. Goldstein further tested the reliability of the DSM III when she asked two experts to re-diagnose a random sample of eight patients to show that her findings were not influenced from bias caused by her awareness of her own hypothesis. The two experts also had a high level of agreement and inter-rater reliability. (Brown et al.2001) also carried out a study which tested the reliability of the DSM however, Brown’s study tested the DSM IV. Two independent interviews were carried out by different clinicians with 362 outpatients in Boston, USA who had anxiety and mood disorders. The researchers found that most of the DSM IV categories showed good to excellent reliability, with inter-rater reliability. However findings did suggest that there were boundary problems for disorders such as generalised anxiety disorder and major depressive disorder and that it was difficult to diagnose disorders close to the boundary, which is a significant reliability issue as this may lead to different clinicians diagnosing patients with different disorders which could affect the treatment they would receive.
When discussing diagnoses, a valid diagnosis is one that can result in successful treatment of the patient, and any other person who presents the same symptoms. It should be noted that if the DSM is not reliable then it cannot be valid because if different diagnoses were made for the same patient then the DSM cannot correctly be measuring what it aims to. Three types of validity related to diagnoses are concurrent validity, predictive validity and convergent validity. Concurrent validity is when the result of a study or test matches a result from another study or set of data done at the same time, for example if two clinicians interviewed a patient and agreed came up with the same diagnosis. Predictive validity is the same as concurrent validity but when the result that is being compared to was obtained at another time. For example when Goldstein re-diagnosed participants in her 1998 study, concurrent validity was shown. Convergent validity is when a test result converges on another test result where exactly the same thing is being measured. One study that tested the validity of the DSM IV was Kim Cohen at al. (2005) study. The study was a longitudinal study looking at conduct disorder in 5 year olds. 2232 children who had previously been diagnosed with conduct disorder were participants in the study. Children who showed three or more symptoms were diagnosed as having a conduct disorder and children with five or more symptoms were diagnosed with moderate to severe conduct disorders. The different measures used including mothers’ response to an interview, teachers’ responses to a questionnaire, self-report data, and observational data all led to a diagnosis of conduct disorder, so the study concluded that the DSM diagnoses were valid. Another study carried out to test the validity of the DSM was Hoffmann’s (2002) study. This study tested validity of diagnoses in the fields of alcohol abuse, alcohol dependence and cocaine dependence to see if such differences showed up using a structured interview that was computer prompted and to see if they corresponded to the DSM-IV- criteria. Hoffman also found the DSM to be valid from the results of the structured interview which showed the symptoms matched, and the data supported the idea that alcohol dependence is more severe than alcohol abuse.

Bibliography http://www.nhs.uk/news/2013/08August/Pages/controversy-mental-health-diagnosis-and-treatment-dsm5.aspx http://www.livestrong.com/article/90176-benefits-dsm-iv-diagnosis/ http://www.futurepsychiatry.com/videos/dsm-v-a-critical-review Edexcel A2 Psychology, Christine Brain