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©2006-2011 Deborah Wiig
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Is the DSM-IV…

• A valuable tool for enabling doctors to care for people in distress? or…
• A controversial instrument that benefits insurance companies and drug makers?
  The answer is, it's both.

What is the DSM-IV?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), published by the American Psychiatric Association, is used by mental health professionals in the United States to identify and categorize mental disorders. Doctors use its descriptions of all illnesses recognized by the APA to diagnose their patients. Its classifications provide a common language between doctors, researchers and others in the field. It is also used in the development of new drugs and by insurance companies, which generally require a DSM-IV mental disease diagnosis to authorize reimbursement for mental health services.

Classifications and statistical analysis are essential to the diagnosis of disease.

If a patient visits his family doctor with a sore throat, the doctor might suspect a virus. But, if she also finds that the patient has a fever and swollen lymph glands, she'll look for other evidence of strep throat because those are the symptoms that typically identify a strep infection.

If a patient tells a psychiatrist that he feels sad and worthless, has no energy or interest in activities and can't concentrate, the doctor will suspect depression, because those are its typical symptoms. He'll go on to rule out physical problems, he'll learn as much as he can about the patient's family history and what may be going on in his life, and he'll compare the patient's symptoms with the criteria in the DSM-IV. Then, he'll call upon his own clinical experience to use this information to make a diagnosis and determine the best course of treatment.

The family doctor can do a lab test to identify a bacterial infection. There are no such tools to determine illnesses of the mind. Strep is strep, from one patient to the next. But clinical depression is varied and complex. Mental health professionals must rely on research to guide them.

The diagnostic criteria in the DSM-IV include descriptions of typical symptoms, associations between symptoms, how many of a list of possible symptoms should be present, and how long and/or how often these symptoms can be expected to occur for that diagnosis. .

The history of the DSM reflects the evolution of the way mental illness has been defined and treated. The “insane” were institutionalized in the 19th century. Decades later, psychoanalysts treated “personality disorders,” believed to be caused by life events, in particular, early experiences. With the dawn of this century, mental disorders are considered distinct biological conditions resulting from an imbalance of brain chemicals and treated most effectively with medications. But that approach, too, may be shifting.

How valid is the DSM?
The DSM's categories and diagnoses are based on statistical models. Critics argue that patients often do not fit into a particular category or fit into several. Many professionals question the usefulness of diagnoses based on an arbitrary set of symptoms. An individual's unique and complex condition can be reduced to a numerical code by a negligent practitioner.

The managed care system promotes quick diagnosis and treatment that will reduce DSM-defined symptoms, and discourages comprehensive examination of the causes of the patient's problems or alternative treatments. Detractors point to the stigma that results from labeling people.

Concerns about conflicts of interest have been directed at DSM contributors, many of whom have strong financial ties to drug companies. The authors of a study published in Psychotherapy and Psychosomatics 2006 investigated the financial ties to the pharmaceutical industry of contributors to the diagnostic criteria produced for the DSM-IV and DSM-IV-TR and found that “56 percent had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on Mood Disorders' and 'Schizophrenia and Other Psychotic Disorders had financial ties to drug companies… The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.”

Pharmaceutical funding and research have long been linked. But with few other sources of funding for medical research, it's how valuable advancements in the medical field continue to be made.

What's next?
DSM-V is scheduled for publication in 2011. Leading authorities expect a move away from the current emphasis on symptom-based diagnosis toward a greater focus on the causes of disorders as current research recognizes the influence of genetic and environmental factors. The update is expected to include more flexibility in diagnosis, recognizing that symptoms fluctuate and overlap beyond existing definitions. For example, today's research is finding that some disorders have similar symptoms but are actually very different in their underlying biology and may respond differently to different treatments. And, current research regards bipolar disorder as a range of symptoms and severity —a spectrum disorder—rather than the rigid subtypes used in DSM-IV.

The DSM-IV is an invaluable, controversial tool that is the best resource of its kind available today. Like any tool, it can be misused. And, as in all branches of medicine, mental health methods are continually evolving. And the DSM will evolve as well.

Excerpts from the DSM-IV can be accessed online.

Related articles
The new DSM-V
More articles

Sources
American Psychiatric Association
Psychotherapy and Psychosomatics Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry
Organizing Madness: Psychiatric nosology in historical perspective

Page updated May 1, 2008