Before, writing this paper I knew very little about the DSM. I know I learned about the DSM in the psychology 101 class I had but, all I could remember was a vague definition about it being a diagnostic tool. The only one thing I could truly remember about the DSM was a telephone conversation that I had with my mother a year earlier. At that time I had just changed my major from computer science (a field that my parents know nothing about) to behavioral science (a field that my parents both hold advanced degrees in). Because of my change in majors, my parents somehow thought that wanted to know everything they where doing at work.
This lead too many painfully long phone conversation about psychological issues that would end with them asking me questions (e. g. testing me) about what we just talked about. Needless to say I came to loath their phone calls, but I knew the calls meant a lot to my parents so I did not complain too much. The call in question, happen on a school day, about 9:30 in the morning. My mother had called to tell me that she was having trouble diagnosing a new patent of hers, and asked me if I thought diagnosis and the DSM was necessary in the treatment of a patent.
At the time I had no idea what the DSM was, but I did not want to sit thought the long winded definition that I was sure she would give, so I stalled the conversation long enough for me to look up the definition on the Internet. Armed with a two sentence definition I had found through www. google. com, I was able to answer the question to my mothers satisfaction. After which I was pretty cocky and thought I knew all about the DSM. Little did I know I was wrong. In the last two weeks, I have learned that there is much more to the DSM then I had previously believed.
What I have found is that, the Diagnostic Statistical Manual of mental disorder (DSM) is the handbook by which all work in clinical psychology is based, but its role in psychology is a controversial one. There are some who swear by the DSM, using it more like a bible than a handbook. Others say the DSM is nearly useless, and its usage should be stopped immediately. From the reading I have done and from lecture, I have come to believe that, the DSM is an ineffective classification system. With its high comorbidity and formal approach, the DSM hinders the overall diagnosis and treatment of patents.
But it is the only system we have, and cannot do without it. What is the DSM? The history of the DSM begins in the mid to late 1800s, when mental disorders first started to be studied within a scientific framework. From the start, it was clear that to further the study of mental disorders, a classification system was needed. Hard sciences had been using classification systems with great success, most notably in the field of medicine. It was only logical to assume that if other sciences had such success with these systems, that psychology should be no different.
However it would take many different attempts, and not until nearly a decade later was an accepted set classification system created. In 1882 the first set psychological classification system was developed in the United Kingdom. From the start, this system was believed to be flawed, and after many revisions the system failed to catch on. In 1948 another major attempt to create a scheme was made. In that year the World Health Organization added abnormal behavior to its list in the International Statistical Classification of Disease, injuries, and causes of death (ICD).
The ICD was widely used and accepted, yet the mental disorder section of the ICD was not (Davison, 2001). Finally in 1952 the American Psychiatric Association published the first DSM (DSM I), which would evolve into the standard of the field. The DSM I was a thin pamphlet that had 106 different classifications within it. Some of these classification were very vague, and heavily based on Freudian believes, needless to say the DSM was far from perfect. It would not be until its third revision (DMS-III) in 1980 that psychopathology would truly have its first set classification system.
Today the DSM-IV (the fourth revision) is the undisputed champion of mental disorder classification, and the most common classification scheme. With the DSM-V in the works, it is safe to assume that the DSM is going to be around for a long time. How does the DSM work? The DSM handles mental disorders as if it were like just like any other medical condition. It is a categorical system, stating you either have a disorder or you do not. The patient is evaluated on five separate axes (also known as dimensions), a process know as multiaxial classification (Davison, 2001).
The five axes are the backbone of the DSM and are key in understanding how the DSM works. Axis one and two make up all the abnormal behavior classification and are the only two axes needed to diagnose patents. However, this does not mean the other three axes are any less important. Axis III records general medical conditions. This axis is used to determine and fully understand the patents medical condition and history. This is important because physical conditions, such as a brain tumor, can cause mental disorders such as depression.
Also, treatments for a mental disorder could be dangerous or even deadly for patients with particular medical conditions. Axis IV codes psychosocial and environmental problems. For this axis, the psychologist looks at the patients home, work, and social environment. If the psychologist finds anything that may be causing, or adding to the patients disorder (e. g. trouble at home, money problems), then it is noted and will be evaluated during treatment of the patient. Axis V describes the patients current level of functioning.
This axis brings together information from the other four axes and helps the psychologist determine how functional the patient is and what treatment should be used to help the patient. Rating the patient on five different axes, allows the psychologist to obtain a wide range of information and therefore provides a rich understanding of the patients symptoms in their life context. Advantages of the DSM-IV The biggest advantage of the DSM is the fact that it is the only comprehensive classification scheme available. Indeed, the lack of competition could be a testament to the overall versatility of the DSM.
The DSM standardizes psychopathology research designs and allows for faster and easier communication between psychologists. Without the DSM, communication between researchers would not only be difficult, but in some cases it would be near impossible. The DSM also gives the psychologist a good starting point. When a psychologist first meets a patient, useful information is often hidden, and he must act like a detective, piecing together a diagnosis (if any) for the patient. The DSM gives the psychologist a framework that allows him/her to organize the patients information.
Another big contribution that the DSM made for psychology was somewhat unintentional. Because the DSM has standardized the classification of mental disorders it has allowed mental disorders to be included under health insurance. Using the DSMs categorical system an insurance company can clearly state which disorders it will or will not cover. Without the DSMs categorical system it would be impossible to tell what should, or would be covered under any given health care package. Because of this, insurance companies would not be able to include mental health care under their coverage.
With out insurance many people would be unable to afford mental health care. Disadvantages of the DSM-IV Even with its advantages, the DSM is severely crippled in many aspects of psychological diagnosis. One of the biggest problems with the DSM is its categorical system. In the first publication of the DSM (DSM-I) there were 106 different categories. That number has increased 180% since then. The fact that psychologists keep splitting the categories creates two major problems. The first problem is with diagnosis. As new categories are created and old ones are spilt up, the numbers of categories are increasing.
This makes one category difficult to distinguish from another. For instance, is there truly a difference between social phobia and panic attack with agoraphobia? According to the DSM-IV there is a difference, and these two different disorders could end up having two very different methods of treatment. With the lines between certain categories blurred, it is very likely that two psychologists could come to different conclusions. As stated earlier, an advantage of the DSM is its reliability, but if splitting continues the reliability rate of the DSM will continue to drop.
The second problem that comes with splitting is comorbidity. Comorbidity is defined as instances where a patient is diagnosed with more than one disorder. The rate of comorbidity is the frequency with which patients are diagnosed with two or more disorders. Comorbidity on axis I in the DSM is widespread. It was found that 91% of individuals diagnosed with panic disorder, 91% of schizophrenics, 75% of depressives, 69% of those with social phobia and 52% of those with alcohol abuse or dependency have at least one comorbid condition (Clark, pg. 128).
Comorbidity rates are even worse among the personality disorders. There are few patients that fit into one category without also fitting into either a similar or a completely different category. Even more disturbing is the fact that comorbidity is not random; certain categories co-occur more frequently than others (Krueger, pg. 486). Psychologists need to start lumping similar categories together to cut down on comorbidity, thereby increasing the reliability of the DSM-IV. Also, psychology is not an exact science; it is not like math where A + B = C.
One can find out what statistically causes a disorder, but can never state that 100% of people with high serotonin will develop schizophrenia. Because psychology is not an exact science, maybe the scientific categorical system it has is not the best way to classify disorders. Continuing with the idea of psychology as a pseudo-science lets take a look at the labeling. In chemistry if you observe a molecule with one proton you can label it as hydrogen and know that it will always be a hydrogen molecule.
The DSM handles psychology in the same fashion. Once a patient is diagnosed with depression, he is labeled a depressive, a burden carried for the rest of his life. With treatment, he/she can overcome depression, but then he/she is labeled as recovering from depression. Labels work for science because science is full of facts and rules that never change. However, there are few facts about the inner workings of the human brain. People are dynamic and constantly changing; diagnoses and labels are too short term when dealing with a person.
A diagnosis is like a snapshot of a persons mental functioning at the time, and just like a bad picture that does not look like the person, a bad diagnosis can really fail to evaluate the persons true mental functioning. Conclusion From this data it is easy to see why I believe that the DSM-IV is an ineffective tool for the diagnoses and treatment of patents. Psychologists should realize that any scientific set of categories is going to have problems expressing the phenomena of psychology. What is needed is a broad and flexible system that can be loosely applied to psychology.
This system would borrow ideas from the DSM, but would rely more on the psychologists intuition than the DSM does. As of today, there is no system like that, and if a system like that was to be created, it could take many years for it to catch on around the world. In the end, the DSM maybe a broken system that does not work too well, but a broken system is better than no system at all. Without a system, psychology would not be able to function at the level that it does today. All that can be done about the DSM now is to accept that it is not going anywhere, and we must work to make it better.
