Advantages and Disadvantages of the Diagnostic Statistical Manual

DSM5

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Currently in its fifth edition (DSM-5), the Diagnostic and Statistical Manual (DSM) is sometimes referred to as psychiatry's bible. Within its covers are specific diagnostic criteria for mental disorders, as well as a series of codes that allow therapists to easily summarize often complex conditions for clinical research and insurance purposes.

This method offers a number of advantages, such as standardization of diagnoses across different treatment providers. But increasingly, mental health professionals are considering the drawbacks of the DSM, including the possibility of over-diagnosis. In order to understand the debate, it is first necessary to understand what the DSM is and is not.

History of the DSM

Although its roots are traceable to the late 19th century, the standardization of mental illness classifications really took hold in the years immediately following World War II. The U.S. Department of Veterans Affairs (then known as the Veterans Administration, or VA) needed a way to diagnose and treat returning service members who had a wide range of mental health difficulties.

In 1949, the World Health Organization released its sixth edition of the International Classification of Diseases (ICD), which for the first time included mental illnesses. Although this work represented some of the earliest standards for mental health diagnosis, it was far from complete.

DSM-I and DSM-II

In 1952, the American Psychiatric Association (APA) published the DSM-I, an adaptation of a classification system developed by the armed forces during WW2. It was designed for use by doctors and other treatment providers.

The DSM-I was the first of its kind, but experts agreed that it still needed work. The DSM-II, released in 1968, attempted to incorporate the psychiatric knowledge of the day. It was heavily influenced by psychoanalytic concepts that were prominent at that time.

DSM-III

Published in 1980, DSM-III represented a radical change in the DSM structure. Its goal was to improve the validity and standardization of psychiatric diagnoses. It was the first version to introduce such elements as the multi-axis system and explicit diagnostic criteria. It also removed much of the earlier versions' bias toward psychodynamic, or Freudian, thought in favor of a more descriptive and categorical approach.

Although the DSM-III was a pioneering work, real-world usage soon revealed its flaws and limitations. Confusing diagnostic criteria and inconsistencies led the APA to develop a revision. Some of these changes were based on changing societal norms. For example, in the DSM-III, homosexuality was diagnosed as ego-dystonic homosexuality. In the revision, this specific classification was removed.

By the late 1980s, however, homosexuality was no longer seen as a disorder, although anxiety and distress about sexual orientation were. The DSM-III-R, released in 1987, fixed many of the internal difficulties of the earlier work.

DSM-IV and DSM-5

Published in 1994, the DSM-IV reflected numerous changes in the understanding of mental health disorders. Some diagnoses were added, others subtracted or reclassified. In addition, the diagnostic system was further refined in an effort to make it more user-friendly.

The DSM-5, published in May 2013, represented another radical shift in thinking in the mental health community. Diagnoses have been changed, removed or added, and the organizational structure underwent a major reworking.

Previous editions went decades between revisions. The DSM-5 is expected to be revised more regularly with mini additions (such as the DSM-5.1, DSM-5.2, etc.) in an effort to be more responsive to research.

Clinical Uses of the DSM

Every mental health professional uses the DSM in his or her own way. Some practitioners rigidly stick to the manual, developing treatment plans for each client based solely on the book's diagnoses. Others use the DSM as a guideline—a tool to help them conceptualize cases while focusing on each client's unique set of circumstances.

But in the modern world, virtually every mental health professional must refer to the DSM's codes in order to bill treatment to insurance companies.

Advantages of the DSM

Despite its flaws, the DSM is uniquely helpful for several reasons.

Standardization

Beyond billing and coding, standardization provides a number of important benefits to the clinician and the client. Standardization of diagnoses helps ensure that clients receive appropriate, helpful treatment regardless of location, social class, or ability to pay. It provides a concrete assessment of issues and helps therapists develop specific goals of therapy, as well as assess the effectiveness of treatment.

Research Guidance

In addition, the DSM helps guide research in the mental health field. The diagnostic checklists help ensure that different groups of researchers are studying the same disorder—although this may be more theoretical than practical, as so many disorders have such widely varying symptoms.

Therapeutic Guidance

For the mental health professional, the DSM eliminates a lot of guesswork. Proper diagnosis and treatment of mental illness remains an art, but the DSM diagnostic criteria serve as a sort of map.

In the age of brief therapy, a clinician may see a specific client only a handful of times, which may not be long enough to delve fully into the client's background and issues. Using the diagnostic criteria contained in the DSM, the therapist can develop a quick frame of reference, which is then refined during individual sessions.

Advantages
  • Standardizes billing and coding

  • Standardizes diagnoses and treatment

  • Guides research

  • Guides treatment

Disadvantages
  • Oversimplifies human behavior

  • Increases risk of misdiagnosis or over-diagnosis

  • Provides labels, which can be stigmatizing

Disadvantages of the DSM 

No tool is perfect, and the DSM is no exception. Being aware of its drawbacks is important for both patients and therapists.

Oversimplification

The latest round of criticism echoes a long running debate on the nature of mental health. Many critics of the DSM see it as an oversimplification of the vast continuum of human behavior. Some worry that by reducing complex problems to labels and numbers, the scientific community risks losing track of the unique human element.

Misdiagnoses and Over-Diagnoses

Possible risks include misdiagnosis or even over-diagnosis, in which vast groups of people are labeled as having a disorder simply because their behavior does not always line up with the current ideal. Childhood attention deficit/hyperactivity disorder (ADHD) is a common example. Shifts in terminology and diagnostic criteria in DSM-IV coincided with a massive upturn in the number of children on Ritalin or other medications.

Labeling and Stigmatization

Other risks involve the possibility of stigmatization. Although mental health disorders are not viewed in the negative light that they once were, specific disorders can be perceived as labels. Some therapists take great care to avoid attaching labels to their clients. But for a variety of reasons, a specific diagnosis may be required.

What You Can Do to Ensure Proper Diagnosis

Despite the concerns of some segments of the mental health community, the DSM remains the standard for diagnosis of mental health conditions. Like any other professional manual, however, the DSM is designed to be used as one of many tools for proper diagnosis and treatment.

There is no substitute for professional judgment on the part of a mental health provider. It is important to interview potential clinicians as you would any other service provider. Ask questions about their background and therapeutic approach, and choose the one whose style best melds with your personality and goals for treatment.

In recent years, some mental health associations have published supplemental handbooks that attempt to address some of the DSM's drawbacks with more specific diagnostic criteria relevant to the association's school of thought. For example, five associations teamed up to create the Psychodynamic Diagnostic Manual, or PDM, in 2006.

That particular handbook is geared toward mental health clinicians who incorporate a psychodynamic or psychoanalytic perspective in their work with patients. The goal of this approach is to describe dimensions of a patient's overall personality and emotional functioning and ways this might influence the therapeutic process.

A Word From Verywell

If you have any concerns about your diagnosis, ask your clinician for more information. Finding the right therapist or mental health professional can be challenging, but the rewards are well worth the trouble.

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