6 Ways the DSM-5 Is Failing Mental Health Care
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in 2013. It has been the standard for diagnosing mental health conditions in the United States since its first edition came out in 1952. While the medicalization of diagnosing mental health conditions has enabled mental health practitioners to get mental health services covered by a patient’s health insurance, the manual has been met with a multitude of concerns.
When I consulted with my own therapist about her thoughts on the pros and cons of the DSM-5, she said the following.
First, she stated its usefulness ends after getting a patient’s sessions covered by insurance. Its benefit in her estimation is that it creates a common language all mental health providers can use regardless of their specific licensure. However, the criteria established for each mental health condition are overly simplified, extremely subjective, and too narrow to effectively encompass every permutation of a particular condition that’s possible. In an effort to make something that is medically useful, the DSM has removed the human condition from its criteria, which ultimately does a disservice to those seeking mental health care.
Other concerns presented by numerous clinicians across a myriad of sources I referenced cited the following limitations:
1. There can be an overreliance on a specific diagnosis in the DSM.
A diagnosis is basically a snapshot of a patient’s symptoms in that moment. It is often not intended by the clinician to be a permanent diagnosis; however, it can be challenging to adjust a diagnosis as a patient progresses in treatment and still get mental health care covered. This creates a catch-22 for a clinician who may believe a patient still needs treatment even if they no longer meet the diagnostic criteria for the condition they originally presented with.
2. There’s a danger of a patient being pathologized by a diagnosis.
Mental illness already tends to come with a certain degree of stigma, but certain conditions (particularly personality disorders) can be a double whammy. A good example of this is the diagnosis of borderline personality disorder (BPD). Many clinicians will avoid treating those with BPD because they consider them “difficult patients” or “untreatable.” Obviously, this is an unfair bias and fails to take each individual patient and their life history into consideration. Yet, it remains that once a person has a BPD diagnosis, they may find getting future treatment challenging, if not impossible. For this reason, many clinicians avoid diagnosing personality disorders and opt instead for less stigmatizing diagnoses that may not completely encompass the full scope of the symptoms a patient may present with.
3. Over-identification with a diagnosis may occur.
This was one my therapist mentioned as a danger of actually telling a patient what diagnosis they used on their insurance claim forms. Too often a diagnosis can end up reinforcing a patient’s sense there is something inherently wrong or “broken” about them, fueling hopelessness and despair. They may become overly identified with their diagnosis, sabotaging their ability to feel a sense of agency over their healing journey. Obviously this isn’t always the case, as certain diagnoses may actually help an individual finally understand their lived experience, adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) come to mind. It does highlight the necessity of careful consideration on the part of a clinician as to the usefulness and ultimate benefit or lack thereof of actually telling a patient what diagnosis they used for insurance coverage.
4. The DSM-5 fails to provide treatment options.
Diagnosing mental health conditions isn’t like diagnosing most medical conditions, even though health insurers want it to be. You can’t take a blood test, get an MRI, or get an ultrasound to determine what mental health condition may best describe your symptoms. With that, unlike many medical diagnoses, there’s no pill, medical procedure, or specific treatment that will work for every patient with a specific diagnosis. Even patients who present with similar symptoms may not respond to the same treatment modalities. Treatment is influenced as much by a patient’s specific life history, cultural upbringing, family history, genetics, and epigenetics as by the presenting symptoms that may situate them within the criteria for a particular diagnosis. Furthermore, trauma isn’t considered as a factor in many diagnoses which may require a very different approach by a clinician in treatment. More on this later.
5. The criteria in the DSM-5 are limiting or incomplete.
This is a multifaceted point. First of all, one person’s definition of depression may be different than another’s. And the ways in which an individual experiences a particular symptom can be more or less disruptive to a person’s daily well-being which makes it hard to define precisely which criteria are relevant to an individual. It puts the onus on the clinician to try to not only read a patient’s mind to an extent, but to translate what they say into a diagnosis. This seems far too subjective to be useful in any practical sense. There are also diagnoses where the criteria are so limited individuals who should qualify, don’t.
Anorexia comes to mind. While the current edition of the DSM no longer includes BMI as part of the criteria, it does still specify “significantly low body weight” as a criteria. In my personal experience, one person’s perception of a person’s weight isn’t necessarily in alignment with what is healthy or average for that individual. This can result in someone with restrictive eating or otherwise disordered eating which is in fact problematic and dangerous, from qualifying for an actual diagnosis or treatment for anorexia. This is particularly concerning for anorexia because it’s the mental health condition with the highest morbidity rate.
6. The definition of trauma is overly simplified.
Much research has been done in the last several years on the subject of trauma and its direct affect on not only the mental health of an individual, but its correlation to chronic illness and biological disease. More and more clinicians are shifting their focus from “what’s wrong with you,” to “what happened to you?” Yet, the trauma-related diagnoses and criteria of trauma as a factor for diagnosis are extremely limited in scope.
Post-traumatic stress disorder (PTSD) in the DSM-5 defines trauma as “exposure to actual or threatened death, serious injury, or sexual violence.” This definition fails to recognize trauma involving childhood emotional neglect, attachment trauma, chronic or developmental trauma, medical trauma, bullying, parental absence, and a myriad of other traumas that are now recognized as directly impactful to a person’s well-being.
Many practitioners now recognize complex post-traumatic stress disorder (C-PTSD) as a legitimate diagnosis, even though it does not appear in the DSM. The criteria are so similar to those for borderline personality disorder that people with a history of trauma may be incorrectly diagnosed with BPD and others who are impacted in serious ways but do not fit the criteria for PTSD, end up receiving diagnoses for anxiety, depression, or adjustment disorder, none of which embody the full scope of how the patient is affected by their trauma.
In an attempt at gaining scientific legitimacy, the field of psychotherapy has bent itself into conformity with other fields within the medical community. The result of this has been the DSM-5. Unfortunately, reducing something as complex as human behavior to a simplistic set of symptoms or criteria often fails to do what’s right and necessary for a patient’s best interest. There is some hope that with developments in neuroscience, we will have more scientifically acceptable and effective ways of actually measuring and seeing a patient’s mental health condition that can be validated, cross-referenced, and tracked.
But for the time being, the best option we have is to play the insurance game to secure much-needed mental health care for those in need and then allowing for what really heals — namely the therapeutic alliance — to do its magic in the privacy of the office of capable and caring clinicians.
Lead image via the American Psychiatric Association