Part 2

Superficial Symptoms

By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to DSM but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer & Michael First  (DSM-IV editor) outlined in 2005: "little progress has been made toward understanding the pathophysiological processes and aetiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined; and we believe not enough is known to structure the classification of psychiatric disorders according to aetiology." However, DSM is based on an underlying structure that assumes discrete medical disorders can be separated from each other by symptom patterns. Its claim to be ‘atheoretical’ is held to be unconvincing because it makes sense if and only if all mental disorder is categorical by nature which only a biological model of mental disorder can satisfy. However, the manual recognises psychological causes of mental disorder - eg. Post-Traumatic Stress Disorder - so that it negates its only possible justification.

The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced) since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.

Despite the lack of consensus on underlying causation, advocates for specific psychopathlogical paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is Evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within Evolutionary Psychology, but one widely challenged within Psychology in general. Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as Depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that, "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimise them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Sigmund Koch, 1992) for mainstream methodological practice."

Dividing Lines

Despite caveats in the introduction to DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review (P K Dalal  & T Sivakumar) noted that attempts to demonstrate natural boundaries between related DSM syndromes or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. DSM does include a step (Axis IV) for outlining ‘Psychosocial and environmental factors contributing to the disorder’ once someone is diagnosed with that particular disorder.

Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who don't meet symptom counts may nevertheless experience comparable distress or disability in their life.

Despite doubts about arbitrary cut-offs, yes/no decisions often need to be made – eg: whether a person will be provided a treatment - and the rest of medicine is committed to categories. Thus, it is thought unlikely that any formal national or international classification will adopt a fully dimensional format.

Cultural Bias

Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to Psychology, critics (such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticised as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman (1997) contends that the Western bias is ironically illustrated in the introduction of cultural factors to DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as ‘culture-bound’, whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Spitzer has opined that the addition of cultural formulations was an attempt to placate cultural critics and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.

Drug Companies & Medicalisation

It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalisation of human nature, which may be attributed to disease mongering by pharmaceutical companies and psychiatrists whose influence has dramatically grown in recent decades. Of the authors who selected and defined DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. In 2008, then American Psychiatric Association presidentSteven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".

However, although the number of identified diagnoses has increased by more than 300% (from 106 in the original DSM to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.

Political Controversies

There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias (sexual fetishes) and Hypoactive Sexual Desire Disorder (low sex drive).

Critics of these and other controversial diagnoses often cite the DSM's previous inclusion of homosexuality -and the APA's eventual decision to remove it - as a precedent for current disputes. That 1974 decision is still challenged by some, mainly conservative and religious, groups who maintain that its removal does not decide empirical issues relating to statistical infrequency, personal distress, maladaptiveness or deviation from social norms. However, the consensus from the American Psychiatric Association, American Psychological Association and other institutions in other countries, is that the research and clinical literature demonstrate that same-sex sexual and romantic attractions feelings and behaviours are normal and positive variations of human sexuality.

Leaders of the Hearing Voices Network, such as psychiatrist Marius Romme (2007), have claimed that many people who hallucinate "are like homosexuals in the 1950s -- in need of liberation, not cure".

Disputes over inclusion or exclusion can underscore the fact that re-evaluation of controversial disorders can be viewed as a political as well as scientific decision. Indeed, Spitzer conceded that a significant reason that certain diagnoses  - eg: - the paraphilias - would not, in his opinion, be removed from the DSM is because "it would be a public relations disaster for Psychiatry".