What is the DSM?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook used by health care practitioners in the United States. The DSM contains descriptions of human experiences and behaviors. These experiences and behaviors are identified as “symptoms” of “mental disorders” and are clustered based on categories and themes that are believed to be in some ways related to each other. For example, experiences such as sadness, fatigue, insomnia, disinterest and restlessness are clustered as symptoms under the broad category of Depressive Disorders. Similarly, the section on Anxiety Disorders includes panic attacks, social anxiety, and many related types of fear and nervousness. Related reading: American Psychiatric Association. DSM-5. (2013)

What is the DSM used for?

The precursors of the DSM were written during the 19th and early 20th centuries. Their purpose was to try to group "idiocy/insanity" into subtypes for census takers and general administrative purposes at mental institutions. By the time of the first official edition of the DSM in 1952, the number of classifications had grown from 7 to 106. Since the publication of the third official edition in 1980, the DSM has incorporated more detailed lists of characteristics/symptoms and added hundreds of new “mental disorders”. ​One aim of the DSM is to establish a particular, illness-focused way of understanding and discussing emotional and behavioral difficulties; unlike medical diagnostic manuals, though, the DSM categories are based on loosely defined behaviors that are not detectable by scientifically or biologically objective means. The DSM’s categorizations instead simply provide a “common language” or set of references for use among certain people and institutions such as mental health practitioners and researchers, governments, survey and census takers, the legal system, policy makers, insurance companies, medical facilities, pharmaceutical companies, and drug regulation agencies. The DSM’s categories, labels, numbered codes and descriptions are used to aid in diagnoses, guide research and consider intervention possibilities. The lists of symptoms in the DSM are also used to help create both formal diagnostic interviews and mental health screening questionnaires. (For more information on these interviews and questionnaires, see ICI’s “How "Mental Disorders" are Diagnosed”.) And most importantly, under U.S. law, the DSM labels and codes must be used by all medical and mental health professionals when they are conducting billing with private and public health insurers. The DSM has helped popularize many mental illness ideas and terms, and has had enormous cultural influence. It has become common for news reporters, health websites, television show hosts, celebrities, scientists, entertainers, artists and many of us in our daily lives to describe various human experiences as “symptoms” of various DSM-defined “mental disorders”, such as "depression," "anxiety disorder", "schizophrenia" or "bipolar". Related reading: American Psychiatric Association. DSM History.

How is the DSM used to help make a diagnosis?

If a person exhibits or reports a certain number of experiences or behaviors that appear to match the ones that are listed under the name of a particular mental disorder in the DSM, then that person can be labeled by a mental health practitioner as having that particular disorder. For instance, to receive a diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD), the DSM-5 states that a child must exhibit or report at least 6 of 9 listed behaviors, such as often talking excessively, often not engaging in play quietly, often having difficulty waiting in line, or often interrupting others. For most disorders, it is also a criterion that the experiences or behaviors seem to be causing some level of “impairment” in a person’s functioning, such as in his or her ability to attend to school, work or daily errands. In that sense, diagnosing a mental disorder is a relatively simple process at its heart. Notably, though, the DSM-5 does not explain many key terms and ideas such as how frequently these behaviors must occur in a child to be considered "often", how much constitutes "excessive" amounts, or what level of “impairment” is considered to be abnormal and unacceptable. Consequently, the assigning of a diagnosis is strongly influenced by the personal opinions of particular mental health practitioners. This large leeway for personal opinion in the diagnostic process is typical of most of the disorders described in the DSM. And because practitioners often in turn rely heavily on the testimonies of patients or patients' family members, friends, teachers, landlords, employers etc., the opinions of ordinary people also contribute significantly towards forming most practitioners' diagnoses.

How are mental disorders and their lists of symptoms developed for the DSM?

The inclusion and exclusion of mental disorders, symptoms and diagnostic criteria in the DSM are based to varying degrees on research and clinical practice experiences, and are ultimately determined by votes of small committees of people appointed by the American Psychiatric Association. In general, proposals for new mental disorders are submitted by practitioners or researchers to be considered for inclusion in the DSM. An appointed committee will evaluate the research and clinical experience in support of the proposal, and then vote on whether or not a particular disorder should be included in the DSM. The process of revising the DSM, therefore, is strongly influenced not just by scientific research but by dominant social values, politics, changing ideals of normality, cultural biases, and vested interests such as those of pharmaceutical companies. For example, under public pressure, homosexuality was removed as a listed mental disorder from the DSM in the 1970s. More recently, some of the DSM disorders relating to people's feelings about their own gender were removed or changed to be more in sync with changing cultural attitudes. Today, conversely, it has become common for people, groups and organizations to lobby for certain perspectives or emotional experiences to be added to the DSM as mental disorders rather than removed from it -- this is because official DSM-designations can often lead to opportunities for obtaining health insurance reimbursement, enhanced school funding, school- or work-related accommodations, unemployment benefits, or disability rights.

Is the DSM accurate, valid and reliable?