The American Psychiatric Association’s (APA; 2013) Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM) and the World Health Organization’s (WHO; 1992)International Classification of Diseases–Tenth edition (ICD) are manuals that are conceptually similar, right down to sharing the same diagnostic codes. In creating the DSM, its authors worked closely with the WHO “with the overarching goal of harmonizing the two classifications” (APA, 2013, p. 13). These classification systems are helpful in several ways: They provide a common language for mental health professionals to communicate about those utilizing their services; its various classification terms, such as major depressive disorder, anxiety disorder, and so on, are short phrases that are convenient for placing them into titles and search engines, and for efficient/streamlined communication in high-speed hospitals and clinics; third-party payers of mental health services have found that their coding system works well as part of a practical method for their record keeping; with the aid of these codes, people manage to access mental health services, mental health service providers manage to get paid, and for-profit health companies tend to make a profit. Despite these benefits, many have pointed out that the DSM/ICD classification systems have a number of shortcomings. In this article, these shortcomings are briefly described. A proposed alternative to the DSM/ICD approach is then presented. It is argued that this alternative could provide all of the perceived practical benefits of the DSM/ICD approach, while having significantly fewer shortcomings.

For those who find DSM / ICM terms objectionable when applied to themselves or someone they care about, there is no way to opt out of this language system without forfeiting access to third-party payer mental health services.

I already knew something was wrong with me. Now I knew I was mad. . . . The diagnosis becomes a burden . . . you are an outcast in society. . . . It took me years to feel OK about myself again. (p. 65)

By the time I was entering my second decade of service use, the medical model, which I had initially found reassuring, seemed increasingly unsatisfactory, without the capacity to encompass the complexity of my interior or exterior life and give it positive value. As a result, I began to actively explore frameworks that better met my needs. (p. 63)

[ . . . ] represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other [ . . . ] There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another [ . . . ] The trouble is that such writers [ . . . ] use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with [ . . . ] The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity [ . . . ] Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all? (pp. 163-165)

Recognition of the stigma associated with the types of medical terms used in the DSM / ICD approach to describe challenging human experiences dates back more than one hundred years ( Rubin, 2000 ). William James, in his 1896 Lowell Lectures on Exceptional Mental States (which were reconstructed by Eugene Taylor [1984] ) stated that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” (p. 15) and give life “a truer sense of values” (p. 15). James went on from there to note that medical writers tend to:

Violating Basic Principles of Science

In addition to concerns about stigma associated with the DSM/ICD approach, its use runs counter to principles of science. The importance of a scientific approach for many psychologists is evident when we look at how the American Psychological Association describes itself. The very first sentence of the home page of its website states that it is “the leading scientific and professional organization representing psychology in the United States” (American Psychological Association, 2015). Note that the third word of its description is “scientific.” Obviously, keeping the profession as scientific as possible is very important to many psychologists.

A major way to study something scientifically is to develop a scientific classification system (Wilkins & Ebach, 2014). This process involves defining a given topic as precisely as we can. Then, we make sure we can reliably identify it. Throughout this process, we remain mindful of the tendency of classifiers to fall into the ontological fallacy, that is, believing that because we have named something, it must exist.

For example, those interested in scientifically studying birds began by defining what a bird is and then made sure they could distinguish birds from mammals, insects, reptiles, automobiles, and so on (Wilkins & Ebach, 2014). They then began classifying types of birds and making sure they could reliably distinguish different kinds of birds as eagles, blue jays, cardinals, and so on. As these bird classifiers began to reliability distinguish different kinds of birds, they became more confident that their classification system worked. Nevertheless, there always remains the tenable hypothesis that there may be a more practical scientific way to organize all the information that has and is being gathered using a classification that has “bird” as its overarching concept.

The developers of the DSM and ICD give the impression their classification systems are scientific. For example, the DSM states that it respects “the state of the science” and “was guided by emerging scientific evidence on the relationships between disorder groups” (APA, 2013, p. 10). The ICD states, “The draft in use in 1987 was the basis of field trials conducted in some 40 countries, which constituted the largest ever research effort of this type designed to improve psychiatric diagnosis” (WHO, 1992, p. 3). For both the DSM and the ICD, the overarching concept is “mental disorder.”

The DSM (APA, 2013) defines a mental disorder as follows:

Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required: A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (p. 20)

Notice how broad this definition is. It makes mention of a “disturbance” that reflects a “mental dysfunction in the individual.” WHO (2001) had an international group of experts develop the International Classification of Functioning, Disability and Health which seeks to provide some specificity to how to assess functioning. The DSM definition does not bother with this nor does it bother to direct us to any reliable or valid way too assess functioning. The process described in the DSM for assessing the subjective notions of “disturbance” and “dysfunction in the individual” is left to the clinician who decides if these are “clinically significant.” Thus, it provides clinicians an opportunity to include anything that benefits their set of values.

Many clinicians have a financial interest in deciding whether their clients have a clinically significant condition. When they judge that their clients’ conditions are significant, they indicate this on the third-party intake forms and this allows them to continue to see these clients and to get paid for additional visits. On the other hand, clinicians who work in an underfunded community government clinic that is being swamped by those seeking to access mental health services might apply a more stringent standard for what constitutes a mental disorder. Thus, we can hypothesize that this type of clinical judgment may often be based on financial self-interest or clinic treatment capacity than one based on principles of science.

Let us look a little more at the DSM’s attempt to draw distinctions between what is a mental disorder and what is not. According to the DSM, certain socially deviant behavior and conflicts are not mental disorders, although they may be. If the deviance or conflict results from a “dysfunction in the individual,” then a mental disorder exists in the individual. How does one make this type of distinction? Can it be done in some recognized precise manner? In practice, this too is left to the subjective judgment of the clinician that can be biased by financial interests and the capacity of his or her clinic.

Another distinction that the definition attempts to make between what is a mental disorder and what is not appears in the following sentence: “An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder” (APA, 2013, p. 20). Let us try to apply this sentence to the following situation. A soldier in combat has his vehicle blown up. Although he survives, he suffers the loss of his legs. Moreover, in the attack, two of his closest team members had burned to death in front of his eyes. This soldier seeks psychological help. He tells his story with tears running down his face and his hands are shaking. He reports having nightmares and difficulty functioning in social situations. The clinician is well aware that such stressful experiences are fairly common in times of war. However, can anyone imagine the clinician denying services to this soldier because his response to the stressor is expected and culturally approved? If the clinician does agree to provide services, he or she would have to provide some mental disorder “diagnosis” on an intake form. In my view, clinicians routinely ignore the above “expected or socially approved” clause. It might have sounded like a good idea to insert into the mental disorder definition for those who developed the DSM, but it is simply implausible that in practice clinicians are turning away customers who have third-party payer plans that require a DSM code whenever someone seeks help from them having experienced the death of a loved one, or any other common stressor.

On reading the DSM, we find that there is no documentation that people, whether they are clinicians or not, can reliably distinguish between those who have mental disorders and those who do not have mental disorders. Thus, the lack of this documentation is analogous to a classification system of birds that has no documentation that people can reliably distinguish birds from nonbirds.

With regard to reliably distinguishing between the different types of mental disorders, some field trials did look at this (Regier et al., 2013). Keep in mind that the DSM defines over 300 different mental disorders. Approximately 270 of them were not tested at all for reliability but are nevertheless included in the DSM. The field trials tried to look at the reliability for 31 “disorders” included in the DSM. Eight had insufficient sample sizes to include in the analysis. Three others had reliability estimates that, according to the authors, fell in the “unacceptable range.” Six others had reliability estimates that fell in the “questionable range.” The remaining 14 mental disorders had, according to the authors, “good to very good” reliability, despite the fact that there are no generally accepted standards for what counts as reliable enough against which the DSM criteria can be judged. Among the “disorders” that were found to have very low reliability were “major depressive disorder” and “generalized anxiety disorder,” two of the most common “diagnoses.”

Given the available evidence, the DSM cannot currently be viewed as a reliable scientific classification system. And reliability is only the first step in developing a classification system that is consistent with principles of science. The classification system must first demonstrate it is reliable, and then we look at the “validity” of the system. On examining the validity of the DSM, Thomas Insel, the current National Institute of Mental Health director, recently stated:

The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century, as we have understood that symptoms alone rarely indicate the best choice of treatment. (Insel, 2013)

In addition to the DSM’s shortcomings with regard to its classification system’s reliability and validity, there are also serious shortcomings with regard to its claim of being a diagnostic system. A diagnostic system speaks to etiology, that is, the cause, set of causes, or manner of causation of a disease or condition. Keeping this in mind, let us take a condition with which we can all easily understand.

You have trouble starting your car. You bring it to Fred, your friendly local mechanic. On hearing your concern, he provides an initial theory of what is causing this—perhaps your car needs a new starter. This is the initial “theoretical” diagnosis. Then, Fred inspects the starter and finds that it is in fine shape. Thus, his original theory of what is wrong proves incorrect. He then theorizes that your spark plugs are dirty. He takes a look and finds that they are indeed dirty. He cleans them up, puts them back in their proper place, and the car starts right up. In the end, he “diagnosed” what was wrong with your car—it had dirty spark plugs.

Now, let us say Fred, instead, had just asked you a few questions. Then, before finding out what was the cause of why your car had not been starting, he told you that the problem is that your car has “Major Nonstarting Disorder.” This statement is very different than “diagnosing” your car’s problem unless we want to dramatically expand the definition so it loses any precision.

The DSM, by claiming it is a manual for making diagnoses, masks the difference between the following three types of statements:

“My theory is that the reason your car is not starting is that it has a broken starter.” “The cause for your car not starting is it has dirty spark plugs.” “Your car has ‘Major Nonstarting Disorder.’”

The first statement offers some theory for understanding the cause for what someone believes has gone wrong. The second statement indicates that the cause for what has gone wrong has been clearly established. The third statement just restates the expressed concern or concerns in some jargon.

Thus, the lack of reliability and validity for the DSM and applying the word “diagnosis” in a misleading, imprecise manner are three violations of the principles of science. The final problem with the DSM that I will discuss here is that despite the questions that have sprung up about its validity, it appears oblivious to the ontological fallacy, that is, to believing that because we have given a name to something we think that we see, that that something must exist. Thus, the DSM skips over the scientific defensible position that a mental disorder is a tentatively proposed hypothetical construct. It makes no arguments that the mental disorder construct is better at achieving some explicitly stated scientific aims than other related hypothetical constructs such as “problems in living” (Szasz, 1961). Instead, the DSM presents the construct as if it unquestionably exists.

The above arguments apply equally well to the ICD, which defines a mental disorder as follows:

“Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here. (WHO, 1992, p. 11)

In case this vague definition does not provide enough wiggle room for clinicians to label all people seeking their services as having a mental disorder, the ICD adds, “When the requirements are only partially fulfilled, it is nevertheless useful to record a diagnosis for most purposes” (WHO, 1992, p. 8).

The ICD manual provides no reliability studies for the theoretical constructs that it classifies. In the absence of this crucial scientific support for its classification system, the ICD points out that:

These descriptions and guidelines carry no theoretical implications, and they do not pretend to be comprehensive statements about the current state of knowledge of the disorders. They are simply a set of symptoms and comments that have been agreed, by a large number of advisors and consultants in many different countries, to be a reasonable basis for defining the limits of categories in the classification of mental disorders. (p. 9)

In sum, the DSM/ICD approach violates the following principles of science: The definition of its overarching proposition (mental disorder) has vague descriptors; neither provides evidence that its definition of mental disorder can be used to reliably distinguish those who are classified as having a mental disorder from those who are not; for the vast majority of items identified by both classification systems as types of mental disorders no evidence is provided that each can be reliably distinguished from the other identified mental disorders; although there is some preliminary evidence for the reliability of a very few theoretical constructs identified as mental disorders, other evidence indicates that the reliability of some “diagnoses” fall well below acceptable limits; without demonstrated reliability, validity remains questionable; both classification systems tend to rely on clinicians who are financially incentivized to make decisions about the presence of a mental disorder rather than on principles of science; both muddle the meaning of what constitutes a diagnosis; there is no questioning regarding whether there may be more practical, scientific ways to organize all of the information now gathered under the theoretical construct of mental disorder.