Diagnostic Debate: No End in Sight

This isn’t the first article on debates about the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), and it won’t be the last. The DSM is the guidebook that is used by therapists and counselors to diagnose their patients’ mental health status. The guidebook, which is revised every few years, features detailed symptoms and criteria that funnel individuals from broad diagnoses (“bipolar,” “personality disorder”) to specific subsets (“Axis II” or “Cluster B”). There’s much debate over whether these categorizations actually help the patients themselves. On the up side, labeling a problem can provide perspective and offer “the answer” a person was looking for. On the down side, labeling problems often turns into labeling people (pathologizing) and can, as Gary Greenberg writes, “chalk up life’s difficulties to mental illness.”

This latter point has been getting a lot of press lately. One of the most outspoken opponents of new changes to the DSM is Allen Francis, the man who spearheaded the manual’s previous revision and has come to regret where several of those revisions have led. Under his watch, the DSM opened up diagnostic criteria to address varying degrees of severity. For example, Francis noted that some people experienced a mild form of autism, known as Asperger’s syndrome, which interfered with social functioning but not much else. Though studies showed that Asperger’s was “vanishingly rare,” its inclusion in the DSM preceded a tidal wave of Asperger’s diagnoses. Similar trends were echoed in the areas of bipolar disorder and ADHD.

The problem, as Allen Francis and other critics see it, is not that these aren’t real conditions that warrant evaluation and treatment from counselors and psychotherapists. These are, in fact, very real struggles faced by people the world over. The problem is that these problems are over-diagnosed and over-treated. Students who exhibit social awkwardness, if diagnosed with a form of autism, are eligible for specialized services and classroom support. Adults diagnosed with bipolar can get prescriptions for mood stabilizers and antipsychotic drugs, which benefit pharmaceutical companies, many of whom have aggressively marketed their mood-related drugs since the last DSM update.

So the problem remains: is it better to broaden the definitions of mental health disorders, so as to allow treatment for people who aren’t eligible for treatment without a diagnosis? Or is it better to play it safe: to, as Will Meek puts it, “look for horses before zebras” when you see footprints? In other words, to look for real life problems—trouble with family, work, relationships, and stress—before looking for a diagnostic label. The debate continues.

© Copyright 2011 by By Noah Rubinstein, LMFT, LMHC, therapist in Olympia, Washington. All Rights Reserved. Permission to publish granted to GoodTherapy.org.

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

  • Leave a Comment
  • pam g

    pam g

    January 6th, 2011 at 11:18 AM

    Goes to show that medicine needs a lot more one on one care than simply consulting a book for a diagnosis!

  • Henry Simon

    Henry Simon

    January 6th, 2011 at 11:42 AM

    Using generic terms is not enough and here should be as much specification as possible. Only then can we effectively tackle a disorder, isn’t it?

  • cathy


    January 6th, 2011 at 11:51 PM

    all the naming and other things will not matter much if these is greater awareness regardin the disorders in the people. then it will also clear any prejudices that they may have and whatever may be the disorder, people will have a clear picture of what it is and how it’s going to be cured!

  • faye raye

    faye raye

    January 7th, 2011 at 5:38 AM

    over diagnosis is killing the validity of many ailments in the psychological fields- kind of like the kid who cries wolf, you do it so much that nobody believes it anymore

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