The DSM-IV
G. Scott Sparrow, Ed.D
University of Texas-Pan American
Published in the Encyclopedia of Multicultural Psychology
In 1952 the American Psychiatric Association published its first official listing of
mental diseases. Titled the Diagnostic and Statistical Manual of Mental Disorders
(DSM), it was conceived as a way to establish a common diagnostic language and to
increase interclinician reliability, which ranged from just over 20 percent to about 42
percent, depending on the study. Largely ignored when it first appeared, the initial DSM
was a spiral bound notebook with cursory descriptions of about 100 disorders, and it
was sold primarily to mental institutions for a mere three dollars and fifty cents. The
DSM-III (1974), and more recent updates -- the DSM-IIIR (1987), the DSM-IV (1994),
and the DSM-IVR (2000) -- have expanded to 900 pages in length, and have sold hundreds of thousands of copies at over eighty dollars apiece.
Theoretical Influences
The first two versions -- the DSM and the DSM-II (1968) -- were heavily influenced by the psychoanalytic model. Mental disease terms -- such as neurosis and psychosis -- derived from Freud's view that psychopathology resided within the person, and
could be traced to unconscious conflicts. From this standpoint, symptom profiles are
comparatively worthless in understanding the etiology of a patient's intrapsychic conflicts and designing an effective treatment.
In contrast, the DSM III (1974) was compiled by research-oriented psychiatrists
who were intent on devising a scientifically supportable system that could be widely
used by clinicians, regardless of their theoretical orientations. Unfortunately, adequate
research was still lacking at the time of the DSM III's development. In the absence of
reliable data, it wasn't unusual for the editor of the DSM-III, psychiatrist Robert Spitzer,
to formulate new diagnoses with the help of only a few committee members.
Carefully navigating a course away from the psychoanalytic assumptions and
terminology, Spitzer and his colleagues retained, in a few instances, the traditional psychoanalytic language while shifting to a method of diagnosis contingent on explicit
symptoms. For the first time, each disorder was based a list of operationally worded criteria upon which a final diagnosis could be determined. If a patient exhibited a certain
number of symptoms out of the total list, the diagnostic threshold was crossed and the
diagnosis was thus applied.
Critics have alleged that political and economic agendas, not science, have accounted for the changes in the DSM's emphasis over the last 50 years. When insurance
companies began to reimburse for mental health treatment in the 1960s, they pressed
for a comprehensive list of specific and treatable disorders. In response, the DSM's reformulators expanded the diagnostic categories in the DSM-III to over 300 disorders.
Such compliance was amply rewarded. Shortly after its publication, the DSM-III leapt
into prominence as insurers began to require a DSM-III code as a prerequisite for reimbursement. Alongside the proliferation of disorders, the influence of the pharmaceutical
companies may account, at least in part, for the DSM's growing emphasis on the biological basis of mental disorders. By the time the DSM-IV was published in 1994, mental
disorders had been largely recast as biologically based disorders that could be treated
with medication. It was a convenient transformation considering the rising influence of
managed care, and its diminishing support for traditional, long-term psychodynamic
therapy.
Multicultural Issues
From the standpoint of culture and gender sensitivity, the DSM has been criticized for minimizing the impact of contextual factors on the development of psychological disorders. For instance, the DSM IV defines a personality disorder \ as "an enduring
pattern of inner experience and behavior that deviates markedly from the expectations
of the individual's culture, is pervasive and inflexible, has an onset in adolescence or
early adulthood, is stable over time, and leads to distress or impairment." By implying
that personality disorders originate within the individual, and remain relatively stable
over time, the DSM discounts the way that social norms can influence the way that individuals behave. consequently, the DSM effectively pathologizes exaggerated compliance with gender and racial sterotypes. For instance, women who have been taught to
be more nurturing, more dependent on relationships, and more emotional than men,
may receive diagnoses of Dependent or Hystrionic Personality Disorders by exhibiting
exaggerated compliance with prescribed gender roles. Similarly, black men who show
resistance to authority may "qualify" for a diagnosis of Antisocial Personality Disorder if
the clinician conducting the diagnostic interview fails to take into account the environmental stressors contributing to such defiance, or the effect of identifying with prevailing
racial stereotypes. In contrast, the DSM does not similarly pathologize compliance with
white male stereotypic behavior, such as putting work above relationships, and disregarding others' needs when making decisions.
The influence of culture and gender bias in the formulation of DSM disorders is
especially apparent in so-called mental disorders that have been revised or stricken
from earlier editions, or effectively challenged prior to inclusion. For example, the DSM
III treated homosexuality as a personality disorder, but the DSM-IIIR downgraded it to
an ego-dystonic disorder. By the time the DSM-IV was published, homosexuality had
been dropped as a mental disorder due to social and political pressure to treat homosexuality as a normal gender choice.
Two other controversial diagnoses would have been enshrined in the DSM III if
women hadn't objected. Under Spitzer's editorship, which lasted through the publication
of the DSM-IIIR, the diagnosis of "masochistic personality disorder" was briefly considered before women expressed concern that it would only serve to pathologize patients - especially women -- who were abused. Another diagnosis that was briefly considered
would have made PMS a mental disorder, but again the outrage from women dissuaded
Spitzer and his colleagues from including it.
Beyond the possible biases inherent in the DSM's criteria, there is evidence that
mental health professionals frequently misdiagnose on the basis of gender and race.
For instance, DSM field trials revealed that black men are more likely to receive a diagnosis of schizophrenia than white men, and white males are more often diagnosed with
affective disorders than their black counterparts. Further, blacks are more likely to be
describes as "paranoid," and Hispanics as "histrionic." When a structured interview approach is used to minimize clinician subjectivity the black-white differences disappear,
leading to the conclusion that misdiagnoses, not objective racial differences, accounts
for the skewed results.
In recent years, the American Psychiatric Association has been calling for increased cultural competency among its members. At an APA symposium in New Orleans in 1999, APA president Allan Tasman, M.D., stated that cultural competency was of
the "most important, underaddressed issues in psychiatry." Speaking at the same conference, Francis Lou, M.D., a clinical professor of psychiatry at the University of California at San Francisco, said that psychiatry needed to be "concerned with the person as a
whole," and must "guard against the temptation to reduce human experience to the
lowest common denominator."
To its credit, the DSM-IV reflects a growing sensitivity to the role of culture in influencing individual behavior, and how cultural competency is essential in making accurate diagnoses. It contains a section at the back of the book on various dimension of
culture's influence. In it, clinicians are called upon to consider the difficulties in applying
DSM-IV criterion to members of different cultural or ethnic groups. A clinician who is ignorant of the subtle aspects of an individual's cultural background may unwittingly
pathologize behaviors and beliefs considered normal within the individual's culture. The
application of the Personality Disorder criteria across cultural settings is, in particular,
especially susceptible to cultural biases, because concepts of the self, coping styles,
and communication patterns may vary significantly between settings. To combat such
misuses of the DSM, the chapter addresses the meaning of cultural or ethnic reference
groups, the impact of culture on psychosocial environment and functioning, cultural explanations of illness, cultural elements influencing the patient-therapist relationship, and
ways in which an overall cultural assessment may affect diagnosis and care.
Despite its universal use by clinicians seeking third-party compensation and by
the Court system in determining the sanity of defendants, the DSM remains far from
universally respected. Some critics argue that the DSM is an emperor without clothes,
and represents an unscientific system that enshrines the opinions of a few powerful
psychiatrists. DSM detractors also point to the sobering fact that the initial premise upon
which the DSM was conceived -- that it would increase the interclinician diagnostic reliability -- remains unsupported by research. Indeed, reliability studies indicate that interclinician reliability associated with the DSM's use is no higher than the levels produced
prior to its publication, and in some cases lower. While clinicians may endeavor to improve their sensitivity to the influence of culture in the use of the DSM, the refinement of
the user can never entirely compensate for the weakness of the tool itself.
Further Readings
Alarcon, R., Foulks, E., & Vakkur, M. (1998). Personality disorders and culture: Clinical
and conceptual interactions. New York: Wiley.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders (4th Ed.), text revision. Washington DC: American Psychiatric Press.
Brown, L. S. (1994). Subversive dialogues. New York: Basic Books.
Caplan, P. (1995) They Say You're Crazy: How the World's Most Powerful Psychiatrists
Decide Who's Normal.
Caplan, P. and Cosgrove, L. (2004) Biased in Psychiatric Diagnosis.