The unreliability of the APA's Diagnostic and Statistical Manual of Mental Disorders

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is the book that contains names and descriptions of 374 so-called mental disorders (including everything from depression to “caffeine withdrawal disorder”).  Doctors, psychiatrists and other medical and mental health practitioners use the DSM to diagnose patients.  Each DSM mental disorder description carries a code that clinicians can use to substantiate claims for health insurance reimbursement. 

Though it has become very influential since it first appeared in 1952 (when it only contained 112 disorders), there is one crucial test the DSM has never passed: scientific validity.  In fact, after more than 50 years of deception, broad exposure is now being given to the unscientific and ludicrous nature of this “943-page doorstop.” [1]  

Despite a growing consensus of people who see the DSM for what it is—a purely subjective work of no scientific substance or authority—it is still accepted in the legal system as being a scientific work that catalogs descriptions of mental disorders as if they were real medical diseases on the order of cancer or diabetes. 

It is strongly suspected that the acceptance of DSM data in the American courtroom is not the product of an informed understanding of DSM by legal authorities but rather an unevaluated acceptance or deference to testimony by psychiatric/psychological experts who neglect to inform judges and others that what they cite for the validation of their testimony (DSM) is a tool of admitted unreliability.  Were the true nature of the DSM broadly known to judges and other legal authorities, one has to wonder how much longer its forensic use would be allowed.

The ironic fact is that, within the covers of the various editions of DSM, its editors freely admit to the book’s intended use and its limitations. 

The following short report provides sections of text from the third and fourth editions of the DSM and additional information on the book’s diagnostic unreliability. 

One personal injury attorney who received this information stated, “I did the deposition of the defendant's psychiatric expert.  I did some major damage!  At the end of the deposition, I began asking questions about the DSM.  Defense counsel just about jumped out of their skin when I brought up the fact that the DSM says that there is the potential for misuse or misunderstanding in forensic psychiatry because of the imperfect fit between the ultimate concerns of the law and psychiatry!” 

It is my hope that this information reveals to you the “chinks in the armor” that you can use in depositions, cross-examination, etc. to prevent DSM from being  used to color judges’ and juries’ perceptions. 

DSM-III-R

By its own admission, the purpose of DSM is to facilitate communication between clinicians in the areas of diagnosis, study and treatment.  You can therefore characterize the DSM as being nothing more than a sort of dictionary for health care providers—and not otherwise any sort of authority in any other arena. 

“The purpose of the DSM-III-R is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat the various mental disorders.  It is to be understood that inclusion here, for clinical and research purposes, of a diagnostic category such as Pathological Gambling or Pedophilia does not imply that the conditions meets legal or other non-medical criteria for what constitutes mental disease, mental disorder, or mental disability.  The clinical and scientific considerations involved in categorization of these conditions as mental disorders may not be wholly relevant to legal judgments, for example, that take into account such issues as individual responsibility, disability determination, and competency.” [2] (Emphasis added.)

DSM-IV

The editors of this edition admit to the frailties of using DSM diagnoses in a forensic setting due to the “imperfect fit between the questions of ultimate concern to the law and the information contained in a clinical diagnosis”: 

• “…although this manual provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of ‘mental disorder.’” [3] 

• “In DSM-IV, there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder.” [4]

• “When the DSM-IV categories, criteria, and textual descriptions are employed for forensic purposes, there are significant risks that diagnostic information will be misused or misunderstood.  These dangers arise because of the imperfect fit between the questions of ultimate concern to the law and the information contained in a clinical diagnosis.  In most situations, the clinical diagnosis of a DSM-IV mental disorder is not sufficient to establish the existence for legal purposes of a ‘mental disorder,’ ‘mental disability,’ ‘mental disease’ or ‘mental defect.’  In determining whether an individual meets a specified legal standard (e.g., for competence, criminal responsibility, or disability), additional information is usually required beyond that contained in the DSM-IV diagnosis.  This might include information about the individual’s functional impairments and how these impairments affect the particular abilities in question.  It is precisely because impairments, abilities, and disabilities vary widely within each diagnostic category that assignment of a particular diagnosis does not imply a specific level of impairment of disability.” [5] (Emphasis added.)

The editors of DSM admit that a psychiatric diagnosis is dependent upon culture and geography—an admission which further erodes any scientific credibility.  In other words, someone who hears voices on a Native American reservation may be considered normal but in Los Angeles would be headed for involuntary commitment:

• “Diagnostic assessment can be especially challenging when a clinician from one ethnic or cultural group uses the DSM-IVClassification to evaluate an individual from a different ethnic or cultural group.  A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual’s culture.  For example, certain religious practices or beliefs (e.g., hearing or seeing a deceased relative during bereavement) may be misdiagnosed as manifestations of a Psychotic Disorder.” [6]

The Myth of the Reliability of the DSM

A 1994 study conducted by researchers from UCLA and the California State University at Sacramento addressed how the DSM-III was supposed to have been revised, updated, etc. to the result of increased diagnostic reliability. However, the study concluded that, “…there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliability by regular mental health clinicians.  Nor is there any credible evidence that any version…has greatly increased its reliability beyond the previous version.” [7]

DSM-V

The fifth edition of DSM is planned for release in 2013.  Since the announcement in 2007 of the individuals chosen to lead each DSM “work group” (groups which concentrate on a single category of disorders, such as depressive disorders), it has been garnering continuous criticism for the widening inclusion of a new series of so-called behavioral addictions to shopping, sex, food, videogames, the Internet and so on.  The contention of many is that the DSM’s developers are seeking to label all manner of normal emotional reactions or human behavioral quirks as mental disorders—thereby falsely increasing the numbers of “mentally ill” people who would then be prescribed one or more drugs that carry all manner of serious warnings.[8]

Such concerns are being expressed inside the profession:  “Each of these proposals [to label behavioral addictions as mental disorders] has the potential for dangerous unintended consequences by inappropriately medicalizing behavioral problems, reducing individual responsibility and complicating disability, insurance, and forensic evaluations” said Allen Frances, Chairman of DSM-IV.  “Psychiatry should not be in the business of inadvertently manufacturing mental disorders.” [9]

Frances has further exposed DSM-V’s developers’ failure to provide a risk/benefit analyses for any of the new “mental disorders” they are proposing for the new edition.  “None of the new proposals has received anything resembling a complete ‘risk/benefit analysis’… I am convinced that any objective balancing of the risks and benefits of these proposals would result in their being scrapped now.” [10]  

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In summation, psychiatric testimony has come to be accepted as legitimate, reliable and scientific, though it is based on a system whose authors admit that it is not.  Additionally, when the DSM’s intended uses and applications are more widely understood by our courts, perhaps it will be relegated back to its intended clinical use, cases of law can again be judged based solely on facts and evidence, and arbitrary and unreliable information can be excluded.

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