The Diagnostic Strengths Manual

As influential as it is, the DSM-IV (the DSM-IV-TR has just been published and has approximately 100 additional pages of text on disorders--primarily because of the increased enumeration of criteria and specifiers) of the American Psychiatric Association (1994) poses some dilemmas and tensions for practitioners and, therefore, for clients and patients who are diagnosed under its protocols and schematics. Volleys of criticism of DSM-III, -III-R, and -IV have come from many fronts, based on a variety of concerns: that the DSM fails to provide convincing evidence for the reliability and validity of diagnostic criteria and standards that other medical specialties ostensibly require (Kutchins & Kirk, 1997), and that it provides an insufficient and hard-to-operationalize conceptualization of mental disorder (Wakefield, 1992). In addition, this lack of a clear definition permits an ever-widening net of definition of disorder so that all manner of common human foibles, annoying traits, and bad habits are captured as mental disorders (Wolin & Wolin, 1993); it has an extensive white male bias and a history of developing diagnostic categories that are inimical to some racial groups and to women (Tavris, 1992); and through its numeric system of taxonomy and the numerical anonymity of the patients who appear in the "casebook," the DSM subtly encourages objectification of individuals with mental disorders (Cutler, 1991). Whatever its weaknesses and whatever the character of its construction of human frailties and foibles, the DSM is enormously popular, and its influence would be hard to understate. It is the lingua franca of mental health professions. Insurance companies and the enormously powerful pharmaceutical industry rely on it heavily for very different reasons. (Goleman, 1994; Kutchins & Kirk, 1997) Finally, the social, medical, scientific, and political processes that have nourished the development of an influential document like DSM reflect an evolving social norm (and its attendant practices) and cultural dynamic of "progressive infirmity." Such a norm decrees that an expanding range of behaviors, internal emotional and mental states, and human conditions come to be labeled as deficiencies requiring medication, sequestering, treatment and, in some cases, imprisonment. This has the cumulative effect of producing a rapidly developing social hierarchy in which a growing number of individuals and professions, employing the lexicon of deficit, have the power to evaluate and act on those who are identified as not measuring up, weakening more communal understandings and melioration of human trials, troubles, and tribulations; and "enfeebling" the sense of self of those who fail under the terms of the new normative lexicon (Gergen, 1994). Obviously, the DSM has a host of individual, disciplinary, professional, and institutional supporters. Its intent to create, like Emil Kraepelin 70 years before (Andreasen, 1984), an encyclopedic, descriptive manual that clearly distinguishes a given disorder, through specific and behavioral criteria, from every other disorder reflects the intent of medicine generally. It must be pointed out, however, that other branches of medicine are interested as well in underlying pathology (causality) because locating and understanding that particular cellular, physiological, or biochemical dynamic is a key to effective treatment, cure, or prevention (Walker, 1996). The framers of DSM seem curiously uninterested in cause. There are two particular problems with DSM-IV that I think are especially disturbing, and both have profound and too often adverse effects on people who seek the help of mental health professionals. It's All in Your Head! Many, if not most physical illnesses, serious and slight, often yield cognitive, emotional, and behavioral changes as part of the symptom picture. In some of these illnesses, the emotional and cognitive changes are the first thing that might be observed by family members or a psychiatrist. …