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Pros and Cons of DSM Diagnosis

Updated on June 25, 2013

Diagnostic approaches, strengths, and downfalls in reference to the modern DSM.

The Diagnostic and Statistical Manual of Mental Disorders is a living piece of research that is continually evolving. It is a necessary evil, having been at the center of rigorous debate much like psychology itself. Its attempts to define criteria that can assist in distinguishing one mental illness from another, and so reaching a correct diagnosis, has been considered unscientific and simply too vague to truly establish differentiating lines. However, in order to maintain a handle on the complexity of psychological illness, a database such as this cannot sensibly be erased.

Addiction is lost in the shuffle, and just like the rest the definitions have changed drastically over the years of study. For example DSM-5 which was released in May of 2013 does away with the distinctions of abuse and dependency, combining them into the idiom substance abuse disorder. These two terms, while similar in definition, had differentiating criteria between them that distinguished one from the other for diagnostic reason. For example, abuse was categorized as recurrent substance use and only had to meet one of the listed criteria within a 12 month period. In contrast, dependency was reliant on meeting three criteria over a 12 month period and cited tolerance as its focus.. Rather than frequency of use, increasing amounts to reach the same effect was referenced. While there appears to be a clear line of behavior differences between the two terms, it seems more utilitarian to instead combine them and contribute them to a continuum of abuse rather than one behavioral pattern or another. The distinction is foggy when considering the overall path addiction tends to follow. Cocaine, for instance, often brings an immediate need for recurrent use even after the first attempt. As time goes on, the craving for the narcotic grows worse and individuals end up using more in one sitting than they had previously to satiate said need; which defines dependency. This ostensibly arbitrary issue has been resolved in DSM-5, however it does outline one con of diagnosis in regards to this guide. Categorizing disorders by the substance abused and severity of said abuse is much more sensible overall. The reasons behind the behavior are what lead to individualized recovery in the end.

The issue with approaching substance abuse or dependency in the way DSM-4 did is a matter of severity and generalization. Needing only one criteria met to diagnose an individual under the term abuse oversimplifies diagnosis, leaving possible room for error. While caffeine was not present under the listed substances, one could argue that this definition involves a very large number of individuals in regards to it. Considering the absolute magnitude of substance abuse diagnoses in such a situation begins to blur the lines as the numbers grow. With this in mind, it would seem that substance abuse was considered a much less severe or complex matter than substance dependency, despite their equal cause for concern. Its counterpart hinged on physical concerns such as withdrawal, however the generality of this statement could incorrectly include individuals suffering from withdrawal symptoms from certain medications that list this as a possible side effect. Clearly, this is an entirely different matter altogether. Diagnosing, labeling, and suggesting counseling for someone who is not in need of it could have very detrimental consequences. In order to combat this possible discrepancy, DSM-5 requires at least 2 criteria be met to even reach the level of mild substance use. It also requires that said symptoms have caused clinically significant distress or impairment. This stricter approach attempts to narrow the selected few down to those who are already showing signs of their substance use adversely affecting one or more aspect of their lives, while sweeping over those with much subtler symptoms; as they can easily be misinterpreted or misdiagnosed in regards to previous more lenient requisites.

Despite this attempt to avoid misconceptions in regards to easily confused unassuming symptoms, some argue that one of the more important aspects of battling addictions and addictive behavior is entirely overlooked with these new edits. Early recognition and intervention is absolutely essential to ceasing the problem before it worsens. More stringent requirements mean more difficulty reaching diagnostic acceptance, and so missing this vital early stage and attempting to tackle this issue at a later one. Some believe that the small opportunity to arbitrate was missed entirely by the time an individual meets the DSM-5 criteria. As previously mentioned, the alternative is to make it much more open and allow it to cover more ground, possibly leading to a false diagnosis. The balance between the two is very strenuous to maintain.

Starting at the beginning is critical when it comes to every individual case. A basic assessment to identify co-occurring disorders is a thorough example of what information should be gathered to gain a well-rounded image of the client. It is a step by step process that works to reveal quite a bit of information about the person his or herself as well as build a trusting relationship. The first portion of the assessment is known as Engage the Client. This is where a rapport is built between clinician and individual in order to establish a warm and trusting environment in which they will be willing to speak openly. It is important to display that the efforts are joint, and the client is a part of the teamwork in their own recovery. Making an empathic connection even if the client does not seem to fit into professional expectations, preferred methods of working, or treatment categories is essential. What they want and what immediate needs are present must be taken into consideration at this stage, as well as the multiaxial DSM-IV diagnoses. Of course, there must be sensitivity to sexual orientation, gender, and cultural influences. Once the clinician has received information and established a camaraderie with the client, the next step is to properly identify and contact friends, family, and other providers to gather more information. At times, understanding the true severity of the issue is not possible unless a third party gives their input. This can also reveal further information about the individual themselves, such as personality, tendencies, and other personal data. The third step is screening for and detecting co-occurring disorders. All individuals who are to endure substance abuse treatment should be screened routinely for these disorders. The content of the screening will entirely vary by the setting. Some will be tested for suicidal risk, for example, when it is seen as appropriate.

The third step of the assessment relates to severity. It is the portion when a quadrant is assigned and the locus of responsibility is established. Quite a bit of the information needed at this stage was collected during step two, however there are subtle differences. The criteria for quadrant assignment varies by state, and some have more stringent requirements than others. Every individual mental health system has a customary method of identifying what aspects can be considered in determining severity of the mental illness. Step four applies all given information to case examples. In many cases, the assessment process often stops after this step with the determination of placement. A more in-depth valuation may be done after placement and in an actual treatment setting. Further steps include ascertaining level of care and eventually establishing a diagnosis. Overall, these types of assessments put a very large strain on the shoulders of clinicians, and require great responsibility in the balancing act. Being unable to establish that essential rapport from the beginning could result in lying or withholding pertinent information. Not being thorough can easily help to misdiagnose an individual and send them down the wrong path. There is a lot of room for error, however there is also quite a bit of benefit in such an exhaustive study.

CAGE is an alternative substance abuse assessment that focuses on a lifetime of alcohol and drug consumption. Each ‘yes’ response gives 1 point. Two yes answers allows for a very small false-positive rate and the clinician will be less likely to wrongly diagnose an individual with a substance abuse disorder when there is none. Conversely, a criticism of this testing method is that it is not gender-sensitive. Women who have issues associated with alcohol use are less likely than men to screen positive when this instrument is put to use. One study involving over 1,000 women found that asking about frequency and amount of drinking, coupled with questioning binge drinking, was more effective in the long run than CAGE. This assessment has also been considered ‘relatively insensitive’ to Caucasian women. This test does have its depth and benefit, if done correctly. Nevertheless, the criticisms seem rather forefront and difficult to avoid.

Assessing an individual from the inside out is the most efficient method of approaching competent diagnoses and eventual treatment. Simply asking surface questions does not approach the matter correctly, nor does it reveal the essential information regarding why the need or desire for their substance of choice exists. Every single individual client is very different from the next, and a shallow assessment or shallow attempts on the part of the clinician can only lead to false results. In many cases, this can only worsen the client’s addiction and circumstances, pushing them closer to a state of no return. It is contingent both on the quality of the evaluation and the competency of the professional involved.


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    • Argosy2015 profile image

      Sarah 4 years ago from Highland, IN

      Thank you, Lambservant I'm glad you enjoyed the Hub/found it interesting. The DSM really is a very complicated issue in psychology. In a science that is mostly conjecture and variation, how can one consider a "how-to" manual of sorts to the final source? Thanks again.

    • lambservant profile image

      Lori Colbo 4 years ago from Pacific Northwest

      I didn't read all of this but what I've read so far is interesting. There is so much controversy around the DSM's. I think they serve a limited purpose but have found them to rigid and at the same time too vague. Each person who has a mental disorder varies in their symptoms and the timetable (that's is where I think DSM is too rigid or limited maybe).

      Great hub. I will finish it soon.