Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders (DSM; latest edition: DSM-5, publ. 2013) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria.
The DSM evolved from systems for collecting census and psychiatric hospital statistics, as well as from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, while removing those no longer considered to be mental disorders.
Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound nosology used in DSM-III. However, it has also generated controversy and criticism, including ongoing questions concerning the reliability and validity of many diagnoses; the use of arbitrary dividing lines between mental illness and "normality"; possible cultural bias; and the medicalization of human distress.
Distinction from ICD
An alternate, widely used classification publication is the International Classification of Diseases (ICD) is produced by the World Health Organization (WHO). The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 5 of the ICD specifically covers mental and behavioural disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM.
The DSM-IV-TR (4th. ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated. Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other.
Mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients. Health-care researchers use the DSM to categorize patients for research purposes.
An international survey of psychiatrists in sixty-six countries compared the use of the ICD-10 and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research.
This section needs additional citations for verification. (December 2017) (Learn how and when to remove this template message)
Census data and report (1840–1888)
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category: "idiocy/insanity". Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns African-Americans were all marked as insane, and calling the statistics essentially useless.
The Association of Medical Superintendents of American Institutions for the Insane was formed in 1844; it has since changed its name twice before the new millennium: in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association (APA).
Edward Jarvis and later Francis Amasa Walker helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume, published in 1888, called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880).
Wines used seven categories of mental illness, which were also adopted by the American Medico-Psychological Association: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis.
American Psychiatric Association Manual (1917)
In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the American Medico-Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This guide included twenty-two diagnoses and would be revised several times by the Association and its successor, the American Psychiatric Association (APA), over the years. Along with the New York Academy of Medicine, the APA provided the psychiatric nomenclature subsection of the U.S. general medical guide, the Standard Classified Nomenclature of Disease, referred to as the Standard.
Medical 203 (1943)
World War II saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. Under the direction of James Forrestal, a committee headed by psychiatrist Brigadier General William C. Menninger, with the assistance of the Mental Hospital Service, developed a new classification scheme called Medical 203, which was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the United States Navy had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance. This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of Medical 203.
In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature".
Early versions (20th century)
An APA Committee, on Nomenclature and Statistics, was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the Standard's nomenclature, and the VA system's modifications of the Standard to approximately 10% of APA members: 46% of whom replied, with 93% approving the changes. After some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic).
In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a heroine to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.
In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science, the Rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.
The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.
An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".
Seventh printing of the DSM-II (1974)
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."
This gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists.
Taking into account data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".
In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the International Classification of Diseases (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States. The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." Personality disorders were placed on axis II along with mental retardation.
The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".
Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry.
When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:
Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator...
In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" [p. xxiii].
In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by Allen Frances and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix.
The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom" It also notes that "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."
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
DSM-IV multi-axial system
The DSM-IV was organized into a five-part axial system. Axis I provided information about clinical disorders, or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM-V as mental retardation. Those were both covered on Axis II. Axis III covered medical conditions that could impact a person's disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person. Axis V was the GAF, or global assessment of functioning, which was basically a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life.
The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials. The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification.
A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses. The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM .
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in 20 years.
A significant change in the fifth edition is the deletion of the subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. The deletion of the subsets of autistic spectrum disorder—namely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified—was also implemented, with specifiers regarding intensity: mild, moderate, and severe.
Severity is based on social communication impairments and restricted, repetitive patterns of behaviour, with three levels:
- requiring support
- requiring substantial support
- requiring very substantial support
During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.
Future revisions and updates
Beginning with the fifth edition, it is intended that subsequent revisions will be added more often, to keep up with research in the field. It is notable that DSM-5 uses Arabic rather than Roman numerals. Beginning with DSM-5, the APA will use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2) and whole numbers for new editions (e.g., DSM-5, DSM-6), similar to the scheme used for software versioning.
Reliability and validity
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Unfortunately, neither the issue of reliability or validity was settled.[better source needed]
In 2013, shortly before the publication of DSM-5, the director of the National Institute of Mental Health (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response."
Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.
This section contains too many or overly lengthy quotations for an encyclopedic entry. (December 2020)
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."
"The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is necessary at all), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per a DSM or ICD-based diagnosis."
"Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology but one that is widely challenged within general psychology." Another example is the strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts like depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."
A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience states "that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects." As an example of the problem of the superficial characterization of psychiatric signs and symptoms, the authors gave the example of a patient saying they "feel depressed, sad, or down," showing that such a statement could indicate various underlying experiences: "not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth." The structured interview comes with a "danger of over confidence in the face value of the answers, as if a simple 'yes' or 'no' truly confirmed or denied the diagnostic criterion at issue." The authors gave an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the experience did not "fully articulate itself" until the patient started talking about his experiences.
Dr. Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]." Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and autism spectrum disorder. Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics.
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.
Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.
Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals. In addition, current diagnostic guidelines have been criticized[by whom?] as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, common responses[by whom?] included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.
Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo in 1989 as an alternative to the DSM in treating patients of the African diaspora.
Medicalization and financial conflicts of interest
There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing medicalization of human nature, very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model". It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.
William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million.
However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients.
Clients, survivors, and consumers
A client is a person who accesses psychiatric services and may have been given a diagnosis from the DSM, while a survivor self-identifies as a person who has endured a psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). A term adopted by many users of psychiatric services is "consumer". This term was chosen to eliminate the "patient" label and restore the person to an active role as a user or consumer of services. Some individuals are relieved to find that they have a recognized condition that they can apply a name to and this has led to many people self-diagnosing. Others, however, question the accuracy of the diagnosis, or feel they have been given a label that invites social stigma and discrimination (the terms "mentalism" and "sanism" have been used to describe such discriminatory treatment).
Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.
Critiques of DSM-5
Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription."
- Disruptive Mood Dysregulation Disorder, for temper tantrums
- Major Depressive Disorder, includes normal grief
- Minor Neurocognitive Disorder, for normal forgetfulness in old age
- Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
- Binge Eating Disorder, for excessive eating
- Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
- First-time drug users will be lumped in with addicts
- Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
- Generalized Anxiety Disorder, includes everyday worries
- Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."
- Are they more like theoretical constructs or more like diseases?
- How to reach an agreed definition?
- Should the DSM-5 take a cautious or conservative approach?
- What is the role of practical rather than scientific considerations?
- How should it be used by clinicians or researchers?
- Is an entirely different diagnostic system required?
In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other APA divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.
- Chinese Classification and Diagnostic Criteria of Mental Disorders
- Classification of mental disorders
- Diagnostic classification and rating scales used in psychiatry
- DSM-IV Codes
- Global Assessment of Functioning (GAF) Scale
- International Statistical Classification of Diseases and Related Health Problems (ICD)
- Kraepelinian dichotomy
- Psychodynamic Diagnostic Manual
- Relational disorder (proposed DSM-5 new diagnosis)
- Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health
- Rosenhan experiment
- Structured Clinical Interview for DSM-IV (SCID)
- Homosexuality in DSM
- Donix, Markus (19 November 2013). "The New Crisis of Confidence in Psychiatric Diagnosis". Annals of Internal Medicine. 159 (10): 720. doi:10.7326/0003-4819-159-10-201311190-00020. PMID 24247685. S2CID 7172347.
- Dalal, PK; Sivakumar, T (October 2009). "Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification". Indian Journal of Psychiatry. 51 (4): 310–9. doi:10.4103/0019-5545.58302. PMC 2802383. PMID 20048461.
- Kendell, Robert; Jablensky, Assen (January 2003). "Distinguishing Between the Validity and Utility of Psychiatric Diagnoses". American Journal of Psychiatry. 160 (1): 4–12. doi:10.1176/appi.ajp.160.1.4. PMID 12505793. S2CID 16151623.
- Baca-Garcia, Enrique; Perez-Rodriguez, Maria M.; Basurte-Villamor, Ignacio; Fernandez Del Moral, Antonio L.; Jimenez-Arriero, Miguel A.; Gonzalez De Rivera, Jose L.; Saiz-Ruiz, Jeronimo; Oquendo, Maria A. (March 2007). "Diagnostic stability of psychiatric disorders in clinical practice". British Journal of Psychiatry. 190 (3): 210–216. doi:10.1192/bjp.bp.106.024026. PMID 17329740. S2CID 4888348.
- Pincus, Harold Alan; Zarin, Deborah A.; First, Michael (1 December 1998). "'Clinical Significance' and DSM-IV". Archives of General Psychiatry. 55 (12): 1145, author reply 1147–8. doi:10.1001/archpsyc.55.12.1145. PMID 9862559.
- ICD-10 Classification of Mental and Behavioural Disorders: "Clinical descriptions and diagnostic guidelines" (aka the "Blue Book"); and "Diagnostic criteria for research" (aka the "Green Book").
- In Appendix G: "ICD-9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders"
- American Psychological Association (2009). "ICD VS. DSM". Monitor on Psychology. 40 (9): 63.
- Mezzich, Juan E. (2002). "International Surveys on the Use of ICD-10 and Related Diagnostic Systems". Psychopathology. 35 (2–3): 72–75. doi:10.1159/000065122. PMID 12145487. S2CID 35857872.
- "Trademark Electronic Search System (TESS)". Retrieved 2010-02-03.
- Gorwitz, Kurt (March–April 1974). "Census enumeration of the mentally ill and the mentally retarded in the nineteenth century". Health Services Reports. 89 (2): 180–187. doi:10.2307/4595007. JSTOR 4595007. PMC 1616226. PMID 4274650.
- History of the DSM Nathaniel Deyoung, Purdue University. Retrieved 9th Sept 2013
- Statistical manual for the use of institutions for the insane (1918) University of Michigan via Internet Archive
- Greenberg, S; Shuman, DW; Meyer, RG (2004). "Unmasking forensic diagnosis". International Journal of Law and Psychiatry. 27 (1): 1–15. doi:10.1016/j.ijlp.2004.01.001. PMID 15019764.
- Sandison, R. A.; Spencer, A. M. (1953). "Mental Hospital Service". British Medical Journal. 1 (4809): 560. doi:10.1136/bmj.1.4809.560. PMC 2015553.
- Houts, Arthur C. (2000). "Fifty years of psychiatric nomenclature: Reflections on the 1943 War Department Technical Bulletin, Medical 203". Journal of Clinical Psychology. 56 (7): 935–967. doi:10.1002/1097-4679(200007)56:7<935::aid-jclp11>3.0.co;2-8. PMID 10902952.
- Grob, GN (April 1991). "Origins of DSM-I: a study in appearance and reality". American Journal of Psychiatry. 148 (4): 421–431. doi:10.1176/ajp.148.4.421. PMID 2006685. S2CID 1602374.
- Oldham, John M. (1 July 2005). "Personality Disorders". FOCUS. 3 (3): 372–382. doi:10.1176/foc.3.3.372 (inactive 2021-01-18).CS1 maint: DOI inactive as of January 2021 (link)
- Edsall, Nicholas C. (2003). Toward Stonewall: Homosexuality and Society in the Modern Western World. University of Virginia Press. ISBN 978-0-8139-2211-9.[page needed]
- Marcus, p. 58–59.[full citation needed]
- Mayes, Rick; Bagwell, Catherine; Erkulwater, Jennifer L. (2009). "The Transformation of Mental Disorders in the 1980s: The DSM-III, Managed Care, and 'Cosmetic Psychopharmacology'". Medicating Children: ADHD and Pediatric Mental Health. Harvard University Press. p. 76. ISBN 978-0-674-03163-0. Retrieved 2013-12-03.
- Kirk, Stuart A.; Kutchins, Herb (1994). "The Myth of the Reliability of DSM". The Journal of Mind and Behavior. 15 (1/2): 71–86. JSTOR 43853633.
- Mayes, Rick; Horwitz, Allan V. (Summer 2005). "DSM-III and the revolution in the classification of mental illness". Journal of the History of the Behavioral Sciences. 41 (3): 249–267. doi:10.1002/jhbs.20103. PMID 15981242.
- Wilson, M. (March 1993). "DSM-III and the transformation of American psychiatry: a history". Am J Psychiatry. 150 (3): 399–410. doi:10.1176/ajp.150.3.399. PMID 8434655.
- Spitzer, Robert L.; Fleiss, Joseph L. (1974). "A re-analysis of the reliability of psychiatric diagnosis". British Journal of Psychiatry. 125 (4): 341–347. doi:10.1192/bjp.125.4.341. PMID 4425771.
- Ronald Bayer Homosexuality and American Psychiatry: The Politics of Diagnosis (1981) Princeton University Press p. 105.
- McCommon, Benjamin (December 2006). "Antipsychiatry and the Gay Rights Movement". Psychiatric Services. 57 (12): 1809, author reply 1809–10. doi:10.1176/appi.ps.57.12.1809. PMID 17158503.
- Rissmiller, David J.; Rissmiller, Joshua (December 2006). "Letter In Reply". Psychiatric Services. 57 (12): 1809–1810. doi:10.1176/appi.ps.57.12.1809-a.
- Spitzer, R.L. (1981). "The diagnostic status of homosexuality in DSM-III: a reformulation of the issues". Am J Psychiatry. 138 (2): 210–215. doi:10.1176/ajp.138.2.210. PMID 7457641.
- Speigel, Alix (3 January 2005). "The Dictionary of Disorder: How one man revolutionized psychiatry". The New Yorker. Archived from the original on 12 December 2006.
- Cooper, John E.; Kendell, Robert E.; Gurland, Barry J.; Sartorius, Norman; Farkas, Tibor (April 1969). "Cross-National Study of Diagnosis of the Mental Disorders: Some Results from the First Comparative Investigation". American Journal of Psychiatry. 125 (10S): 21–29. doi:10.1176/ajp.125.10s.21. PMID 5774702.
- Lane, Christopher (2007). Shyness: How Normal Behavior Became a Sickness. Yale University Press. p. 263. ISBN 978-0-300-12446-0.
- Spiegel, Alix; Glass, Ira (18 January 2002). "81 Words". This American Life. Chicago: WBEZ Chicago Public Radio.
- Frances, Allen; Mack, Avram H.; Ross, Ruth; First, Michael B. (2000) . "The DSM-IV Classification and Psychopharmacology". In Bloom, Floyd E.; Kupfer, David J. (eds.). Psychopharmacology: The Fourth Generation of Progress. American College of Neuropsychopharmacology.
- Shaffer, David (August 1996). "A Participant's Observations: Preparing DSM-IV". The Canadian Journal of Psychiatry. 41 (6): 325–329. doi:10.1177/070674379604100602. PMID 8862851. S2CID 28547523.
- "The New Definition of a Mental Disorder". Psychology Today.
- Stein, Dan J.; Phillips, Katharine A.; Bolton, Derek; Fulford, K.W.M; Sadler, John Z.; Kendler, Kenneth S. (November 2010). "What is a Mental/Psychiatric Disorder? From DSM-IV to DSM-V". Psychological Medicine. 40 (11): 1759–1765. doi:10.1017/S0033291709992261. PMC 3101504. PMID 20624327.
- Maser, Jack D; Patterson, Thomas (December 2002). "Spectrum and nosology: implications for DSM-V". Psychiatric Clinics of North America. 25 (4): 855–885. doi:10.1016/s0193-953x(02)00022-9. PMID 12462864.
- DSM-IV Sourcebook. 1. Washington, DC: American Psychiatric Association. 1994. ISBN 978-0-89042-065-2.
- DSM-IV Sourcebook. 2. Washington, DC: American Psychiatric Association. 1996. ISBN 978-0-89042-069-0.
- DSM-IV Sourcebook. 3. Washington, DC: American Psychiatric Association. 1997. ISBN 978-0-89042-073-7.
- Sadock, Benjamin J. (October 1999). "DSM-IV Sourcebook, vol. 4 (Book Forum: Assessment and Diagnosis)". American Journal of Psychiatry. 156 (10): 1655. doi:10.1176/ajp.156.10.1655. Archived from the original on 2013-12-06. Retrieved 2013-12-03.
- Poland, JS. (2001) Review of Volume 1 of DSM-IV sourcebook Archived May 1, 2005, at the Wayback Machine
- Poland, JS. (2001) Review of vol 2 of DSM-IV sourcebook Archived September 27, 2007, at the Wayback Machine
- "DSM-IV replaced by DSM-IV-TR: changes in diagnostic criteria". Behavenet.[unreliable source?]
- First, Michael B.; Pincus, Harold Alan (March 2002). "The DSM-IV Text Revision: Rationale and Potential Impact on Clinical Practice". Psychiatric Services. 53 (3): 288–292. doi:10.1176/appi.ps.53.3.288. PMID 11875221.
- Cassels, Caroline (2 December 2012). "DSM-5 Gets APA's Official Stamp of Approval". Medscape. WebMD, LLC. Retrieved 2012-12-05.
- Kinderman, Peter (20 May 2013). "Explainer: what is the DSM?". The Conversation Australia. The Conversation Media Group. Retrieved 2013-05-21.
- Sharon Jayson (12 May 2013). "Books blast new version of psychiatry's bible, the DSM". USA Today. Retrieved 2013-05-21.
- Catherine Pearson (20 May 2013). "DSM-5 Changes: What Parents Need To Know About The First Major Revision In Nearly 20 Years". The Huffington Post. Retrieved 2013-05-21.
- "Highlights of Changes from DSM-IV-TR to DSM-5" (PDF). American Psychiatric Association. 17 May 2013. Archived from the original (PDF) on 2015-02-26. Retrieved 2015-01-04.
- "DSM-5". psychiatry.org. Retrieved 2019-08-29.
- "DSM-5 FAQ". psychiatry.org. Retrieved 2019-08-29.
- Harold, Eve; Valora, Jamie (9 March 2010). "APA Modifies DSM Naming Convention to Reflect Publication Changes" (Press release). Arlington, VA: American Psychiatric Association. Archived from the original (PDF) on 13 June 2010.
Beginning with the upcoming fifth edition, new versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be identified with Arabic rather than Roman numerals, marking a change in how future updates will be created, ... Incremental updates will be identified with decimals, i.e. DSM-5.1, DSM-5.2, etc., until a new edition is required.
- Ghaemi, S. Nassir; Knoll, James L., IV; Pearlman, Theodore (14 October 2013). "Why DSM-III, IV, and 5 are Unscientific". Psychiatric Times: Couch in Crisis Blog.[self-published source?]
- Insel, Thomas (29 April 2013). "Transforming Diagnosis". Director's Blog. National Institute of Mental Health. Retrieved 2013-09-02.
- "NIMH » Transforming Diagnosis". nimh.nih.gov. Retrieved 2019-02-25.
- Lane, Christopher. "The NIMH Withdraws Support for DSM-5". Psychology Today.
- Freedman, Robert; Lewis, David A.; Michels, Robert; Pine, Daniel S.; Schultz, Susan K.; Tamminga, Carol A.; Gabbard, Glen O.; Gau, Susan Shur-Fen; Javitt, Daniel C.; Oquendo, Maria A.; Shrout, Patrick E.; Vieta, Eduard; Yager, Joel (January 2013). "The Initial Field Trials of DSM-5: New Blooms and Old Thorns". American Journal of Psychiatry. 170 (1): 1–5. doi:10.1176/appi.ajp.2012.12091189. PMID 23288382. S2CID 34537713.
- McHugh, Paul R. (25 May 2005). "Striving for Coherence: Psychiatry's Efforts Over Classification". JAMA. 293 (20): 2526–8. doi:10.1001/jama.293.20.2526. PMID 15914753.
- Davis, John B. (5 April 1980). "Classification of psychiatric disorders". Canadian Medical Association Journal. 122 (7): 750. PMC 1801862. PMID 20313414.
- Kamble, Dattatraya (2019). PERSONALITY AND PHOBIC REACTION OF CHILDERN. Lulu. p. 63. ISBN 978-0-359-73746-8.[self-published source?]
- Fadul, Jose A., ed. (2014). "Diagnostic and Statistical Manual of Mental Disorders (DSM)". Encyclopedia of Theory & Practice in Psychotherapy & Counseling. Lulu. pp. 137–146. ISBN 978-1-312-07836-9.[self-published source?]
- Murphy, Dominic; Stich, Stephen (2000). "Darwin in the madhouse: Evolutionary psychology and the classification of mental disorders". Evolution and the Human Mind. pp. 62–92. doi:10.1017/CBO9780511611926.005. ISBN 978-0-521-78331-6.
- Cosmides, Leda; Tooby, John (1999). "Toward an evolutionary taxonomy of treatable conditions". Journal of Abnormal Psychology. 108 (3): 453–464. doi:10.1037//0021-843x.108.3.453. PMID 10466269.
- McNally, Richard J (March 2001). "On Wakefield's harmful dysfunction analysis of mental disorder". Behaviour Research and Therapy. 39 (3): 309–314. doi:10.1016/s0005-7967(00)00068-1. PMID 11227812.
- Kamble, Dattatraya (2019). PERSONALITY AND PHOBIC REACTION OF CHILDERN. Lulu. p. 64. ISBN 978-0-359-73746-8.[self-published source?]
- Hands, D. Wade (December 2004). "On Operationalisms and Economics". Journal of Economic Issues. 38 (4): 953–968. doi:10.1080/00213624.2004.11506751. S2CID 141997867.
- Nordgaard, Julie; Sass, Louis A.; Parnas, Josef (June 2013). "The psychiatric interview: validity, structure, and subjectivity". European Archives of Psychiatry and Clinical Neuroscience. 263 (4): 353–364. doi:10.1007/s00406-012-0366-z. PMC 3668119. PMID 23001456.
- "Overdiagnosis, Mental Disorders and the DSM-5". World of Psychology. 2010-07-26. Retrieved 2018-09-18.
- "Psychiatric Fads and Overdiagnosis". Psychology Today. Retrieved 2018-09-18.
- Thomas, R.; Mitchell, G. K.; Batstra, L. (5 November 2013). "Attention-deficit/hyperactivity disorder: are we helping or harming?". BMJ. 347 (nov05 1): f6172. doi:10.1136/bmj.f6172. PMID 24192646. S2CID 32080132.
- Bruchmüller, Katrin; Margraf, Jürgen; Schneider, Silvia (February 2012). "Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis". Journal of Consulting and Clinical Psychology. 80 (1): 128–138. doi:10.1037/a0026582. PMID 22201328.
- Vande Voort, Jennifer L.; He, Jian-Ping; Jameson, Nicole D.; Merikangas, Kathleen R. (July 2014). "Impact of the DSM-5 Attention-Deficit/Hyperactivity Disorder Age-of-Onset Criterion in the U.S. Adolescent Population". Journal of the American Academy of Child & Adolescent Psychiatry. 53 (7): 736–744. doi:10.1016/j.jaac.2014.03.005. PMID 24954823.
- Wing, Lorna; Potter, David (2002). "The epidemiology of autistic spectrum disorders: is the prevalence rising?". Mental Retardation and Developmental Disabilities Research Reviews. 8 (3): 151–161. doi:10.1002/mrdd.10029. PMID 12216059.
- Spitzer, Robert L.; Williams, Janet B.W.; First, Michael B.; Gibbon, Miriam. "Biometric Research". Psychiatric Institute 2001-2002. New York State Psychiatric Institute. Archived from the original on 7 March 2003.
- Maser, Jack D.; Akiskal, Hagop S. (December 2002). "Spectrum concepts in major mental disorders". Psychiatric Clinics of North America. 25 (4): xi–xiii. doi:10.1016/S0193-953X(02)00034-5. PMID 12462854.
- Krueger, Robert F.; Watson, David; Barlow, David H. (2005). "Introduction to the Special Section: Toward a Dimensionally Based Taxonomy of Psychopathology". Journal of Abnormal Psychology. 114 (4): 491–493. doi:10.1037/0021-843X.114.4.491. PMC 2242426. PMID 16351372.
- Wakefield, Jerome C.; Schmitz, Mark F.; First, Michael B.; Horwitz, Allan V. (1 April 2007). "Extending the Bereavement Exclusion for Major Depression to Other Losses". Archives of General Psychiatry. 64 (4): 433–40. doi:10.1001/archpsyc.64.4.433. PMID 17404120.
- Spitzer, Robert L.; Wakefield, Jerome C. (1 December 1999). "DSM-IV Diagnostic Criterion for Clinical Significance: Does It Help Solve the False Positives Problem?". American Journal of Psychiatry. 156 (12): 1856–1864. doi:10.1176/ajp.156.12.1856 (inactive 2021-01-18). PMID 10588397. INIST:1188640.CS1 maint: DOI inactive as of January 2021 (link)
- Widiger, T. A.; Sankis, L. M. (February 2000). "Adult Psychopathology: Issues and Controversies". Annual Review of Psychology. 51 (1): 377–404. doi:10.1146/annurev.psych.51.1.377. PMID 10751976.
- Vedantam, Shankar (June 26, 2005). "Psychiatry's Missing Diagnosis: Patients' Diversity Is Often Discounted". The Washington Post.
- Kleinman, Arthur (January 1997). "Triumph or Pyrrhic Victory? The Inclusion of Culture in DSM-IV". Harvard Review of Psychiatry. 4 (6): 343–344. doi:10.3109/10673229709030563. PMID 9385013. S2CID 43256486.
- Bhugra, Dinesh; Munro, Alistair (1997). Troublesome Disguises. Wiley. ISBN 978-0-86542-674-0. OCLC 45844487.[page needed][verification needed]
- Atwell, Irene; Azibo, Daudi Ajani ya (February 1991). "Diagnosing Personality Disorder in Africans (Blacks) Using the Azibo Nosology: Two Case Studies". Journal of Black Psychology. 17 (2): 1–22. doi:10.1177/00957984910172002. S2CID 144458287.
- Azibo, Daudi Ajani ya (November 2014). "The Azibo Nosology II: Epexegesis and 25th Anniversary Update: 55 Culture-focused Mental Disorders Suffered by African Descent People" (PDF). Journal of Pan African Studies. 7 (5): 32–176.
- Zulu, Itibari M. "The Azibo Nosology: An Interview with Daudi Ajani ya Azibo" (PDF). Journal of Pan African Studies. 7 (5): 209–214.
- Chandler, Emily (17 September 2012). "Religious and Spiritual Issues in DSM-5: Matters of the Mind and Searching of the Soul". Issues in Mental Health Nursing. 33 (9): 577–582. doi:10.3109/01612840.2012.704130. PMID 22957950. S2CID 3453154.
- Healy, David (11 April 2006). "The Latest Mania: Selling Bipolar Disorder". PLOS Medicine. 3 (4): e185. doi:10.1371/journal.pmed.0030185. PMC 1434505. PMID 16597178.
- Cosgrove, Lisa; Krimsky, Sheldon; Vijayaraghavan, Manisha; Schneider, Lisa (2006). "Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry". Psychotherapy and Psychosomatics. 75 (3): 154–160. doi:10.1159/000091772. PMID 16636630. S2CID 11909535.
- "(Susan Bowman, 2006)". The National Psychologist. 2006-11-01. Retrieved 2013-12-03.
- Greenberg, Gary (January 29, 2012). "The D.S.M.'s Troubled Revision". The New York Times. The article’s closing words: "it [the APA] will be laughing all the way to the bank."
- Halpern, L, Trachtman, H. and Duckworth, K. "From Within: A Consumer Perspective on Psychiatric Hospitals," in Textbook of Hospital Psychiatry, S. Sharfstein, F. Dickerson and J. Oldham eds. American Psychiatric Publishing, 2009, pp.237-244.
- Sanism in Theory and Practice Archived 2014-03-17 at the Wayback Machine May 9/10, 2011. Richard Ingram, Centre for the Study of Gender, Social Inequities and Mental Health. Simon Fraser University, Canada
- "How Using the Dsm Causes Damage: A Client's Report" Journal of Humanistic Psychology, Vol. 41, No. 4, 36-56 (2001)
- Cape Town Mad Pride (2013-06-08). "Known as the 'psychiatric bible', the Diagnostic and Statistical Manual of Mental Disorders appears in a fifth edition". Retrieved 28 Feb 2019.
- Michael T. Compton (2007) Recovery: Patients, Families, Communities Conference Report, Medscape Psychiatry & Mental Health, October 11–14, 2007
- Frances, Allen (11 May 2012). "Diagnosing the D.S.M." New York Times (New York ed.). p. A19.
- Frances, Allen J. (December 2, 2012). "DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes: APA approval of DSM-5 is a sad day for psychiatry". Psychology Today. Retrieved 2013-03-09.
- Phillips, James; Frances, Allen; Cerullo, Michael A; Chardavoyne, John; Decker, Hannah S; First, Michael B; Ghaemi, Nassir; Greenberg, Gary; Hinderliter, Andrew C; Kinghorn, Warren A; LoBello, Steven G; Martin, Elliott B; Mishara, Aaron L; Paris, Joel; Pierre, Joseph M; Pies, Ronald W; Pincus, Harold A; Porter, Douglas; Pouncey, Claire; Schwartz, Michael A; Szasz, Thomas; Wakefield, Jerome C; Waterman, G Scott; Whooley, Owen; Zachar, Peter (2012). "The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis". Philosophy, Ethics, and Humanities in Medicine. 7 (1): 3. doi:10.1186/1747-5341-7-3. PMC 3305603. PMID 22243994.
- "Professor co-authors letter about America's mental health manual". Point Park University. Retrieved 6 February 2017.
- "Professor co-authors letter about America's mental health manual". Point Park University. December 12, 2011. Archived from the original on 2012-03-29. Retrieved 2012-04-04.
- Allday, Erin (November 26, 2011). "Revision of psychiatric manual under fire". San Francisco Chronicle.
- American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR®. American Psychiatric Pub. ISBN 978-0-89042-025-6.
- Robert L. Spitzer (2002). Dsm-Iv-Tr Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Pub. ISBN 978-1-58562-059-3.