Genuine question, what’s wrong with the DSM?

[OP refers to the Diagnostic and Statistical Manual of Mental Disorders, which I mentioned being unpopular among mental health professionals.] Disclaimer: I'm not a psychiatrist, I'm not a therapist, and I'm not trained in counseling. I'm a social psychology researcher. If a therapist contradicts me, listen to the therapist.

The problem with the DSM as I understand it: a lot of counselors/ psychiatrists/ etc. want to move away from a category- and source-based diagnostic system, toward a symptom-based treatment system. For example, think about Pepto Bismol: you feel nauseous, you chew pink tablets, it ends your nausea. It doesn't matter if your nausea is indigestion or seasickness or lactose intolerance. You match a treatment (pink bismuth) to a symptom (nausea) and don't waste time or money on diagnosis unless that treatment proves ineffective.

A large percent of counselors etc. would like to take the same approach to mental health. So we'd be researching treatments for nightmares (neurofeedback? MDMA?) in the long-term, and giving clients treatments for nightmares (meditation! Ambien!) in the short-term. All without worrying too much about whether the nightmares are caused by General Anxiety Disorder or a phobia or Seasonal Affective Disorder. There are many strengths to that approach.

Only, see, there's this big purple dinosaur holding us back.

[Image ID: Hardcover copy of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5, American Psychiatric Association; the title is white text on a purple background.]

So if everyone who uses the DSM also hates the DSM, why does it still exist and why do we keep buying it every time a $100 text revision gets published? Two reasons, in order of importance:

Insurance

Communication

Insurance is, I kid you not, the DSM's #1 reason for existence. American insurance companies won't cover treatment unless it's for a diagnosed illness, and so therapists put diagnosed illnesses on what they'd often be more comfortable describing as "bro, this dude is hella distressed and I'm trying to help undistress him." Note the word American on the cover; other countries have other manuals, and no other country's counselors are as chained to theirs as we are to ours. This means that the DSM helps — yay, affordable therapy! It means the DSM hurts — sets of symptoms get grouped artificially, spectra get split into categories, and diagnosis happens way too early in the therapeutic process.

Another comparison to unmental health: I don't have carpal tunnel syndrome, but my insurance provider thinks I do. I only announce that I don't because I haven't told you who I am or where I live. (If the insurance companies find us... Well, we just won't let them find us. The thing you should know is everyone is getting screwed by health insurance. Yeah, even you.) I have wrist pain and tingling. It has the wrong antecedents for carpal tunnel, and it has weird manifestations — pressure on the base of my thumb causes pain in my pinky — but my OT wrote down "Carpal Tunnel" on the forms because the alternative was a $500+ round of diagnostic scans. No one cares whether my median nerve is inflamed or not; occupational therapy still looks like "try this stretch, that stretch, this brace, that brace, and these activity changes; keep whichever combination makes the pain and tingling go away."

This kind of thing also happens in mental health all the time. Many therapists don't care — and neither should you — if your serotonin levels are low; if you're miserable and an SSRI prevents the misery, take the dang SSRI. If your mother was harshly critical and now you feel panic at any hint of criticism, it doesn't matter whether that better fits C-PTSD or NPD; it matters whether you cope with soothing self-talk or if you cope with alcohol. Put something from the DSM on the forms, and focus on finding which stretches (breathing exercises) make the tingling (panic) go away.

Communication is the biggest strength of the DSM. It means that clients can benefit from labels ("I'm not lazy, I'm ADHD") and consistent standards of treatment can be applied across different clients in different states. The DSM has huge lists of things like "if your client shows memory problems, be sure to check for alcohol abuse" or "if they have self-harm, make sure it's non-suicidal before you do anything else" that are tremendously helpful. It can help therapists who encounter a set of behaviors they've never seen before to go "client is rigid, rule-bound, and lacks insight... huh, looks like I'd better refer them to an OCPD specialist." (It's also the source of a lot of toxic misinformation on social media when symptom lists get taken out of context without that all-important differential diagnosis information, but I digress.)

However, diagnosis should never be the beginning point for therapy — it's impossible to know your client's mind without first building trust and transference — but reliance on the DSM for insurance often forces it to be. Diagnosis should never be the end point for therapy — knowing your perceptions don't match others' because of Bipolar I won't stop you hearing the dang hallucinations — but home use of the DSM often acts that way. Categorical diagnosis is limiting if your therapist is primarily interested in how depressed you are but the Beck Depression Inventory uses an absolute cutoff point for "depressed" or "non-depressed." Categorical diagnosis is useless if over 50% of people diagnosed with a depression are later diagnosed with an anxiety disorder, and vice versa. So it's an imperfect book that does a lot of things well and a few things badly, and many of its heaviest users would argue that it shouldn't exist at all.

For further reading, I recommend The Body Keeps the Score by Bessel van der Kolk. I don't agree with all the axes he grinds or all the ways he grinds them, but he's got decades of psychiatry experience and is (I hope) predicting the next paradigm shift in mental health.

For instance, van der Kolk argues that it doesn't matter if at intake your client has long blond hair and is named Linda, only to show up the next time with no hair and the name Gerald, only to come next time with short red hair and the name Taylor. The therapist should only be asking "how does the client feel about these changes?" and "what are these changes doing for the client?" If Linda can't remember what Gerald did, then focus on the terrible memory gaps that alter identities create. If Taylor became Gerald to try and please you, then focus on teaching mindfulness and self-compassion. If this is a happily genderqueer person, then figure out why they're seeking help and don't worry about the appearance changes. If this is someone who thinks in absolutes and regards their personality as constantly changing, then work on teaching them to see the world and themself with moral complexity. It doesn't matter whether Dissociative Identity Disorder exists or not; just ask your client what they need and how you can help, then go from there.

Anyway, the DSM is an imperfect solution to a complex problem, and a lot of mental health practitioners view it as a relic of a more paternalizing era. No one has come up with a really good solution for how to remove and replace it, so for now it's the least-bad option.

2-27-2024

so like I JUST NOW a few minutes ago found out about 'posic' and 'objectum'

from what little I've seen so far, it's well, odd, but harmless its something I think we all experienced as kids but also deeper and sense no laws or morals are being broken, (and sense I believed all things, even object, where sentient in some way up until I was in my late teens) I guess ya'll are alright. :)

edit: AND ALSO if showing (and feeling) love and respect towards (and from) objects AND the planet keeps more people from contributing to pollution I'm extra supportive of that-

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i feel like a lot of people i know who are the same age as me have very specific inflections/vocal tics that i also use constantly. i can't explain it. zoomerisms

I’ve been behind on night vale for a while now, it had just kinda been eh to me but I finally binged and caught up. Holy fuck that ten years later destroyed me. And with that post credits scene I am fully back. I’m going to devote so much time to this funky group it’s not even funny

Wartenberg wheels are so funny to me because in addition to being metal and spiky and generally scary-looking, it is in theory a medical instrument, which should carry a certain kind of emotional charge if you’re into that sort of thing. (And I am sort of into that sort of thing.) But in reality you can get away with not even knowing that origin, because their reputation is now so firmly established as a thing you buy in the sex shop next to the fuzzy handcuffs and the flavored lube. Which is fine! Nothing wrong with it as a sensation toy, just that on paper it sounds like it would be something else.

...Am I a vampire or do I simply vibe with them?

My brain has forgotten how to write smut.

re: cat hockey

would they tuck their tails into their pants for safety? or would they have an armor like piece for it as well? or do they just leave it be for balance and such. however i cant imagine a guy would want to take a chance with his tail getting sliced off goalies especially given their propensity to be on the ground

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omg how are you liking ouran high school host club?! I'm so excited for u <3

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So you’re telling me that I produce less dopamine, and that the effects of a reward are less intense and shorter lived, but that somehow makes me more susceptible to getting habituated into infinite scrolling because of the dopamine hit?

I rag on 100 gecs in passing, feel guilty / skeptical about it, decide to try to listen to them again with an open mind and then just decide their music sucks and I hate them even more. Here's the ridiculous part: By the same process, I think I may have accidentally sniped myself into becoming a Yeat fan

Considering drawing the turtles from my AU but also not sure how to do character turn arounds and that’s what I want to do. So…research and trial and error it is!!

@adamfare1996