For those who know not, it is a compendium of psychiatric conditions that are reviewed with every edition with tthe latest edition being DSM-5 TR published by the American Psychiatric Association (APA).
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The thing you have to understand is that the DSM is not the holy grail of psychiatry.
It’s a classification of diseases, so that everyone use the same language. It should not be used purely as a checklist to diagnose people, without digging any further.
The DSM is supposed to be an instruction manual for identifying problems so you can match them with solutions. The way we study things to put them in the DSM does neither of those things.
It doesn’t identify problems because it thinks syndromally. In Medicine, sometimes it helps to start by describing symptoms so you can identify what parts of the body are not doing their jobs through process of elimination, but since we dont know much about how the brain does its job right, there’s no point to trying to find patterns in how it does its job wrong. Instead, the patterns we identify say more about how we think people should think or act (moral principles) than how brains are supposed to work (functional principles).
It doesn’t produce solutions because psychotherapies and medicines don’t operate on diagnoses, they instead operate on processes. Medicines modify neurotransmitter levels in various parts of the brain, which aren’t mentioned in the dsm at all, while psychotherapies address particular intentional behavioral or cognitive strategies, which generally aren’t targeted at specific diagnoses (with a couple of exceptions like DBT or TFCBT that mostly prove the rule).
The altenatives to a syndromal approach are either to start taking a purely neurological or neuriscientific approach to defining what a brain should/shouldnt be doing and ignoring what a mind should/shouldn’t be doing, or to focus our attention on psychological health instead of on deficit. In the last 20-30 years most or all of the popular psychotherapeutic approaches have been focusing less on finding what’s wrong/fixing it and more on figuring out what healthy is/promoting it. The dsm gets in the way of that way of thinking. That’s why people don’t like it.
So this is from the perspective of social work as I am currently a social work student taking coursework on this very topic. Clinical social workers can make mental heath diagnoses using the DSM-5 and often have to do so for insurance billing, but the reason why our field in particular criticizes the DSM is honestly a greater critique of the medical model. The DSM is a psychiatry based book. Psychiatry works on the medical model where all conditions, physical or mental, have primarily biological origins and clearly defined cut and dry symptoms. If someone has enough symptoms, they get diagnosed and then treated, ideally with medication.
The problem with this from a social work perspective is that mental health comprises far more than a series of symptoms. Social workers are trained to look not only at a person’s individual psychology, but also on the social, economic, relational, spiritual, community and many other factors that influence their life. Diagnosing someone with Major depression under the DSM-V doesn’t by itself tell me what a client is going through. A psychiatrist might look at a diagnosis of MDD and say “cool, I’ll prescribe an antidepressant and we’ll see how that works”. But what if the person’s depressive symptoms aren’t a result of a chemical imbalance and genetics? What if their symptoms are a result of grief from losing their entire family in a drunk driving accident they were never able to properly process? What if the symptoms are the result of a sexual assault and then not being believed by anyone they reported it to, possibly even being blamed for it? What if it’s related to exhaustion and hopelessness from a life of poverty and hardship? The DSM does not adequately take into account these social and environmental factors that make everyone’s experience of depressive thoughts unique and sometimes even an expected and natural testimony, which is important because you will approach all of these scenarios differently when it comes to treatment planning.
Another issue with the DSM 5 is that it’s not strengths based. Social work is a strengths-based profession. That means we identify and make use of clients’ strengths to guide their treatment, not their deficits. A single mother accused of neglect for leaving her kids at home in order to go to work will still be recognized for her belief in the importance of work to have an income to keep a roof over her family’s head, while we work on finding suitable childcare so she can continue working, rather than blaming her for making a bad choice and possibly pressuring her to quit her job. The DSM does not recognize strengths. It categorizes what are often human emotions and reactions as “diseases”, contributing to the stigma surrounding mental illness. A person who attempts to end their life due to financial stresses diagnosed with MDD will forever be labeled “mentally ill” in their medical records. They will never be able to serve in the military. Their life insurance premiums will rise. If they have a security clearance for their job, they will lose it. Diagnosis, for all that it misses in terms of assessing people, labels their behaviors and emotions as problems to be “fixed” rather than reactions to life circumstances that people can be taught to better manage and thrive with. The final issue is that some diagnoses are HEAVILY influenced by situational factors as to whether they’re actually harmful. There are still many psychiatrists and psychologists who will diagnose anyone with a fetish with a paraphilic disorder or any trans individual with gender dysphoria even if that condition is causing no loss of function or other problems in their day to day life.
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