How the Diagnostic and Statistical Manual of Mental Disorders Works


Controversies and Reversals with the DSM
Gay and lesbian activists protest discrimination during the Christopher Street Liberation Day March, June 1971 in New York. At the time, the DSM still classified homosexuality as a mental disorder. Michael Ochs Archives/Getty Images

Some key about-faces are proof that the DSM isn't opposed to changing with the times. Here are some examples of major turnarounds:

Consenting adults who enjoy relatively unconventional BDSM, fetishes or even cross-dressing need not fear being considered mentally ill, thanks to the DSM-5 update, which "depathologized" kinky sex. Instead, they are now considered people with "unusual sexual interests" [source: National Coalition for Sexual Freedom].

Also, in keeping with the greater acceptance of transgender people, DSM-5 replaced the diagnosis of "gender identity disorder" with the less controversial "gender dysphoria," which does not classify those who don't identify with their birth gender as having a mental disorder. However, the diagnosis does spell out some of the challenges of living with gender dysphoria, as well as the different paths people choose to take to resolve this [source: APA]. (Some critics of the change point out that some insurance companies won't cover hormonal or surgical treatment if the condition is not considered a mental disorder.)

Another big change was the removal of homosexuality as a mental disorder from DSM-II. "APA's 1973 diagnostic revision was the beginning of the end of organized medicine's official participation in the social stigmatization of homosexuality," writes Jack Drescher in the journal Behavioral Sciences. "Similar shifts gradually took place in the international mental health community as well. In 1990, the World Health Organization removed homosexuality per se from the International Classification of Diseases (ICD-10). "

This was all accomplished in baby steps. Initially, DSM-III made a distinction between people who were comfortable with their homosexuality and those who weren't — the latter could be diagnosed with the mental disorder Sexual Orientation Disturbance. Eventually, this diagnosis was also removed from the manual in the 1980s [source: Group for the Advancement of Psychiatry].

One complaint about the DSM is that once a condition is included in the manual, it may turn what once was considered "normal" behavior into a pathological illness that must be treated — often with medication. "Many millions of people with normal grief, gluttony, distractibility, worries, reactions to stress, the temper tantrums of childhood, the forgetting of old age, and 'behavioral addictions' will soon be mislabeled as psychiatrically sick and given inappropriate treatment," wrote psychiatrist Allen J. Frances in Psychology Today at the time that DSM-5 was going to press.

But Wang points out that DSM-5 has incorporated an acuity measure to help with that, since so many disorders range widely in their severity. These scales help clinicians better evaluate symptoms and levels of impairment. For example, let's say you're grieving over the death of your father. Are you still able to cope with life or are you barely able to get out of bed? Once assessed, clinicians will be better able to land on the appropriate treatment, whether medication, watchful waiting, talk therapy or a combination of these [source: APA Integrated Assessment fact sheet].

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