A Critical History of the DSM
by: mike morse, 6/10/2021
For the past 150 years, psychology has sought to medicalize the ‘human experience’ and establish a racial hierarchy of human behavior, pathologizing people who do not fit into our capitalist society. From its inception, scientific psychology has used a vacuum to examine human thoughts and behaviors, defining people as being biologically predestined, individualized objects, rather than socially influenced subjects with autonomy. In fact, many critical psychologists recognize that the existence of the psy-complex (fields of psychology, psychiatry, social work, etc.) has primarily served the purpose of maintaining social order. Instead of looking at the social structures and institutions that influence people’s behavior, psychological academics and experts created a medicalized model to focus on the individual. This framework implies that not only are people helpless victims of their biology, but also that they are innately sick and in need of help. Although there have been some more modern ideological shifts within psychology to attempt a more humanitarian approach, the field is still centered around the power dynamic between the expert and the vulnerable non-expert.
The medicalized view of insanity ultimately resulted in the first American initiative to create a standardized diagnostic criteria for mental illness (the Statistical Manual for the Use of Institutions for the Insane (SMUII)) when the U.S. Census Bureau wanted to estimate the prevalence of mental illness in America for the 1920 census. By 1950, five different ‘official’ diagnostic classification systems were used, one for each of the following: insane asylums, the Navy, the Army, the Department of Veterans Affairs (VA), and the American Prison Association. In response, the American Psychiatric Association set out to standardize all the diagnostic systems, and in 1952 the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was created. The DSM-I separated diagnoses into two main categories: those with a known brain/neurological cause, and those with an unknown (generally socioenvironmental) cause. At the time, mental disorders were viewed as reactions to stressors, and in general people would not receive comorbid diagnoses. The introduction of the DSM-I resulted in increased inpatient psychiatric care (i.e. mental asylums), which meant isolating those who were deemed unfit to function in ‘normal’ society.
Sixteen years later (1968), the second edition (DSM-II) was released as an attempt to mirror the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD). Although the major reason for the update was to bridge the disconnect between American and European diagnostic criteria, the DSM-II also permitted comorbid diagnoses for the first time. While this may seem minor, it allowed for the development of varying degrees of ‘mental illnesses’. As some people were labeled as more severely mentally ill than others, society effectively devalued the lives of those who functioned outside of social norms and expectations.
Throughout the 1960’s, critics of psychiatry argued that human behavior should not be medicalized; Thomas Szasz discussed how mental illnesses are merely social constructs, meaning their existence relies on a joint social construction of reality, rather than a hard physical or biological truth. In the 1970’s, the DSM began to receive criticism for the lack of empirical research that went into the diagnostic criteria (since it was previously adopted from a military guide). The DSM-III was released in 1980 as an attempt to further validate medical psychiatry by creating empirically-based diagnostic criteria; the number of ‘mental disorder’ categories increased by nearly 100, supposedly to reflect the growing psychological knowledge available from this research. This edition introduced diagnoses such as PTSD and ADHD, and it broadened the categories of previous ‘disorders’ (for example, the category ‘phobic neurosis’ was broken down into five individual ‘phobic disorders’). It also officially removed ‘homosexuality’ as a diagnosis; however, the impacts of pathologizing queerness can still be seen today (for example, in many states, medical professionals require trans patients to have a psychologist sign off on gender-affirming procedures or care).
The DSM-III did not provide any specific treatment options for its diagnoses; in fact, the symptom-focused diagnostic criteria opened a door for pharmaceutical research to attempt to create medical solutions to the new pathologies of the DSM. The 1980’s dramatically expanded the field of psychiatric pharmaceutical research, which was incentivised by the U.S. Government (the National Institute for Mental Health’s budget was increased by 84% in 1984 for research). This alignment of the psy-complex with medicine has trickled down to the modern mindset of treating mental health in the same manner as physical health. While it is not wrong that we need to prioritize caring for our emotional and mental well-being, the simplification of our psyche to a biological condition belittles and ignores the socioenvironmental factors (such as racism, sexism, classism, ableism) that have morphed our society and impact our lives.
The fourth edition of the DSM (DSM-IV, published in 1994) was initiated by another update to the ICD. The largest change was the addition of “clinically significant distress or impairment” to all diagnostic criteria. This suggests that someone may have ‘symptoms’ that meet diagnostic criteria that do not cause distress to the individual; however, it was rarely the choice of the individual whether or not they were experiencing ‘impairment’. Instead, this gave more power to the expert to determine whether or not someone’s situation should merit a diagnosis, which could then impact access to care, medications, insurance coverage, and more. On the other hand, this also allowed those most vulnerable to the psy-complex to show how they did not perceive themselves incapable or distressed. Those of us who experience neurodivergence are not any lesser of people; however, we are aware of the ways in which our capitalist society does not want to accommodate our needs. Rather than working to empower neurodivergent people to live autonomously, the psy-complex has assisted in the growth of the psychopharmaceutical industrial complex, the prison industrial complex, and the more recently recognized mental health industrial complex.
The most recent edition of the DSM (DSM-5) was published in 2012. This version was the first collaborative effort between American psychiatric organizations and European health organizations. Most of the changes in this latest version were centered around the terminology: some ‘disorders’ were reframed as spectrums rather than stagnant diagnoses (for example Autism Spectrum Disorder replaced Autistic Disorder and Asperger’s Disorder). This version also introduced developmental periods to diagnostic criteria for the first time (i.e. to receive an ADHD diagnosis, you must have experienced symptoms before age 12). This is very limiting to people who decide to seek out a diagnosis later in life, or who don’t find their experience to be debilitating until they’re in a certain situation. For example, I began having trouble focusing and sitting still through three-hour class blocks during college. I never had this issue previously as I had never taken classes this long before college. I met enough of the diagnostic criteria for ADHD, but because I did not have the same struggles as a child (since my school environment was different) I was unable to receive the diagnosis. Although not everyone benefits from or desires to have a diagnosis, using age as a restriction for diagnostic criteria pushes the false idea that development is a linear process.
Psychology as a scientific and academic field grew under the research ideology known as positivism, or the belief that scientific data and findings are genuinely reflective of real life. Researchers who use a positivist epistemology generally seek to find answers, which they believe to be universal truths. The epistemology of positivism is what allows psychology to follow the medical model; psychological research attempts to find the sole cause of deviant or abnormal behaviors, ignoring socioeconomic nuances and personal agency of the individual. Psychology also frames people as individual products of their biology and immediate environment who lack self-reflective abilities, rather than seeing the ways in which the overlapping oppressive systems of racial capitalism, global imperialism, and settler colonialism have contributed to the day-to-day sexism, racism, ableism, heterosexism, and other prejudices people face.
The development of the DSM outlines the ways in which the mainstream American view has evolved over the past 75 years regarding mental health. What originated as a statistical tool with a black and white ‘mad’ vs. ‘sane’ mindset transitioned into a multi-billion dollar industry (the ‘mental health industrial complex’) that profits upon individual suffering by assigning power to the ‘expert’ over the people. The power given to the ‘experts’ in psychology implies that there is a mysterious complexity to human thoughts, feelings, and behaviors that people are unable to understand on their own. Rather than empowering individuals to learn about and care for themselves, psychology convinces us there is something we need to fix. While on an individual level receiving diagnoses can be a source of joy, relief, and understanding for many people, the primary role of the DSM has been to continue the original function of social control that psychology has always played. Instead of working with individuals to understand and see the broader structures that have formed their lives, the psy-complex encourages people to look inward and focus on the ways in which they are individually at fault for their circumstances. I do not want to belittle the importance of self-care, inward reflection, self-understanding, and resilience building; instead, I am trying to emphasize the oppressive structures on which the Western field of psychology was built. It is possible, and necessary, to be critical of what brought us to where we are today with regards to how we view our mental well-being while still being purposeful about practicing self-care.
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