By Eric Vandenbroeck and co-workers
The secrets behind making the Diagnostic and Statistical Manual of Mental Disorders(DSM) Part Two
Already early on, a group of psychiatrists argued that they were “concerned about the lowering of diagnostic thresholds for multiple disorder categories, about the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and about specific proposals that appear to lack empirical grounding.”
This was followed by several high-profile articles by Professor Allen Frances, whose arguments carry more weight than most, as he was chair of the task force for DSMIV-TR (the previous update in 1994). In an article entitled DSM 5 Is Guide Not Bible – Ignore its Ten Worst Changes, he highlighted changes to the manual that he argued were examples of over-medicalization of mental health.
We will cover DSM and psychiatric diagnosis aspects that make clinicians and researchers vulnerable to biased diagnostic decisions. These include Value-laden and vague concepts of mental disorder, upon which the entire DSM nosology is based. Criterion biases, biases within diagnostic criteria for specific disorders. Clinician bias, unfolding in a clinician–client interaction. We will also add further clarifications and examinations of bias in psychiatric diagnosis to understand it best and how diagnostic decision-making may be linked to clinical competency to serve better clients who seek our help.
Initially, the DSM-I was well suited for the needs of psychiatrists and other clinicians in the 1950s and 1960s, when no professional, economic, or cultural purposes were served. Psychiatric researchers, who did require well-defined diagnostic criteria, were few and not highly valued in the profession. Third parties who might have demanded diagnoses did not have major roles in the economic aspects of therapeutic encounters: hospital-based psychiatrists were salaried while patients themselves reimbursed outpatient therapists. By the time the DSM-II became available in 1968, all these factors were in flux.
Psychiatry was highly visible in the general culture, but the DSM was not. Particular diagnoses were rarely used and were not highly valued. Interest in psychiatric diagnosis in the 1960s was probably at an all-time low. However, the rise of a biomedically oriented group of psychiatrists and demands from government agencies, third-party insurers, and the drug industry eventually produced an entirely new diagnostic system.
The early need for a replacement
Several factors, both within and outside of psychiatry, created intense demands on the field to discard the DSM-II and replace it with a completely different classification. A subspecialty was arising that was more focused on diagnosis than its psychodynamic counterpart. Before the 1950s, virtually nothing was known about brain chemistry. The decoding of DNA in 1953 generated intense new interest in this organ. From that time onward, researchers strove to identify specific neural mechanisms associated with various mental disorders. Although the idea that particular brain malfunctions were responsible for mental pathology revived a dominant strain of thinking in nineteenth-century psychiatry and neurology, the biological view seemed genuinely new at the time.
As psychopharmacologists began to serendipitously discover various psychotropic drugs, including phenothiazine, imipramine, and monoamine oxidase inhibitors (MAOIs) in the 1950s, researchers became attracted to the notion that drugs targeted at specific brain regions could aid in the diagnostic process itself. Psychiatrist Donald Klein proposed the idea of “psychopharmacological dissection” to show how the close observation of the varying effects drugs produced among different patients could help diagnose what specific conditions they had in the first place.1
The antidepressant imipramine provided an example: “All research workers who used this drug initially were unanimous in the conclusion that, unlike many other psychopharmacological agents, it specifically affects depressive conditions and has minimal effect on paranoid states or disturbing behavior, particularly in schizophrenics.”2 The conviction developed that imipramine or an MAOI should be directed at depression, phenothiazine at schizophrenia, and lithium at manic depression.
The narrative emerging from psychopharmacological research thoroughly contrasted with the analytic focus on uncovering unconscious conflicts from the distant past and using the therapeutic relationship to resolve them. A distinctly nonanalytic conception of mental illness also started to penetrate US culture in the mid-1950s when popular media began to pay attention to biologically based research and treatments. In 1955, Congress passed the Mental Health Study Act, which allocated $2 million annually to the National Institute of Mental Health for psychopharmacological research.3
Congress to cut the NIMH budget
Changing approaches to mental illness within the federal government was also central in elevating the need for a new diagnostic system grounded in specificity. Two agencies, the National Institute of Mental Health and the Food and Drug Administration, pushed the field to place greater emphasis on diagnoses. The NIMH was the major source of funding for psychiatric research and education. At the same time, research-oriented psychiatrists turned away from the psychosocial model; the NIMH confronted an intense political backlash over its initial focus on social issues.4
Since the mid-1960s, this agency’s activist policies and resulting perception that it did not deal with true diseases led Congress to consistently cut the NIMH budget and, consequently, funding for psychiatric researchers. A new diagnostic system grounded in disease-like entities was hoped to be the perfect antidote for the now-toxic focus on social problems. The NIMH became an important partner of the American Psychiatric Association in sponsoring a new biomedically oriented DSM that would serve their mutual interests. The FDA was a second federal agency that turned psychiatry toward the study of specific diseases. In the early 1960s, a public uproar resulted when the sedative drug thalidomide was found to produce severe congenital disabilities in the children of mothers who had taken it for relief of morning sickness. In response to this crisis, in 1962, Congress passed the Kefauver-Harris drug amendments that directed the FDA to scrutinize more tightly which drugs could come to market and how they should be used. The agency began to mandate randomized, placebo-controlled, and double-blind trials as necessary demonstrations of drug efficacy. This directive stimulated a new diagnostic system because such procedures required members of both the treated and the control groups to have the same disease condition. Congress and the FDA made no distinction between psychiatric and medical conditions, assuming both could be defined in particular ways. Yet, the extant DSM criteria were too vague and, in many cases, too infused with psychodynamic assumptions to serve as the basis for defining the targets of particular drugs.
The central change in the DSM-III, which persisted through the III-R and IV, was to split substance use into two separate categories of dependence and abuse. The DSM-IV criteria for dependence required the presence of three or more out of seven possible symptoms, which included the two physiological dependence symptoms of growing tolerance to the substance or maladaptive problems from withdrawal, and five behavioral symptoms, including giving up activities, continuing use despite harmful effects, trying and failing to stop, taking larger amounts than intended, and spending significant time obtaining and taking the substance.5 Research indicated that the substance dependence diagnosis had good reliability and validity in capturing the essential qualities of addictive behavior.6
The DSM-IV, however, made the diagnosis of substance abuse that involved “impairment in social or occupational functioning due to substance use” much more problematic. Unlike the definition of dependence, which tried to define the intrinsically dysfunctional properties of substance use, abuse referred solely to the adverse social consequences of use.7
It required just one symptom of abuse, such as substance-related legal problems or arguments with spouses about intoxication. Therefore, the DSM-IV contained one diagnosis of substance dependence, which captured the general nature of addiction, and another of substance abuse, which violated the DSM principle of avoiding diagnoses that solely rested on harm in the absence of underlying dysfunction, on social deviance, or conflicts between an individual and society. A resolution of this situation seemed to involve correcting or eliminating the invalid abuse category. The DSM-5, however, moved in a different direction.8
The primary change in the renamed class of substance-related and addictive disorders was to abandon the division between substance dependence and substance abuse that had persisted in every manual since the DSM-III. In its stead, the manual substituted the single category of substance use disorders, which combined criteria for the previous two diagnoses into a single entity.9 The head of the DSM-5 workgroup responsible for the new diagnosis attributed the change to an “overwhelming abundance of evidence in favor of combining the abuse and dependence criteria.”10 The DSM-5 criteria, however, seem to be a step backward from previous formulations of substance use disorders. The new diagnosis contained 10 possible symptoms, 7 from the earlier dependence diagnosis, 3 from the earlier abuse diagnosis, and a new symptom of “craving.”11 The workgroup justified this change because statistical analyses indicated that symptoms of dependence and abuse were highly correlated.
Because the new DSM-5 criteria are easier to obtain than the DSM-IV diagnosis, it is subject to many false-positive results. It was reasonable the DSM-5 criteria would increase the number of symptoms for SUD, but they decreased the number of necessary symptoms. One review predicted the lowered criteria would produce a 62 percent increase in SUD diagnoses in the general population compared to the DSM-IV criteria.12
The second problem was that the new unitary diagnosis incorporated the invalidity problems of the old substance abuse diagnosis. A person whose substance use led to social or interpersonal problems and the inability to fulfill major role obligations met the revised criteria. For example, someone who argues with their spouse about smoking in bed could have a “tobacco use disorder.”13 Changing patterns of law enforcement, legislation, and social attitudes might all influence the prevalence of the new diagnosis: Localities that established checkpoints for drunken driving could at the same time be increasing levels of a mental disorder. A law that legalized medical or recreational use of marijuana would simultaneously decrease rates of mental disorders in that state. Someone could become mentally ill by moving from one state to another! Instead of having one valid and one invalid substance use condition, as in the DSM-IV, the DSM-5 criteria had a single diagnosis that could often be invalid.
Third, the new diagnosis was more heterogeneous than previous manuals. It confounds dysfunction and social deviance.14 It combines in a single entity someone who persistently uses large amounts of a substance, is unable to stop using, and has constant cravings for it with someone who oversleeps and misses an exam.15 It outnumbers the former, resulting in misleadingly high estimates of SUD.
The DSM-5 changes to substance use disorders have led the area to become, in the words of one of its leading practitioners, Griffith Edwards, “a field in disarray.
They blurred the distinction between mental disorder and social deviance and conflicts between individuals and society, created the potential for large numbers of false positives, and led to greater diagnostic heterogeneity. These changes refute the proclamations that diagnostic changes reflect growing knowledge and show how diagnoses can regress from their portrayals in earlier manuals.
Just a year before the DSM-5 was published, APA president-elect Jeffrey Lieberman proclaimed, “Since DSM-IV was released in 1994, there has been a wealth of new research and knowledge about the nature and frequency of mental disorders, how the brain functions and its neurobiology, and the lifelong influences of genes and environment on a person’s health and behavior. Accordingly, the new edition—DSM-V—will reflect that new body of knowledge.”16
The DSM-5 closely resembles its predecessors: the grand ambitions of its creators are not evident in the diagnostic section, though they are found in its appendices. While no evidence of brain functions, neurobiology, genes, or the like is found in the DSM-5, it maintains the descriptive, categorical, and theory-neutral approach of the preceding manuals. The search for unbiased diagnoses grounded in objective tests is no more advanced than when the first modern classifications emerged a century ago. Only external signs and symptoms are still the only resources available to categorize disorders.
The DSM-5, with its predecessors, was marked by hostility, controversy, and factionalism. The leadership of the revision process and the NIMH repudiated and delegitimated the basic structure of previous DSMs. The APA membership and trustees rejected researchers’ aspirations to implement a new diagnostic paradigm. The process revealed the distinct functions of the DSM. Kupfer, Regier, and the task force were tone-deaf to the importance the DSM had assumed outside of the research community. Clinicians are often skeptical about the inherent reality of diagnoses but require them for practical reasons. One psychiatrist who combined both roles observed, "I am incredibly disciplined in the diagnostic classifications in my research, but in my private practice, I’ll call a kid a zebra if it will get him the educational services I think he needs."17
No single diagnostic system can satisfy both constituencies
The DSM-5 Task Force failed to understand that psychiatric diagnoses cannot solely reflect the findings of research committees, epidemiological studies, and field trials. For most APA members and other interest groups, the DSM has become an indispensable practical tool. Clinicians were unconcerned with issues regarding dimensions, categories, or kappas, and they did not have to believe in the validity of the DSM diagnoses. Most patients and their families required a diagnosis to be reimbursed for treatment and receive other forms of valued resources. The extant DSM was well suited for their needs, while a new dimensional system would have been a radical transformation with unknown consequences.
A dimensional system would have disrupted the DSM's diagnostic system's clinical, research, and administrative functions. All mental health clinicians have been trained using the DSM categorical system. Psychology, psychiatry, and social work textbooks are organized using these diagnostic conceptualizations, and epidemiological data, service use and medical, economic data, outcome data, and so forth.
The rank and file of the APA and outside advocacy groups were not willing to accept the uncertainties that a wholesale change of the DSM would have brought about. The embeddedness of diagnoses within clinical and institutional practice posed a formidable barrier to making any fundamental changes in the classification. The DSM-5 will serve clinicians, administrators, families, and patients just as well as earlier DSMs.
The DSM-5 saga was unsettling for psychiatry. The participants initially repudiated the model but were thwarted in their determination to replace it. Although the manual has few fundamental changes from the previous versions, it emerged from the revision process with its credibility shaken. The myth that the DSM rested on a firm scientific basis was exposed by the same people who had propagated it. The DSM-5 process might have signaled the end of the manual’s 40 years of unquestioned dominance in shaping the mental disorder. Despite the overall similarity of the DSM-5 to previous manuals, its critics were not satisfied. Allen Frances, who has taught psychiatry for 45 years, said, “You don’t buy it, you don’t use it, and you don’t teach it.” He urged, “Take away the diagnostic system, and the APA must be taken away from the American Psychiatric Association.”18
Since 1980 the DSM has fundamentally shaped psychiatric thought and practice. It overturned the psychodynamic notion that mental disorders were intrinsically grounded in each individual’s existence and the social critique that madness resulted from civilization. The manual became the touchstone for diagnoses and research. Its labels dictate what mental health conditions insurance companies reimburse, government programs pay for, and drug companies market their products to treat. DSM diagnoses frame how Americans and, increasingly, people worldwide understand their own interior problems.
If the DSM powerfully impacts all facets of mental disorder, the manual itself results from the dynamics and organization of the psychiatric profession and wider cultural, political, and economic currents. Fluctuations in the politics of psychiatry, the nature of reimbursement for treatment, and the benefits patients, families, clinicians, and researchers receive shape the manual’s uses. Over the DSM period, the manual changed from being the starting point for understandings to becoming the authoritative source for such understandings and explanations. The DSM is a fundamentally social document that influences and reflects psychiatry's changing internal and external dynamics.
The Social Embeddedness of the DSM
The history of the DSM indicates the manual’s deep entrenchment in the intra-professional and general sociocultural forces that impact the psychiatric profession. Some of these influences arise from within the field. Between the mid-twentieth century and the present, the psychiatric practice relocated from mental institutions to offices and clinics. At the same time, the profession’s political center of gravity moved from the psychodynamic clinicians who dominated the initial DSM period to researchers who held a very different diagnostic agenda. As well, changing medical norms forced the profession to adopt a more scientific-seeming classification system. Other forces came from outside the field. Once psychiatry moved from the hospital to the community, patients and their families were less likely to view diagnoses as imposed and unwanted labels than valued treatment sources and other resources. Federal agencies, schools, and insurance companies all made DSM conditions requirements for service provision. Drug advertisements became major channels for suggesting which diagnosis described a consumer’s problems. These factors changed dramatically from the manual’s emergence in 1952 through its most recent version in 2013.19
When the DSM arose, the psychiatric practice was undergoing a profound transformation. Before World War II, nearly all psychiatrists were affiliated with mental hospitals, where diagnoses mostly served administrative purposes. The war forced psychiatrists to confront the power of environmental stressors to produce mental disorders in previously normal individuals, dislodging the organic orientation that had shaped prior diagnostic manuals.
The DSM-I deftly responded to the new world of postwar psychiatry. It split mental disorders into organic and psychogenic categories, reflecting the recent hospital-based and community-oriented psychiatry division. The profound psychic impacts of combat also led the initial DSM to add the far broader and more heterogeneous difficulties found in the general population to the largely psychotic problems that previous manuals emphasized. Shortly after the first DSM appeared, mental institutions began a precipitous decline. The roughly half-million patients residing in the state and county mental hospitals in the early 1950s fell to just 63,000 at the turn of the century and to below 40,000 at present.20 The status of the major diagnostic categories changed accordingly. Compared to the initial duality of organic and psychogenic conditions, the most recent DSM devotes just 2 of its 22 chapters to the psychoses.
Outpatient practitioners had little need for diagnoses in the 1950s and 1960s, as most clients paid for their own treatment. Dominant analytic theories downplayed or dismissed the diagnostic process. Thus, the brief and nonspecific descriptions of the psychogenic conditions found in the first two DSMs sufficed.
Political conflicts within the profession profoundly influenced the course of the DSM. The first DSM arose when almost all psychiatrists were clinicians or administrators. By the early 1970s, psychiatric researchers had gained considerable power and prestige, and diagnoses were essential for their goals. The extant DSM did not provide them with the precise descriptions and decision rules that ensured they dealt with homogeneous groups. Robert Spitzer, the leader of the researchers who promulgated the DSM-III revolution, understood that the manual also had to meet clinical needs.
Practitioners did not require uniform diagnostic criteria, and many held cynical attitudes about DSM diagnoses. By the 1970s, however, they had no choice but to put diagnostic codes on reimbursement forms. Clinicians also needed an inclusive system with categories that encompassed all their clients. Spitzer realized that the manual had to span the range of conditions found in psychiatric practice.
Now the anxiety and depressive classes, the former neuroses best illustrate how intra-professional concerns shape DSM diagnoses. In the initial two manuals, anxiety was the core dynamic behind all the psychoneuroses, including depressive neurosis. It was by far the most commonly found condition during the 1950s and 1960s. Unlike anxiety, depression was mostly associated with severe psychotic conditions and was much less likely to be diagnosed. In the following decade, while clinicians remained dedicated to the anxiety-based neuroses, the biological psychiatrists gaining power in the profession targeted depression.
The researcher-driven DSM-III inverted the relative standing of anxiety and depression diagnoses. Spitzer and his task force were determined to demolish the analytic concept of neuroses, which entailed removing anxiety from the core position it held in the previous two manuals. The DSM-III split anxiety into nine discrete conditions, which simultaneously decreased its sweeping scope. The carving up of the anxiety disorders contrasted with the unification of the formerly distinct psychotic and neurotic depressive conditions into a single major depressive disorder diagnosis. The DSM-III also allocated the most common symptoms of the neurasthenic tradition, for example, sadness, fatigue, sleep, and appetite difficulties, to MDD rather than to any anxiety diagnosis. Further, the two-week duration required for depression was far shorter than the typical six-month duration for anxiety conditions.
Intra-professional dynamics drove the divergent diagnostic criteria for anxiety and depression that arose in the DSM-III. Researchers were both attracted to depressive conditions and determined to sideline the anxiety-based neurotic diagnoses. Because its symptoms were so common and criteria easy to meet, MDD became the diagnosis of choice in outpatient psychiatric and general medical practices rather than any anxiety disorder. After 1980 the MDD diagnosis flourished. An unforeseen outcome of the DSM’s different treatment of depression and anxiety came when the SSRI drugs entered the market in the late 1980s. These drugs were not selective for depression, anxiety, or any other condition but act very generally to elevate serotonin levels in the brain. The manual’s distinct formulations of anxiety and depression led drug marketers to call them “antidepressants” rather than “anxiolytics.” The enormous success of the “antidepressant” SSRIs echoed that of the “antianxiety” drugs of the 1950s and 1960s and reinforced the prominence of depression in the post-DSM-III period.
The intense intra-professional conflicts between clinical and research psychiatrists subsided during the DSM-III-R and IV eras. Researchers embraced a diagnostic system that they expected would lead to breakthroughs in mental illnesses' understanding and treatments. Clinicians shed their former suspicions of a classification that brought them monetary rewards, elevated their status in the medical profession, and enhanced their cultural prestige.
The conflicts that rocked psychiatry during the making of the DSM-III reemerged in the twenty-first century when researchers again attempted to revolutionize psychiatry’s diagnostic system. By that time, the research community viewed the DSM categories as obstacles to comprehending the nature of mental disorders. The new incarnation of the struggle between clinicians and researchers resurrected a question that has vexed the profession: Are mental disorders best seen as categorical or dimensional? Diagnostic manuals before World War II generally relied on the categorical approach. Spitzer and his Washington University collaborators then returned to the earlier categorical model in developing the DSM-III. After the findings from neuroscientific research indicated a sharp disconnect from the DSM categories, the DSM-5 Task Force decided that the way forward lay in reverting to the conception of mental disorders as continuous.
The DSM-5 process highlighted personality disorders as a central concern to dynamic clinicians during the DSM-I and II period. They were the most frequently diagnosed conditions and were scorned because they did not fit the essential qualities of disease entities. The clash between clinicians and researchers over the inclusion of personality disorders in the DSM-III was one of the most intense conflicts during the construction of that manual. Spitzer ingeniously mollified both researchers and clinicians by using the new multiaxial system to separate this class from the other DSM conditions.
In an interesting twist from prior DSM history, researchers, not clinicians, made the personality disorders central to their efforts to overhaul the DSM system. Allying with personality psychologists, the DSM-5 Task Force used this class as the model for its attempts to transform the manual. The Personality Disorders work group’s proposal imported a common type of continuous measurement from psychologists, who studied populations where they did not need to make diagnoses or even consider actual behavior or real-life situations. Individuals receive a quantitative score on several personality dimensions that related their traits to the means of others in the population. Adherents to this school of thought would affix the prefix of “factor,” not “psycho,” before the term “analysis.”21
If the establishment of the DSM-III signified the new power of psychiatric researchers, their failed attempt to transform the DSM-IV showed how deeply embedded in clinical practice the manual’s diagnoses had become. This time, the intense conflicts over dimensionalizing the personality disorders were confined to the psychiatric profession. No drugs target this category, and no outside groups promote them. Earlier feminist opposition to diagnoses that targeted stereotypical female character traits had subsided. Even now, researchers continue to make strenuous efforts to dimensionalize personality disorders. However, it is an open question whether they can impose a system that radically departs from conventional clinical views in future DSMs.
When researchers involved in the DSM-5 revision attempted to make fundamental changes in the manual, they found that the DSM categories had become so important for clinicians that they could not be dislodged. One reason was that practitioners worried that a dimensional system would threaten insurance reimbursement. The researchers who proposed a new dimensional system also underestimated how medical thinking and culture emphasize dichotomies. While medical diagnoses are often uncertain and ambiguous, most diseases are distinct from, not continuous with, health. Such dimensional conditions as blood pressure or cholesterol levels are divided at cut points, indicating likely pathology. Regardless of whether any illness is dichotomous or continuous in nature, clinicians must make decisions to treat or not to treat it. Therefore, the constraints of medical practice lead physicians, including psychiatrists, to think in black and white. Perhaps most important, diagnostic categories make mental disorders seem more real to the public, physicians in other medical specialties, insurance companies, and federal regulators.22
Any system that must legitimize its diagnoses as medical diseases will inevitably rely on categories rather than dimensions. In 1980 researchers successfully overcame clinical opposition to the new DSM system; by 2013, clinicians beat back the efforts of researchers to change the classification.
Anxiety, depression, and personality disorders illustrate how intra-professional disputes shaped some of the core DSM diagnoses. External interests played more important roles in developing a number of the manual’s other conditions.
Before the early 1970s, no groups outside of the psychiatric profession showed much interest in the manual. At that time, the fierce public debate over homosexuality marked the first entry of outside forces into the DSM process. The success of LGBT organizations in removing this condition from the DSM-II turned out to be an exception. By the time the DSM-III appeared, unwanted diagnoses were already uncommon. Most subsequent attempts of patients, their families, and other external groups to change the manual involved broadening its existing conditions or incorporating new ones.
The determined efforts of Vietnam veterans to ensure that the DSM-III contained a PTSD diagnosis provided the model for future activists. Although its predecessor, gross stress reaction, stimulated the development of the DSM-I, the DSM-II lacked a comparable stress-related diagnosis.
This gap did not concern the DSM-III Task Force, who believed that other categories such as anxiety and depression could capture the psychic impacts of environmental stressors. However, the lack of an appropriate stress-related diagnosis was of intense concern to Vietnam War veterans, who launched a highly publicized and successful campaign to recognize persistent or long-delayed stress reactions as mental disorders. The veterans’ advocacy efforts provided a model for lobbying that feminist groups employed to expand the PTSD criteria in the DSM-III-R and DSM-IV. The monetary benefits and access to care that can accompany a PTSD diagnosis have made this one of the DSM’s most popular diagnoses. “It is rare to find a psychiatric diagnosis that anyone likes to have,” psychiatrist Nancy Andreasen observes, “but PTSD seems to be one of them.”23
As third parties increasingly required DSM diagnoses to pay for treatment and other services, consumers and their families came to view them as valuable commodities. After federal legislation made the manual’s conditions necessary tickets to educational and mental health benefits and monetary compensation through social security disability payments, the worth of the DSM labels was considerably enhanced. For example, by 2007, 1 in every 76 American adults received federal income assistance because of mental disability.24 Local and state governments also required DSM diagnoses before children could receive mental health treatments and special education services. Organized parents helped drive the huge expansion of mental disorders among children and adolescents from 1980 to the present. Indeed, when changes in the DSM-5 criteria set for autism and Asperger syndrome threatened to restrict diagnoses, strong parental pushback forced the manual to allow all previously diagnosed children to maintain their labels even when they no longer met the new criteria. It is now far easier to broaden diagnostic criteria that lead to benefits than it is to reverse this process.25
As the use of the DSM turned from social control purposes to a necessary precondition for desired therapies, drugs, and other forms of assistance, the anti-diagnostic narrative that was extremely influential during the 1960s and early 1970s became anachronistic. The DSM diagnoses were so highly valued that by the time the DSM-5 revision began, even the LGBT organizations that led earlier conflicts to remove the homosexuality diagnosis from the DSM-II fought to maintain the gender dysphoria diagnosis because it was a precondition to pay for gender transition surgery. The DSM-5 kept this condition at activists' insistence and gave it its own chapter, 1 of just 22 in the manual.
The pharmaceutical industry is another potent interest that has promoted the DSM diagnoses. Since 1972, the FDA had forced drug companies to demonstrate that their products effectively treated specific mental disorders. Henceforth, all research on drug effectiveness would rely on DSM categories. In turn, psychiatry departments and many of their members became dependent on funding from pharmaceutical interests. Nearly 70 percent of DSM-5 Task Force members had financial ties to the industry.26 Since the 1990s, the powerful pharmaceutical industry has been inseparable from the rise of the DSM diagnoses into public consciousness. Drug companies were especially successful in capitalizing on parental desires to regulate their children’s distressing and disruptive behavior. In addition to massive advertising campaigns, they generously funded advocacy groups concerned with childhood and adolescent conditions. Sales of stimulant drugs for ADHD quintupled from 2002 to 2013, by which time they amounted to almost $9 billion. Similarly, fueled by researchers who received generous funding from the drug industry, childhood bipolar disorder underwent a stunning fortyfold increase in rates from 1994 to 2003. The number of persons under 20 years old who received prescriptions for antipsychotic medications jumped from about 200,000 in 1993–95 to about 1.2 million in 2002.27
Many psychiatric labels were imposed on involuntarily hospitalized patients or other socially deviant groups when the DSM-I appeared. By now, few are forced on resistant patients, but many bring about benefits for consumers and industries. No powerful groups push for abolishing DSM conditions. Both internal and external interests should ensure that the manual’s large array of diagnoses persist in the years ahead.
Footnotes upon request by writing to firstname.lastname@example.org