Evaluating the usefulness of DSM in diagnosing mental health problems : A review of the literature

Understanding the needs of individuals with mental disabilities is really important in terms of improving quality of life, intervention and promotion. Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is widely used book for mental health professionals in order to make diagnosis. The present study discusses the usefulness of DSM in diagnosing mental health problems by emphasizing it’s advantages and criticisms. This study used document analysis method in order to provide an overview and discussion of recent literature regarding advantages and criticisms of DSM. Various issues have been discussed and conclusions have been made based on the literature review of this study.


Introduction
Psychiatric diagnosis is one of the most persistently discussed issues in clinical psychology.Accordingly, diagnosing mental health is also a crucial issue for professionals working in the field of mental health.According to World Health Organization, mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community (World Health Organization, 2014).Diagnostic and Statistical Manual of Mental Disorders (generally abbreviated as DSM) is the most commonly used diagnostic classification system for mental health problems by professionals.DSM basically includes essential characteristics of the disorder and diagnostic criteria which is a list of typical symptoms that must exist for the diagnosis.According to the diagnostic criteria, if a particular number of symptoms of a disorder present, then the individual is said to have that disorder.
DSM is published by American Psychiatric Association and it has been subsequently revised over years.DSM has five revised versions, they are DSM-I, DSM-II, DSM-III, DSM-III-R, DSM-IV, DSM-IV-TR and DSM-V which is the current version.The first version of DSM was published in 1952 and the last version has been published in 2013.Each version includes more mental disorders or criteria for mental disorder, some of them are removed and some of them are not considered as a disorder anymore.
Publication of the fifth edition of DSM has brought some debates as it has been exposed to many criticisms beginning from its first publication.In the current version, there are three main sections in DSM-V.The first section includes an introduction and instructions on how to use the new version, second section covers the diagnostic categories and third section includes conditions that need additional research, a glossary of terms, and other important information (Wakefield, 2016).In addition, mental health problems are included under the category of neurodevelopmental disorders in DSM-V.This category covers eight sub-categories including mental or intellectual disabilities, communication disorders, autism spectrum disorder, attention deficit/hyperactivity disorder, learning disorder, motor disorders, tic disorders and other neurodevelopmental disorders (American Psychiatric Association, 2013).DSM is the most widely used classification system for mental disorders especially in the United States and its usage has been increased all around the world (Cooper, 2004).Besides its wide usage and benefits, DSM has been also criticized in various aspects.The present study discusses both the benefits and criticisms of the usage of DSM.Understanding the needs of individuals with mental disabilities is really important in terms of improving quality of life, intervention and promotion.Therefore, this study aims to provide an overview and discussion of recent literature related with DSM in diagnosing mental health through discussing advantages and criticisms of using DSM.

Method
This review provides an overview and discussion of recent literature that produces conclusions regarding evidence-based practice.In order to identify the topics regarding the advantages and criticisms of DSM, document analysis method was used in the present study.Document analysis is a widely used qualitative research method which includes reviewing printed or electronic materials systematically and analyzing them based on identified categories thematically (Saban, 2009;Camnalbur, Bayraktar & Amuce, 2013).

Advantages of Using DSM in Diagnosis
First of all, it is necessary to point out that having a diagnostic classification system is useful in many aspects.Anello (1989) stated that although DSM has some limitations, it is a useful and helpful diagnostic tool for professionals in clarification and diagnosis of a disorder.Besides, since DSM provides a comprehensive list of symptoms and tries to consider every symptom, it helps clinicians to reach more comprehensive conclusions about a disorder.In addition to being a helpful diagnostic tool and providing a diagnostic criteria, DSM has some another advantages.For instance, the process of diagnosis proceeds fast with DSM and it is not a time consuming or an expensive diagnostic alternative.
According to another point of view, DSM aims to facilitate communication between mental health care professionals, mental health care administrators and the public in general Nevertheless, categories of DSM provides a convenient shorthand for identifying an individual's symptomatic behaviors (First & Spitzer, 2003).
Furthermore, there is a considerable fact that the DSM revised versions in which it takes into account the criticisms of prior versions and tries to improve its challenges.This is an important feature of DSM since it really tries to eliminate and overcome the problems that create controversies for DSM.Achenbach (2009) indicated that the DSM revised and improved subsequent versions which consider the criticisms for previous versions.
DSM is a manual that guides diagnosis, treatment and research.It is also obvious that DSM supports biological perspective and consistently neurodevelopment to neurocognitive disorder categories have been included in the current version.Besides, diagnostic classification follows a chronological criterion in DSM-V whether the symptoms appear in childhood and adolescence or in adulthood (Adam, 2013).This supports the notion that DSM tries to overcome the problems of previous versions.

Criticisms of DSM
As mentioned before, usage of DSM has many beneficial aspects that might be seen as sufficient to use DSM in the process of diagnostic assessment.However, besides its benefits, DSM has also been criticized in many aspects.The issue of labelling people as having a disorder is one of the main criticisms of DSM.It has been emphasized that making a diagnosis will lead the individual feel as labelled or stigmatized as ''mentally ill''.The issues of labelling and stigmatization have been entirely discussed in the study of Corrigan (2007) as well.In this study, it has been stated that stigma and labelling might exacerbate the symptoms or experience of the mental illness.The diagnostic label might also lead to long-term negative consequences for the individual.For instance, individuals may perceive themselves as different from the society.According to Corrigan (2007), some strategies might be used to decrease the effects of diagnostic label.For instance, use of dimensional approaches, regular interaction with the patient or focusing on the recovery process may decrease the detrimental effect of the diagnostic label on the individual.In addition, Corrigan (2007) indicated that the stigma of mental illness might make the society to perceive the mentally ill individuals as ''different'' and this might also exacerbate the notion that individuals with mental illness do not recover.Therefore, it can be said that making a diagnosis with DSM might bring negative outcomes which is not good for the overall health of the individual.
Nevertheless, there is a problem with the definition of mental disorder in DSM.This problem of definition of mental disorders was entirely discussed in Cooper (2004).DSM generally in almost all versions defines mental disorder as clinically significant behavioral or psychological syndrome or pattern and these are associated with either a painful symptom which refers to distress or impairment in one or more areas of functioning which refers to disability and also it is inferred that there is a biologically or psychologically harmful dysfunction in the individual.According to Cooper (2004), considering disorders as harmful dysfunctions is flawed and inadequate.DSM also has problems with definitions of some kind of disorders and need to be changed especially in the cases of children with special needs (Achenbach, 2009).

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DSM has also been criticized for not having good amount of reliability and validity from the past.As pointed out in Pierre (2008), there are validity problems for schizophrenia.Pierre (2008) claimed that DSM has not only validity problems with the definition of schizophrenia; validity problems also exist for determining symptoms such as delusions and hallucinations and these issues should be resolved in further revisions of DSM by providing scientifically validated reformulations of diagnostic categories for schizophrenia.
Furthermore, the problems related with validity of DSM exist with other types of disorders such as Attention Deficit Hyperactivity Disorder (ADHD).Woo and Rey (2005) suggests that data supporting the validity of subtypes of ADHD with the publication of the DSM-IV-TR is still limited.This uncertainty still continues even after the publication of the DSM-V.Furthermore, DSM is also criticized for the changes in diagnostic criteria of autism.In DSM-IV-TR, there was a category of prevalent developmental disorders including five sub-types namely Asperger Syndrome, Rett Syndrome, Autism, Childhood Disintegrative Disorder and Prevalent Developmental Disorder-Not Otherwise Specified.This has been changed in the current version of DSM.There is a category named as Autism Spectrum Disorders and the sub-categories have been removed.It is claimed that removal of sub-categories, ignoring gender differences and widening of the criteria for autism spectrum conditions would increase the diagnosis and therefore prevalence of autism (Wing, Gould & Gillberg, 2011).
Additionally, there is a criticism claiming that DSM has inadequate diagnostic quantifications.According to Achenbach (2009), it has been claimed that subsequent versions of DSM requires more quantified diagnostic criteria and adjustable diagnostic thresholds especially for children, but it is also required for adults.Achenbach (2009) also states that DSM should include and make more emphasis on developmental and gender differences, differences between data from different sources and cultural differences.After the publication of DSM, these issues still have not been resolved and need to be considered.
There are other criticisms of DSM including tendency to reification of disorders and presence of marketing by the pharmacology industry (Obiols, 2012;Reed, Anaya, & Evans, 2012).It is widely known that DSM is being criticized about increasing the need for drug use because of diagnosis and therefore it supports pharmacology industry.As it can be understood, there are various criticisms of DSM for past editions and present edition that need to be resolved in the subsequent version or versions.

Some Additional Problematic Issues
There are another various problematic issues that have been criticized up till now and also that should be pointed out here.For instance, it has been argued that the system of classification of DSM makes certain categorical distinctions and puts a cut-off dividing line between normal and abnormal (Ghaneian & Rahimi, 2012).It has been also argued that DSM is primarily concerned with the symptoms and treatment of the disorder and ignores the underlying causes which play a major role in diagnosing and treating a mental disorder.
Moreover, some mental health professionals argue that DSM primarily gives excessive amount of importance to biological, neurological or physiological factors and ignores the scientific importance of social, environmental and psychological variables.Also, there are some claims that since DSM perceives mental disorders as diseases that must be intervened by medical treatment, the drug companies utilizes from this situation.These problematic issues exist and continue to create debates and therefore needed to be studied.

Conclusion and Recommendations
Overall, advantages and criticisms of the usage of DSM in diagnosing mental health problems are evaluated and discussed in the present study.There are supportive evidence for the advantages and criticisms of the usage of DSM in the literature.There are many disadvantages that might lead crucial negative consequences which would detriment the diagnostic and treatment process of the mental disorder.On the other hand, there are many advantages of DSM such as providing a universal diagnostic system for mental health problems.Therefore, it can be inferred that it is a useful and beneficial diagnostic tool for psychiatrists and clinical psychologists.DSM basically gives a preliminary view about the diagnosis that can be taken into account also for the treatment process.According to Joyce (2008), if any diagnostic classification system provides an understanding that about the etiology and the outcome of the mental disorder, then this diagnostic system is said to be clinically useful.In conclusion, if the criticism of DSM is considered and controlled when using DSM, it will serve as a useful and helpful diagnostic tool for the identification and treatment of the mental disorder.
As a final point, further research might investigate psychological, social and environmental variables which might play role in the occurrence of mental health problems.Therefore, DSM might become more comprehensive since it will encompass biological, psychological and social aspects of a disorder.Subsequent versions of DSM might include these variables and therefore improve in terms of comprehensiveness.