The DSM-IV-TR is Stupid

The Diagnostic and Statistical Manual, 4th Edition with Text Revision (DSM-IV-TR) is the Bible for Psychiatrists, Psychologists, Social Workers, and any other providers of mental health services. It is a 943 page monster that contains every known psychological/psychiatric disorder, as well as other conditions that require further study before they can be officially labeled as “disorders.” Any college student who takes Abnormal Psychology will either use the manual directly or take relevant sections from it to aid in their learning. Fortunate graduate students will commit to memory the major sections and philosophy of the text over approximately 5-6 years, while the unfortunate ones will have the book thrown at them in their first week of study with one simple instruction: memorize this before the first semester ends.

In fact, during my postdoctoral training, one of my colleagues claimed to have memorized the entire tome within the first week of graduate school; however, he also claimed that he could “will people out of being HIV positive,” so his words need to be taken with a grain of salt (yes, some shrinks are that weird). Practicing therapists use the DSM-IV-TR at least somewhat regularly to confirm symptoms of disorders that they are considering as a diagnosis.

Few practitioners would question that the manual is flawed in many ways. One of its main problems is that it utilizes a dichotomous approach to diagnosis, as opposed to treating symptoms with degree of impact. For example, in order to diagnosis Major Depressive Disorder, the patient must have “a depressed mood for most of the day, nearly every day…” In other words, you either are depressed for most of the day, or you are not depressed for most of the day. There is no gray area, and very few things in life are black or white:

Dr. Dobrenski: When you say you’re “depressed,” would you say that’s most of the day, nearly every day?

Client: How the hell should I know if it’s most of the day? I don’t measure my mood with a fucking stopwatch.

Dr. Dobrenski: I see. Tell me this: would you say it’s nearly every day?

Client: No, Dr. Dobrenski, it’s one day every four year, just during Leap Year. That’s why I’m here, because I can’t bear to feel sad for one day, 3.1 years from now. Of course it’s nearly every day, Christ! Are you working from some manual or something?

A clinician could gain much more knowledge if the system were designed to provide levels of depressive symptoms in a given day, even if this is simply a 1-10 scale to distinguish the gray, middle of the road areas. This can more thoroughly help clinicians to decide which method of treatment would be best (e.g., medication, therapy, or a combination), and could be used as a rough guide to whether or not treatment is working well.

Another issue with the current DSM is its presentation of most disorders with a colossal amount of symptom variability. Using Major Depressive Disorder again as an example, the patient must show “Five or more of the following (nine) symptoms…during the same two-week period…” This allows for literally dozens of symptom combinations. In other words, if I say to Dr. John that I have a new client with Major Depressive Disorder, Dr. John really doesn’t have a grasp of the symptoms the client is experiencing. This defeats the purpose of the manual.

However, the biggest issue with the DSM-IV-TR is that so many of the disorders are so incredibly rare that the odds of a clinician seeing them actually affecting a person are slim. Conversely, there are fairly common psychological problems that aren’t actually in the book at all.

When I was in training, I saw a lot of college students in the university clinic for relationship difficulties. Because the undergraduate experience is transitory, long-term monogamy and commitment is not the norm. Students would become extremely distressed when relationships did not work out, which was basically always. Poor sleep, lack of appetite, excessive substance use, sad mood, crying spells, poor concentration and many other symptoms would trouble these clients. Many of the students seemed to be suffering from a type of depressive episode, but not exactly. Others showed a type of anxiety disorder but, again, not exactly. One pattern that did emerge was an initial feeling of shock, followed by a sense of betrayal that ultimately led to anger. In heterosexual relationships, this anger was often expressed in therapy with an initial use of vulgarity related to a gender-specific body part, followed by a desire to have something horrific happen to that part. Consider:

Female Client: That fucking dick! I hope he gets Gangrene and his cock falls off!

Male Client: Man, what a Goddamn cunt! I hope that bitch’s pussy freezes shut!

In homosexual relationships, the anger was usually expressed, ironically, as a gay hate term:

Male Client: That bastard cocksucker! I hope that fudgepacker rots in hell.

Female Client: I’m going to cut that rugmuncher if I ever see her again.

Armed with this newfound knowledge of creative ways to express unadulterated hatred and distressed at a lack of “Romantic Jealousy” Disorder, I ultimately decided to take a step toward resolving this problem by studying romantic jealousy for my doctoral dissertation and positing that this syndrome is a diagnosable condition worthy of DSM-IV-TR inclusion. In just a few years, I had seen multiple cases with similar and overlapping symptoms, and the problem clearly caused significant distress for the people involved. I submitted a few papers to psychological journals to support my case, and all were rejected. Professionals in the publishing field said that “we need to focus on conditions that impact a significant number of people, Rob.” This is not the most optimal way to transition from student to professional.

After five years of post-graduate practice, I’ve directly encountered, at most, 20% of the disorders in the DSM-IV. Most conditions seen in general practice can be broken down to: mood, anxious, psychotic, substance abuse, eating disorders, personality disorders and childhood disorders. Within those categories are asinine amounts of minutiae regarding psychological problems that most clinicians will never see. Selective Mutism is a disorder in the DSM-IV-TR. This is essentially a difficulty where the individual has a consistent failure to speak in specific social situations where talk is expected, despite speaking in other situations. The DSM-IV-TR reports that this condition occurs in less than 1% of patients seen in mental health settings. Not less than 1% of the population; less than 1% of people who are receiving mental health services. I’ve already seen more cases of romantic jealousy (which doesn’t exist,) in five years of practice than the entire world will see of Selective Mutism.

Another example is Pica, the persistent eating of non-nutritive substances for at least one month. In other words, Pica is a problem where you eat things that are not food. For comparison purposes, I’m sure many of you know at least one person who has been devastated when he or she finds out that they’ve been cheated on or when an ex-lover starts dating someone else. Do you know a lot of people who have said, “Man, I’m starving. Oh look, a set of nuts and bolts! Let me just swallow those right now!”? I didn’t think so.

This is not to say that people who are suffering from the more obscure conditions deserve anything less than optimal care. But for the purposes of my practice, I now have a disorder/non-disorder that I’d like to treat, but I’m immediately handcuffed. As a general rule, when I develop a diagnosis for a client, I relay this to him/her and explain what it means. Information is power. The more a client knows about his difficulty, the better off he is:

“Okay David, what you are describing is consistent with what is known as Romantic Jealousy Syndrome. While it is not the most common problem in the world, we do know a good bit about it. Here are some articles that I’d like you to read before our next session. My hope is that it will provide you with information about the problem and how we are going to treat it going forward. You and I will talk about and expand on what you’ve read next week.”

This isn’t going to happen, because there isn’t a diagnosis, and therefore there is limited interest in discovering more about it, all while my dissertation collects dust on the bookshelf. There is the occasional piece written up in a journal on “Jealousy as a Syndrome?” or “Thinking about Jealousy as Obsessive-Compulsive Disorder,” but they are few and far between. My publishing colleagues have, in essence, shut my work out of the ivory tower, leaving me jaded and the clients with less than optimal care. This is an example of a tangible rift between academic psychologists and practicing ones. The former generally see the field as a relentless pursuit of discovery and publication, while sometimes missing the relevance or lack thereof of their subject matter. Knowledge for knowledge’s sake is the unspoken mantra, even if it means pouring money into “Bird Behavior,” a real journal that is part of the American Psychological Association’s journal database. I am not against Ornithology as a science, but I am opposed to an association funding it when the organization itself is based on the study of people. Many researchers will point out that studying birds is “comparative psychology,” meaning that information learned about animals can be used to infer knowledge about humans. But should the direct study of humans take a back seat to studies done on animals for mere inference?

Practicing psychologists, in contrast, generally read journal articles or attend seminars to gain practical, hands-on knowledge and techniques to help their patients. They see research as a means to an end. Many of these practitioners don’t care about the finer details of a study: how it was conducted, what statistical analyses were used, did the researcher debrief all participants upon the study’s conclusion? They just want to know how, if at all, this study is useful in the treatment of psychological conditions. Can your study help my patients? If not, go away.

In reality, most psychologists carry a little bit of both philosophies. Unfortunately however, the academic psychologists make the decisions on what makes it into the field’s journals, whether they work directly with patients or not. Unless the field starts to swing in the practitioners’ direction a bit more, we’re going to continue to have a lot of relatively useless knowledge out there. Or maybe just an exorbitant amount of smarts about how birds walk. We can infer a lot about the human mind from studies like that. Or at least, that’s what I’m told.

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21 Responses to “The DSM-IV-TR is Stupid”

  1. Amber says:

    Wow. That’s a lot to digest. I think if I had ever followed through with my thoughts of going to school to study psychology I think I would have thrown the book, then myself, out the window. There is such a thing as mental overload, and I believe that book is it.
    However, I also believe that people are trying to invent, give name to, and diagnose people with disorders that already exist. How many times have you referenced a client that showed symptoms of multiple disorders and you found yourself playing a guessing game as to which it is?
    To each his own, but personally, if I were to see a psychologist again it’d be merely for a sounding board. I’d let the pent up emotions go for 45-60 then be done with it until next week.
    The US is truly over medicated, and I didn’t see that until I moved to Canada.

  2. luvs2spooge says:

    pardon me for stating the obvious, but this seems to be an instance of psychologists not realizing who exactly they’re working for. Academic psychologists work for themselves, not for practicing psychologists. the goals of both types are different which makes what both types do extremely counterproductive. Practicing ones need the academic ones to start studying to help them, whereas the academic ones don’t really want to do anything more than the equivalent of mental masturpation. It should be a cohesive effort, but it’s not, so as far as actual progress is concerned, perhaps the practicing ones should start publishing their own journals, perhaps then will the academic ones take notice that their going to become obsolete.
    In theory, if people stop working for you, you fire them. What’s the difference here?

  3. Anonymous says:

    Good read.

  4. Charles says:

    I never knew that about homosexuals. Very funny and interesting.

  5. Sean says:

    It sounds to me like you need to find a sympathetic academic research psychologist (perhaps one who has experienced it) to partner up with and start churning out the data.
    Hell, if I were in a position to do direct studies, I’d do it. It’s not like this is something obscure – a little outside the box thinking could easily leverage the fact that you’re dealing with something people actually care about and would want to hear about (thus will give it attention.) Once people give it attention, the natural order of egotistical attention seeking researchers will do the rest of the job for you.
    Of course, as our expatriate above noted, maybe US psychologists aren’t the best to do this research. If they did, we’d be prescribing anti-breakup pills within a few months.

  6. Silvyr says:

    “Any college student who takes Abnormal Psychology will either use the manual directly or take relevant sections from it to aid in their learning.”
    Thankfully I didn’t; my Ab Psych professor, also the chair of our Psychology department, thinks the DSM is bullshit and preferred to let us watch videos of people actually dealing with the disorders. I thought (and still think) it’s a really good idea – you get to hear from a real person what it’s actually like to deal with bipolar disorder/depression/schizophrenia and get a better idea of what the symptoms actually look like.

  7. Amber says:

    In regards to Sean’s comment, do I sense a bit of sarcasm in your response to my comment? Maybe defensiveness?
    I didn’t say what I did to offend. I state what I see. And I’m not speaking only of the mental health division of the medical community. Nor am I saying that Canada’s pill poppers are any better. Maybe it’s just not as obvious in Edmonton, I don’t know. I do know, however, that as soon as I got home every house I’ve visited has had a stack of pills laying on counters.
    I made a list of the medications my aunt is on for her MS, which, oddly enough didn’t include the injectable treatments that she’d been on for years because when she made the choice to quit taking them she was able to walk on her own again. I discussed with my mother the issues with a cousin abusing vicoden, percocet, and other prescription narcotics. A friend’s friend told me how she’d go to the free clinic, claim her back was hurting, and she’d get a full prescription of vicoden which she’d sell to get money to cover the costs of her daughter’s formula and diapers. The list goes on.
    Such as it is, I’m not saying I agree with the ideals of some that think the world would be better medication free. I’m also not saying I agree with one that would rather shove some drugs down a person’s throat because they don’t want to get to the core of the problem.
    To those who truly need medicative help, take it, don’t abuse it. I needed help a few times myself, dealing with a severe ppd and a colicky baby, if I didn’t have the aid of antidepressants who knows where I’d be now.
    When there’s a three year old boy though, who seems a little more rowdy than most, really study the child before you diagnose him with add and starting stuffing him with ritalin. He is just a child.
    Oh, and none of this has to do with my living in Canada. I fell in love with a Canadian, that’s all. My heart, my home, and my citizenship are still, and always will be, in the United States of America.

  8. Rorschach says:

    Why does every undesirable aspect of human behavior need to be labeled a disorder and slapped with an ICD-10 code to be dealt with? I understand that there’s a difference between, “I just lost my job and I feel lousy,” and “I feel so awful that I’m going to hang myself in the shower,” but everybody is going to experience some degree of romantic jealousy at some point, in some degree. If a person is so messed up with it that they require therapy, I’d be more inclined to see it as one aspect of a larger emotional/maturity issue than as a distinct psychopathology.


    Very often, so called ‘academics’ may appear to overlook what more pragmatic practitioners have been banging on about for years. However, I see this as ‘planned ignoring’ and by this I mean deliberate. Discrediting your findings was probably merely a shrewd ploy to bury your original concepts, thus allowing time for a cannibalised version of this theory to be put forward as the “new and groundbreaking” conception of someone ‘more worthy (e.g. an academic): otherwise known as ‘Survival of the Fittest.’
    Your theory about ‘Romantic Jealousy Syndrome’ is very interesting – especially your observations on the ‘initial use of vulgarity related to gender-specific body part, followed by a desire to have something horrific happen to that part.’ Nevertheless, fascinating though this is, I’m much more interested in your suggested treatment for such a ‘condition.’
    I have a questions too. Does the cessation of a romantic relationship – as a result of infidelity – always have to lead to negative responses? What about Romantic Liberation Syndrome?

  10. Wayland says:

    Different write-up. More of a vent than a story. I still thoroughly enjoyed this. You made your points and backed them up. Good luck with this. Some of the technical things you have to deal with is ridiculous.

  11. Jackie says:

    I think a big question this brings up for me is – what is just degrees of normal variation and what is an actual pathology being the cause of behaviors? The word “disorder” is used, and for some it’s pretty much true (bipolar, schizophrenia, panic disorder)… but some of the other sections I’m not so sure.

  12. Mary Liz says:

    well, as a student taking psychology classes, I have to agree… it is stupid, and etc etc with what you’ve said, all I have to ask is… would you call my psych teacher and tell him that? (just kidding)

  13. el kev says:

    I’ll start with the disclaimer that I am an academic psychologist (studying biopsychology and neuroscience).
    I think you’re too quick to disparage the academic psych community as writing off your research. You’re not being singled out in having your work rejected for publication; we’ve all had it happen. You’re also not being fair in your assessment of the APA and its journals.
    First off, there is no real journal put out by the APA titled Bird Behavior. A quick Google search revealed that that journal is published by a group called Cognizant Communications (ShrinkTalk.Net edit: Bird Behavior is part of the APA’s journal database (; most journals are not published by APA themselves, according to this site)).
    Second, if you look at the list of APA-published journals, you’ll see more in the subfield of Clinical Psychology than in any other (, which means that your clinical research has more APA-funded opportunities for publication than my non-clinical work (which is not on birds).
    Finally, you suggest that human research is given a back seat to animal work in the interest of knowledge for knowledge’s sake. To say this is to miss the important point that work in animals is not just used for inference and comparison; it is very often a guide for work in humans. I can point to direct instances where my work in rats has served as a roadmap for work done in humans, and how that work can have real-world applications to the treatment of psychological disorders.
    I understand your frustration at not being able to publish work that you think will be of use to your clients. But it seems to me that you’ve allowed yourself to wallow in hurt feelings instead of responding in a much more constructive fashion: continue counseling people who present your Romantic Jealousy syndrome, collect more data to solidify your argument, and resubmit a piece of work that is unassailably good and impossible to reject.

  14. Jessica says:

    Although you can not diagnose your patients with “romantic jealousy” disorder. I have just diagnosed myself after reading your blog. I completely agree that it is a problem. The self-help book “It’s Called a Break Up Because It’s Broken” is the only thing that I have found that remotely makes me feel better. But it only makes me feel better as I’m reading it. I’m driving down the road, he calls my phone… I can’t help but answer, we end up fighting… and I’m right back where I started. Relationships make people crazy. You start going crazy during the relationship… and when the relationship ends, you’re completely nuts and alone on top of it. I’m not saying every relationship is like this. I know this is the first time I’ve ever experienced these feelings after a break up, but I know that it’s not uncommon. Think about all the people who kill their ex’s after a break up. Hello?!?! If that’s not Romantic Jealousy Disorder.. than what the hell is it?

  15. Grant says:

    A Pyschology professor taught me that the DSM-IV is mainly an insurance tool which allows psychiatrists to prescribe more expensive medication to their patients. Is there any truth to that?

  16. JHG says:

    Ah, I had some experience with academic psychologists over the summer and some of them, at least my group leader at our summer program, who is a well known social psychology researcher, said he just researches topics that he randomly finds interesting, and that he doesn’t really care whether they’re relevant or not to therapy or anything for that matter. The guy went on to said that finding relevance is other people’s jobs. Now not everyone’s like this, but there are a lot of people that are using funding for random ass studies.

  17. Gates VP says:

    Here’s a ping-back for you:
    An excerpt:
    The DSM is basically crap, but it’s really just a small piece of the puzzle. B/c let’s face it, most of North American medicine is crap. To follow up Amber’s comment, I’m living in Canada (Edmonton) and I think that Canadian doctors over-prescribe (the American system is just a giant mess I don’t want to touch).
    But ironically, I think that the problem doesn’t stem from the doctors, it stems from human nature (the pool from which we select doctors). Human nature is to desire the quick fix and the nature of the world is to favor the “gradual change”: people want to wake up 20 lbs lighter, they don’t want to lose weight; they want to “become” happy rather than “discover” happy. Like all classic dual-edged swords the “quick-fix” is both a source of success and failure.

  18. Scott says:

    I’ve only had a small taste of the DSM in my Abnormal Psych class and can already tell what a huge pain that thing is…I don’t think i’ve ever heard any different from any Psychology Professors i’ve talked to.

  19. Famous Mortimer says:

    Whatever happened to people being eccentric, or quirky?
    Everything has become conditionalized. Reading the DSM is like reading a horoscope. The predictions cover such a wide swathe of ground that ultimately everyone suffers from some type of psychological condition.
    Pyschology, although with many dutiful adherents seems to often resemble Chiropractic Medicine. You create a condition so you can treat it.

  20. Bilka says:

    I just subscribed for your RSS feed, great stuff.

  21. naive people are dangerous says:

    So, these quacks write a “Bible” based on weird “science” and then they want us to believe it’s true. It sounds like a sect, instead that in this case they have the power to institutionalized you and they have the power to prescribe “legal drugs” that you’ll have to take for life. Great business plan. I’ll bet that 99% of us will be diagnosed with any of the 900+ syndromes if we ever show up at one of their shops. Why is that this happens more often in the USA? Are they more gullible than the rest of the world? Have they suffered a lack of critical-thinking education? All of the above?

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