If the basic logic of the DSM is flawed, it should be abandoned. Instead, psychiatrists should move towards a system that looks at an individual’s mental experiences in context, alongside their unique developmental vulnerabilities and strengths, as the main source for analysing and responding to their distress. Diagnosis would no longer name a disorder but map what kinds of support, relationships and learning processes are most likely to help a person regain agency, coherence and a sense of future.
Sorry, you said insurance and I missed it somehow. I agree that laymen and insurance companies treat it as a bible, but I also think that’s how the APA presents it. If the goal is to compile “symptoms that tend to present together” the DSM does a poor job of making that clear.
I have several problems with the DSM. This isn’t an exhaustive list but off the top of my head:
-It’s based on the idea that there’s a clear line between “normal” and “disordered” mental functioning, and that we can quantify all of a person’s experiences to land on either side of that line. There are a handful of diagnoses that are discrete enough for me to say “you either have it or you don’t” but the majority of them are so arbitrary that they’re not useful. Mood disorders are especially vague.
-Inter-rater reliability is notoriously poor. I can diagnose anyone with a disorder to argue medical necessity for therapy.
-It includes conditions that cannot and should not be diagnosed by mental health professionals, like narcolepsy. It’s good for providers to know what narcolepsy is, but unless they’re going to include every other medical condition, I don’t know why they include the ones they do.
-DSM-5 broadened the criteria for several disorders, possibly to increase access to insurance coverage, but it’s edging ever closer to categorizing every human experience as a disorder. According to DSM-5, if you’re having depressive symptoms for more than 2 weeks after a loved one dies, it’s no longer grief and it’s considered a major depressive episode. When people criticized that bereavement clause, DSM-5-TR included “prolonged grief disorder” which extends the time you can grieve the loss without a MDD diagnosis. But grief is absolutely a normal response to loss, and sometimes it can be really disruptive and long-lasting. Why are we pretending that’s disordered?
-The majority of every DSM task force has been older white men, and we should be very skeptical of what they consider normal or not.
Because if it’s “really disruptive” then a person might need support to be able to function well enough to, e.g., keep a roof over their head. Insurance companies require a label in order to pay out for that support, so there it is. If you’re grieving for 2 weeks plus 1 day, but still able to function, no one is going to arbitrarily slap a diagnosis on you.
Fwiw, “disordered” doesn’t necessarily mean abnormal in the context of mental health, it really just means causing problems (or, “really disruptive”). Indeed, it’s normal to grieve for more than 2 weeks, but our broader society is geared toward extracting profit from you, not toward making sure you can work through your emotions, so mental health professionals are often stuck with just trying to facilitate the least-bad outcomes. Also, as you said, sometimes the changes are just to appease insurers; the system is dumb, so sometimes you have to do nonsensical things in order to make it help people like it should.
As for narcolepsy/etc., yeah … As a mental health professional, I am also befuddled. I suppose a psychiatrist with appropriate training could diagnose and treat that, but normally it would be a sleep specialist.
Tl;Dr: the healthcare system itself doesn’t make sense, so we do things that don’t make sense in order to make it work for patients.
Well …
You’re wrong. Sorry to be blunt, but you’re just not getting it
https://psycnet.apa.org/record/2013-14907-000
Like, the APA can’t be more explicit that the DSM is not what you think it is…
And you just fucking insist that we take your word on what they say it is
But you’re wrong.
There’s nothing to debate here, there’s no discussion or interpretation.
That’s the abstract for the DSM written by the APA. I have no idea where you are getting the shit you’re saying from.
You are talking to a bot. That’s why it missed an obvious keyword in your initial message. ‘somehow’