Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:

Axis I: Clinical disorders, including major mental disorders, and learning disorders

Axis II: Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)

Axis III: Acute medical conditions and physical disorders

Axis IV: Psychosocial and environmental factors contributing to the disorder

Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism, phobias, and schizophrenia.
Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and mental retardation.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

Cautions

The DSM-IV-TR states, because it is produced for the completion of Federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”.[18] The APA notes diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis/label may have different etiologies (causes) or require different treatments; the DSM contains no information regarding treatment or cause for this reason. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered “illnesses”.

Sourcebooks

The DSM-IV doesn't specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials.[19][20][21][22] The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.[23][24]

Criticism

Beginning with the problem that there is no single objective diagnostic test for a mental illness in the field of psychiatry — a problem the DSM sidesteps by referring only to "mental disorders", defined as dysfunctional psychological or behavioral patterns — the DSM-IV has come under various criticisms over the years.

Validity and reliability

The most fundamental criticism of the DSM concerns the construct validity and reliability of its diagnostic categories and criteria.[25][26][27] Although increasingly standardized, critics argue that the DSM's claim of an empirical foundation is overstated.[23] A reliance on operational definitions necessitates that intuitive concepts such as depression be operationally defined before they can be used in scientific investigation. Such definitions are used as a follow up to a conceptual definition, in which the specific concept is defined as a measurable occurrence. John Stuart Mill pointed out the dangers of believing anything that could be given a name must refer to a thing and Stephen Jay Gould and others have criticized psychologists for doing just that. A committed operationalist would respond that speculation about the thing in itself, or noumenon, should be resisted as meaningless, and would comment only on phenomena using operationally defined terms and tables of operationally defined measurements. This line of criticism has also appeared in non-specialist venues. In 1997, Harper's Magazine published an essay, ostensibly a book review of the DSM-IV, that criticized the lack of hard science and the proliferation of disorders. The language of the DSM was described as "simultaneously precise and vague", and the manual itself compared to "a militia's Web page, insofar as it constitutes an alternative reality under siege," and a "fertilizer bomb" against hard science.

Symptomatological bias

By design, the DSM is primarily concerned with the symptoms of mental disorders, it does not attempt to analyze or explain the conditions it lists or even to discuss possible patterns or relationships between and among them. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages.[29] The lack of causative or explanatory material, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."[30] The DSM's apparent superficiality is therefore largely a result of necessity, since there is no agreement on a more explanatory classification system.
Despite the lack of consensus, advocates for specific psychopathlogical paradigms have nonetheless faulted the current diagnostic scheme for not incorporating the innovations of their particular models; the most recent example being evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology.[31][32][33]

Reductionist bias

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-V may move away from this categorical approach in some limited areas, some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[34][35][36][37] Similarly, the current individual symptom-based approach has been argued to not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual or a psychological response to adverse situations.[38][39] Because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the standard of distress or disability can often produce false positives.[40]
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables.[41] Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.[42]. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only prove consistency, not legitimacy.[41] Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal.[43] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.[44] Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has opined that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.[41]

It has also been suggested that the apparent reductionism of the DSM, as well as its substantial expansions, are representative of an increasing medicalization of human nature, a result of disease mongering by drug companies, whose influence on psychiatry has dramatically grown in recent decades.[45] Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest.[46] In 2008, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".[47]