Working with the DSM

The Diagnostic and Statistical Manual, now on its fifth edition, (DSM-5) is a categorical indication-based approach to mental illness and psychopathology. The DSM and the International Classification of Diseases (ICD-11) define how mental health problems are assessed, managed, and treated within the fields of social work, psychiatry, and psychology.

The DSM considers psychological disorders dichotomously, as either absent or present. Diagnostic decisions are based on whether an individual’s clinical presentation meets or does not meet a criterion threshold for qualification for a specific categorial diagnosis.

The DSM focuses on biomedical perspectives of psychological disorders without taking into account social context. There is a growing concern that the DSM and ICD may hinder how mental health is understood, treated, and managed (Dalgleish et al., 2020; Insel, 2014; Kotov et al., 2017).

The Numinus Care Model

Thinking back to the Numinus care model, when speaking about diagnostic decisions within the context of the DSM, we need to apply both a trauma- and violence-informed care lens and a justice, equity, dignity, and inclusion lens.

Question

Take a look at the statements below.

  • BIPOC are more likely to be diagnosed with schizophrenia than White People who are more likely to be diagnosed with a mood disorder (Akinhanmi et al., 2018; Olbert et al., 2018)

  • Black Children are more likely to be diagnosed with oppositional defiant disorder (ODD) than White Children (Ballentine, 2019)

  • White Children are more likely to be diagnosed with attention-deficit hyperactivity disorder (ADHD) (Ballentine, 2019)

Why are these statements true? Is there a social or biological determinant?

If we apply a JEDI lens, structural racism appears to be at play here. The DSM has historically codified discrimination, creating implicit and explicit bias.

As a result, there has been a disproportionate labelling of Black People as mentally ill. Consequently, if certain mental illnesses are more prominent in Black communities, it might imply to health professionals that being Black is a risk factor for schizophrenia and oppositional defiant disorder. However, there are no scientific grounds to suggest that race or skin colour is a true risk factor for these conditions (Metzl, 2009). In addition, these disparities in diagnoses across social groups can lead to disproportionate access to services, delayed intervention, and in some cases harmful treatments (Riquino et al., 2021). Therefore, we must apply a transdiagnostic lens to better understand why certain communities (especially marginalized communities) may be more likely to be diagnosed more than others.

To learn more about implicit bias, please watch We all have implicit bias. So what can we do about it?

References

Agarwal, T. M., Muneer, M., Asim, M., Awad, M., Afzal, Y., Al-Thani, H., . . . El-Menyar, A. (2020). Psychological trauma in different mechanisms of traumatic injury: A hospital-based cross-sectional study. PLOS ONE, 15(11), e0242849.

Akinhanmi, M. O., Biernacka, J. M., Strakowski, S. M., McElroy, S. L., Balls Berry, J. E., Merikangas, K. R., Assari, S., McInnis, M. G., Schulze, T. G., LeBoyer, M., Tamminga, C., Patten, C., & Frye, M. A. (2018). Racial disparities in bipolar disorder treatment and research: A call to action. Bipolar Disorders, 20(6), 506-514.

Dalgleish, T., Black, M., Johnston, D., & Bevan, A. (2020). Transdiagnostic approaches to mental health problems: Current status and future directions. Journal of consulting and clinical psychology, 88(3), 179–195.

Insel, T. R. (2014). The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. The American Journal of Psychiatry, 171, 395–397.

Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby R. M., . . . Zimmerman, M. (2017). The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126, 454–477.

Metzl, J. M. (2009). The protest psychosis: How schizophrenia became a Black disease. Beacon Press.

Olbert, C. M., Nagendra, A., & Buck, B. (2018). Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities? Journal of Abnormal Psychology, 127(1), 104-115.

Riquino, M. R., Nguyen, V. L., Reese, S. E., & Molly, J. (2021). Using a transdiagnostic perspective to disrupt white supremacist applications of the DSM. Advances in Social Work, 21(3), 766-778.