Why the DSM Differential Diagnosis is So Disappointing

James Schroeder, PhD

For many clinicians like myself, families come to us with insurance that they seek to use in addressing psychological issues.  As most know, in order to utilize the insurance benefits, a diagnostic code has to be billed that is specifically assigned to the identified patient, who in my case is a child or adolescent.  As has been widely documented on MIA and other venues, this presents many challenges/controversies, both of an ethical and etiological origin.  The categorical system itself utilized by DSM is fraught with many issues, and recent changes in DSM-5 have not seemed to help matters.

But this article is about a very specific concern, one that is inherent in the categorical, disease-based model, but also one that continues to depict the human person as a set of parts, not a dynamic, holistic being constantly interfacing with his or her environment.  This concern was further manifested in the DSM-5 changes, which no longer utilizes a multiaxial system.  While information provided by APA cites concerns with the Global Assessment of Functioning (previously Axis V) as one reason for this change, and indicates that medical conditions (previously Axis III) are now subsumed under the single axis system, it negates to mention just why Axis IV was removed.  Axis IV was previously designed to code the major psychosocial stressors that an individual faced (e.g., recent divorce, father left home, mother lost a job, etc…) which impacted their functioning.  At the very least, despite the justified criticisms of the categorical system, this multiaxial approach allowed those reviewing the report to see how different factors may have coalesced into the problems an individual displayed.  Now with DSM-V, this is not even brought to attention unless an individual reads the report thoroughly (assuming the information is included at all), which often does not occur.

But beyond this, there is another specific problem I would like to address with the DSM model, especially as it relates to youth.  This is not new to DSM-V, but is now magnified through the single axis system.  I will use the diagnosis of Oppositional Defiant Disorder (ODD) to demonstrate this problem, but I could illustrate the same issue with many other diagnoses, such as ADHD, depression, and anxiety disorders.  The criteria for ODD focuses on significant difficulties with losing temper, anger, argumentative behavior, defiance, vindictiveness, etc…that either cause significant distress or impairment beyond what is appropriate for development.  However, the criteria do not indicate that this has to occur across multiple settings as symptoms “may be confined to only one setting, and this is the most frequently at home.” As DSM notes “behaviors are common among siblings” and “typically more evident in interactions with adults or peers whom the individuals know well.” As stated, “It can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences.”  DSM-5 goes on to acknowledge the role that “hostile parenting” plays, and amazingly admits that “it is often impossible to determine if the child’s behavior caused the parents to act in a more hostile manner toward the child, if the parents’ hostility led to the child’s problematic behavior, or if there was some combination of both.”

It only gets more disconcerting from there.  As DSM further notes, “whether or not the clinician can separate the relative contribution of potential causal factors should not influence whether or not the diagnosis is made.  In the event the child may be living in particularly poor conditions where neglect and mistreatment may occur (e.g., in institutional settings), clinical attention to reducing the contribution of the environment may be helpful.”

Okay, for those of you have read my posts before, you know I strive to be as balanced and reasonable as possible when it comes to understanding various positions.  But I have to be honest.  This makes me downright angry and uncomfortable, as I had to actually read the paragraph multiple times to make sure it actually said what it did.

Let’s review.  First, when a child is diagnosed with ODD using DSM-5, they are diagnosed with a disorder, one that clearly puts the onus on them as a person (now and potentially for a long time), not the environment and people that surround them.  However, DSM not only acknowledges (what we all know) that harsh, inconsistent, unstable circumstances can create ODD behaviors (especially if your biologically-driven temperament was challenging to begin with), but that it is often impossible to know just who is the chicken and who is the egg.  Most inexplicably, though, DSM goes on to say that even if all these diagnostic and etiological challenges present themselves, it doesn’t matter—diagnose them anyway.  Then, after the fact, try and do what you can to reduce environmental factors that may be actually causing the “disorder” in the first place.  Huh?  As father of six kids, if my 7-year-old was diagnosed with ODD because I verbally and physically abused him, made him stay in the room for an entire night without food because he accidentally broke a bowl during dinner while his fighting and cussing went unaddressed, and rarely showed him any love and nurturing at all except in apologetic circumstances, would this not seem like a terribly confusing and misdirected message?

It provides a chilling flashback of my earliest experience in psychology as a mental health technician before graduate school, admittedly where diagnoses such as ODD were the disorder “du jour.”  I was sitting in on a family meeting focused on discussing the needs and progress of a child.  The father suddenly looked at us in a condescending, authoritarian way and said, “You just need to fix my child.”  I could only think that the degree of naïve insolence he displayed must have been directly correlated with the severity of problems present in the home environment.  But in some ways, he was echoing just what DSM is saying—diagnose and treat the child first and foremost, and then go about addressing factors that may actually be causing the problem.

Unfortunately, this story only gets worse as the next DSM pages are turned, and final problem is uncovered.  It is when I get to the Differential Diagnosis section of the DSM, and I start to discern other possible reasons that oppositional defiant behaviors may be occurring, which would not warrant a diagnosis of ODD.  Here are my options: conduct disorder, ADHD, depressive and bipolar disorders, disruptive mood dysregulation disorder, intermittent explosive disorder, intellectual disability, language disorder, and social anxiety disorder.  Something missing?  DSM just got done acknowledging that environmental factors, such as harsh parenting, can cause ODD behaviors.  But now, when I go to figure out how I am going to code this, nothing is available except another disorder/disability.  Again, the inconsistency is glaring.  The underlying message seems to be that no matter what is causing the problems, we have to find a disorder for it.

For clinicians such as myself, who utilize insurance benefits for most of our patients, it creates a really unfair ethical dilemma.  There is no doubt that many children and families I see with the aforementioned issues are in serious need of intervention, but because no insurance company will pay (which is a subject for another time) for V-codes (such as child physical, psychological, sexual abuse, or child neglect), we and families are put in the wrong position of having to utilize a diagnosed disorder in a child when all involved know that the issue has way more to do with the parents bringing him or her in.

Given all this, I have a genuine request to any APA official involved with subsequent DSM revisions.  If the categorical model continues to be utilized (despite obvious concerns), I would like to see the following offered as a diagnostic option for Disruptive, Impulse-Control, and Conduct Disorders (under which ODD is subsumed) in addition to all other diagnostic categories where environmental factors can clearly induce significant impairment or distress (which is about every category).  The option would include the following 2 provisions:

  • Remove the term “disorder” and replace with “difficulties” or “problems”
  • Include the term “due to dysfunctional and/or unstable circumstances”

So, instead of diagnosing ODD (or even Other/Unspecified Disruptive, Impulse-Control, and Conduct Disorder) for a child whose behaviors seems to be a response to a harsh, inconsistent environment, the condition would be labeled something like “Oppositional Defiant Difficulties due to Dysfunctional and/or Unstable Circumstances.”  Although I realize that some will critique this for various reasons (including the “mouthful” reason), I believe it is much better option than what currently exists.  Furthermore, no one disagrees with this contention.  Not the DSM-V committee.  Not the clinicians.  Not even the family, if they are willing to look in the mirror.  When we look at other conditions, we find the same story.  Unstable, harsh circumstances (or lack of good sleep and too much screen time) cause ADHD-like behaviors.  Serious depressive features can arise from hopeless, abusive, and deprived situations.  And so on.  Furthermore, this new option would not be unprecedented.  DSM-V already has the provision for many diagnoses that includes “Due to Another Medical Condition” or “Substance/Medication-Induced,” so the stretch from documenting a medical or substance cause to a psychosocial one would hardly be a stretch at all.

When it comes to labeling behaviors, why would we settle for anything less than what we know, especially when it is more confusing, pathologizing, and unrepresentative than other options available?  Especially when pages next to each other, in the same diagnostic manual, tell such different and contradictory story.  No one likes reading a book where the protagonist lacks clear motives and identity, and changes role midstream in a way that renders everything else said or done before as meaningless.  So why we would accept the same from a diagnostic manual where real lives are at stake?


  1. If the DSM authors were to emphasize the obvious fact that environmental factors are key contributors to emotional distress, that would undermine the myth of a strong biological-genetic basis for these “illnesses”, and undermine the validity of the current categorization system period. This could in turn threaten profits extracted from long-term medication use and magnified by the continual rebranding of life problems as illnesses.

    Since the drug companies are major backers of the DSM authors, taking the steps that Schroeder advocates would be betrayal of one’s masters. For many psychiatrists and all drug companies, profit and status must take precedence over the wellbeing of real people.

    So, I think that is why the DSM authors have so much trouble admitting the obvious.

    This state of affairs makes me think of this scene from Lord of the Rings, in which good King Theoden is possessed and almost destroyed by the power-hungry Saruman – https://www.youtube.com/watch?v=Y6wE2W3ag1g

    This reminds me of how not all, but many psychiatrists have been psychologically invaded and possessed by various myths about psychiatric diagnoses and medications. They are truly people in need of an exorcism…

  2. I am wondering how having a DSM diagnosis would adversely affect a child’s future and follow them throughout life in terms of insurance and medical issues. I know that insurance companies cannot refuse to insure children due to pre-existing conditions anymore right? But I believe they can still deny adults for pre-existing conditions. I am curious about this aspect. I understand the emotional, treatment, and social implications. Thank you!

    • How about “mental” patients are almost never treated seriously by doctors and any medical complains are usually dismissed as “it’s all in your head”? I think there’s hardly anyone with a “diagnosis” who having his “diagnosis” disclosed to a doctor was not met with a dismissive attitude and denied treatment or told to see a shrink or take psych meds for a physical condition.

      • Exactly as that is the reason I have not disclosed my psych med history to doctors after getting badly burned when I stupidly did it. And with electronic medical records and more medical appointments that are way too short, this will become even more of an issue in my opinion.

    • With Obamacare, that is no longer the case but as B rightfully point out, a mental health diagnosis can greatly interfere with getting good care because once doctors seen that in the electronic medical records, they will be prone to attribute every complaint to “MI”.

  3. Or we could say, “The kid has a challenging temperament and his parents treat him poorly, understandably resulting in a lot of acting out behavior.” Or “His needs are not being met by his parents and his behavior reflects that lack.” Why bother diagnosing at all? Just describe the problem we need to address and go from there.

    —- Steve

  4. I was in training as a psychiatry resident when the DSM III came out. We were taught, and I believe that it was stated in the DSM III, that the diagnoses were meant as a guide only, especially as they were not etiologically based. It seems that the message in the DSM V is that these diagnoses do actually exist and that etiology is totally irrelevent. This is a very frightening affair. The implication is that any investigations into cause of distress is not important as treatment should be based on diagnosis only and in trying to reduce symptoms on each diagnostic list. Say goodbye to humanistic psychotherapy and prevention of child abuse.

      • I agree, the ‘mental health’ industrial complex has become an institution of not only abuse, but abuse cover-up, starting with child abuse, leading right into adult abuse and shaming. It has become epidemic, and there are still heads buried in the sand. Not for long, I’m sure.

          • I think you’re right, the psychological and psychiatric industries actual function within society, historically and today, seems to have always been about covering up abuse, particularly abuse of children and women. And the men who harm children do all seem to know this “dirty little secret of the two original educated professions.” Bonnie Burstow’s most recent book even points out that the psychiatric field basically usurped the role of the witch hunters of old.

  5. I liked your article…. DSM V is a disaster…

    But it was not created by accident to be that way. The insurance companies have realized that they can save money by not employing clinicians to process claims, and take clinical when a therapist calls for an authorization. Because once clinical information is received that results in the likelihood of an authorization. Its my perception that the insurance industries received a healthy consideration on the formulation of the DSM V.

    Eliminating the five axis diagnosis process saves them time, and allows them to shift work to third world countries like the Philippines, where it can be processed more cheaply. It also allows them to process things electronically, another savings for them.

    • Deck chairs on the Titanic, I’m afraid. It’s just a bad idea from the ground up, unless you are a pharmaceutical company trying to make as much money as possible by pathologizing every emotional reaction a human being can have. They really need to give it up.

  6. Most of my real damaging diagnoses came after I had put on several different kinds of toxic, addictive psychiatric drugs which conventianly made it so I was kind of like the DSM descriptions they had made up in their minds without any kind of scientific “testing.” As they were starting me on the drugs in the early nineties and again in the late nineties; they just “made it up as they went along” so they would have a reason to give me a prescription. I probably assisted; as I even made up things to get their approval. But, the real worst of it came after I had been on several different toxic, addictive drugs, anti-depressants, anti-psychotics, benzos, etc. It’s amazing how they think you need drugs for common life experiences as losing your very best friend, your sister and moving and leaving one town and one job for a new town and the unknown. It is tragic how they can pathologize being a “normal human being” reacting to the experiences of being a “normal human being.” I could go on and on. Thank you.

  7. Thanks for another excellent article, James. I share your righteous indignation with the “never mind the conflicting and mitigating factors, just diagnose!” nonsense you bring to light here. I see a strong parallel to our special education system, in which i was immersed for many years as a school psychologist (now retired, still involved part-time). Like the DSM diagnoses, several of the special education diagnoses are quite ambiguous (e.g., “learning disability”, “emotional disturbance”, “other health impairment”) and subject to a variety of confounding factors, which can be difficult if not impossible to sort out. There’s a missing classification that i believe has at least as much validity as these ones I’ve mentioned: “School Toxicity Syndrome”. And the remediation is much more clear cut: change the environment! (Maybe I’ll see if I can get “The Onion” to publish my research on that one!)

    But back to the parallel between the mental health system and the special education system. I see a similar problem that stems partly from the erroneous application of a “medical model” to behaviors that really have no clear medical etiology. Furthermore, even with the best of intentions (which I’m not assuming are always present), the “cures” to these supposed “illnesses” have a rather dismal track record, whether in educational or mental health outcomes. With regard to both mental health and education, the difficulties that individuals experience are very real and often do need attention. And unless one is blessed with a built-in, supportive social network to provide that attention free of charge, someone has to pay for services. I won’t be so cynical to say that funding is the ONLY reason for the DSM and the special education classification system in our country, but it sure is a major factor! No label, no services. On the one hand, you could say it could be no other way; after all, we don’t have unlimited funds. So if you’re “in the system” and want to get needed services for your client, it appears you have to “hold your nose” and pick the best label.

    But as you, James, and several others have pointed out, there are many problems with this–some of them very grievous. Perhaps the worst is that the onus for the problem is placed squarely on the child or individual, who may have to drag that label (with all of it’s limiting implications) around for the rest of his/her life. And maybe even worse, in the case of DSM diagnosis, there is the strong likelihood of being subjected to a variety of mind- and body-altering drugs or other harmful “interventions”. And in any case, the REAL problem may never be addressed or even identified!

    Another problem that seems inherent in either system is that an ever-expanding array of procedures, regulations, specialists, etc. are interposed between the person needing help of some sort and the actual service! So funds that could be used for those in need get eaten up by the bureaucracy (and maybe that would include me!)

    I certainly don’t see any easy solution, but I do think we need to move toward a system that identifies specific needs tied to services, without reliance on bogus labels. Such a system would involve a complete overhaul of the current funding system. With the guild and financial interests at stake (as Robert Whitaker and Lisa Cosgrove so clearly elucidate in “Psychiatry Under the Influence”) that will surely be a daunting task!