The DSM-5 Definition of Mental Disorder: Critique and Alternatives

  • Bruce A. ThyerEmail author
Part of the Essential Clinical Social Work Series book series (ECSWS)


The chapter begins by dissecting the definition of mental disorder offered in the latest edition of the diagnostic manual, incisively pointing out its flaws and shortcomings. These flaws are of two kinds. First, there is the DSM’s overreach in what it “counts” as a mental disorder—e.g., enduring conditions with a clear biological etiology such as Down’s syndrome; temporary states caused by events such as alcohol intoxication, dehydration, or fever-induced delirium; and reactions to adverse environmental stressors. For a condition to be categorized as a mental disorder, its etiology ought to be mentally related, not simply represent a condition that adversely effects mental functioning; indeed, distress and dysfunction can be caused by a wide range of factors, not all of which constitute “mental disorders.” Second, there are fundamental errors in logical reasoning found throughout the manual—e.g., the assumption that diagnoses represent natural and coherent syndromes, as well as the pervasive reification and tautological reasoning in how mental disorder is “explained” by the very elements that comprise its definition. Alternatives to the DSM are explored including various forms of “denialism,” symptomatic treatment, and functional behavioral assessment. The chapter concludes with a reflection on the consequences for clinical assessment and treatment of the DSM’s vision of mental disorder and a call for social workers to critically examine its tenets and decide for themselves the model(s) they wish to use.


Denialism Etiology Syndrome Reification Circular reasoning Symptomatic treatment Functional assessment of behavior 


  1. Akers, R. L. (1977). Deviant behavior: A social learning approach. Belmont, CA: Wadsworth.Google Scholar
  2. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.Google Scholar
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  4. Berg, I. K. (1994). Family-based services: A solution-focused approach. New York: W. W. Norton.Google Scholar
  5. Casement, M. D., & Germain, A. (2014). Is group imagery rehearsal for posttraumatic nightmares as good at reducing PTSD symptoms as group treatment for PTSD? Psychological Trauma, 6, 259–260.CrossRefGoogle Scholar
  6. Casement, M. D., & Swanson, L. M. (2012). A meta-analysis of imagery rehearsal for post-trauma nightmares: Effects on nightmare frequency, sleep quality, and posttraumatic stress. Clinical Psychology Review, 32, 566–574.CrossRefGoogle Scholar
  7. Cipani, E. (2014). Comorbidity in DSM childhood mental disorders: A functional perspective. Research on Social Work Practice, 24, 78–85.CrossRefGoogle Scholar
  8. Deguchi, H. (1984). Observational learning from a radical-behaviorist viewpoint. The Behavior Analyst, 7, 83–95.Google Scholar
  9. Deschner, J. P., & McNeil, J. S. (1986). Resulting of anger control training for battering couples. Journal of Family Violence, 1, 111–120.CrossRefGoogle Scholar
  10. Donahue, S. A., Jackson, C. T., Shear, K. M., Felton, C. J., & Essock, S. M. (2006). Outcomes of enhanced counseling services provided to adults through Project Liberty. Psychiatric Services, 57, 1298–1303.CrossRefGoogle Scholar
  11. Dowling, F. G., Moynihan, G., Genet, B., & Lewis, J. (2006). A peer-based assistance program for officers with the New York City Police Department: Report of the effects of Sept. 11, 2001. Psychiatric Services, 163, 151–153.Google Scholar
  12. Etnyre, W. (2008). Psychodynamic diagnostic manual. Clinical Social Work Journal, 36, 403–406.CrossRefGoogle Scholar
  13. Favod, J., Rexhaj, S., Bardy, S., Ferrari, P., Hayoz, C., & Moritz, S. (2013). Sustained antipsychotic effect of metacognitive training in psychosis: A randomized controlled study. European Psychiatry, 29, 275–281.CrossRefGoogle Scholar
  14. Filter, K. J., & Alvarez, M. E. (2012). Functional behavioral assessment. New York: Oxford University Press.Google Scholar
  15. Filter, K. J., & Horner, R. H. (2009). Function-based academic interventions for problem behavior. Education and Treatment of Children, 31(2), 1–19.Google Scholar
  16. First, M. B., & Wakefield, J. C. (2010). Defining ‘mental disorder’ in DSM-V. Psychological Medicine, 40, 1779–1782.CrossRefGoogle Scholar
  17. Francis, A. (2013). Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5. New York: Guilford.Google Scholar
  18. Franklin, C. S. (Ed.). (2012). Solution-focused brief therapy: A handbook of evidence-based practice. New York: Oxford University Press.Google Scholar
  19. Franklin, C. S., & Jordan, C. (Eds.). (2011). Clinical assessment for social workers (3rd ed.). Chicago: Lyceum Books.Google Scholar
  20. Fryling, M. J., Johnston, C., & Hayes, L. J. (2011). Understanding observational learning. The Analysis of Verbal Behavior, 27, 191–203.Google Scholar
  21. Greisinger, W. (1867). Mental pathology and therapeutics. New York: Hafner (1965 reprinted facsimile).Google Scholar
  22. Hagen, R., Turkington, D., Berge, T., & Grawe, R. W. (2013). CBT for psychosis: A symptom-based approach. New York: Routledge/Taylor & Francis.Google Scholar
  23. Harrison, K., & Harrison, R. (2009). The school social worker’s role in the tertiary support of functional assessment. Child and Schools, 31, 119–127.CrossRefGoogle Scholar
  24. Holmes, D. (1967). Bridging the gap between research and practice in social work. In National Conference on Social Welfare (Ed.), Social work practice, (pp. 94–108). New York: Columbia University Press.Google Scholar
  25. Horwtiz, A. V., & Wakefield, J. C. (2012). All we have to fear: Psychiatry’s transformation of natural anxieties into mental disorders. New York: Oxford University Press.Google Scholar
  26. Hyman, S. W. (2010). The diagnosis of mental disorders: The problem of reification. Annual Review of Clinical Psychology, 6, 155–179.CrossRefGoogle Scholar
  27. Insell, T. (2014). The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. American Journal of Psychiatry, 171, 395–397.CrossRefGoogle Scholar
  28. Jun, J. J., Zoellner, L. A., & Feeny, N. C. (2013). Sudden gains in prolonged exposure and sertraline for chronic PTSD. Depression and Anxiety, 30, 607–613.CrossRefGoogle Scholar
  29. Karls, J. M., Lowery, C. T., Mattaini, M. A., & Wandrei, K. E. (1997). The use of the person-in-environment system in social work education. Journal of Social Work Education, 33, 48–58.Google Scholar
  30. Karls, J. M., & O’Keefe, M. (2008). Person-in-environment system manual (2nd ed.). Washington, DC: NASW Press.Google Scholar
  31. Karls, J. M., & O’Keefe, M. (2009). Person-in-environment system. In A. R. Roberts (Ed.), Social worker’s desk reference (2nd ed., pp. 371–376). New York: Oxford University Press.Google Scholar
  32. Karls, J. M., & Wandrei, K. E. (1994a). Person-in-environment system: The PIE classification system for social functioning problems. Washington, DC: NASW Press.Google Scholar
  33. Karls, J. M., & Wandrei, K. E. (1994b). The PIE manual. Washington, DC: NASW Press.Google Scholar
  34. Kirk, S. A., & Hsieh, D. K. (2004). Diagnostic consistency in assessing conduct disorder: An experiment on the effect of social context. American Journal of Orthopsychiatry, 74, 43–55.CrossRefGoogle Scholar
  35. Lamb, S. D. (2014). Pathologist of the mind: Adolph Meyer and the origins of American psychiatry. Baltimore: Johns Hopkins University Press.Google Scholar
  36. Lee, Q. A., Doctor, J. N., Zoellner, L. A., & Feeny, N. C. (2014). Cost-effectiveness of prolonged exposure therapy versus pharmacotherapy and treatment choice in posttraumatic stress disorder (the Optimizing PTSD Treatment Trial): A doubling randomized preference trial. Journal of Clinical Psychiatry, 75, 222–230.CrossRefGoogle Scholar
  37. Masson, J. M. (1986). The assault on truth: Freud’s suppression of the seduction theory. New York: Farra, Straus and Giroux.Google Scholar
  38. McLendon, T. (2014). Social work perspectives regarding the DSM: Implications for social work education. Journal of Social Work Education, 50, 454–471.Google Scholar
  39. Morkved, N., Hartman, K., Aarsheim, L. M., Holen, D., Milde, A. M., Bomyea, J., & Thorp, S. R. (2014). A comparison of narrative exposure therapy and prolonged exposure therapy for PTSD. Clinical Psychology Review, 34, 453–467.CrossRefGoogle Scholar
  40. Nesse, R. M., & Stein, D. J. (2012). Towards a genuinely medical model for psychiatric nosology. BMC Medicine, 10, 5.
  41. Nilsson, D., Joubert, L., Holland, L., & Posenelli, S. (2013). The why of practice: Using PIE to analyze social work practice in Australian hospitals. Social Work in Health Care, 52, 280–295.CrossRefGoogle Scholar
  42. Pull, C. N., & Pull, C. B. (2013). Current status of treatment for posttraumatic stress disorder: Focus on treatments combining pharmacotherapy and cognitive-behavioral therapy. International Journal of Cognitive Therapy, 7, 149–161.CrossRefGoogle Scholar
  43. Robbins, S. P. (2014). From the editor—the DSM-5 and its role in social work assessment and research. Journal of Social Work Education, 50, 201–205.Google Scholar
  44. Rowe, W. R. (1996). Client-centered theory: A person-centered approach. In F. Turner (Ed.), Social work treatment (pp. 69–93). New York: Free Press.Google Scholar
  45. Schneier, F. R., Neria, Y., Pavlicova, M., Hembree, E., Suh, E. J., Amsel, L., & Marshall, R. D. (2012). Combined prolonged exposure therapy and Paroxetine for PTSD related to the World Trade Center attack: A randomized controlled trial. American Journal of Psychiatry, 169, 80–88.CrossRefGoogle Scholar
  46. Schock, K., Clay, C., & Cipani, E. (1998). Making sense of schizophrenic symptoms: Delusional statements and behavior may be functional in purpose. Journal of Behavior Therapy and Experimental Psychiatry, 29, 131–141.CrossRefGoogle Scholar
  47. School Social Work Association of America. (2001). Functional behavioral assessments and behavior intervention plans. Indianapolis, IN: Author.Google Scholar
  48. Sloan, D. M., Feinstein, B. A., Gallagher, M. W., Beck, J. G., & Keane, T. M. (2013). Efficacy of group treatment for posttraumatic stress disorder symptoms: A meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 176–183.CrossRefGoogle Scholar
  49. Szasz, T. (1961). The myth of mental illness. New York: Hoeber-Harper.Google Scholar
  50. Thyer, B. A. (2006). It is time to rename the DSM. Ethical Human Psychology and Psychiatry, 8, 61–67.CrossRefGoogle Scholar
  51. Thyer, B. A. (2012). Respondent learning theory. In B. A. Thyer, C. N. Dulmus, & K. M. Sowers (Eds.), Human behavior in the social environment: Theories for social work practice (pp. 47–81). New York: Wiley.Google Scholar
  52. Thyer, B. A. (2014a). A review of Essentials of psychiatric diagnosis: Responding to the challenge of DSM-5 by Allen Frances. Research on Social Work Practice, 24, 165–169. doi: 10.1177/1049731513505000.CrossRefGoogle Scholar
  53. Thyer, B. A., & Myers, L. L. (2007). A social worker’s guide to evaluating practice outcomes. Alexandria, VA: Council on Social Work Education.Google Scholar
  54. Thyer, B. A., & Wodarski, J. S. (Eds.). (2007). Social work in mental health: An evidence-based approach. New York: Wiley.Google Scholar
  55. Turkington, D., Munetz, M., Pelton, J., Montesana, V., Sivec, H., Nausheen, B., & Kingdon, D. (2014). High-yield cognitive behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms. Journal of Nervous and Mental Disease, 202, 30–34.CrossRefGoogle Scholar
  56. Van der Gaag, M., Valmiggia, L. R., & Smith, F. (2014). The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis. Schizophrenia Research, 156, 30–36.CrossRefGoogle Scholar
  57. Wakefield, J. C. (1992). Disorder as harmful dysfunction: A conceptual critique of DSM-III-R’s definition of mental disorder. Psychological Review, 99, 232–247.CrossRefGoogle Scholar
  58. Watts, B. V., Schnurr, P. P., Mayo, L., Young, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74, E541–E550.CrossRefGoogle Scholar
  59. Wessely, S. (2009). Surgery for the treatment of psychiatric illness: The need to test untested theories. Journal of the Royal Society of Medicine, 102, 445–451.CrossRefGoogle Scholar
  60. Whitaker, R. (2010). Anatomy of an epidemic. New York: Crown Publishing Group.Google Scholar
  61. Wilder, D. A., & Wong, S. E. (2007). Schizophrenia and other psychotic disorders. In P. Sturmey (Ed.), The handbook of functional analysis and clinical psychology (pp. 283–305). Philadelphia, PA: Elsevier.Google Scholar
  62. Wong, S. E. (2012). Operant learning theory. In B. A. Thyer, C. N. Dulmus, & K. M. Sowers (Eds.), Human behavior in the social environment: Theories for social work practice (pp. 83–123). New York: Wiley.Google Scholar
  63. Wong, S. E. (2014). A critique of the diagnostic construct Schizophrenia. Research on Social Work Practice, 24, 132–141.CrossRefGoogle Scholar
  64. Thyer, B. A. (2014b). The definition of mental disorder found in the DSM-5: Too much and too little. Mental Health and Social Work, 42(4), 21–33.Google Scholar
  65. Wood, A. D. (1973). “The fashionable diseases”: Women’s complaints and their treatment in nineteenth-century America. Journal of Interdisciplinary History, 4, 25–52. doi: 10.2307/202356.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.College of Social WorkFlorida State UniversityTallahasseeUSA

Personalised recommendations