I'll never forget my introduction to the Diagnostic and Statistical Manual of Mental Disorders (DSM). It was during my first quarter of graduate school in a Psychopathology class. Our professor asked us to pull out our DSMs, and I had zero knowledge of what she had just requested. After all, my undergraduate degree was in communications—so the DSM meant nothing to me. I looked around, noticing everyone reaching into their bags and pulling out a book. I spoke up and shamelessly asked, "What's the DSM?"
The expression on my professor's face is forever tattooed in my brain: a pause, a still face with zero expression, silently screaming, "How are you even here?" She turned to the class and asked, "Can someone please show us the DSM?" The student beside me grabbed her book and placed it before me. I immediately opened my laptop, headed to Amazon—when Amazon was still just for books—and bought the DSM-IV-TR.
That was in 2008. For the record, I received an A in the class, graduated cum laude, and have since enjoyed a prosperous and enriching career as a licensed marriage and family therapist—with the DSM at its center. As all mental health professionals know, the DSM is considered the Bible of our industry—unfortunately.
Throughout my years as a therapist—learning, memorizing, and diagnosing clients using the DSM—it never occurred to me to question the very book upon which our entire industry was built until 2018.
A common practice in my field is obtaining continuing education units (CEUs) to maintain one's license. Courses can range from addiction studies to mandated diversity training. These courses may be standalone via Zoom webinar or part of multi-day conferences held at popular locations.
One such conference I attended included a workshop dedicated to the DSM. The workshop provided an in-depth understanding of how the DSM was developed and the process of canonizing various mental health disorders. It was eye-opening, and this information is not widely taught within our industry. I was shocked.
I previously believed the DSM was based on years of rigorous research and empirical studies involving individuals with mental health conditions, from which diagnoses emerged. I was utterly mistaken.
No such studies are conducted, and nothing is proven. There is no established empirical research standard to support diagnoses. Instead, the DSM is constructed through clinical experience, pharmaceutical influence, insurance reimbursement considerations, cultural and political pressures, and professional self-preservation.
Gary Greenberg's insightful book, The Book of Woe: The DSM and the Unmaking of Psychiatry (2013), thoroughly explains the DSM's history, evolution, and the flawed document it has become.
The DSM originated in the early 20th century as a tool to standardize psychiatric diagnosis. Its roots trace back to 1840, but it wasn't until World War II that a more structured system became necessary. The U.S. Army developed a classification system to manage the influx of soldiers returning with psychological issues, which the American Psychiatric Association (APA) adapted into the DSM-I, published in 1952. This first edition listed 106 disorders, heavily influenced by Freudian psychoanalysis, featuring vague, subjective descriptions. The DSM-II followed in 1968, expanding to 182 disorders without empirical grounding. The turning point was DSM-III in 1980, aiming to make psychiatry appear more "scientific" by introducing symptom checklists and diagnostic criteria—partially to counter criticism that psychiatry lacked legitimacy compared to other medical fields. The newest edition, DSM-5-TR, now lists 312 possible diagnoses. How these disorders are determined is the shocking part.
When revising the DSM, the APA creates a Task Force composed of researchers and clinicians. These individuals then nominate members of the Work Groups, drawn mainly from professional networks and institutional affiliations (e.g., universities, hospitals). According to a 2012 study published in PLoS Medicine, over 70% of Task Force and Work Group members have financial ties to pharmaceutical companies. Approximately 160 psychiatrists, psychologists, and other mental health experts, divided into 13 disorder-specific Work Groups (e.g., Mood Disorders, Anxiety Disorders), collaborate and debate what should qualify as a disorder. When disagreements arise about criteria for a specific disorder, the members settle them by majority vote. They do not consider biomarkers, empirical evidence, or scientific research; they decide by voting. Once finalized, these decisions are submitted to the APA's elected Board of Trustees for final approval.
Let's pause here to appreciate the gravity of what occurs during this critical moment. For example, with a diagnosis like Gender Dysphoria, if members debate its classification as a mental health disorder (similarly, homosexuality was once listed but later removed due to stigma concerns), the decision is made through voting. Considering over 90% of mental health professionals identify as politically liberal (according to a study by SAGE Journals), it's reasonable to assume votes will lean toward removing stigmas associated with disorders like Gender Dysphoria. With no biomarkers, scientific studies, or definitive evidence to validate such disorders, decisions rely heavily on the voting members' political, cultural, and personal experiences.
This debate occurred. In the DSM-IV (1994) and DSM-IV-TR (2000), the diagnosis was called Gender Identity Disorder, framing transgender identity itself as pathological—a "disorder." Advocates and some professionals argued this stigmatized gender variance, paralleling how homosexuality was classified until 1973. Despite the desire to eliminate the stigma, the APA renamed it Gender Dysphoria in DSM-5 (2013). Why? Insurance coverage. Insurance companies require formal DSM diagnoses to cover treatments such as hormone therapy or gender reassignment surgery; without a diagnosis, these treatments become "cosmetic," not "medically necessary," forcing patients to pay out-of-pocket. To avoid further marginalizing the affected community, the APA shifted the diagnosis to emphasize distress from gender incongruence rather than labeling gender identity itself pathological—partially addressing stigma without removing eligibility for treatment.
The past decade has vividly illustrated our society's mental health trajectory. We've seen gender dysphoria evolve into acceptance of "furries," drag queen story hours for children in public schools, attempts to reclassify pedophilia as Minor Attracted Persons (MAPs), expansion of neurodivergence beyond autism or Asperger's syndrome, the informal introduction of Trump Derangement Syndrome (TDS), women claiming to be men and men infiltrating women's sports and spaces, pronoun declarations in biographies, medical mutilation of children for gender affirmation, doctors refusing to assign biological sex at birth, and countless other insanities. The very individuals advocating subjective realities are often those sitting on APA Task Forces and Work Groups, voting on what qualifies as "mental health."
The DSM is essentially a list of definitions masquerading as the psychiatric Bible. It's a catalog of human suffering presented as medical facts to legitimize psychiatry. Lacking biological validity and scientific rigor, it reveals psychiatry's uncomfortable truth: it invents its material to justify its existence.
