Like more traditional religious documents, DSM resides on a strong foundation and is encased and protected in a fortress that seems impenetrable. The DSM foundation consists of criteria and evidence assembled and validated by a notable group of mental health “authorities”. Furthermore, the nature of the evidence that has been assembled is fully aligned with the methods and values of the paradigm (Kuhn, 2012) that currently prevails in the domain of mental health services.
The DSM fortress has been designed, built and maintained by not only the American Psychiatric Association—with all of its economic and political power—but also state and federal agencies who not only provide regulations but also funding that are guided by DSM. A similar fortress has been built in many other countries to protect the integrity and consistent application of the DSM.
Finally, there are the insurance companies which play a key role in determining economic funding of many mental health services in the United States. This third architect, builder and maintainer of the DSM fortress is unique to the United States (and a few other countries) that rely in part on third party reimbursements of mental health services.
One way to portray the successful introduction, expansion and protection of the DSM is to look at its history over the past seventy years. DSM-I was published in 1952. DSM-5 published in 2013. During this seven-decade interval, five other editions of DSM have been published (DSM-II, DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR). Here is a graph portraying the growth of DSM in terms of both number of pages in the manual and number of diagnostic categories being identified and described.
