DIAGNOSTIC & STATISTICAL
OF MENTAL DISORDERS
The Diagnostic and Statistical Manual published
by the American Psychiatric AssociationThe Diagnostic and Statistical
Manual of Mental Disorders (DSM) is an American handbook for mental
health professionals that lists different categories of mental disorders
and the criteria for diagnosing them, according to the publishing
organization the American Psychiatric Association. It is used worldwide
by clinicians and researchers as well as insurance companies, pharmaceutical
companies and policy makers. It has attracted controversy and criticism
as well as praise.
There have been five revisions of the DSM since
it was first published in 1952. The last major revision was the
DSM-IV published in 1994, although a "text revision" was
produced in 2000. The DSM-V is currently in consultation, planning
and preparation, due for publication in approximately 2012. The
mental disorders section of the International Statistical Classification
of Diseases and Related Health Problems (ICD) is another commonly-used
guide, and the two classifications use the same diagnostic codes.
The Diagnostic and Statistical Manual of Mental
Disorders was first published in 1952, by the American Psychiatric
Association. It was developed from an earlier classification system
adopted in 1918 to meet the need of the federal Bureau of the Census
for uniform statistics from psychiatric hospitals; from categorization
systems in use by the United States military; and from a survey
of the views of 10% of APA members. The manual was 130 pages
long and contained 106 categories of mental disorder. The DSM-II
was published in 1968, listed 182 disorders, and was 134 pages long.
These manuals reflected the predominant psychodynamic psychiatry.
Symptoms were not specified in detail for specific disorders, but
were seen as reflections of broad underlying conflicts or maladaptive
reactions to life problems, rooted in a distinction between neurosis
and psychosis (roughly, anxiety/depression broadly in touch with
reality, or hallucinations/delusions appearing disconnected from
reality). Sociological and biological knowledge was also incorporated,
in a model that did not emphasize a clear boundary between normality
In 1974, the decision to create a new revision
of the DSM was made, and Robert Spitzer was selected as chairman
of the task force. The initial impetus was to make the DSM nomenclature
consistent with the International Statistical Classification of
Diseases and Related Health Problems (ICD), published by the World
Health Organization. The revision took on a far wider mandate under
the influence and control of Spitzer and his chosen committee members.
One goal was to improve the reliability of psychiatric diagnosis.
The practices of mental health professionals, especially in different
countries, were not uniform. The establishment of specific criteria
was also an attempt to facilitate mental health research. The multiaxial
system attempts to yield a more complete picture of the patient,
rather than just a simple diagnosis. The criteria and classification
system of the DSM-III was based on a process of consultation and
committee meetings. An attempt was made to base categorization on
description rather than assumptions of etiology, and the psychodynamic
view was abandoned, perhaps in favor of a biomedical model, with
a clear distinction between normal and abnormal.
The criteria adopted for many of the mental disorders
were expanded from the Research Diagnostic Criteria (RDC) and Feighner
Criteria which had been developed for psychiatry research in the
1970s. Other criteria were established by consensus in committee
meetings, as determined by Spitzer. The approach is generally seen
as “neo-Kraepelinian”, after the work of the psychiatrist Emil Kraepelin.
Spitzer argued that “mental disorders are a subset of medical disorders”
but the task force decided on the DSM statement: “Each of the mental
disorders is conceptualized as a clinically significant behavioral
or psychological syndrome.” The first draft of the DSM-III was prepared
within a year. Many new categories of disorder were introduced.
Field trials sponsored by the U.S. National Institute of Mental
Health (NIMH) were conducted between 1977 and 1979 to test the reliability
of the new diagnoses. A controversy emerged regarding deletion of
the concept of neurosis, a mainstream of psychoanalytic theory and
therapy but seen as vague and unscientific by the DSM task force.
Faced with enormous political opposition, such that the DSM-III
was in serious danger of not being approved by the APA Board of
Trustees unless “neurosis” was included in some capacity, a political
compromise reinserted the term in parentheses after the word “disorder”
in some cases. In 1980, the DSM-III was published, at 494 pages
long and listing 265 diagnostic categories. The DSM-III rapidly
came into widespread international use by multiple stakeholders
and has been termed a revolution or transformation in psychiatry.
In 1987 the DSM-III-R was published as a revision
of DSM-III, under the direction of Spitzer. Categories were renamed,
reorganized, and significant changes in criteria were made. Six
new categories were deleted while others were added. Controversial
diagnoses such as pre-menstrual dysphoric disorder and Masochistic
Personality Disorder were considered and discarded. Altogether,
DSM-III-R contained 292 diagnoses and was 567 pages long.
In 1994, DSM-IV was published, listing 297 disorders
in 886 pages. The task force was chaired by Allen Frances. A steering
committee of 27 people was introduced, including four psychologists.
The steering committee created 13 work groups of 5–16 members. Each
work group had approximately 20 advisers. The work groups conducted
a three step process. First, each group conducted an extensive literature
review of their diagnoses. Then they requested data from researchers,
conducting analyses to determine which criteria required change,
with instructions to be conservative. Finally, they conducted multicenter
field trials relating diagnoses to clinical practice. A major
change from previous versions was the inclusion of a clinical significance
criterion to almost half of all the categories, which required that
symptoms cause “clinically significant distress or impairment in
social, occupational, or other important areas of functioning”.
A "Text Revision" of the DSM-IV, known
as the DSM-IV-TR, was published in 2000. The diagnostic categories
and the vast majority of the specific criteria for diagnosis were
unchanged. The text sections giving extra information on each
diagnosis were updated, as were some of the diagnostic codes in
order to maintain consistency with the ICD.
Use of the DSM
Many mental health professionals use this book
to help communicate a patient's diagnosis after an evaluation. Many
hospitals, clinics, and insurance companies require a 'five axis'
DSM diagnosis of the patients that are seen. The DSM can be consulted
for the diagnostic criteria. It does not address the method of the
evaluation or treatment. The DSM is less frequently used by health
professionals who do not specialize in mental health.
Another use of the DSM is for research purposes.
Studies that are done to on specific diseases often recruit patients
whose symptoms match the criteria listed in the DSM for that disease.
Students may also refer to the DSM to learn criteria
required for their courses.
DSM and politics
Following controversy and protests from gay activists
at APA annual conferences from 1970 to 1973, as well as the emergence
of new data from researchers such as Alfred Kinsey and Evelyn Hooker,
the seventh printing of the DSM-II, in 1974, no longer listed homosexuality
as a category of disorder. After talks led by the psychiatrist Robert
Spitzer, who had been involved in the DSM-II development committee,
a vote by the APA trustees in 1973, confirmed by the wider APA membership
in 1974, had replaced the diagnosis with a milder category of "sexual
orientation disturbance". This was replaced with the diagnosis
of ego-dystonic homosexuality in the DSM-III in 1980, but this was
removed in 1987 with the release of the DSM-III-R. A category
of "sexual disorder not otherwise specified" continues
in the DSM-IV, which may include "persistent and marked distress
about one’s sexual orientation”.
The current DSM
The DSM-IV is a categorical classification system.
The categories are prototypes, and a patient with a close approximation
to the prototype is said to have that disorder. DSM-IV states that
“there is no assumption that each category of mental disorder is
a completely discrete entity with absolute boundaries...” but isolated,
low-grade and noncriterion (unlisted for a given disorder) symptoms
are not given importance. Qualifiers are sometimes used, for
example mild, moderate or severe forms of a disorder. For nearly
half the disorders, symptoms must be sufficient to cause “clinically
significant distress or impairment in social, occupational, or other
important areas of functioning", although DSM-IV-TR removed
the distress criterion from tic disorders and several of the paraphilias.
Each category of disorder has a numeric code taken from the ICD
coding system, used for health service (including insurance) administrative
The DSM-IV organizes each psychiatric diagnosis
into five levels (axes) relating to different aspects of disorder
Axis I: clinical disorders, including major mental
disorders, as well as developmental and learning disorders
Axis II: underlying pervasive or personality conditions, as well
as mental retardation
Axis III: Acute medical conditions and Physical disorders.
Axis IV: psychosocial and environmental factors contributing to
Axis V: Global Assessment of Functioning or Children’s Global Assessment
Scale for children under the age of 18. (on a scale from 100 to
Common Axis I disorders include depression, anxiety disorders, bipolar
disorder, ADHD, and schizophrenia.
Common Axis II disorders include borderline personality
disorder, schizotypal personality disorder, antisocial
personality disorder, narcissistic personality disorder, and mild mental retardation.
The DSM-IV-TR states that, because it is produced
for mental health specialists, its use by people without clinical
training can lead to inappropriate application of its contents.
Appropriate use of the diagnostic criteria is said to require extensive
clinical training, and its contents “cannot simply be applied in
a cookbook fashion”. The APA notes that diagnostic labels are
primarily for use as a “convenient shorthand” among professionals.
The DSM advises that laypersons should consult the DSM only to obtain
information, not to make diagnoses, and that people who may have
a mental disorder should be referred to psychiatric counseling or
treatment. Further, people sharing the same diagnosis/label may
not have the same etiology (cause) or require the same treatment;
the DSM contains no information regarding treatment or cause for
this reason. The range of the DSM represents an extensive scope
of psychiatric and psychological issues, and it is not exclusive
to what one may consider “illnesses”.
The DSM-IV doesn't specifically cite its sources,
but there are four volumes of "sourcebooks" intended to
be APA's documentation of the guideline development process and
supporting evidence, including literature reviews, data analyses
and field trials. The Sourcebooks have been said
to provide important insights into the character and quality of
the decisions that led to the production of DSM-IV, and hence the
scientific credibility of contemporary psychiatric classification.
The DSM-V is tentatively scheduled for publication
in 2011. In 1999, a DSM–V Research Planning Conference, sponsored
jointly by APA and the National Institute of Mental Health (NIMH),
was held to set the research priorities. Research Planning Work
Groups produced "white papers" on the research needed
to inform and shape the DSM-IV, and the resulting work and recommendations
were reported in an APA monograph and peer-reviewed literature.
There were six workgroups, each focusing on a broad topic: Nomenclature,
Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality
and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural
Issues. Three additional white papers were also due by 2004 concerning
gender issues, diagnostic issues in the geriatric population, and
mental disorders in infants and young children. The white papers
have been followed by a series of conferences to produce recommendations
relating to specific disorders and issues, with attendance limited
to 25 invited researchers.
On July 23rd 2007, the APA announced the task
force that will oversee the development of DSM-V. The DSM-V Task
Force consists of 27 members, including a chair and vice chair,
who collectively represent research scientists from psychiatry and
other disciplines, clinical care providers, and consumer and family
advocates. Scientists working on the revision of the DSM have experience
in research, clinical care, biology, genetics, statistics, epidemiology,
public health and consumer advocacy. They have interests ranging
from cross-cultural medicine and genetics to geriatric issues, ethics
and addiction. The APA Board of Trustees required that all task
force nominees disclose any competing interests or potentially conflicting
relationships with entities that have an interest in psychiatric
diagnoses and treatments as a precondition to appointment to the
task force. The APA made all task force members' disclosures available
during the announcement of the task force. Several individuals were
ruled ineligible for task force appointments due to their competing
interests. Revision of the DSM will continue over the next five
years. Future announcements will include naming the workgroups on
specific categories of disorders and their research-based recommendations
on updating various disorders and definitions.
There have been a number of persistent critical
debates concerning the DSM. There has been continuing scientific
debate concerning the construct validity and practical reliability
of the diagnostic categories and criteria in the DSM, even though
they have been increasingly standardized to improve inter-rater
agreement in controlled research. It has been argued
that the DSM's claims to being empirically founded are overstated
Despite caveats in the introduction to the DSM, it has long been
argued that its system of classification makes unjustified categorical
distinctions between disorders, and between normal and abnormal.
Although the DSM-IV may move away from this categorical approach
in some limited areas, some argue that a fully dimensional, spectrum
or complaint-oriented approach would better reflect the evidence.
It has been argued that purely symptom-based diagnostic criteria
fail to adequately take into account the context in which a person
is living, and whether there is real internal disorder of an individual
or simply a response to an ongoing situation. It is claimed
that the use of distress and disability as additional criteria for
many disorders has not solved this false-positives problem, because
the level of impairment is often not correlated with symptom counts
and can stem from various individual and social factors.
The political context of the DSM is a topic of controversy, including
its use by drug and insurance companies. The potential for conflict
of interest has been raised because roughly 50% of the authors who
previously selected and defined the DSM psychiatric disorders have
had or have financial relationships with pharmaceutical industries
and drug companies. Some argue that the expansion of disorders
in the DSM has been influenced by profit motives and represents
an increasing medicalization of human nature, while others argue
that mental health problems are still under-recognized and under-treated.
Some people object to the DSM's inclusion of pedophilia, gender
identity disorder and transvestic fetishism as diagnoses. They cite
the APA's decision to remove homosexuality from the DSM as evidence
that the APA incorrectly refers to these states of being or orientations
as mental illnesses.
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