The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. It is used in the United States and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies and policy makers.
The DSM has attracted controversy and criticism as well as praise. There have been five revisions since it was first published in 1952, gradually including more disorders, though some have been removed and are no longer considered to be mental disorders. It initially evolved out of systems for collecting census and psychiatric hospital statistics, and from a manual developed by the US Army. The last major revision was the fourth edition ("DSM-IV"), published in 1994, although a "text revision" was produced in 2000. The fifth edition ("DSM-V") is currently in consultation, planning and preparation, due for publication in May 2013.[1 ] The mental disorders section of the International Statistical Classification of Diseases and Related Health Problems (ICD) is another commonly-used guide, used more often in Europe and other parts of the world. The coding system used in the DSM-IV is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously.
Many mental health professionals use this book to determine and help communicate a patient's diagnosis after an evaluation; hospitals, clinics, and insurance companies also generally require a 'five axis' DSM diagnosis of all the patients treated. The DSM can be used to establish a diagnosis or categorize patients using diagnostic criteria. The DSM may also be used in mental health research. Studies done on specific diseases often recruit patients whose symptoms match the criteria listed in the DSM for that disease. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinically absent diagnosis while the latter was more valued for research.
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census which used a single category, "idiocy/insanity". The 1880 census distinguished among seven categories: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917, a "Committee on Statistics" from what is now known as the American Psychiatric Association (APA), together with the National Commission on Mental Hygiene, developed a new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane", which included 22 diagnoses. This was subsequently revised several times by APA over the years. APA, along with the New York Academy of Medicine, also provided the psychiatric nomenclature subsection of the US medical guide, the "Standard Classified Nomenclature of Disease", referred to as the "Standard".
World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist and brigadier general William C. Menninger developed a new classification scheme called Medical 203, issued in 1943 as a "War Department Technical Bulletin" under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the US Navy had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces", and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of Medical 203.
In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD) which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature." An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950 the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system and the Standard's Nomenclature, to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in it being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text identical. The manual was 130 pages long and listed 106 mental disorders.
Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to also go ahead with a revision of the DSM. It was also published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. The term “reaction” was dropped but the term “neurosis” was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although they also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many 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 and abnormality.
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. But through the efforts of psychiatrist Robert Spitzer, who had led the DSM-II development committee, a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance", presently referred to as gender identity disorder (GID).
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 uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a need to standardize diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA. The establishment of these criteria was also an attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by Federal administrative offices), rather than assumptions of etiology, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian”). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued, “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; a number of the unpublished documents that aim to justify them have recently come to light. 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, so 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. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".
Finally published in 1980, the DSM-III was 494 pages long and listed 265 diagnostic categories. It 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 categories were deleted while others were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were considered and discarded. "Sexual orientation disturbance" was also removed, but was largely subsumed under "sexual disorder not otherwise specified" which can include "persistent and marked distress about one’s sexual orientation." 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 symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
ADHD (Attention Deficit Hyperactivity Disorder) was characterized at this stage.
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.
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, “there is no assumption 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 purposes.
The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:
Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and mental retardation.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
The DSM-IV-TR states, because it is produced for the completion of Federal legislative mandates, 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 diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis/label may have different etiologies (causes) or require different treatments; 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 or conditions, and it is not exclusive to what may be considered “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.
Beginning with the problem that there is no single objective diagnostic test for a mental illness in the field of psychiatry — a problem the DSM sidesteps by referring only to "mental disorders", defined as dysfunctional psychological or behavioral patterns — the DSM-IV has come under various criticisms over the years.
The most fundamental criticism of the DSM concerns the construct validity and reliability of its diagnostic categories and criteria. Although increasingly standardized, critics argue that the DSM's claim of an empirical foundation is overstated. A reliance on operational definitions necessitates that intuitive concepts such as depression be operationally defined before they can be used in scientific investigation. Such definitions are used as a follow up to a conceptual definition, in which the specific concept is defined as a measurable occurrence. John Stuart Mill pointed out the dangers of believing anything that could be given a name must refer to a thing and Stephen Jay Gould and others have criticized psychologists for doing just that. A committed operationalist would respond that speculation about the thing in itself, or noumenon, should be resisted as meaningless, and would comment only on phenomena using operationally defined terms and tables of operationally defined measurements. This line of criticism has also appeared in non-specialist venues. In 1997, Harper's Magazine published an essay, ostensibly a book review of the DSM-IV, that criticized the lack of hard science and the proliferation of disorders. The language of the DSM was described as "simultaneously precise and vague", and the manual itself compared to "a militia's Web page, insofar as it constitutes an alternative reality under siege," and a "fertilizer bomb" against hard science.
By design, the DSM is primarily concerned with the symptoms of mental disorders, it does not attempt to analyze or explain the conditions it lists or even to discuss possible patterns or relationships between and among them. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of causative or explanatory material, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology." The DSM's apparent superficiality is therefore largely a result of necessity, since there is no agreement on a more explanatory classification system.
Despite the lack of consensus, advocates for specific psychopathlogical paradigms have nonetheless faulted the current diagnostic scheme for not incorporating the innovations of their particular models; the most recent example being evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology.
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-V 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. Similarly, the current individual symptom-based approach has been argued to not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual or a psychological response to adverse situations. Because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the standard of distress or disability can often produce false positives.
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has opined that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.
It has also been suggested that the apparent reductionism of the DSM, as well as its substantial expansions, are representative of an increasing medicalization of human nature, a result of disease mongering by drug companies, whose influence on psychiatry has dramatically grown in recent decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. In 2008, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".
There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias (sexual fetishes) and hypoactive sexual desire disorder (low sex drive). Critics of these and other controversial diagnoses often cite the DSM's previous inclusion of homosexuality, as well as the APA's eventual decision to remove it, as a precedent for current disputes. That 1974 decision, however, is still challenged by many conservative and religious groups who maintain that homosexuality is in fact a mental disorder, even though the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality and the longstanding consensus of the behavioral and social sciences and the health and mental health professions is that homosexuality per se is a normal and positive variation of human sexual orientation. The fact that this diagnostic revision continues to be passionately disputed, so many years after the fact, underscores that any reevaluation of controversial disorders must be viewed as a political as well as scientific decision. Indeed, even Robert Spitzer (psychiatrist), a leading proponent of scientific impartiality in the DSM, conceded that a significant reason that certain diagnoses are not removed from the DSM is because "it would be a public relations disaster for psychiatry".
The next (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM-V, is currently in consultation, planning and preparation. It is due for publication in May 2013.[1 ]