Diagnostic and Statistical Manual of Mental Disorders
Encyclopedia
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association
and provides a common language and standard criteria for the classification of mental disorders
. It is used in the United States of America and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance
companies, pharmaceutical companies, and policy makers. There have been five revisions since it was first published in 1952, gradually including more mental disorders, although some have been removed and are no longer considered to be mental disorders, most notably homosexuality
.
The manual evolved from systems for collecting census and psychiatric hospital
statistics, and from a manual developed by the US Army, and was dramatically revised in 1980. 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-5
") is currently in consultation, planning and preparation, due for publication in May 2013. ICD-10 Chapter V: Mental and behavioural disorders
, part of the International Classification of Diseases produced by the World Health Organization
(WHO), is another commonly used guide, more so 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.
The DSM has attracted controversy and criticism as well as praise. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. William Glasser
refers to the DSM as "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money".
The DSM, including DSM-IV, is a registered trademark belonging to the American Psychiatric Association
(APA).
which used a single category, "idiocy/insanity". 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".
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 that was headed by psychiatrist Brigadier General
William C. Menninger
developed a new classification scheme called Medical 203 that was 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.
” 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 incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.
Bayer explains that the first protest by gay rights activists against the APA began in 1970 when this organization held its convention in San Francisco. Gay rights activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled, "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."
Presented with 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 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".
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 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 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. However Robert Spitzer
later criticized his own work on it in an interview with Adam Curtis
saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.
were considered and discarded. "Sexual orientation disturbance" was also removed and 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.
. 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”.
s and several of the paraphilia
s. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
Common Axis I disorders include depression
, anxiety disorders, bipolar disorder
, ADHD
, autism spectrum disorders, anorexia nervosa
, bulimia nervosa
, and schizophrenia
.
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 intellectual disabilities.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
and reliability
of its diagnoses. This refers, roughly, to whether the disorders it defines are actually real conditions in people in the real world, that can be consistently identified by its criteria. These are long-standing criticisms of the DSM, originally highlighted by the Rosenhan experiment
in the 1970s, and continuing despite some improved reliability since the introduction of more specific rule-based criteria for each condition.
Proponents argue that the inter-rater reliability
of DSM diagnoses (via a specialized Structured Clinical Interview for DSM-IV
(SCID) rather than usual psychiatric assessment
) is reasonable, and that there is good evidence of distinct patterns of mental, behavioral or neurological dysfunction to which the DSM disorders correspond well. It is accepted, however, that there is an "enormous" range of reliability findings in studies, and that validity is unclear because, given the lack of diagnostic laboratory
or neuroimaging
tests, standard clinical interviews are "inherently limited" and only a ("flawed") "best estimate diagnosis" is possible even with full assessment of all data over time.
Critics, such as psychiatrist Niall McLaren, argue that the DSM lacks validity because it has no relation to an agreed scientific model of mental disorder and therefore the decisions taken about its categories (or even the question of categories versus dimensions) were not scientific ones; and that it lacks reliability partly because different diagnoses share many criteria, and what appear to be different criteria are often just rewordings of the same idea, meaning that the decision to allocate one diagnosis or another to a patient is to some extent a matter of personal prejudice.
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." However, the DSM is based on an underlying structure that assumes discrete medical disorders that can be separated from each other by symptom patterns. Its claim to be “atheoretical” is held to be unconvincing because it makes sense if and only if all mental disorder is categorical by nature, which only a biological model of mental disorder can satisfy. However, the Manual recognizes psychological causes of mental disorder, for example, PTSD, so that it negates its only possible justification.
The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.
Despite the lack of consensus on underlying causation, advocates for specific psychopathological
paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is 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. Another example is a strong operationalist
viewpoint, which contends that reliance on operational definition
s, as purported by the DSM, necessitates that intuitive concepts such as depression
be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."
makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.
Because an individual's degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.
Despite doubts about arbitrary cut-offs, yes/no decisions often need to be made (e.g. whether a person will be provided a treatment) and the rest of medicine is committed to categories, so it is thought unlikely that any formal national or international classification will adopt a fully dimensional format.
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 held the opinion 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.
of human nature, which may be attributed to disease mongering
by pharmaceutical companies and psychiatrists, whose influence 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 2005, 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".
However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.
s (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, and the APA's eventual decision to remove it, as a precedent for current disputes. The consensus though from the American Psychiatric Association, American Psychological Association, and other institutions in other countries, is that the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality. Leaders of the Hearing Voices Network
such as psychiatrist Marius Romme
have claimed that many people who hallucinate "are like homosexuals in the 1950s -- in need of liberation, not cure."
Disputes over inclusion or exclusion can underscore the fact that reevaluation of controversial disorders can be viewed as a political as well as scientific decision. Indeed, Robert Spitzer
, a past editor and leading proponent of scientific impartiality in the DSM, conceded that a significant reason that certain diagnoses (the paraphilias) would not, in his opinion, be removed from the DSM is because "it would be a public relations disaster for psychiatry".
A similar line of criticism has 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" in order to provide an aura of scientific objectivity yet not limit psychiatrists in a semantic or financial sense, and the manual itself compared to "a militia's Web page, insofar as it constitutes an alternative reality under siege" by critics.
and discrimination
, or one that they simply do not feel is accurate. Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists find that this can worsen symptoms and inhibit the healing process. Some in the consumer/survivor/ex-patient movement
actively campaign against their diagnosis, or its assumed implications, and/or against the DSM system in general. It has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model
, and that can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity
.
.
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
and provides a common language and standard criteria for the classification of mental disorders
Classification of mental disorders
The classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services...
. It is used in the United States of America and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
companies, pharmaceutical companies, and policy makers. There have been five revisions since it was first published in 1952, gradually including more mental disorders, although some have been removed and are no longer considered to be mental disorders, most notably homosexuality
Homosexuality
Homosexuality is romantic or sexual attraction or behavior between members of the same sex or gender. As a sexual orientation, homosexuality refers to "an enduring pattern of or disposition to experience sexual, affectional, or romantic attractions" primarily or exclusively to people of the same...
.
The manual evolved from systems for collecting census and psychiatric hospital
Psychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...
statistics, and from a manual developed by the US Army, and was dramatically revised in 1980. 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-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
("DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
") is currently in consultation, planning and preparation, due for publication in May 2013. ICD-10 Chapter V: Mental and behavioural disorders
ICD-10 Chapter V: Mental and behavioural disorders
- Organic, including symptomatic, mental disorders :* Dementia in Alzheimer's disease* Vascular dementia** Multi-infarct dementia* Dementia in other diseases classified elsewhere** Dementia in Pick's disease...
, part of the International Classification of Diseases produced by the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(WHO), is another commonly used guide, more so in Europe
Europe
Europe is, by convention, one of the world's seven continents. Comprising the westernmost peninsula of Eurasia, Europe is generally 'divided' from Asia to its east by the watershed divides of the Ural and Caucasus Mountains, the Ural River, the Caspian and Black Seas, and the waterways connecting...
and other parts of the world. The coding system
DSM-IV Codes
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders...
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.
The DSM has attracted controversy and criticism as well as praise. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. William Glasser
William Glasser
William Glasser, M.D. is an American psychiatrist.Born in Cleveland, Ohio, he is the developer of reality therapy and choice theory...
refers to the DSM as "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money".
Uses
Many mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a 'five axis' DSM diagnosis of all the patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder. 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 clinical diagnosis while the latter was more valued for research.The DSM, including DSM-IV, is a registered trademark belonging to the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
(APA).
History
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 censusUnited States Census, 1840
The United States Census of 1840 was the sixth census of the United States. Conducted by the Bureau of the Census on June 1, 1840, it determined the resident population of the United States to be 17,069,453 — an increase of 32.7 percent over the 12,866,020 persons enumerated during the 1830...
which used a single category, "idiocy/insanity". In 1917, a Committee on Statistics from what is now known as the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
(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
New York Academy of Medicine
The New York Academy of Medicine was founded in 1847 by a group of leading New York City metropolitan area physicians as a voice for the medical profession in medical practice and public health reform...
, also provided the psychiatric nomenclature
Nomenclature
Nomenclature is a term that applies to either a list of names or terms, or to the system of principles, procedures and terms related to naming - which is the assigning of a word or phrase to a particular object or property...
subsection of the US medical guide, the Standard Classified Nomenclature of Disease, referred to as the "Standard".
DSM-I (1952)
World War IIWorld War II
World War II, or the Second World War , was a global conflict lasting from 1939 to 1945, involving most of the world's nations—including all of the great powers—eventually forming two opposing military alliances: the Allies and the Axis...
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 that was headed by psychiatrist Brigadier General
Brigadier general (United States)
A brigadier general in the United States Army, Air Force, and Marine Corps, is a one-star general officer, with the pay grade of O-7. Brigadier general ranks above a colonel and below major general. Brigadier general is equivalent to the rank of rear admiral in the other uniformed...
William C. Menninger
William C. Menninger
William Claire Menninger was a co-founder with his brother Karl and his father of The Menninger Foundation in Topeka, Kansas, which is an internationally known center for treatment of behavioral disorders.-Boy Scouts:...
developed a new classification scheme called Medical 203 that was 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
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
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.
DSM-II (1968)
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 go ahead with a revision of the DSM. It was 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 “neurosisNeurosis
Neurosis is a class of functional mental disorders involving distress but neither delusions nor hallucinations, whereby behavior is not outside socially acceptable norms. It is also known as psychoneurosis or neurotic disorder, and thus those suffering from it are said to be neurotic...
” 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
Neurosis
Neurosis is a class of functional mental disorders involving distress but neither delusions nor hallucinations, whereby behavior is not outside socially acceptable norms. It is also known as psychoneurosis or neurotic disorder, and thus those suffering from it are said to be neurotic...
and psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
(roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.
Seventh printing of the DSM-II, 1974
Ronald Bayer, a psychiatrist and gay rights activist, described the events of 1971-3 in his book Homosexuality and American Psychiatry: The Politics of Diagnosis (1981).Bayer explains that the first protest by gay rights activists against the APA began in 1970 when this organization held its convention in San Francisco. Gay rights activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled, "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."
Presented with data from researchers such as Alfred Kinsey
Alfred Kinsey
Alfred Charles Kinsey was an American biologist and professor of entomology and zoology, who in 1947 founded the Institute for Sex Research at Indiana University, now known as the Kinsey Institute for Research in Sex, Gender, and Reproduction, as well as producing the Kinsey Reports and the Kinsey...
and Evelyn Hooker
Evelyn Hooker
Evelyn Hooker was a North American psychologist most notable for her 1957 paper "The Adjustment of the Male Overt Homosexual" in which she administered psychological tests to groups of self-identified homosexuals and heterosexuals and asked experts, based on those tests alone, to select the...
, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After 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".
DSM-III (1980)
In 1974, the decision to create a new revision of the DSM was made, and Robert SpitzerRobert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
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
The International Statistical Classification of Diseases and Related Health Problems is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease...
(ICD), published by the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
. 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
Rosenhan experiment
The Rosenhan experiment was a famous experiment into the validity of psychiatric diagnosis conducted by psychologist David Rosenhan in 1973. It was published in the journal Science under the title "On being sane in insane places." The study is considered an important and influential criticism of...
. 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 an attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria
Research Diagnostic Criteria
The Research Diagnostic Criteria are a collection of psychiatric diagnostic criteria published in late 1970s . As psychiatric diagnoses widely varied especially between the USA and Europe, the purpose of the criteria were allow diagnoses to be consistent in psychiatric research...
(RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis
Washington University in St. Louis
Washington University in St. Louis is a private research university located in suburban St. Louis, Missouri. Founded in 1853, and named for George Washington, the university has students and faculty from all fifty U.S. states and more than 110 nations...
and the New York State Psychiatric Institute
New York State Psychiatric Institute
The New York State Psychiatric Institute, established in 1895 and located on Riverside Drive at the foot of Washington Heights, the far upper west side of Manhattan in New York City, was one of the first institutions in the United States to integrate teaching, research and therapeutic approaches to...
. 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
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian
Emil Kraepelin
Emil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
”). 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
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
. 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
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of 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
Ego-dystonic sexual orientation
Ego-dystonic sexual orientation is an ego-dystonic condition characterized by having a sexual orientation or an attraction that is at odds with one's idealized self-image, causing anxiety and a desire to change one's orientation or become more comfortable with one's sexual...
replaced the DSM-II category of "sexual orientation disturbance".
Finally published in 1980, the DSM-III was 494 pages 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. However Robert Spitzer
Robert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
later criticized his own work on it in an interview with Adam Curtis
Adam Curtis
Adam Curtis is a British BAFTA winning documentarian and a writer, television producer, director and narrator. He works for BBC Current Affairs.-Early life and education:Curtis was born in 1955...
saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.
DSM-III-R (1987)
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 disorderSelf-defeating personality disorder
Self-defeating personality disorder is a personality disorder that was never formally admitted into the Diagnostic and Statistical Manual of Mental Disorders . It was discussed in an appendix of the manual's revised third edition...
were considered and discarded. "Sexual orientation disturbance" was also removed and 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.
DSM-IV (1994)
In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen FrancesAllen Frances
Allen J. "Al" Frances is an American psychiatrist. He was chair of the DSM-IV Task Force. He also served as Chair of the department of psychiatry at Duke University School of Medicine...
. 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”.
DSM-IV-TR (2000)
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 to maintain consistency with the ICD.Categorization
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 disorderTic disorder
Tic disorders are defined in the Diagnostic and Statistical Manual of Mental Disorders based on type and duration of tics...
s and several of the paraphilia
Paraphilia
Paraphilia is a biomedical term used to describe sexual arousal to objects, situations, or individuals that are not part of normative stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her...
s. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
Multi-axial system
The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:- Axis I: Clinical disorders, including major mental disorders, and learning disorders, Substance Use Disorders
- Axis II: Personality disorders and intellectual disabilities (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)
- Axis III: Acute medical conditions and physical disorders
- Axis IV: Psychosocial and environmental factors contributing to the disorder
- Axis V: Global Assessment of FunctioningGlobal Assessment of FunctioningThe Global Assessment of Functioning is a numeric scale used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living. The scale is presented and...
or Children's Global Assessment ScaleChildren's Global Assessment ScaleThe Children's Global Assessment Scale is a numeric scale used by mental health clinicians and doctors to rate the general functioning of children under the age of 18.-Application:...
for children and teens under the age of 18
Common Axis I disorders include depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
, anxiety disorders, bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
, ADHD
Attention-deficit hyperactivity disorder
Attention deficit hyperactivity disorder is a developmental disorder. It is primarily characterized by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone" and symptoms starting before seven years of age.ADHD is the most commonly studied and...
, autism spectrum disorders, anorexia nervosa
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
, bulimia nervosa
Bulimia nervosa
Bulimia nervosa is an eating disorder characterized by binge eating and purging or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed, usually by purging and/or by laxative, diuretics or excessive exercise. Bulimia nervosa is...
, and schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
.
Common Axis II disorders include personality disorders: paranoid personality disorder
Paranoid personality disorder
Paranoid personality disorder is a psychiatric diagnosis characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others....
, schizoid personality disorder
Schizoid personality disorder
Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary lifestyle, secretiveness, emotional coldness, and sometimes apathy, with a simultaneous rich, elaborate, and exclusively internal fantasy world...
, schizotypal personality disorder
Schizotypal personality disorder
Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and often unconventional beliefs.-Genetic:...
, borderline personality disorder
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
, antisocial personality disorder
Antisocial personality disorder
Antisocial personality disorder is described by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition , as an Axis II personality disorder characterized by "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood...
, narcissistic personality disorder
Narcissistic personality disorder
Narcissistic personality disorder is a personality disorder in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity...
, histrionic personality disorder
Histrionic personality disorder
Histrionic personality disorder is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriately seductive behavior, usually beginning in early...
, avoidant personality disorder
Avoidant personality disorder
Avoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
, dependent personality disorder
Dependent personality disorder
Dependent personality disorder , formerly known as asthenic personality disorder, is a personality disorder that is characterized by a pervasive psychological dependence on other people...
, obsessive-compulsive personality disorder
Obsessive-compulsive personality disorder
Obsessive–compulsive personality disorder is a personality disorder characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency.- Signs and symptoms :The primary symptoms of OCPD...
; and intellectual disabilities.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
Cautions
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 or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. 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”.Sourcebooks
The DSM-IV does not 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.Criticism
Validity and reliability
The most fundamental scientific criticism of the DSM concerns the validityValidity (statistics)
In science and statistics, validity has no single agreed definition but generally refers to the extent to which a concept, conclusion or measurement is well-founded and corresponds accurately to the real world. The word "valid" is derived from the Latin validus, meaning strong...
and reliability
Reliability (statistics)
In statistics, reliability is the consistency of a set of measurements or of a measuring instrument, often used to describe a test. Reliability is inversely related to random error.-Types:There are several general classes of reliability estimates:...
of its diagnoses. This refers, roughly, to whether the disorders it defines are actually real conditions in people in the real world, that can be consistently identified by its criteria. These are long-standing criticisms of the DSM, originally highlighted by the Rosenhan experiment
Rosenhan experiment
The Rosenhan experiment was a famous experiment into the validity of psychiatric diagnosis conducted by psychologist David Rosenhan in 1973. It was published in the journal Science under the title "On being sane in insane places." The study is considered an important and influential criticism of...
in the 1970s, and continuing despite some improved reliability since the introduction of more specific rule-based criteria for each condition.
Proponents argue that the inter-rater reliability
Inter-rater reliability
In statistics, inter-rater reliability, inter-rater agreement, or concordance is the degree of agreement among raters. It gives a score of how much homogeneity, or consensus, there is in the ratings given by judges. It is useful in refining the tools given to human judges, for example by...
of DSM diagnoses (via a specialized Structured Clinical Interview for DSM-IV
Structured Clinical Interview for DSM-IV
The Structured Clinical Interview for DSM-IV Axis I Disorders is a diagnostic exam used to determine DSM-IV Axis I disorders and Axis II disorders . There are at least 700 published studies in which the SCID was the diagnostic instrument used...
(SCID) rather than usual psychiatric assessment
Psychiatric assessment
A psychiatric assessment, or psychological screening, is a process of way of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for...
) is reasonable, and that there is good evidence of distinct patterns of mental, behavioral or neurological dysfunction to which the DSM disorders correspond well. It is accepted, however, that there is an "enormous" range of reliability findings in studies, and that validity is unclear because, given the lack of diagnostic laboratory
Laboratory
A laboratory is a facility that provides controlled conditions in which scientific research, experiments, and measurement may be performed. The title of laboratory is also used for certain other facilities where the processes or equipment used are similar to those in scientific laboratories...
or neuroimaging
Neuroimaging
Neuroimaging includes the use of various techniques to either directly or indirectly image the structure, function/pharmacology of the brain...
tests, standard clinical interviews are "inherently limited" and only a ("flawed") "best estimate diagnosis" is possible even with full assessment of all data over time.
Critics, such as psychiatrist Niall McLaren, argue that the DSM lacks validity because it has no relation to an agreed scientific model of mental disorder and therefore the decisions taken about its categories (or even the question of categories versus dimensions) were not scientific ones; and that it lacks reliability partly because different diagnoses share many criteria, and what appear to be different criteria are often just rewordings of the same idea, meaning that the decision to allocate one diagnosis or another to a patient is to some extent a matter of personal prejudice.
Superficial symptoms
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, 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 SpitzerRobert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological
Pathophysiology
Pathophysiology is the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome...
processes and etiology
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
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." However, the DSM is based on an underlying structure that assumes discrete medical disorders that can be separated from each other by symptom patterns. Its claim to be “atheoretical” is held to be unconvincing because it makes sense if and only if all mental disorder is categorical by nature, which only a biological model of mental disorder can satisfy. However, the Manual recognizes psychological causes of mental disorder, for example, PTSD, so that it negates its only possible justification.
The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.
Despite the lack of consensus on underlying causation, advocates for specific psychopathological
Psychopathology
Psychopathology is the study of mental illness, mental distress, and abnormal/maladaptive behavior. The term is most commonly used within psychiatry where pathology refers to disease processes...
paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists
Evolutionary psychology
Evolutionary psychology is an approach in the social and natural sciences that examines psychological traits such as memory, perception, and language from a modern evolutionary perspective. It seeks to identify which human psychological traits are evolved adaptations, that is, the functional...
' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology
Evolutionary psychology
Evolutionary psychology is an approach in the social and natural sciences that examines psychological traits such as memory, perception, and language from a modern evolutionary perspective. It seeks to identify which human psychological traits are evolved adaptations, that is, the functional...
, but one widely challenged within general psychology. Another example is a strong operationalist
Operationalization
In humanities, operationalization is the process of defining a fuzzy concept so as to make the concept clearly distinguishable or measurable and to understand it in terms of empirical observations...
viewpoint, which contends that reliance on operational definition
Operational definition
An operational definition defines something in terms of the specific process or set of validation tests used to determine its presence and quantity. That is, one defines something in terms of the operations that count as measuring it. The term was coined by Percy Williams Bridgman and is a part of...
s, as purported by the DSM, necessitates that intuitive concepts such as depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."
Dividing lines
Despite caveats in the introduction to the DSM, it has long been argued that its system of classificationClassification of mental disorders
The classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services...
makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.
Because an individual's degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.
Despite doubts about arbitrary cut-offs, yes/no decisions often need to be made (e.g. whether a person will be provided a treatment) and the rest of medicine is committed to categories, so it is thought unlikely that any formal national or international classification will adopt a fully dimensional format.
Cultural bias
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 BellCarl Bell (physician)
Carl Compton Bell is the President/C.E.O. of the Community Mental Health Council, Inc. one of the largest not-for-profit community mental health centers in the U.S...
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
Cross-cultural psychiatry
Cross-cultural psychiatry or transcultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorders and psychiatric services...
psychiatrist Arthur Kleinman
Arthur Kleinman
Arthur Kleinman is a prominent American psychiatrist and is the Esther and Sidney Rabb Professor of medical anthropology and cross-cultural psychiatry at Harvard University, USA. He is well known for his work on mental illness in Chinese culture, was the chair of the Harvard Department of...
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
Culture-bound syndrome
In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture...
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
Robert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
, a lead architect of the DSM-III, has held the opinion 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.
Drug companies and medicalization
It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalizationMedicalization
Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals to study, diagnose, prevent or treat...
of human nature, which may be attributed to disease mongering
Disease mongering
]Disease mongering is a pejorative term for the practice of widening the diagnostic boundaries of illnesses, and promoting public awareness of such, in order to expand the markets for those who sell and deliver treatments, which may include pharmaceutical companies, physicians, and other...
by pharmaceutical companies and psychiatrists, whose influence 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 2005, then American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
President Steven Sharfstein
Steven Sharfstein
Steven Samuel "Steve" Sharfstein is an American psychiatrist. He was Secretary of the American Psychiatric Association from 1991-95, its Vice President from 2002-2004, and President from 2005-2006...
released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".
However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.
Political controversies
There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphiliaParaphilia
Paraphilia is a biomedical term used to describe sexual arousal to objects, situations, or individuals that are not part of normative stimulation and that may cause distress or serious problems for the paraphiliac or persons associated with him or her...
s (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, and the APA's eventual decision to remove it, as a precedent for current disputes. The consensus though from the American Psychiatric Association, American Psychological Association, and other institutions in other countries, is that the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality. Leaders of the Hearing Voices Network
Hearing Voices Network
The Hearing Voices Network is a self-help user-run organization for people who experience auditory hallucinations . Although members may have a psychiatric diagnosis, the group promotes an alternative approach, where voices are not necessarily seen as signs of mental illness.-Description and...
such as psychiatrist Marius Romme
Marius Romme
Marius Anton Joannes Romme is a Dutch psychiatrist. He is best known for his work on hearing voices and regarded as the founder and principal theorist for the Hearing Voices Movement....
have claimed that many people who hallucinate "are like homosexuals in the 1950s -- in need of liberation, not cure."
Disputes over inclusion or exclusion can underscore the fact that reevaluation of controversial disorders can be viewed as a political as well as scientific decision. Indeed, Robert Spitzer
Robert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
, a past editor and leading proponent of scientific impartiality in the DSM, conceded that a significant reason that certain diagnoses (the paraphilias) would not, in his opinion, be removed from the DSM is because "it would be a public relations disaster for psychiatry".
A similar line of criticism has appeared in non-specialist venues. In 1997, Harper's Magazine
Harper's Magazine
Harper's Magazine is a monthly magazine of literature, politics, culture, finance, and the arts, with a generally left-wing perspective. It is the second-oldest continuously published monthly magazine in the U.S. . The current editor is Ellen Rosenbush, who replaced Roger Hodge in January 2010...
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" in order to provide an aura of scientific objectivity yet not limit psychiatrists in a semantic or financial sense, and the manual itself compared to "a militia's Web page, insofar as it constitutes an alternative reality under siege" by critics.
Consumers
A consumer is a person who has accessed psychiatric services and been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders. Some consumers are relieved to find that they have a recognized condition to which they can give a name. Indeed, many people self-diagnose. Others, however, feel they have been given a "label" that invites social stigmaSocial stigma
Social stigma is the severe disapproval of or discontent with a person on the grounds of characteristics that distinguish them from other members of a society.Almost all stigma is based on a person differing from social or cultural norms...
and discrimination
Discrimination
Discrimination is the prejudicial treatment of an individual based on their membership in a certain group or category. It involves the actual behaviors towards groups such as excluding or restricting members of one group from opportunities that are available to another group. The term began to be...
, or one that they simply do not feel is accurate. Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists find that this can worsen symptoms and inhibit the healing process. Some in the consumer/survivor/ex-patient movement
Psychiatric survivors movement
The psychiatric survivors movement is a diverse association of individuals who are either currently clients of mental health services , or who consider themselves survivors of interventions by psychiatry, or who identify themselves as ex-patients of mental health services...
actively campaign against their diagnosis, or its assumed implications, and/or against the DSM system in general. It has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model
Recovery model
The Recovery Model as it applies to mental health is an approach to mental disorder or substance dependence that emphasizes and supports each individual's potential for recovery...
, and that can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity
Chronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
.
DSM-5: the next version
The next (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM-5, is currently in consultation, planning and preparation. It is due for publication in May 2013. APA has a website about the development, including draft versions. APA.org is currently listing several sections of DSM-V for review and discussion. It includes several changes, including proposed deletion of several types of schizophreniaSchizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
.
See also
- Relational disorderRelational disorderAccording to Michael First, MD, of the DSM-5 working committee the locus of a relational disorder, in contrast to other DSM-IV disorders, "is on the relationship rather than on any one individual in the relationship."...
(proposed DSM-5 new diagnosis) - Classification of mental disordersClassification of mental disordersThe classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services...
- Chinese Classification and Diagnostic Criteria of Mental Disorders
- DSM-IV CodesDSM-IV CodesDiagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders...
- GAF ScaleGlobal Assessment of FunctioningThe Global Assessment of Functioning is a numeric scale used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living. The scale is presented and...
- Psychodynamic Diagnostic ManualPsychodynamic diagnostic manualThe Psychodynamic Diagnostic Manual is a diagnostic handbook similar to the International Statistical Classification of Diseases and Related Health Problems or the Diagnostic and Statistical Manual of Mental Disorders...
- Structured Clinical Interview for DSM-IVStructured Clinical Interview for DSM-IVThe Structured Clinical Interview for DSM-IV Axis I Disorders is a diagnostic exam used to determine DSM-IV Axis I disorders and Axis II disorders . There are at least 700 published studies in which the SCID was the diagnostic instrument used...
(SCID) - Diagnostic classification and rating scales used in psychiatryDiagnostic classification and rating scales used in psychiatryThe following diagnostic systems and rating scales are used in psychiatry and clinical psychology.-Diagnostic Criteria:*Diagnostic and Statistical Manual of Mental Disorders *ICD-10 Chapter V: Mental and behavioural disorders...
External links
- Official DSM-5 development website
- Topic Center from the Psychiatric Times: DSM-5
- DSM-IV-TR Official Site - American Psychiatric Association
- Diagnostic Criteria from DSM-IV-TR
- DSM-IV Made Easy Summary of diagnostic criteria by James Morrison
- Sections of the DSM-IV-TR on Google Books
- Sections of the DSM-IV-TR case book on Google Books
- Reproduction of Medical 203