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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. 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 DSM-IV published in 1994, although a "text revision" was produced in 2000. The DSM-V is currently in consultation, planning and preparation, due for publication in May 2012. An early draft will be released for comment in 2009.  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 some parts of the world. The two classifications have developed alongside each other and use the same diagnostic codes.
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-II. 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.
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 of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a perceived need to standardize diagnostic practices within the US and with other countries. 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 and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by a 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. 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 the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity, a political compromise reinserted the term in parentheses after the word “disorder” in some cases. In 1980, the DSM-III was published, at 494 pages long and listing 265 diagnostic categories. The DSM-III rapidly came into widespread international use by multiple stakeholders and has been termed a revolution or transformation in psychiatry.
In 1987 the DSM-III-R was published as a revision of DSM-III, under the direction of Spitzer. Categories were renamed, reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were considered and discarded. Altogether, DSM-III-R contained 292 diagnoses and was 567 pages long.
In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three step process. First, each group conducted an extensive literature review of their diagnoses. Then they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative. Finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.
A "Text Revision" of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD.
Use of the DSM
Many mental health professionals use this book to help communicate a patient's diagnosis after an evaluation. Many hospitals, clinics, and insurance companies require a 'five axis' DSM diagnosis of all the patients seen. The DSM can be consulted for the diagnostic criteria. It does not address the method of the evaluation or treatment. The DSM is less frequently used by health professionals who do not specialize in mental health.
Another use of the DSM is for research purposes. Studies 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 clinical diagnosis while the latter was more valued for research.
Students may also refer to the DSM to learn criteria required for their courses.
The DSM, including DSM-IV, is a registered trademark belonging to the American Psychiatric Association.
The current DSM
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “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:
- Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders
- Axis II: underlying pervasive or personality conditions, as well as mental retardation
- Axis III: Acute medical conditions and physical disorders.
- Axis IV: psychosocial and environmental factors contributing to the disorder
- Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children under the age of 18. (on a scale from 100 to 1)
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 psychiatric 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.
The DSM-V is tentatively scheduled for publication in 2012. In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-IV, and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.
On July 23rd 2007, the APA announced the task force that will oversee the development of DSM-V. The DSM-V Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Revision of the DSM will continue over the next five years. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.
The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, has led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"
DSM and sexual orientation
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." That was replaced with the diagnosis of ego-dystonic homosexuality in the DSM-III in 1980, but then was removed in 1987 with the release of the DSM-III-R. A category of "sexual disorder not otherwise specified" continues in the DSM-IV-TR, which may include "persistent and marked distress about one’s sexual orientation."
Criticism of DSM
Starting with the fact there is no single objective diagnostic test for mental illness in the field of psychiatry (but then the DSM only refers to "mental disorder", defined as a psychological or behavioral pattern), the DSM-IV has come under various criticisms over the years. It has been argued the design of the DSM and the expansion of the criteria represents an increasing medicalization of human nature, or "disease mongering", driven by drug company influence on psychiatry. The potential for direct conflict of interest has been raised, partly because roughly half the authors who selected and defined the DSM-IV psychiatric disorders have or previously had financial relationships with the pharmaceutical industry. The president of the organisation designs and publishes the DSM, the American Psychiatric Association, recently acknowledged in general American psychiatry has "allowed the biopsychosocial model to become the bio-bio-bio model" and routinely accepted "kickbacks and bribes" from pharmaceutical companies.
There has also been continuing scientific doubt concerning the construct validity and reliability of the diagnostic categories and criteria in the DSM even though they have been increasingly standardized to improve inter-rater agreement in controlled research. It has been argued the DSM's claims to being empirically founded are overstated in general. Reliance on operational definitions demand intuitive concepts, such as depression need to be operationally defined before they become amenable to 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 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.
Despite caveats in the introduction to the DSM, it has long been argued 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 a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
It has been argued purely symptom-based diagnostic criteria fail to 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. It is claimed the use of distress and disability as additional criteria for many disorders has not solved this false-positives problem, because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors.
Similarly, it has been argued the DSM fails to identify what lies beneath patterns of symptoms or relations between disorders. Being based on appearances, it is said to be like a naturalist’s field guide to birds, with similar advantages and disadvantages. However, key figures in the development of the modern DSM argue that "...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."
Some argue the existing scheme does not take an integrated evolutionary approach to the conditions it classifies. It is claimed it is "not guided by any theory about the structure and functioning of normal minds," and fails to make distinctions between those conditions which are "malfunctions" in the cognitive machinery and those which are evolved psychological adaptations. Some argue these distinctions have real implications for diagnosis and treatment, but there is also debate about their implications and the value judgements involved.
There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias (sexual fetishes) and female hypoactive sexual desire disorder (low female sex drive). Some cite the APA's decision to remove homosexuality from the DSM as evidence the APA incorrectly referred to these states of being or orientations as mental illnesses. Religious groups argue that homosexuality should never have been removed and that it meets the criteria for being a mental disorder.
The DSM has been criticized for using criteria, definitions and terminology which are inconsistent with a recovery model, and it can therefore hinder recovery. It has been suggested the DSM-V requires greater sensitivity to cultural issues and gender; needs to recognise the need for others to change as well as just those diagnosed with DSM disorders; and needs to adopt a dimensional approach in a way that better captures individuality and does not erroneously imply excess psychopathology or chronicity.
- Relational disorder (proposed DSM-V new diagnosis)
- Classification of mental disorders
- Chinese Classification and Diagnostic Criteria of Mental Disorders
- DSM-IV Codes
- GAF Scale
- International classification of diseases
- Psychodynamic Diagnostic Manual
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