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Diagnostic and Statistical Manual of Mental Disorders

May 03, 2023

The Diagnostic and Statistical Manual of Mental Disorders (DSM; latest edition: DSM-5-TR, published in March 2022[1]) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and is considered one of the principle guides of psychiatry along with the ICD, CCMD and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide since the ICD's mental disorder diagnoses are used around the world[2] and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.[3][4][5][6]

1952 edition of the DSM (DSM-1)

It is used – mainly in the United States – by researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policymakers. Some 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 United States may require a DSM diagnosis for all patients with mental disorders. Health-care researchers use the DSM to categorize patients for research purposes.

The DSM evolved from systems for collecting census and psychiatric hospital statistics, as well as from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, while removing those no longer considered to be mental disorders.

Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound nosology (the branch of medical science that deals with the classification of diseases) used in DSM-III.[citation needed] However, it has also generated controversy and criticism, including ongoing questions concerning the reliability and validity of many diagnoses; the use of arbitrary dividing lines between mental illness and "normality"; possible cultural bias; and the medicalization of human distress.[7][8][9][10][11] The APA itself has published that the inter-rater reliability is low for many disorders in the DSM-5, including major depressive disorder and generalized anxiety disorder.[12]

Distinction from ICD

An alternate, widely used classification publication is the International Classification of Diseases (ICD) is produced by the World Health Organization (WHO).[13] The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 5 of the ICD specifically covers mental and behavioral disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM. An international survey of psychiatrists in sixty-six countries compared the use of the ICD-10 and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research.[14] This may be because the DSM tends to put more emphasis on clear diagnostic criteria, while the ICD tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated. That is, the ICD descriptions of psychiatric disorders tend to be more qualitative information, such as general descriptions of what various disorders tend to look like. The DSM focuses more on quantitative and operationalized criteria; e.g. to be diagnosed with X disorder, one must fulfill 5 of 9 criteria for at least 6 months.[15]

The DSM-IV-TR (4th. ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated.[16] Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other.[17] For instance, the two manuals contain overlapping but substantially different lists of recognized culture-bound syndromes.[18] The ICD also tends to focus more on primary-care and low and middle-income countries, as opposed to the DSM's focus on secondary psychiatric care in high-income countries.[15]

Antecedents (1840–1949)

Census Office, AMA and ISI (1840–1911)

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". Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns African Americans were all marked as insane, and calling the statistics essentially useless.[19]

The Association of Medical Superintendents of American Institutions for the Insane ("The Superintendents' Association") was formed in 1844.[20]

In 1860, during the international statistical congress held in London, Florence Nightingale made a proposal that was to result in the development of the first international model of systematic collection of hospital data.

In 1872, the American Medical Association (AMA) published its Nomenclature of Diseases, which included various "Disorders of the Intellect".[21] Its use was short-lived however.[22]

Edward Jarvis and later Francis Amasa Walker helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880.[23]

In 1888, the Census Office published Frederick H. Wines' 582-page volume called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880). Wines used seven categories of mental illness, which were also adopted by the Superintendents: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis.[24]

In 1892, the Superintendents' Association expanded its membership to include other mental health workers, and renamed to the American Medico-Psychological Association (AMPA).[25]

In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute (ISI) in Chicago.[26][27] (The ISI had commissioned him to create it in 1891).[27] A number of countries adopted the ISI's system. In 1898, the American Public Health Association (APHA) recommended that United States registrars also adopt the system.[27]

In 1900, an ISI conference in Paris reformed the Bertillion Classification, and created the International Classification of Causes of Death (ICD).[27] This would later be known as the ICD-1. Another conference would be held every ten years, and a new edition of the ICD would be released. Non-fatal conditions were not included.

In 1903, New York's Bellevue Hospital published "The Bellevue Hospital nomenclature of diseases and conditions," which included a section on "Diseases of the Mind". Revisions were released in 1909 and 1911. It was produced with the assistance of the AMA and Bureau of the Census.[28]

APA Statistical Manual (1917) and AMA Standard (1933)

In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the American Medico-Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This guide included twenty-two diagnoses. It would be revised several times by the Association and its successor, the American Psychiatric Association (APA), and by the tenth edition in 1942, was titled Statistical Manual for the Use of Hospitals of Mental Diseases.[29][30]

In 1921, the AMPA became the present American Psychiatric Association (APA).[31]

The first edition of the DSM notes in its foreword: "In the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution."[32]

In 1933, the AMA's general medical guide the Standard Classified Nomenclature of Disease, (referred to as the Standard), was released.[33] Along with the New York Academy of Medicine, the APA provided the psychiatric nomenclature subsection.[34] It became well adopted in the US within two years.[32] A major revision of the Statistical Manual was made in 1934, to bring it in line with the new Standard.[32] A number of revisions of the Standard were produced, with the last in 1961.[35]

Medical 203 (1945)

World War II saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers.[36] This moved the focus away from mental institutions and traditional clinical perspectives. The U.S. armed forces initially used the Standard, but found it lacked appropriate categories for many common conditions that troubled troops. The United States Navy 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."[32]

Under the direction of James Forrestal,[37] a committee headed by psychiatrist Brigadier General William C. Menninger, with the assistance of the Mental Hospital Service,[38] developed a new classification scheme in 1944 and 1945.

Issued in War Department Technical Bulletin, Medical, 203 (TB MED 203); Nomenclature and Method of Recording Diagnoses was released shortly after the war in October 1945 under the auspices of the Office of the Surgeon General.[39] It was reprinted in the Journal of Clinical Psychology for civilian use in July 1946 with the new title Nomenclature of Psychiatric Disorders and Reactions.[40] This system came to be known as "Medical 203".

This nomenclature eventually was adopted by all the 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 the standard in 1947.[37]

The further developed Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions was released in 1949.[41]

ICD-6 (1948)

In 1948, the newly formed World Health Organization took over the maintenance of the ICD. They greatly expanded it, included non-fatal conditions for the first time, and renamed it the International Statistical Classification of Diseases. The foreword to the DSM-I states the ICD-6 "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature."[32]

Early versions (20th century)

DSM-I (1952)

The APA Committee on Nomenclature and Statistics was empowered to develop a version of Medical 203 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 Standard's nomenclature, and the VA system's modifications of the Standard to approximately 10% of APA members. 46% of members replied, with 93% approving the changes. After some further revisions, 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 were identical.[39] The manual was 130 pages long and listed 106 mental disorders.[42] These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic).[43]

The foreword to this edition describes itself as being a continuation of the Statistical Manual for the Use of Hospitals of Mental Diseases.[32] Each item was given an ICD-6 equivalent code, where applicable.

 

The DSM-I centers around three classes of symptoms: psychotic, neurotic, and behavioral.[44]  Within each class of mental disorder, classifying information is provided to differentiate conditions with similar symptoms.  Under each broad class of disorder (e.g. “Psychoneurotic Disorders” or “Personality Disorders”), all possible diagnoses are listed, generally from least to most severe.[44] The 1952 DSM version also includes sections detailing how to record patients’ disorders along with their demographic details.[44]  The form includes information like a patient's area of residence, admission status, discharge date/condition, and severity of disorder.[44] See Figure 1. for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information.[44]

Furthermore, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession.[45] In 1956, however, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference.[45] Her study stunned the medical community and made her a heroine to many gay men and lesbians,[46] but homosexuality remained in the DSM until May 1974.[47]

DSM-II (1968)

In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science, the Rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.[48]

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, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry,[49] although both manuals 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 that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality.[50] The idea that personality disorders did not involve emotional distress was discarded.[43]

An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool.[51] Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".[52]

Seventh printing of the DSM-II (1974)

As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The 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 at 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."[53]

This gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists.[54][55]

Taking into account 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.[a] 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".[56][57]

DSM-III (1980)

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 that of the International Classification of Diseases (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members.[58] One added 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 felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States.[59] The establishment of consistent 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 School of Medicine and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still 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 a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome."[49] Personality disorders were placed on axis II along with "mental retardation".[43]

The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light.[60] 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, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form; 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". The gender identity disorder in children (GIDC) diagnosis was introduced in the DSM-III; prior to the DSM-III's publication in 1980, there was no diagnostic criteria for gender dysphoria.[61][62]

Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry.[49][50]

When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:

Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalizability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator ...[48]

DSM-III-R (1987)

In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as Premenstrual Dysphoric Disorder and Masochistic Personality Disorder, were considered and discarded. (Premenstrual Dysphoric Disorder was later be reincorporated in the DSM-5, published in 2013).[63] "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation."[49][64] Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" [p. xxiii].[43]

DSM-IV (1994)

In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by Allen Frances and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. 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 multi-center field trials relating diagnoses to clinical practice.[65][66] A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix.[43] Further information can be found in the journal of Personality and Mental Health.[citation needed]

DSM-IV Definitions

See also: DSM-IV codes

The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom".[67] It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder."[68]

DSM-IV 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 non-criterion (unlisted for a given disorder) symptoms are not given importance.[69] Qualifiers are sometimes used: for example, to specify 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 due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

DSM-IV multi-axial system

The DSM-IV was organized into a five-part axial system. Axis I provided information about clinical disorders, or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM-V as "mental retardation". Those were both covered on Axis II. Axis III covered medical conditions that could impact a person's disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person. Axis V was the GAF, or global assessment of functioning, which was basically a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life.[70]

DSM-IV 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.[71][72][73][74] 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 the scientific credibility of contemporary psychiatric classification.[75][76]

DSM-IV-TR (2000)

A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses.[77] The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, and course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM .[78]

DSM-5 (2013)

Main article: DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012.[79] Published on May 18, 2013,[80] the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases.[81] The DSM-5 is the first major edition of the manual in 20 years.[82] DSM-5, and the abbreviations for all previous editions, are registered trademarks owned by the American Psychiatric Association.[8][83]

A significant change in the fifth edition is the deletion of the subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual.[84] The deletion of the subsets of autistic spectrum disorder – namely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified – was also implemented, with specifiers regarding intensity: mild, moderate, and severe.

Severity is based on social communication impairments and restricted, repetitive patterns of behavior, with three levels:

  1. requiring support
  2. requiring substantial support
  3. requiring very substantial support

During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.[85]

Future revisions and updates

Beginning with the fifth edition, the APA communicated that they intend to add subsequent revisions more often, to keep up with research in the field.[86] It is notable that DSM-5 uses Arabic rather than Roman numerals. Beginning with DSM-5, the APA will use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2)[b] and whole numbers for new editions (e.g., DSM-5, DSM-6),[87] similar to the scheme used for software versioning.

DSM-5-TR (2022)

A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and ICD-10-CM codes.[88] The diagnostic criteria for avoidant/restrictive food intake disorder was changed,[89] along with adding entries for prolonged grief disorder, unspecified mood disorder and stimulant-induced mild neurocognitive disorder.[90] Prolonged grief disorder, which had been present in the ICD-11, had criteria agreed upon by consensus in a one day in-person workshop sponsored by the APA.[89] A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD-11 could be explained by the DSM-5-TR criteria requiring symptoms persist for 12 months, and the ICD-11 requiring only 6 months.[91]

Three review groups for sex and gender, culture and suicide, along with an "ethnoracial equity and inclusion work group" were involved in the creation of the DSM-5-TR which led to additional sections for each mental disorder discussing sex and gender, racial and cultural variations, and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self-injury for mental disorders.[90][89]

Other changed mental disorders included:[92]

DSM Library

The APA have supplemented the DSM with supporting works, collectively forming the "DSM Library."[93] As of 2022, the other books in the library are "DSM-5 Handbook of Differential Diagnosis", "DSM-5 Clinical Cases", "DSM-5 Handbook on the Cultural Formulation Interview" and "Guía De Consulta De Los Criterios Diagnósticos Del DSM-5".[93]

Criticisms

There are a number of different criticisms that have been leveled against the DSM and its usefulness as a diagnostic manual.

Reliability and validity

The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability – the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Neither the issue of reliability or validity was settled.[94][95]

In 2013, shortly before the publication of DSM-5, the director of the National Institute of Mental Health (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity.[96] Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response."[97][98]

Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.[99]

Diagnosis based on 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 these disorders 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.[100] 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. Proponents argue this absence of explanatory classification is necessary, but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria.[8][101] As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and cause 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."[102]

While there is generally a lack of consensus on underlying causation for most psychiatric disorders, some proponents of specific psychopathological paradigms have faulted the DSM for failing to incorporate evidence from other disciplines. For instance, evolutionary psychology distinguishes between genuine cognitive malfunctions and malfunctions due to psychological adaptations (that is learned behaviors may be adaptive in one context but maladaptive in another). However, this distinction is one that is challenged within general psychology.[103][104][105]

There is also criticism of the strong operationalist viewpoint of the DSM. The DSM relies on operational definitions, which means that intuitive concepts like depression are defined by specific measurable criteria (observable behavior, specific timelines). Some have argued that instead of replacing metaphysical terms like "desire" or "purpose" the DSM chose to legitimize them by giving them operational definitions. However, this may have served only to provide a "reassurance fetish" for mainstream methodological practice, rather than representing a substantial and meaningful alteration of mainstream psychiatric practice.[106]

A central problem with the use of superficial symptoms is that psychiatry deals with the phenomena of consciousness, which adds much more complexity than the somatic symptoms and signs used by most of medicine. A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience gives the example of the problem of superficial characterization of psychiatric signs and symptoms . If a patient says they "feel depressed, sad, or down" there are actually a wide variety of underlying experiences they could be referencing: "not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth." This criticism is especially pertinent to the structured interview, as simple "yes or no" questions may not be specific enough to truly confirm or deny the diagnostic criterion at issue. That is, whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience. There is thus danger in being overconfident in the face value of the answers. The authors of the 2013 review give an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the experience did not "fully articulate itself" until the patient started talking about his experiences.[107]

Obscuring the Root Causes of Psychological Distress

The role of the DSM-5 in protecting the interests of wealthy and politically powerful owners of the means of production in the United States has been criticized as well.[108] Placing the blame for predictable and common psychological distress caused by the deleterious effects of economic inequality in the United States on individuals by attributing it to mental pathology has been criticized as hindering change of the root causes of the distress.[108] The DSM-5's expansive criteria that attribute mental pathology to people with distress or impairment from a wide-ranging constellation of experiences has been criticized for pathologizing an unhelpful number of people that a psychiatric diagnosis is not benefical for.[109]

Overdiagnosis

Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]."[110][111] Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and autism spectrum disorder.[112][113][114][115] Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics.[113]

Dividing lines

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and 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.[8] Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[116][117][118]

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.[119] 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.[120] On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

Cultural bias

Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables.[121] Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals.[122] In addition, current diagnostic guidelines have been criticized[123] as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-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.[121] Cross-cultural psychiatrist Arthur Kleinman contends that 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.[124] Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, 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.[125][page needed]

Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of 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.[121] One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM in treating patients of the African diaspora.[126][127][128]

Historically, the DSM tended to avoid issues involving religion; the DSM-5 relaxed this attitude somewhat.[129]

Medicalization and financial conflicts of interest

There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing medicalization of human nature, very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades.[130] In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".[131] It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.

William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money".[132] A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million.[133]

However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients.[8]

The National Board of Medical Examiners (NBME) which is responsible for creating and publishing board exams for medical students around the United States conforms to the use of DSM-5 criteria[134] despite the known problems with an unquestioning checklist approach to diagnosis and treatment based on the DSM that have been outlined by critics.

Potential harm of labels

A core function of the DSM is the categorization of people's experiences into diagnoses based on symptoms. However, there is disagreement about the use of diagnoses as labels. Some individuals are relieved to find they have a recognized condition that they can apply a name to, and this has led to many people self-diagnosing.[135] Others, however, question the accuracy of diagnosis, or feel they have been given a label that invites social stigma and discrimination (the terms "mentalism" and "sanism" have been used to describe such discriminatory treatment).[136]

Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result.[137] Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general.[138][139] Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.[139]

Critiques of DSM-5

Psychiatrist Allen Frances has been critical of proposed revisions to the DSM–5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription."[140]

In a December 2012, blog post on Psychology Today, Frances provides his "list of DSM 5's ten most potentially harmful changes:"[141]

  • Disruptive Mood Dysregulation Disorder, for temper tantrums
  • Major Depressive Disorder, includes normal grief
  • Minor Neurocognitive Disorder, for normal forgetfulness in old age
  • Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
  • Binge Eating Disorder, for excessive eating
  • Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
  • First-time drug users will be lumped in with addicts
  • Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
  • Generalized Anxiety Disorder, includes everyday worries
  • Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."[141]

A group of 25 psychiatrists and researchers, among whom were Frances and Thomas Szasz, have published debates on what they see as the six most essential questions in psychiatric diagnosis:[142]

  • Are they more like theoretical constructs or more like diseases?
  • How to reach an agreed definition?
  • Should the DSM-5 take a cautious or conservative approach?
  • What is the role of practical rather than scientific considerations?
  • How should it be used by clinicians or researchers?
  • Is an entirely different diagnostic system required?

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter.[143] Thirteen other APA divisions have endorsed the petition.[143] Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.[144]


See also

Notes

  1. ^ Determining the correct DSM-II printing where the change occurred can be confusing because the American Psychiatric Association publication that announced the change is titled, in part, "Proposed change in DSM-II, 6th printing, page 44". However, a notice in that publication indicates that "the change appears on page 44 of this, the seventh printing."
  2. ^ However, this planned change was not adopted for the initial revision of the DSM-5, which is named DSM-5-TR, in accordance with past convention.

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Further reading

  • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR®. American Psychiatric Pub. ISBN 978-0-89042-025-6.
  • Spitzer RL (2002). Dsm-Iv-Tr Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Pub. ISBN 978-1-58562-059-3.

External links

  • Official DSM-5 development website
  • Diagnostic Criteria from DSM-IV-TR[dead link]
  • The Multiaxial System of Diagnosis in DSM-IV Criteria 2021-01-16 at the Wayback Machine

May 03, 2023
diagnostic, statistical, manual, mental, disorders, latest, edition, published, march, 2022, publication, american, psychiatric, association, classification, mental, disorders, using, common, language, standard, criteria, main, book, diagnosis, treatment, ment. The Diagnostic and Statistical Manual of Mental Disorders DSM latest edition DSM 5 TR published in March 2022 1 is a publication by the American Psychiatric Association APA for the classification of mental disorders using a common language and standard criteria It is the main book for the diagnosis and treatment of mental disorders in the United States and is considered one of the principle guides of psychiatry along with the ICD CCMD and the Psychodynamic Diagnostic Manual However not all providers rely on the DSM 5 as a guide since the ICD s mental disorder diagnoses are used around the world 2 and scientific studies often measure changes in symptom scale scores rather than changes in DSM 5 criteria to determine the real world effects of mental health interventions 3 4 5 6 1952 edition of the DSM DSM 1 It is used mainly in the United States by researchers psychiatric drug regulation agencies health insurance companies pharmaceutical companies the legal system and policymakers Some 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 United States may require a DSM diagnosis for all patients with mental disorders Health care researchers use the DSM to categorize patients for research purposes The DSM evolved from systems for collecting census and psychiatric hospital statistics as well as from a United States Army manual Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders while removing those no longer considered to be mental disorders Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence as opposed to the theory bound nosology the branch of medical science that deals with the classification of diseases used in DSM III citation needed However it has also generated controversy and criticism including ongoing questions concerning the reliability and validity of many diagnoses the use of arbitrary dividing lines between mental illness and normality possible cultural bias and the medicalization of human distress 7 8 9 10 11 The APA itself has published that the inter rater reliability is low for many disorders in the DSM 5 including major depressive disorder and generalized anxiety disorder 12 Contents 1 Distinction from ICD 2 Antecedents 1840 1949 2 1 Census Office AMA and ISI 1840 1911 2 2 APA Statistical Manual 1917 and AMA Standard 1933 2 3 Medical 203 1945 2 4 ICD 6 1948 3 Early versions 20th century 3 1 DSM I 1952 3 2 DSM II 1968 3 2 1 Seventh printing of the DSM II 1974 3 3 DSM III 1980 3 4 DSM III R 1987 3 5 DSM IV 1994 3 5 1 DSM IV Definitions 3 5 2 DSM IV Categorization 3 5 3 DSM IV multi axial system 3 5 4 DSM IV Sourcebooks 3 6 DSM IV TR 2000 4 DSM 5 2013 4 1 Future revisions and updates 4 2 DSM 5 TR 2022 5 DSM Library 6 Criticisms 6 1 Reliability and validity 6 2 Diagnosis based on superficial symptoms 6 3 Obscuring the Root Causes of Psychological Distress 6 4 Overdiagnosis 6 5 Dividing lines 6 6 Cultural bias 6 7 Medicalization and financial conflicts of interest 6 8 Potential harm of labels 6 9 Critiques of DSM 5 7 See also 8 Notes 9 References 10 Further reading 11 External linksDistinction from ICD EditAn alternate widely used classification publication is the International Classification of Diseases ICD is produced by the World Health Organization WHO 13 The ICD has a broader scope than the DSM covering overall health as well as mental health chapter 5 of the ICD specifically covers mental and behavioral disorders Moreover while the DSM is the most popular diagnostic system for mental disorders in the US the ICD is used more widely in Europe and other parts of the world giving it a far larger reach than the DSM An international survey of psychiatrists in sixty six countries compared the use of the ICD 10 and DSM IV It found the former was more often used for clinical diagnosis while the latter was more valued for research 14 This may be because the DSM tends to put more emphasis on clear diagnostic criteria while the ICD tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated That is the ICD descriptions of psychiatric disorders tend to be more qualitative information such as general descriptions of what various disorders tend to look like The DSM focuses more on quantitative and operationalized criteria e g to be diagnosed with X disorder one must fulfill 5 of 9 criteria for at least 6 months 15 The DSM IV TR 4th ed contains specific codes allowing comparisons between the DSM and the ICD manuals which may not systematically match because revisions are not simultaneously coordinated 16 Though recent editions of the DSM and ICD have become more similar due to collaborative agreements each one contains information absent from the other 17 For instance the two manuals contain overlapping but substantially different lists of recognized culture bound syndromes 18 The ICD also tends to focus more on primary care and low and middle income countries as opposed to the DSM s focus on secondary psychiatric care in high income countries 15 Antecedents 1840 1949 EditCensus Office AMA and ISI 1840 1911 Edit 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 Three years later the American Statistical Association made an official protest to the U S House of Representatives stating that the most glaring and remarkable errors are found in the statements respecting nosology prevalence of insanity blindness deafness and dumbness among the people of this nation pointing out that in many towns African Americans were all marked as insane and calling the statistics essentially useless 19 The Association of Medical Superintendents of American Institutions for the Insane The Superintendents Association was formed in 1844 20 In 1860 during the international statistical congress held in London Florence Nightingale made a proposal that was to result in the development of the first international model of systematic collection of hospital data In 1872 the American Medical Association AMA published its Nomenclature of Diseases which included various Disorders of the Intellect 21 Its use was short lived however 22 Edward Jarvis and later Francis Amasa Walker helped expand the census from two volumes in 1870 to twenty five volumes in 1880 23 In 1888 the Census Office published Frederick H Wines 582 page volume called Report on the Defective Dependent and Delinquent Classes of the Population of the United States As Returned at the Tenth Census June 1 1880 Wines used seven categories of mental illness which were also adopted by the Superintendents dementia dipsomania uncontrollable craving for alcohol epilepsy mania melancholia monomania and paresis 24 In 1892 the Superintendents Association expanded its membership to include other mental health workers and renamed to the American Medico Psychological Association AMPA 25 In 1893 a French physician Jacques Bertillon introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute ISI in Chicago 26 27 The ISI had commissioned him to create it in 1891 27 A number of countries adopted the ISI s system In 1898 the American Public Health Association APHA recommended that United States registrars also adopt the system 27 In 1900 an ISI conference in Paris reformed the Bertillion Classification and created the International Classification of Causes of Death ICD 27 This would later be known as the ICD 1 Another conference would be held every ten years and a new edition of the ICD would be released Non fatal conditions were not included In 1903 New York s Bellevue Hospital published The Bellevue Hospital nomenclature of diseases and conditions which included a section on Diseases of the Mind Revisions were released in 1909 and 1911 It was produced with the assistance of the AMA and Bureau of the Census 28 APA Statistical Manual 1917 and AMA Standard 1933 Edit In 1917 together with the National Commission on Mental Hygiene now Mental Health America the American Medico Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane This guide included twenty two diagnoses It would be revised several times by the Association and its successor the American Psychiatric Association APA and by the tenth edition in 1942 was titled Statistical Manual for the Use of Hospitals of Mental Diseases 29 30 In 1921 the AMPA became the present American Psychiatric Association APA 31 The first edition of the DSM notes in its foreword In the late twenties each large teaching center employed a system of its own origination no one of which met more than the immediate needs of the local institution 32 In 1933 the AMA s general medical guide the Standard Classified Nomenclature of Disease referred to as the Standard was released 33 Along with the New York Academy of Medicine the APA provided the psychiatric nomenclature subsection 34 It became well adopted in the US within two years 32 A major revision of the Statistical Manual was made in 1934 to bring it in line with the new Standard 32 A number of revisions of the Standard were produced with the last in 1961 35 Medical 203 1945 Edit World War II saw the large scale involvement of U S psychiatrists in the selection processing assessment and treatment of soldiers 36 This moved the focus away from mental institutions and traditional clinical perspectives The U S armed forces initially used the Standard but found it lacked appropriate categories for many common conditions that troubled troops The United States Navy 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 32 Under the direction of James Forrestal 37 a committee headed by psychiatrist Brigadier General William C Menninger with the assistance of the Mental Hospital Service 38 developed a new classification scheme in 1944 and 1945 Issued in War Department Technical Bulletin Medical 203 TB MED 203 Nomenclature and Method of Recording Diagnoses was released shortly after the war in October 1945 under the auspices of the Office of the Surgeon General 39 It was reprinted in the Journal of Clinical Psychology for civilian use in July 1946 with the new title Nomenclature of Psychiatric Disorders and Reactions 40 This system came to be known as Medical 203 This nomenclature eventually was adopted by all the 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 the standard in 1947 37 The further developed Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions was released in 1949 41 ICD 6 1948 Edit In 1948 the newly formed World Health Organization took over the maintenance of the ICD They greatly expanded it included non fatal conditions for the first time and renamed it the International Statistical Classification of Diseases The foreword to the DSM I states the ICD 6 categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature 32 Early versions 20th century EditDSM I 1952 Edit The APA Committee on Nomenclature and Statistics was empowered to develop a version of Medical 203 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 Standard s nomenclature and the VA system s modifications of the Standard to approximately 10 of APA members 46 of members replied with 93 approving the changes After some further revisions 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 were identical 39 The manual was 130 pages long and listed 106 mental disorders 42 These included several categories of personality disturbance generally distinguished from neurosis nervousness egodystonic 43 The foreword to this edition describes itself as being a continuation of the Statistical Manual for the Use of Hospitals of Mental Diseases 32 Each item was given an ICD 6 equivalent code where applicable The DSM I centers around three classes of symptoms psychotic neurotic and behavioral 44 Within each class of mental disorder classifying information is provided to differentiate conditions with similar symptoms Under each broad class of disorder e g Psychoneurotic Disorders or Personality Disorders all possible diagnoses are listed generally from least to most severe 44 The 1952 DSM version also includes sections detailing how to record patients disorders along with their demographic details 44 The form includes information like a patient s area of residence admission status discharge date condition and severity of disorder 44 See Figure 1 for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information 44 Furthermore the APA listed homosexuality in the DSM as a sociopathic personality disturbance Homosexuality A Psychoanalytic Study of Male Homosexuals a large scale 1962 study of homosexuality by Irving Bieber and other authors was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent child relationships This view was influential in the medical profession 45 In 1956 however the psychologist Evelyn Hooker performed a study comparing the happiness and well adjusted nature of self identified homosexual men with heterosexual men and found no difference 45 Her study stunned the medical community and made her a heroine to many gay men and lesbians 46 but homosexuality remained in the DSM until May 1974 47 DSM II 1968 Edit In the 1960s there were many challenges to the concept of mental illness itself These challenges came from psychiatrists like Thomas Szasz who argued mental illness was a myth used to disguise moral conflicts from sociologists such as Erving Goffman who said mental illness was another example of how society labels and controls non conformists from behavioural psychologists who challenged psychiatry s fundamental reliance on unobservable phenomena and from gay rights activists who criticised the APA s listing of homosexuality as a mental disorder A study published in Science the Rosenhan experiment received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis 48 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 which was published in 1968 DSM II was similar to DSM I listed 182 disorders and was 134 pages long The term reaction was dropped but the term neurosis was retained Both the DSM I and the DSM II reflected the predominant psychodynamic psychiatry 49 although both manuals 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 that were rooted in a distinction between neurosis and psychosis roughly anxiety depression broadly in touch with reality as opposed to hallucinations or delusions disconnected from reality Sociological and biological knowledge was incorporated under a model that did not emphasize a clear boundary between normality and abnormality 50 The idea that personality disorders did not involve emotional distress was discarded 43 An influential 1974 paper by Robert Spitzer and Joseph L Fleiss demonstrated that the second edition of the DSM DSM II was an unreliable diagnostic tool 51 Spitzer and Fleiss found that different practitioners using the DSM II rarely agreed when diagnosing patients with similar problems In reviewing previous studies of eighteen major diagnostic categories Spitzer and Fleiss concluded that there are no diagnostic categories for which reliability is uniformly high Reliability appears to be only satisfactory for three categories mental deficiency organic brain syndrome but not its subtypes and alcoholism The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories 52 Seventh printing of the DSM II 1974 Edit As described by Ronald Bayer a psychiatrist and gay rights activist specific protests by gay rights activists against the APA began in 1970 when the organization held its convention in San Francisco The 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 at 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 53 This gay activism occurred in the context of a broader anti psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis Anti psychiatry activists protested at the same APA conventions with some shared slogans and intellectual foundations as gay activists 54 55 Taking into account 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 a 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 56 57 DSM III 1980 Edit 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 that of the International Classification of Diseases ICD The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members 58 One added 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 felt a need to standardize diagnostic practices within the United States and with other countries after research showed that psychiatric diagnoses differed between Europe and the United States 59 The establishment of consistent 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 School of Medicine and the New York State Psychiatric Institute Other criteria and potential new categories of disorder were established by consensus during meetings of the committee chaired by Spitzer A key aim was to base categorization on colloquial English which would be easier to use by federal administrative offices rather than by assumption of cause although its categorical approach still 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 a simple diagnosis Spitzer argued mental disorders are a subset of medical disorders but the task force decided on this statement for the DSM Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome 49 Personality disorders were placed on axis II along with mental retardation 43 The first draft of DSM III was ready within a year It introduced many new categories of disorder while deleting or changing others A number of unpublished documents discussing and justifying the changes have recently come to light 60 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 DSM III was in serious danger of not being approved by the APA Board of Trustees unless neurosis was included in some form 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 The gender identity disorder in children GIDC diagnosis was introduced in the DSM III prior to the DSM III s publication in 1980 there was no diagnostic criteria for gender dysphoria 61 62 Finally published in 1980 DSM III listed 265 diagnostic categories and was 494 pages long It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry 49 50 When DSM III was published the developers made extensive claims about the reliability of the radically new diagnostic system they had devised which relied on data from special field trials However according to a 1994 article by Stuart A Kirk Twenty years after the reliability problem became the central focus of DSM III there is still not a single multi site study showing that DSM any version is routinely used with high reliably by regular mental health clinicians Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version There are important methodological problems that limit the generalizability of most reliability studies Each reliability study is constrained by the training and supervision of the interviewers their motivation and commitment to diagnostic accuracy their prior skill the homogeneity of the clinical setting in regard to patient mix and base rates and the methodological rigor achieved by the investigator 48 DSM III R 1987 Edit In 1987 DSM III R was published as a revision of the DSM III under the direction of Spitzer Categories were renamed and reorganized with significant changes in criteria Six categories were deleted while others were added Controversial diagnoses such as Premenstrual Dysphoric Disorder and Masochistic Personality Disorder were considered and discarded Premenstrual Dysphoric Disorder was later be reincorporated in the DSM 5 published in 2013 63 Ego dystonic homosexuality was also removed and was largely subsumed under sexual disorder not otherwise specified which could include persistent and marked distress about one s sexual orientation 49 64 Altogether the DSM III R contained 292 diagnoses and was 567 pages long Further efforts were made for the diagnoses to be purely descriptive although the introductory text stated for at least some disorders particularly the Personality Disorders the criteria require much more inference on the part of the observer p xxiii 43 DSM IV 1994 Edit In 1994 DSM IV was published listing 410 disorders in 886 pages The task force was chaired by Allen Frances and was overseen by a steering committee of twenty seven people including four psychologists The steering committee created thirteen work groups of five to sixteen members each work group having about twenty advisers in addition 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 multi center field trials relating diagnoses to clinical practice 65 66 A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories which required symptoms causing clinically significant distress or impairment in social occupational or other important areas of functioning Some personality disorder diagnoses were deleted or moved to the appendix 43 Further information can be found in the journal of Personality and Mental Health citation needed DSM IV Definitions Edit See also DSM IV codes The DSM IV characterizes a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death pain disability or an important loss of freedom 67 It also notes that although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of mental disorder 68 DSM IV Categorization Edit 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 non criterion unlisted for a given disorder symptoms are not given importance 69 Qualifiers are sometimes used for example to specify 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 due to their egosyntonic nature Each category of disorder has a numeric code taken from the ICD coding system used for health service including insurance administrative purposes DSM IV multi axial system Edit The DSM IV was organized into a five part axial system Axis I provided information about clinical disorders or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM V as mental retardation Those were both covered on Axis II Axis III covered medical conditions that could impact a person s disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person Axis V was the GAF or global assessment of functioning which was basically a numerical score between 0 and 100 that measured how much a person s psychological symptoms impacted their daily life 70 DSM IV Sourcebooks Edit 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 71 72 73 74 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 the scientific credibility of contemporary psychiatric classification 75 76 DSM IV TR 2000 Edit A text revision of DSM IV titled DSM IV TR was published in 2000 The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses 77 The majority of the text was unchanged however the text of two disorders pervasive developmental disorder not otherwise specified and Asperger s disorder had significant and or multiple changes made The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM III R and the text for Asperger s disorder was practically entirely rewritten Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings demographic information prevalence and course Also some diagnostic codes were changed to maintain consistency with ICD 9 CM 78 DSM 5 2013 EditMain article DSM 5 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders DSM the DSM 5 was approved by the Board of Trustees of the APA on December 1 2012 79 Published on May 18 2013 80 the DSM 5 contains extensively revised diagnoses and in some cases broadens diagnostic definitions while narrowing definitions in other cases 81 The DSM 5 is the first major edition of the manual in 20 years 82 DSM 5 and the abbreviations for all previous editions are registered trademarks owned by the American Psychiatric Association 8 83 A significant change in the fifth edition is the deletion of the subtypes of schizophrenia paranoid disorganized catatonic undifferentiated and residual 84 The deletion of the subsets of autistic spectrum disorder namely Asperger s syndrome classic autism Rett syndrome childhood disintegrative disorder and pervasive developmental disorder not otherwise specified was also implemented with specifiers regarding intensity mild moderate and severe Severity is based on social communication impairments and restricted repetitive patterns of behavior with three levels requiring support requiring substantial support requiring very substantial supportDuring the revision process the APA website periodically listed several sections of the DSM 5 for review and discussion 85 Future revisions and updates Edit Beginning with the fifth edition the APA communicated that they intend to add subsequent revisions more often to keep up with research in the field 86 It is notable that DSM 5 uses Arabic rather than Roman numerals Beginning with DSM 5 the APA will use decimals to identify incremental updates e g DSM 5 1 DSM 5 2 b and whole numbers for new editions e g DSM 5 DSM 6 87 similar to the scheme used for software versioning DSM 5 TR 2022 Edit A revision of DSM 5 titled DSM 5 TR was published in March 2022 updating diagnostic criteria and ICD 10 CM codes 88 The diagnostic criteria for avoidant restrictive food intake disorder was changed 89 along with adding entries for prolonged grief disorder unspecified mood disorder and stimulant induced mild neurocognitive disorder 90 Prolonged grief disorder which had been present in the ICD 11 had criteria agreed upon by consensus in a one day in person workshop sponsored by the APA 89 A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD 11 could be explained by the DSM 5 TR criteria requiring symptoms persist for 12 months and the ICD 11 requiring only 6 months 91 Three review groups for sex and gender culture and suicide along with an ethnoracial equity and inclusion work group were involved in the creation of the DSM 5 TR which led to additional sections for each mental disorder discussing sex and gender racial and cultural variations and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self injury for mental disorders 90 89 Other changed mental disorders included 92 Autism spectrum disorder Bipolar I disorder Bipolar II disorder and related bipolar disorders Obsessive compulsive personality disorder in the alternative DSM 5 model for personality disorders Depressive episodes with short duration hypomania Intellectual developmental disorder Delusional disorder Disruptive mood dysregulation disorder Brief psychotic disorderDSM Library EditThe APA have supplemented the DSM with supporting works collectively forming the DSM Library 93 As of 2022 the other books in the library are DSM 5 Handbook of Differential Diagnosis DSM 5 Clinical Cases DSM 5 Handbook on the Cultural Formulation Interview and Guia De Consulta De Los Criterios Diagnosticos Del DSM 5 93 Criticisms EditThere are a number of different criticisms that have been leveled against the DSM and its usefulness as a diagnostic manual Reliability and validity Edit The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability the degree to which different diagnosticians agree on a diagnosis Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable If clinicians and researchers frequently disagree about the diagnosis of a patient then research into the causes and effective treatments of those disorders cannot advance Hence diagnostic reliability was a major concern of DSM III When the diagnostic reliability problem was thought to be solved subsequent editions of the DSM were concerned mainly with tweaking the diagnostic criteria Neither the issue of reliability or validity was settled 94 95 In 2013 shortly before the publication of DSM 5 the director of the National Institute of Mental Health NIMH Thomas R Insel declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria due to its lack of validity 96 Insel questioned the validity of the DSM classification scheme because diagnoses are based on a consensus about clusters of clinical symptoms as opposed to collecting the genetic imaging physiologic and cognitive data to see how all the data not just the symptoms cluster and how these clusters relate to treatment response 97 98 Field trials of DSM 5 brought the debate of reliability back into the limelight as the diagnoses of some disorders showed poor reliability For example a diagnosis of major depressive disorder a common mental illness had a poor reliability kappa statistic of 0 28 indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients The most reliable diagnosis was major neurocognitive disorder with a kappa of 0 78 99 Diagnosis based on superficial symptoms Edit By design the DSM is primarily concerned with the signs and symptoms of mental disorders rather than the underlying causes It claims to collect these disorders 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 100 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 Proponents argue this absence of explanatory classification is necessary but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria 8 101 As DSM III chief architect Robert Spitzer and DSM IV editor Michael First outlined in 2005 little progress has been made toward understanding the pathophysiological processes and cause 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 102 While there is generally a lack of consensus on underlying causation for most psychiatric disorders some proponents of specific psychopathological paradigms have faulted the DSM for failing to incorporate evidence from other disciplines For instance evolutionary psychology distinguishes between genuine cognitive malfunctions and malfunctions due to psychological adaptations that is learned behaviors may be adaptive in one context but maladaptive in another However this distinction is one that is challenged within general psychology 103 104 105 There is also criticism of the strong operationalist viewpoint of the DSM The DSM relies on operational definitions which means that intuitive concepts like depression are defined by specific measurable criteria observable behavior specific timelines Some have argued that instead of replacing metaphysical terms like desire or purpose the DSM chose to legitimize them by giving them operational definitions However this may have served only to provide a reassurance fetish for mainstream methodological practice rather than representing a substantial and meaningful alteration of mainstream psychiatric practice 106 A central problem with the use of superficial symptoms is that psychiatry deals with the phenomena of consciousness which adds much more complexity than the somatic symptoms and signs used by most of medicine A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience gives the example of the problem of superficial characterization of psychiatric signs and symptoms If a patient says they feel depressed sad or down there are actually a wide variety of underlying experiences they could be referencing not only depressed mood but also for instance irritation anger loss of meaning varieties of fatigue ambivalence ruminations of different kinds hyper reflectivity thought pressure psychological anxiety varieties of depersonalization and even voices with negative content and so forth This criticism is especially pertinent to the structured interview as simple yes or no questions may not be specific enough to truly confirm or deny the diagnostic criterion at issue That is whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience There is thus danger in being overconfident in the face value of the answers The authors of the 2013 review give an example A patient who was being administered the Structured Clinical Interview for the DSM IV Axis I Disorders denied thought insertion but during a conversational phenomenological interview a semi structured interview tailored to the patient the same patient admitted to experiencing thought insertion along with a delusional elaboration The authors suggested 2 reasons for this discrepancy either the patient did not recognize his own experience in the rather blunt implicitly either or formulation of the structured interview question or the experience did not fully articulate itself until the patient started talking about his experiences 107 Obscuring the Root Causes of Psychological Distress Edit The role of the DSM 5 in protecting the interests of wealthy and politically powerful owners of the means of production in the United States has been criticized as well 108 Placing the blame for predictable and common psychological distress caused by the deleterious effects of economic inequality in the United States on individuals by attributing it to mental pathology has been criticized as hindering change of the root causes of the distress 108 The DSM 5 s expansive criteria that attribute mental pathology to people with distress or impairment from a wide ranging constellation of experiences has been criticized for pathologizing an unhelpful number of people that a psychiatric diagnosis is not benefical for 109 Overdiagnosis Edit Allen Frances an outspoken critic of DSM 5 states that normality is an endangered species because of fad diagnoses and an epidemic of over diagnosing and suggests that the DSM 5 threatens to provoke several more epidemics 110 111 Some researchers state that changes in diagnostic criteria following each published version of the DSM reduce thresholds for a diagnosis which results in increases in prevalence rates for ADHD and autism spectrum disorder 112 113 114 115 Bruchmuller et al 2012 suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis ADHD is affected by heuristics 113 Dividing lines Edit Despite caveats in the introduction to the DSM it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and 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 8 Some argue that rather than a categorical approach a fully dimensional spectrum or complaint oriented approach would better reflect the evidence 116 117 118 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 119 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 120 On the other hand individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life Cultural bias Edit Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social psychological variables 121 Advocating a more culturally sensitive approach to psychology critics such as Carl Bell and Marcello Maviglia contend that researchers and service providers often discount the cultural and ethnic diversity of individuals 122 In addition current diagnostic guidelines have been criticized 123 as having a fundamentally Euro American outlook Although these guidelines have been widely implemented opponents argue that even when a diagnostic criterion 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 121 Cross cultural psychiatrist Arthur Kleinman contends that 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 124 Other cross cultural critics largely share Kleinman s negative view toward the culture bound syndrome 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 125 page needed Mainstream psychiatrists have also been dissatisfied with these new culture bound diagnoses although not for the same reasons Robert Spitzer a lead architect of 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 121 One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM in treating patients of the African diaspora 126 127 128 Historically the DSM tended to avoid issues involving religion the DSM 5 relaxed this attitude somewhat 129 Medicalization and financial conflicts of interest Edit There was extensive analysis and comment on DSM IV published in 1994 in the years leading up to the 2013 publication of DSM 5 It was alleged that the way the categories of DSM IV were structured as well as the substantial expansion of the number of categories within it represented increasing medicalization of human nature very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies the power and influence of the latter having grown dramatically in recent decades 130 In 2005 then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had allowed the biopsychosocial model to become the bio bio bio model 131 It was reported that of the authors who selected and defined the DSM IV psychiatric disorders roughly half had financial relationships with the pharmaceutical industry during the period 1989 2004 raising the prospect of a direct conflict of interest The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment such as schizophrenia and mood disorders where 100 of the panel members had financial ties with the pharmaceutical industry William Glasser referred to DSM IV as having phony diagnostic categories arguing that it was developed to help psychiatrists to help them make money 132 A 2012 article in The New York Times commented sharply that DSM IV then in its 18th year through copyrights held closely by the APA had earned the Association over 100 million 133 However although the number of identified diagnoses had increased by more than 300 from 106 in DSM I to 365 in DSM IV TR psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology thereby allowing better grouping of similar patients 8 The National Board of Medical Examiners NBME which is responsible for creating and publishing board exams for medical students around the United States conforms to the use of DSM 5 criteria 134 despite the known problems with an unquestioning checklist approach to diagnosis and treatment based on the DSM that have been outlined by critics Potential harm of labels Edit A core function of the DSM is the categorization of people s experiences into diagnoses based on symptoms However there is disagreement about the use of diagnoses as labels Some individuals are relieved to find they have a recognized condition that they can apply a name to and this has led to many people self diagnosing 135 Others however question the accuracy of diagnosis or feel they have been given a label that invites social stigma and discrimination the terms mentalism and sanism have been used to describe such discriminatory treatment 136 Diagnoses can become internalized and affect an individual s self identity and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result 137 Some members of the psychiatric survivors movement more broadly the consumer survivor ex patient movement actively campaign against their diagnoses or the assumed implications or against the DSM system in general 138 139 Additionally it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model and such content can erroneously imply excess psychopathology e g multiple comorbid diagnoses or chronicity 139 Critiques of DSM 5 Edit Psychiatrist Allen Frances has been critical of proposed revisions to the DSM 5 In a 2012 New York Times editorial Frances warned that if this DSM version is issued unamended by the APA it will medicalize normality and result in a glut of unnecessary and harmful drug prescription 140 In a December 2012 blog post on Psychology Today Frances provides his list of DSM 5 s ten most potentially harmful changes 141 Disruptive Mood Dysregulation Disorder for temper tantrums Major Depressive Disorder includes normal grief Minor Neurocognitive Disorder for normal forgetfulness in old age Adult Attention Deficit Disorder encouraging psychiatric prescriptions of stimulants Binge Eating Disorder for excessive eating Autism defining the disorder more specifically possibly leading to decreased rates of diagnosis and the disruption of school services First time drug users will be lumped in with addicts Behavioral Addictions making a mental disorder of everything we like to do a lot Generalized Anxiety Disorder includes everyday worries Post traumatic stress disorder changes opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings 141 A group of 25 psychiatrists and researchers among whom were Frances and Thomas Szasz have published debates on what they see as the six most essential questions in psychiatric diagnosis 142 Are they more like theoretical constructs or more like diseases How to reach an agreed definition Should the DSM 5 take a cautious or conservative approach What is the role of practical rather than scientific considerations How should it be used by clinicians or researchers Is an entirely different diagnostic system required In 2011 psychologist Brent Robbins co authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM Over 15 000 individuals and mental health professionals have signed a petition in support of the letter 143 Thirteen other APA divisions have endorsed the petition 143 Robbins has noted that under the new guidelines certain responses to grief could be labeled as pathological disorders instead of being recognized as being normal human experiences 144 See also EditChinese Classification and Diagnostic Criteria of Mental Disorders Classification of mental disorders Diagnostic classification and rating scales used in psychiatry DSM IV Codes Global Assessment of Functioning GAF Scale International Statistical Classification of Diseases and Related Health Problems ICD Kraepelinian dichotomy Psychodynamic Diagnostic Manual Relational disorder proposed DSM 5 new diagnosis Research Domain Criteria RDoC a framework being developed by the National Institute of Mental Health Rosenhan experiment Structured Clinical Interview for DSM IV SCID Homosexuality in DSMNotes Edit Determining the correct DSM II printing where the change occurred can be confusing because the American Psychiatric Association publication that announced the change is titled in part Proposed change in DSM II 6th printing page 44 However a notice in that publication indicates that the change appears on page 44 of this the seventh printing However this planned change was not adopted for the initial revision of the 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SP Francis E July 1999 Racism in psychiatry necessitates reappraisal of general procedures and Eurocentric theories BMJ 319 7204 254 doi 10 1136 bmj 319 7204 254 PMC 1116337 PMID 10417096 Kleinman A 1997 Triumph or pyrrhic victory The inclusion of culture in DSM IV Harvard Review of Psychiatry 4 6 343 344 doi 10 3109 10673229709030563 PMID 9385013 S2CID 43256486 Bhugra D amp Munro A 1997 Troublesome Disguises Underdiagnosed Psychiatric Syndromes Blackwell Science Ltd ISBN missing Irene A Azibo DA 1991 Diagnosing personality disorder in Africans Blacks using the Azibo nosology Two case studies Journal of Black Psychology 17 2 1 22 doi 10 1177 00957984910172002 S2CID 144458287 ya Azibo DA November 2014 The Azibo Nosology II Epexegesis and 25th Anniversary Update 55 Culture focused Mental Disorders Suffered by African Descent People PDF Journal of Pan African Studies 7 5 32 176 Archived PDF from the original on 2015 11 21 Zulu IM The Azibo Nosology An Interview with Daudi Ajani ya Azibo PDF Journal of Pan African Studies 7 5 209 214 Archived PDF from the original on 2016 08 20 Chandler E September 2012 Religious and spiritual issues in DSM 5 matters of the mind and searching of the soul Issues in Mental Health Nursing 33 9 577 582 doi 10 3109 01612840 2012 704130 PMID 22957950 S2CID 3453154 Given the important role that spirituality and religion play for many people in the experiences of coping with health and illness it seems odd that such important elements are in the margins of the powerful and commanding nosology of the DSM Explanations for understanding the glaring absence are complex and impacted by some very powerful political and sociological forces including contributory elements from within the mental health disciplines This article invites the reader to explore salient issues in the emergence of a broader recognition of religion spirituality and psychiatric diagnosis in the DSM 5 Healy D 2006 The Latest Mania Selling Bipolar Disorder Archived 2009 02 12 at the Wayback Machine PLoS Med 3 4 e185 Cosgrove L Krimsky S Vijayaraghavan M Schneider L 2006 Financial ties between DSM IV panel members and the pharmaceutical industry Psychotherapy and Psychosomatics 75 3 154 160 doi 10 1159 000091772 PMID 16636630 S2CID 11909535 Susan Bowman 2006 The National Psychologist 2006 11 01 Archived from the original on 2017 06 26 Retrieved 2013 12 03 Greenberg G January 29 2012 The D S M s Troubled Revision The New York Times The article s closing words it the APA will be laughing all the way to the bank Update Exams to Transition to DSM 5 Giles DC Newbold J March 2011 Self and Other Diagnosis in User Led Mental Health Online Communities Qualitative Health Research 21 3 419 428 doi 10 1177 1049732310381388 ISSN 1049 7323 PMID 20739589 S2CID 1853974 Sanism in Theory and Practice Archived 2014 03 17 at the Wayback Machine May 9 10 2011 Richard Ingram Centre for the Study of Gender Social Inequities and Mental Health Simon Fraser University Canada How Using the Dsm Causes Damage A Client s Report Journal of Humanistic Psychology Vol 41 No 4 36 56 2001 Cape Town Mad Pride 2013 06 08 Known as the psychiatric bible the Diagnostic and Statistical Manual of Mental Disorders appears in a fifth edition Retrieved 28 Feb 2019 a b Michael T Compton 2007 Recovery Patients Families Communities Conference Report Medscape Psychiatry amp Mental Health October 11 14 2007 Frances A 11 May 2012 Diagnosing the D S M New York Times New York ed p A19 a b Frances AJ December 2 2012 DSM 5 Is Guide Not Bible Ignore Its Ten Worst Changes APA approval of DSM 5 is a sad day for psychiatry Psychology Today Retrieved 2013 03 09 Phillips J Frances A Cerullo MA Chardavoyne J Decker HS First MB et al January 2012 The six most essential questions in psychiatric diagnosis a pluralogue part 1 conceptual and definitional issues in psychiatric diagnosis Philosophy Ethics and Humanities in Medicine 7 1 3 doi 10 1186 1747 5341 7 3 PMC 3305603 PMID 22243994 a b Professor co authors letter about America s mental health manual Point Park University December 12 2011 Archived from the original on 2012 03 29 Retrieved 2012 04 04 Allday E November 26 2011 Revision of psychiatric manual under fire San Francisco Chronicle Further reading EditAmerican Psychiatric Association 2000 Diagnostic and Statistical Manual of Mental Disorders Fourth Edition DSM IV TR American Psychiatric Pub ISBN 978 0 89042 025 6 Spitzer RL 2002 Dsm Iv Tr Casebook A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders American Psychiatric Pub ISBN 978 1 58562 059 3 External links EditOfficial DSM 5 development website Diagnostic Criteria from DSM IV TR dead link Diagnostic Criteria from DSM IV TR The Multiaxial System of Diagnosis in DSM IV Criteria Archived 2021 01 16 at the Wayback Machine Retrieved from https en wikipedia org w index php title Diagnostic and Statistical Manual of Mental Disorders amp oldid 1152791810, wikipedia, wiki, book, books, library,

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