- A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders: Issues and implications for the future of psychiatric canon and practice
- A review of American psychiatry through its diagnoses: the history and development of the Diagnostic and Statistical Manual of Mental Disorders
- Adopting a continuous improvement model for future DSM revisions
In the 1800s, there was a movement to find successful treatments for individuals who had been filling up mental hospitals in America, Britain, and Continental Europe. The treatment in these hospitals focused on the use of “moral treatment” as opposed to the harsher methods used in medieval asylums. The need to determine more successful modes of treatment for individuals with mental health disorders led to the need to also classify these disorders. The first recognized attempt to classify mental health disorders came from the French psychiatrist Jean-Etienne-Dominique Esquirol and was titled Concerning Mental Illnesses.
Some years later, German psychiatrist Emil Kraepelin developed his classification of mental illness, Compendium der Psychiatrie. Kraepelin distinguished two major forms of mental illness: dementia praecox (which would later be classified as schizophrenia) and manic-depressive disorder (which later would form the basis for clinical depression and bipolar disorder). Kraepelin also documented three different presentations of dementia praecox that included:
- Paranoia, which primarily consisted of hallucinations and delusions
- Hebephrenia, which mainly presented with inappropriate behaviors and inappropriate types of reactions
- Catatonia, which presented as posturing, odd mannerisms, or extreme agitation
Kraepelin’s classification system would later become the basis for the modern Diagnostic and Statistical Manual of Mental Disorders series (DSM).
In 1840, the term idiocy/insanity was used to describe certain individuals in the census. The government decided that it needed to collect data on the prevalence of mental illness. As time went on, the idiocy/insanity category grew to seven categories that included melancholia, paresis, mania, monomania, dipsomania, dementia, and epilepsy. The expanded categories resulted in confusion regarding mental illness diagnoses and led to issues with uncertainty attempting to formally identify these diagnostic categories.
In 1917, the Statistical Manual for the Use of Institutions for the Insane was created by the Committee on Statistics of the American Medico-Psychological Association (which later became the American Psychiatric Association [APA]) and another organization, the National Commission on Mental Hygiene. These two committees separated forms of mental illness into 22 different groups, and this information was used by the Bureau of Census.
The publication continued to be revised and went through 10 editions up until 1942. This manual is considered to be the predecessor to the first edition of the DSM. It contained very broad categorizations of mental disorders and had very limited use in diagnosing them. In addition, the Freudian model was predominant in psychiatry during this period, and diagnoses represented this influence.
The confusion regarding what to diagnose was enhanced by a number of other different diagnostic systems that were present in the US. There was a real need to develop a classification system that minimized this situation and resulted in agreement in the area of psychiatry as well as the provision of a common diagnostic scheme that could be used nationwide. The APA decided to create a new classification system, and in 1952, the first edition of the DSM (DSM-I) was released.
The DSM-I contained 102 very broad diagnostic categories that were based on psychodynamic (Freudian) principles. The diagnostic categories were divided into two major groups of mental disorders that included:
- Conditions that were assumed to be caused by some type of brain dysfunction
- Conditions that were assumed to be the result of the effects of environmental stress in a person and resulted in an inability to adapt
The second group was subdivided into (1) psychoses: severe conditions, such as schizophrenia and manic depressive disorder, and (2) psychoneuroses, which included personality disorders, depression, and anxiety related conditions
Despite the development of an organized classification system with diagnostic categories, the manual had very little diagnostic utility and exhibited little influence on the diagnostic process. This set the stage for the development of a second edition of the DSM.
In an effort to compensate for the deficiencies of the DSM-I, a second edition of the DSM was published in 1968. The DSM-II was still heavily influenced by Freudian principles even though these principles were losing popularity during this time. DSM-II had two major modifications.
- There was an expansion of the definition of mental illness that took into account milder conditions that occurred in the general population. Some of these conditions appear to be obvious attempts to broaden the client base of psychiatry, such as conditions without manifest psychiatric disorder (normal individuals who nevertheless need to be examined by a psychiatrist). While the inclusion of some of these categories was designed to account for reactions to environmental stresses, it also produced quite a bit of confusion.
- There was also an increased categorization that resulted in multiple subdivisions of existing categories. For example, there was an addition of eight different “alcoholic brain syndromes” and an increased number of qualifiers for diagnoses. The DSM-I contained four qualifiers for a diagnosis, whereas the DSM-II contained nine qualifiers for many of the diagnoses.
The number of diagnostic categories was increased to 182, and the descriptions were still not useful in developing a formal diagnosis. They required subjective interpretations of prose-like descriptions of behaviors.
A number of critics had surfaced during the 1960s and 1970s. Many of these, such as psychiatrist Thomas Szasz, brought up serious challenges to the fundamental principle of the DSM that psychiatric conditions were actually real illnesses. In addition, the total lack of clear boundaries between mental health, normal behavior, and illness, and the low reliability of the psychiatric categories in the DSM-II, was criticized almost universally.
The National Institute of Mental Health (NIMH) withdrew research support and insurance providers demonstrated a lack of confidence in the diagnostic scheme. Competition from nonmedical mental health treatment providers also made the conditions for psychiatrists rather tenuous. In addition, the development of more biologically oriented schools of thought and psychiatry, the development of quantitative assessment tools such as rating scales, and the need to decrease the overall treatment time of individuals also led to the need for a new classification system.
The DSM-III was released in 1980. The number of diagnostic categories increased to 265, and the removal of many psychiatric terms used in earlier editions was replaced by more biologically based terminology. Several disorders were divided into a number of distinct categories (e.g., the old “feeding disturbance” category was replaced by four types of “eating disorders”). A number of diagnoses that contained labels that were obviously Freudian in nature were also renamed; the most common change was using the term disorder in place of the former term neurosis.
Many novel disorders were also included in this edition, including post-traumatic stress disorder, attention deficit disorder, etc. In addition, homosexuality as a disorder was deleted in the DSM-III; it had actually been removed in the seventh printing of the DSM-II that occurred in 1974, but this edition was the first new one to exclude homosexuality as a category of mental illness. However, the notion of ego-dystonic homosexuality remained in the manual (defined as individuals who are homosexual and suffer emotional distress because of their sexual orientation). Several other modifications designed to depict the diagnostic categories as mutually exclusive illnesses were also made.
The DSM-III is considered by many to be the benchmark in the change of focus of the diagnostic system of psychiatry. These changes included a move toward more biologically oriented views of mental illness consistent with a medical approach to diagnoses and a shunning of the Freudian principles that had been predominant in psychiatry up to this point. The subsequent editions of the DSM revisions continue the tradition set by the DSM- III.
In 1987, the APA published a revised edition of the DSM-III that renamed and reorganized certain categories and made changes in the diagnostic criteria of others. The DSM-III-R contained 292 diagnostic categories and removed a number of controversial diagnoses including ego-dystonic homosexuality. Interestingly, this manual was significantly longer than other manuals (567 pages).
Efforts to make the diagnostic categories purely descriptive, list specific symptoms as opposed to using prose descriptions, and concentrate on the reliability of the diagnoses were continued. A major issue with former editions of the DSM was the reliability of the diagnostic categories. This refers to the ability of different clinicians in different areas giving the same person the same psychiatric diagnosis as a result of using the DSM. The concentration on diagnostic reliability began with the DSM-III, and it continued in the DSM-III-R. Prior to these editions, it was not uncommon for two different psychiatrists assessing the same individual to give totally different diagnoses. This was a major criticism of earlier editions of the DSM.
DSM-IVBy the 1990s, the pattern of the development of the diagnostic categories and their diagnostic criteria had been established. The revision in 1994, the DSM-IV was published, listing 297 different disorders over 886 pages. The other major change from the DSM-III-R was the addition of the descriptive diagnostic term clinical significance. This criterion indicated that the symptoms displayed by the person must result in “clinically significant distress or impairment in social, occupational, or other important areas of functioning” in order for them to receive a specific diagnosis. Other minor changes and diagnoses were deleted or removed.
In 2000, the DSM-IV-TR was published. The diagnostic categories in this revision remained essentially the same, and the text sections describing certain aspects of the diagnostic criteria were updated and revised. In addition, the manual used a five-part axial diagnostic system that incorporated several different dimensions of diagnoses, including:
- Axis I: the clinical syndromes
- Axis II: personality and developmental disorders (mental retardation)
- Axis III: general medical conditions
- Axis IV: psychosocial and environmental issues
- Axis V: global assessment of functioning (rated on a scale of 0-100)
In 2013, the DSM-5 was released, which had a number of significant changes. For example, a number of disorders were deleted (e.g., subsets of autism spectrum disorder, such as Asperger’s syndrome, classic autism, Rett syndrome, etc., in favor of one overall diagnosis); the traditional five subtypes of schizophrenia were deleted; schizophrenia was conceptualized as a singular disorder; and other disorders were given their own category (e.g., post traumatic stress disorder) or changed significantly (e.g., somatization disorder). A number of these changes were very controversial, such as the designation of a bereavement disorder.
The use of the axial diagnostic system in the DSM-IV-TR was also dropped. The long-awaited revision stirred quite a bit of controversy, and a number of organizations, including the National Institute of Mental Health, vowed to begin research to develop their own diagnostic system for mental illnesses.
General Issues with the DSM Series
Entire books have been written critiquing the DSM series. Descriptions of some of the major critiques follow.
- The process of determining a specific diagnosis, selecting diagnostic criteria, and evaluating the information is performed by a committee as opposed to using actual medical evidence or tests. For example, nearly all of the diagnostic criteria in all of the DSM editions are behavioral observations and not formal biological or medical test results. Despite numerous attempts to make these diagnostic criteria objective, they are descriptions that are entirely subjective and require a lot of interpretation from the clinician. The National Institute of Mental Health has proposed research to develop specific biological markers or biological tests to identify mental health disorders.
- The composition of the committees in the past was suspect, although in the current edition, this may not be as big of an issue. Many of the committee members contributing to the diagnostic categories and past editions had significant ties to the pharmacological industry. This was a major criticism of previous editions of the DSM, but is not as salient a criticism of the DSM-5.
- The concentration on reliability is problematic. First of all, the actual reliability of the DSM diagnostic categories is relatively poor even though the committee focused on the reliability of the categories. Secondly, the concentration on reliability does not guarantee that the diagnostic categories are valid. Validity refers to the truthfulness of some issue. There are many critiques regarding the actual validity of many of the diagnostic categories in the DSM
- The DSM pathologizes many normal behaviors. This is a critique that has been ongoing since the inception of the series. For example, in the DSM-5, quite a bit of controversy was generated by the notion of a bereavement disorder. Many individuals believe that classifying bereavement as a potential mental illness was inappropriate.
- The choice of how many diagnostic criteria should be used to satisfy the actual diagnosis appears to be relatively arbitrary. Some diagnoses required four diagnostic criteria, some five, some two, etc. Critics ponder if the difference between having three diagnostic criteria compared to four diagnostic criteria is actually based on any meaningful assumptions.
- Individuals who receive the same diagnosis may have totally different presentations. Because only a certain number of diagnostic criteria need to be satisfied in order to receive a diagnosis (e.g., four of nine total diagnostic criteria), there are a number of different scenarios where individuals receiving the exact same diagnostic label have clearly different presentations. This makes no conceptual sense.
- Finally, the designation of mental disorders into mutually exclusive categories is not consistent with the understanding of human behavior. As it turns out, the so-called mutually exclusive diagnostic categories in the DSM series are not mutually exclusive, and other more functional approaches for certain diagnostic categories, such as personality disorders, have been suggested but have not been implemented by the committees. The conceptualization of mental illness by the committees and the APA is often not consistent with much of the research in the field, even though the committees that form the diagnoses review this research and use it to develop their diagnostic criteria and categories. Attempting to classify mental disorders in the same way that physical diseases are classified may not be a valid approach.
The DSM was developed as a diagnostic manual to classify different forms of mental illness and to provide objective diagnostic criteria used in identifying them in the field. The DSM has undergone a number of different revisions, and for the most part, the DSM series remains highly criticized despite still being “the only game in town.” Other organizations, such as the National Institute of Mental Health, have decided to attempt to develop their own diagnostic scheme for mental illness as a result of their dissatisfaction with the DSM; however, any new approach to diagnosing mental illness is most likely far off. Mental health clinicians will continue to use the DSM-5 despite reservations or current concerns.