The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American
Psychiatric Association, offers a common language and standard criteria for the classification of
mental disorders. It is used, or relied upon, by clinicians, researchers, psychiatric drug regulation
agencies, health insurance companies, pharmaceutical companies, the legal system, and policy
makers together with alternatives such as the International Statistical Classification of Diseases and
Related Health Problems (ICD), produced by the World Health Organization (WHO). The DSM is
now in its fifth edition, DSM-5, published on May 18, 2013.
The DSM evolved from systems for collecting census and psychiatric hospital statistics, and from a
United States Army manual. Revisions since its first publication in 1952 have incrementally added
to the total number of mental disorders, although also removing those no longer considered to be
mental disorders.
The International Statistical Classification of Diseases and Related Health Problems (ICD),
produced by the World Health Organization (WHO), is the other commonly used manual for mental
disorders. It is distinguished from the DSM in that it covers health as a whole. While the DSM is
the official diagnostic system for mental disorders in the US, the ICD is used more widely in
Europe and other parts of the world. The DSM-IV-TR (4th. ed.) contains, in Appendix G, an "ICD9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders" that
allows for comparisons between the DSM and the ICD manuals, which may not systematically
match because revisions are not simultaneously coordinated.
While the DSM has been praised for standardizing psychiatric diagnostic categories and criteria, it
has also generated controversy and criticism. Critics, including the National Institute of Mental
Health, argue that the DSM represents an unscientific and subjective system.[1] There are ongoing
issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial
symptoms; the use of artificial dividing lines between categories and from normality; possible
cultural bias; medicalization of human distress.[2][3][4][5][6] The publication of the DSM, with
tightly guarded copyrights, now makes APA over $5 million a year, historically totaling over $100
million.[7]
Uses and definition
Many mental health professionals use the manual to determine and help communicate a patients
diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally
require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and
also to categorize patients using diagnostic criteria for research purposes. Studies done on specific
disorders often recruit patients whose symptoms match the criteria listed in the DSM for that
disorder. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and
DSM-IV found the former was more often used for clinical diagnosis while the latter was more
valued for research.[8]
DSM-5, and all previous editions, are registered trademarks owned by the American Psychiatric
Association (APA).[3][9]
The current version of the DSM characterizes a mental disorder as a clinically significant
behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated
with present distressor disabilityor with a significant increased risk of suffering. It also notes
that no definition adequately specifies precise boundaries for the concept of mental disorder
different situations call for different definitions. It states that there is no assumption that each
category of mental disorder is a completely discrete entity with absolute boundaries dividing it from
other mental disorders or from no mental disorder (APA, 1994 and 2000). There are attempts to
adjust the wording for the upcoming DSM-V.[dated info][10][11]
History
The initial impetus for developing a classification of mental disorders in the United States was the
need to collect statistical information. The first official attempt was the 1840 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 and pointing out that in many towns AfricanAmericans were all marked as insane, and the statistics were essentially useless.
The Association of Medical Superintendents of American Institutions for the Insane was formed in
1844, changing its name in 1892 to the American Medico-Psychological Association, and in 1921 to
the present American Psychiatric Association (APA).
Edward Jarvis and later Francis Amasa Walker helped expand the census, from 2 volumes in 1870
to 25 volumes in 1880. Frederick H. Wines was appointed to write a 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) (published 1888). Wines used seven
categories of mental illness: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy,
mania, melancholia, monomania and paresis. These categories were also adopted by the
Association.[12]
In 1917, together with the National Commission on Mental Hygiene (now Mental Health America),
the APA developed a new guide for mental hospitals called the Statistical Manual for the Use of
Institutions for the Insane. This included 22 diagnoses and would be revised several times by the
APA over the years.[13] Along with the New York Academy of Medicine, the APA also provided
the psychiatric nomenclature subsection of the US general medical guide, the Standard Classified
Nomenclature of Disease, referred to as the Standard.[14]
DSM-I (1952)
World War II saw the large-scale involvement of US psychiatrists in the selection, processing,
assessment, and treatment of soldiers. This moved the focus away from mental institutions and
traditional clinical perspectives. A committee headed by psychiatrist Brigadier General William C.
Menninger developed a new classification scheme called Medical 203, that was issued in 1943 as a
War Department Technical Bulletin under the auspices of the Office of the Surgeon General.[15]
The foreword to the DSM-I states the US Navy had itself made some minor revisions but the Army
established a much more sweeping revision, abandoning the basic outline of the Standard and
attempting to express present day concepts of mental disturbance. This nomenclature eventually
was adopted by all Armed Forces, and assorted modifications of the Armed Forces nomenclature
[were] introduced into many clinics and hospitals by psychiatrists returning from military duty.
The Veterans Administration also adopted a slightly modified version of Medical 203.[citation
needed] In 1949, the World Health Organization published the sixth revision of the International
Statistical Classification of Diseases (ICD), which included a section on mental disorders for the
first time. The foreword to DSM-1 states this categorized mental disorders in rubrics similar to
those of the Armed Forces nomenclature. An APA Committee on Nomenclature and Statistics was
empowered to develop a version specifically for use in the United States, to standardize the diverse
and confused usage of different documents. In 1950, the APA committee undertook a review and
consultation. It circulated an adaptation of Medical 203, the VA system, and the Standards
Nomenclature to approximately 10% of APA members. 46% replied, of which 93% approved, and
after some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical
Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and
conceptual framework were the same as in Medical 203, and many passages of text were identical.
[15] The manual was 130 pages long and listed 106 mental disorders.[16] These included several
categories of personality disturbance, generally distinguished from neurosis (nervousness,
egodystonic).[17] In 1952, 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, was used to justify inclusion of the disorder as a supposed pathological
hidden fear of the opposite sex caused by traumatic parentchild relationships. This view was
widely influential in the medical profession.[18] In 1956, however, the psychologist Evelyn Hooker
performed a study that compared the happiness and well-adjusted nature of self-identified
homosexual men with heterosexual men and found no difference.[19] Her study stunned the
medical community and made her a hero to many gay men and lesbians,[20] but homosexuality
remained in the DSM until May 1974.[21]
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 that mental illness was a myth used to
disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was
merely another example of how society labels and controls non-conformists; from behavioural
psychologists who challenged psychiatrys fundamental reliance on unobservable phenomena; and
from gay rights activists who criticised the APAs listing of homosexuality as a mental disorder. A
study published in Science by Rosenhan received much publicity and was viewed as an attack on
the efficacy of psychiatric diagnosis.[22]
Although the APA was closely involved in the next significant revision of the mental disorder
section of the ICD (version 8 in 1968), it decided to go ahead with a revision of the DSM. It was
published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I.
The term reaction was dropped, but the term neurosis was retained. Both the DSM-I and the
DSM-II reflected the predominant psychodynamic psychiatry,[23] although they also included
biological perspectives and concepts from Kraepelins system of classification. Symptoms were not
specified in detail for specific disorders. Many were seen as reflections of broad underlying
conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and
psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions
appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a
model that did not emphasize a clear boundary between normality and abnormality.[24] The idea
that personality disorders did not involve emotional distress was discarded.[17]
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.[25] They found that different
practitioners using the DSM-II were rarely in agreement when diagnosing patients with similar
problems. In reviewing previous studies of 18 major diagnostic categories, Fleiss and Spitzer
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.[26]
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 against the APAs
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.[27]
This 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.[28][29]
Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh
printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a
vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the
diagnosis was replaced with the category of sexual orientation disturbance.[30]
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 the International Statistical Classification of Diseases and Related Health Problems
(ICD), published by the World Health Organization. The revision took on a far wider mandate under
the influence and control of Spitzer and his chosen committee members.[31] One goal was to
improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques,
including the famous Rosenhan experiment. There was also a need to standardize diagnostic
practices within the US and with other countries after research showed that psychiatric diagnoses
differed markedly between Europe and the USA.[32] The establishment of these criteria was an
attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic
Criteria (RDC) and Feighner Criteria, which had just been developed by a group of researchorientated psychiatrists based primarily at Washington University in St. Louis and the New York
State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established
by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base
categorization on colloquial English descriptive language (which would be easier to use by federal
administrative offices), rather than assumptions of etiology, although its categorical approach
assumed each particular pattern of symptoms in a category reflected a particular underlying
pathology (an approach described as neo-Kraepelinian). The psychodynamic or physiologic view
was abandoned, in favor of a regulatory or legislative model. A new multiaxial system attempted
to yield a picture more amenable to a statistical population census, rather than just a simple
diagnosis. Spitzer argued that mental disorders are a subset of medical disorders but the task force
decided on the DSM statement: Each of the mental disorders is conceptualized as a clinically
significant behavioral or psychological syndrome.[23] The personality disorders were placed on
axis II along with mental retardation.[17]
The first draft of the DSM-III was prepared within a year. Many new categories of disorder were
introduced, while some were deleted or changed. A number of the unpublished documents
discussing and justifying the changes have recently come to light.[33] 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, the DSM-III was in serious danger
of not being approved by the APA Board of Trustees unless neurosis was included in some
capacity; a political compromise reinserted the term in parentheses after the word disorder in
some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II
category of sexual orientation disturbance.
Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It
rapidly came into widespread international use and has been termed a revolution or transformation
in psychiatry.[23][24] However, Robert Spitzer later criticized his own work on it in an interview
with Adam Curtis, saying it led to the medicalization of 20-30 percent of the population who may
not have had any serious mental problems.
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 generalisability 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[22]
DSM-III-R (1987)
In 1987, the DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer.
Categories were renamed and reorganized, and significant changes in criteria were made. Six
categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual
dysphoric disorder and masochistic personality disorder, were considered and discarded. Sexual
orientation disturbance was also removed and was largely subsumed under sexual disorder not
otherwise specified, which can include persistent and marked distress about ones sexual
orientation.[23][34] 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 that for at least some disorders, particularly the Personality Disorders, the criteria require
much more inference on the part of the observer (p. xxiii).[17]
DSM-IV (1994)
In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by
Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The
steering committee created 13 work groups of 516 members. Each work group had approximately
20 advisers.[clarification needed] The work groups conducted a three-step process: first, each group
conducted an extensive literature review of their diagnoses; then, they requested data from
researchers, conducting analyses to determine which criteria required change, with instructions to
be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical
practice.[35][36] A major change from previous versions was the inclusion of a clinical significance
criterion to almost half of all the categories, which required that symptoms cause 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.[17]
DSM-IV-TR (2000)
A text revision of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic
categories and the vast majority of the specific criteria for diagnosis were unchanged.[37] The text
sections giving extra information on each diagnosis were updated, as were some of the diagnostic
codes to maintain consistency with the ICD. The DSM-IV-TR was organized into a five-part axial
system. The first axis incorporated clinical disorders. The second axis covered personality disorders
and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and
childhood factors functionally necessary to provide diagnostic criteria for health care assessments.
DSM-5 (2013)
Main article: DSM-5
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-V,
was approved by the Board of Trustees of the American Psychiatric Association (APA) on
December 1, 2012.[38] Published on May 18, 2013,[39] the DSM-5 contains extensively revised
diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other
cases.[40] The DSM-5 is the first major edition of the manual in twenty years,[41] and the Roman
numerals numbering system has been discontinued to allow for greater clarity in regard to revision
numbers. A significant change in the fifth edition is the proposed deletion of the subtypes of
schizophrenia.[42][43] During the revision process, the APA website periodically listed several
sections of the DSM-5 for review and discussion.[44]
DSM-IV-TR
DSM-IV-TR, the predecessor to the most current DSM edition, the DSM-5
Categorization
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with
a close approximation to the prototype is said to have that disorder. DSM-IV states, there is no
assumption each category of mental disorder is a completely discrete entity with absolute
boundaries but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are
not given importance.[45] Qualifiers are sometimes used, for example mild, moderate or severe
forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause clinically
significant distress or impairment in social, occupational, or other important areas of functioning,
although DSM-IV-TR removed the distress criterion from tic disorders and several of the
paraphilias 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.
