Diagnostic and Statistical Manual of Mental Disorders

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The Diagnostic and Statistical Manual published by the American Psychiatric Association

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook for mental health professionals that lists different categories of mental disorder and the criteria for diagnosing them, according to the publishing organization the American Psychiatric Association. It is used worldwide by clinicians and researchers as well as insurance companies, pharmaceutical companies and policy makers. It has attracted controversy and criticism as well as praise.

The DSM has gone through five revisions since it was first published in 1952. The last major revision was the DSM-IV published in 1994, although a "text revision" was produced in 2000. The DSM-V is currently in consultation, planning and preparation, due for publication in approximately 2011.^[1] The mental disorders section of the International Statistical Classification of Diseases and Related Health Problems (ICD) is another commonly-used guide, and the two classifications use the same diagnostic codes.

1 History
2 The current DSM
3 DSM-V planning
4 Criticism
5 See also
6 References
7 External links

[edit] History

The Diagnostic and Statistical Manual of Mental Disorders was first published in 1952, by the American Psychiatric Association. It was developed from an earlier classification system adopted in 1918 to meet the need of the federal Bureau of the Census for uniform statistics from psychiatric hospitals; from categorization systems in use by the US military; and from a survey of the views of 10% of APA members.^[2] The manual was 130 pages long and contained 106 categories of mental disorder. The DSM-II was published in 1968, listed 182 disorders, and was 134 pages long. These manuals reflected the predominant psychodynamic psychiatry^[3] Symptoms were not specified in detail for specific disorders, but were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was also incorporated, in a model that did not emphasize a clear boundary between normality and abnormality^[4]

The seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. This followed controversy and protests from gay activists at APA annual conferences from 1970 to 1973. After talks led by the psychiatrist Robert Spitzer, who had been involved in the DSM-II development committee, a vote by the APA trustees in 1973, confirmed by the wider APA membership in 1974, replaced the diagnosis with a milder category of "sexual orientation disturbance".^[3]

Also in 1974, the decision to create a new revision of the DSM was taken, 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^[5]. One goal was to improve the reliability of psychiatric diagnosis. The practices of mental health professionals, especially in different countries, was not uniform. The establishment of specific criteria was also an attempt to facilitate mental health research. The multiaxial system attempts to yield a more complete picture of the patient, rather than just a simple diagnosis. The criteria and classification system of the DSM-III was based on a process of consultation and committee meetings. An attempt was made to base categorization on description rather than assumptions of etiology, and the psychodynamic view was abandoned, perhaps in favor of a biomedical model, with a clear distinction between normal and abnormal.

The criteria adopted for many of the mental disorders were expanded from the Research Diagnostic Criteria (RDC) and Feighner Criteria which had been developed for psychiatry research in the 1970s. Other criteria were established by consensus in committee meetings, as determined by Spitzer. The approach is generally seen as "Neo-Kraepelinian", after the work of the psychiatrist Emil Kraepelin. 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”. The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced. Field trials sponsored by the US 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, such that the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity, a political compromise reinserted the term in parentheses after the word “disorder” in some cases. In 1980, the DSM-III was published, at 494 pages long and listing 265 diagnostic categories. The DSM-III rapidly came into widespread international use by multiple stakeholders and has been termed a revolution or transformation in psychiatry^[3]^[4]

In 1987 the DSM-III-R was published as a revision of DSM-III, under the direction of Spitzer. Categories were renamed, reorganized, and significant changes in criteria were made. Six new categories were deleted while others were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were considered and discarded. Altogether, DSM-III-R contained 292 diagnoses and was 567 pages long.

In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including 4 psychologists. The steering committee created 13 work groups of 5-16 members. Each work group had approximately 20 advisors. The work groups conducted a 3-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.^[6]^[7]

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.^[8]. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD.

[edit] The current DSM

[edit] 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 have that disorder. DSM-IV states that “there is no assumption that 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.^[9] Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. The DSM-IV also introduced a diagnostic criterion of “clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed this distress criterion from tic disorders and several of the paraphilias. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) adminstrative purposes.

[edit] Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:

Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders
Axis II: underlying pervasive or personality conditions, as well as mental retardation
Axis III: medical conditions which may be relevant to the understanding and treatment of the mental disorder
Axis IV: psychosocial and environmental factors contributing to the disorder
Axis V: Global Assessment of Functioning (on a scale from 100 to 0 — GAF score)

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, and schizophrenia.

Common Axis II disorders include borderline personality disorder, schizotypal personality disorder, antisocial personality disorder, narcissistic personality disorder, and mild mental retardation.

[edit] Cautions

The DSM-IV-TR states that, because it is produced for mental health specialists, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents "cannot simply be applied in a cookbook fashion."^[10] The APA notes that diagnostic labels are primarily for use as a "convenient shorthand" among professionals. The DSM advises that laypersons should consult the DSM only to obtain information, not to make diagnoses, and that people who may have a mental disorder should be referred to psychiatric counseling or treatment. Further, people sharing the same diagnosis/label may not have the same etiology (cause) or require the same treatment; the DSM contains no information regarding treatment or cause for this reason. The range of the DSM represents an extensive scope of psychiatric and psychological issues, and it is not exclusive to what one may consider "illnesses."

[edit] DSM-IV sourcebooks

The DSM-IV doesn't specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials.^[11] ^[12] ^[13] ^[14] The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.^[15]^[16]

[edit] DSM-V planning

The DSM-V is tentatively scheduled for publication in 2011.^[17] In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-IV,^[18] and the resulting work and recommendations were reported in an APA monograph^[19] and peer-reviewed literature.^[20] There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children.^[21] The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendence limited to 25 invited researchers.^[22]

[edit] Criticism

The DSM has been criticised through the years. The manual is, to an extent, a historical document. The science used to create categories, taxonomies, and diagnoses is based on statistical models. These systems are thus subject to the limitations of the methods used to create them. Deconstructive critics assert that DSM invents illnesses and behaviors. Detractors of DSM argue that patients frequently fail to fit into any particular category or fall into several, that time limits and numbers of clinical characteristics required for a categorization are arbitrary and that attention directed towards finding a suitable DSM category for a patient would be better spent discussing possible life-history events that precipitated a mental disturbance or monitoring treatment. Since effective treatment is the aim of the psychiatric profession they would argue that it makes more sense to regard ailments on the basis of how they should be treated rather than on deciding what clinically irrelevant differences place them in one category and not another.

The DSM has also been criticized for allegedly classifying behaviors that are simply uncommon in the current society as disorders. For example, until 1974 the DSM listed homosexuality. It was removed after mounting protests by homosexuals who did not regard their sexual orientation as a mental disorder.[1] Broader criticisms of the antipsychiatry movement are also applicable to the DSM inasmuch as it is a central reference in psychiatry.

A Columbia University team headed by Robert Spitzer, an editor of the DSM, acknowledges a concern about the DSM in their annual report of 2001, “Problems with the current DSM-IV categorical (present vs. absent) approach to the classification of personality disorders have long been recognized by clinicians and researchers.” Among the problems, they list “arbitrary distinction between normal personality, personality traits and personality disorder” and point out the fact that the most commonly diagnosed personality disorder is 301.9, Personality Disorder not Otherwise Specified. ^[23]

There have also been questions of potential bias of DSM authors who define psychiatric disorders. According to The Washington Post, an analysis published in Psychotherapy and Psychosomatics^[24] pointed out that "every psychiatric expert involved in writing the standard diagnostic criteria for disorders such as depression and schizophrenia has had financial ties to drug companies that sell medications for those illnesses."^[25] However, an important limitation of this study was that the analysis did not reveal the extent of their relationships with industry or whether those ties preceded or followed their work on the manual.

In the United States, health insurance typically will not pay for psychological or psychiatric services unless a DSM-IV mental disease diagnosis accompanies the insurance claim. The website of the DSM-V Prelude Project^[26] covers shortcomings of the DSM-IV that may be subject for improvements for the DSM-V.