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The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) and provides a common language and standard criteria for the classification of mental disorders. It is used in the United States - and in varying degrees around the world - by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies and policy makers.


The DSM has attracted controversy and criticism as well as praise. There have been 5 revisions since it was first published in 1952, gradually including more mental disorders - though some have been removed and are no longer considered to be mental disorders.


DSM evolved from systems for collecting census and psychiatric hospital statistics and from a manual developed by the US Army. It was dramatically revised in 1980. The last major revision was the fourth edition (DSM-IV), published in 1994, although a ‘text revision’ was produced in 2000. The fifth edition (DSM-V) is currently in consultation, planning and preparation, due for publication in May 2013.


Users

Many mental health professionals use DSM to determine and help communicate a patient's diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a 5-axis DSM diagnosis of all the patients treated. The DSM can be used clinically in this way and also to categorise 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.

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’. The 1880 census distinguished among seven categories: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917 a Committee on Statistics from what is now known as the American Psychiatric Association, together with the National Commission on Mental Hygiene, developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane which included 22 diagnoses. APA, along with the New York Academy of Medicine, also provided the psychiatric nomenclature subsection of the US medical guide, the Standard Classified Nomenclature of Disease, referred to as the ‘Standard’.


DSM (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 and brigadier general William C Menninger developed a new classification scheme, Medical 203, issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to DSM-I states the US Navy had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces" and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty."


The Veterans Administration also adopted a slightly modified version of Medical 203.


In 1949, the World Health Organisation 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 states this "categorised mental disorders in rubrics similar to those of the Armed Forces nomenclature". An APA Committee on Nomenclature & Statistics was empowered to develop a version specifically for use in the United States, to standardise the diverse and confused usage of different documents. In 1950 the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system and the Standard's nomenclature, to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions, the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text identical. The manual was 130 pages long and listed 106 mental disorders.


DSM-II (1968)

Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to also go ahead with a revision of DSM. This was also published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the original DSM. The term ‘reaction’ was dropped but the term ‘neurosis’ was retained. Both DSM and the DSM-II reflected the predominant Psychodynamic psychiatry, although they also included biological perspectives and concepts from Emil Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was also incorporated, in a model that did not emphasise a clear boundary between normality and abnormality.


Following controversy and protests from gay activists at APA annual conferences from 1970 to 1973, as well as the emergence of new data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of DSM-II in 1974 no longer listed homosexuality as a category of disorder. But through the efforts of psychiatrist Robert Spitzer, who had led the DSM-II development committee, a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of ‘sexual orientation disturbance’, presently referred to as ‘gender identity disorder’ (GID).


For all that he had been so heavily involved in its development, Spitzer & Joseph Fleiss (1974) published a paper damning DSM-II as unreliable.


DSM-III (1980)

In 1974, the decision to create a new revision of the DSM was made and Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with ICD. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including David Rosenhan’s ‘On being Sane in Insane Places’ (1973). There was also a need to standardise diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA. The establishment of these criteria was also an attempt to facilitate the pharmaceutical regulatory process.


The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University 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 categorisation on colloquial English descriptive language (which would be easier to use by Federal administrative offices), rather than assumptions of aetiology, 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 view was abandoned, in favor of a regulatory or legislative model. A new multiaxial system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued, “mental disorders are a subset of medical disorders” but the task force decided on the DSM statement: “Each of the mental disorders is conceptualised as a clinically significant behavioural 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 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, with DSM-III in 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 long and listed 265 diagnostic categories. It rapidly came into widespread international use by multiple stakeholders and has been termed a revolution or transformation in Psychiatry.


DSM-III-R (1987)

In 1987 the DSM-III-R was published as a revision of DSM-III, under the direction of Spitzer. Categories were renamed, reorganised, and significant changes in criteria were made. 6 categories were deleted while others were added. Controversial diagnoses such as Pre-Menstrual Dysphoric Disorder and Masochistic Personality Disorder were considered and discarded. ‘Ego-dystonic homosexuality’ was also removed, but was largely subsumed under ‘sexual disorder not otherwise specified’ which can include "persistent and marked distress about one’s sexual orientation". Altogether DSM-III-R contained 292 diagnoses and was 567 pages long.


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 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three step process. First, each group conducted an extensive literature review of their diagnoses. Then they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative. Finally, they conducted multi-centre field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.


ADHD (Attention Deficit Hyperactivity Disorder) was characterised at this stage.


DSM-IV-TR (2000)

A "Text Revision’ of DSM-IV, known as DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD.


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. Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.


Multi-axial system

The DSM-IV organises each psychiatric diagnosis into 5 levels (axes) relating to different aspects of disorder or disability:-


Common Axis I disorders include Depression, anxiety disorders, Bipolar Disorder, ADHD, Autism Spectrum Disorders, phobias, and Schizophrenia.


Common Axis II disorders include personality disorders: Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder, Borderline Personality Disorder, Antisocial Personality Disorder, Narcissistic Personality Disorder, Histrionic Personality Disorder, Avoidant Personality Disorder, Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder and mental retardation. Axis II has a rating scale to measure mental retardation.


Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.


Reservations

The DSM-IV-TR states, because it is produced for the completion of Federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”. The APA notes diagnostic labels are primarily for use as a ‘convenient shorthand’ among professionals. The DSM advises laypersons should consult the DSM only to obtain information - not to make diagnoses - and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis/label may have different aetiologies (or require different treatments; DSM contains no information regarding treatment or cause for this reason. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered ‘illnesses’.


Sourcebooks

The DSM-IV doesn't specifically cite its sources but there are 4 volumes of ‘sourcebooks’ intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials. The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV and, hence, the scientific credibility of contemporary psychiatric classification


Validity & Rreliability

The most fundamental scientific criticism of the DSM concerns the validity and reliability of its diagnoses. This means whether the disorders it defines are actually real conditions in people in the real world that can be consistently identified by its criteria. These are long-standing criticisms of the DSM, originally highlighted by Rosenhan and continuing despite some improved reliability since the introduction of more specific rule-based criteria for each condition.


Proponents argue that the inter-rater reliability of DSM diagnoses (via a specialised Structured Clinical Interview for DSM-IV (SCID) rather than the usual psychiatric assessment) is reasonable and that there is good evidence of distinct patterns of mental, behavioural or neurological dysfunction to which the DSM disorders correspond well. It is accepted, however, that there is a large range of reliability findings in studies and that validity is unclear because, given the lack of diagnostic laboratory or neuroimaging tests, standard clinical interviews are "inherently limited" and only a ("flawed") "best estimate diagnosis" is possible even with full assessment of all data over time.


Critics, such as psychiatrist Niall McLaren, argue that the DSM lacks validity because it has no relation to an agreed scientific model of mental disorder and, therefore, the decisions taken about its categories (or even the question of categories vs dimensions) were not scientific ones; and that it lacks reliability partly because different diagnoses share many criteria, and what appear to be different criteria are often just rewordings of the same idea, meaning that the decision to allocate one diagnosis or another to a patient is to some extent a matter of personal prejudice.


J M Goldstein (1988) rediagnosed 199 female schizophrenics using DSM-III who had originally been diagnosed using DSM-II. She found some differences between the 2 versions of the systems but, between herself and her colleagues using DSM-III, there was good inter-rater reliability.


Cleusa et al (1990) compared DSM-IV and the Portuguese classification system on dependence disorders and found good agreement for measuring the severity of dependence on cocaine, cannabis and alcohol.


Brown et al (2001) aimed to test the reliability of DSM-IV with 362 Boston out-patients suffering from anxiety and mood disorders. The patients underwent 2 independent interviews using the DSM-IV Anxiety Disorders Interview Schedule. For most of the DSM-IV categories there was good to excellent reliability, with inter-rater reliability. Where they did find some difficulties was with boundaries between disorders - eg: between Generalised Anxiety Disorder and Major Depression.


Hoffmann (2002) looked at the different diagnoses of alcohol abuse, alcohol dependence and cocaine dependence in prison inmates to see how they corresponded to DSM-IV-TR criteria. He found that the diagnoses were valid – thus claiming Descriptive Validity - and that interview data supported the DSM concept that dependence was a more severe syndrome than abuse.


Randy Stinchfield (2003) tested both reliability and validity with DSM-IV criteria for pathological gambling with 803 men and women from Minnesota who were on a gambling treatment programme. Using a 19-item questionnaire, Stinchfeld found DSM-IV diagnostic criteria for pathological gambling were both reliable and valid.


Kim-Cohen et al (2006) studied the validity of DSM-IV in respect of conduct disorder in 5-year-olds. Their participants were 2,232 children already being followed as part of another longitudinal study. They found that 6.6% of the children were diagnosed with conduct disorder (3 or more symptoms) and 2.5% with moderate to severe conduct disorder (5 or more symptoms). The children diagnosed with conduct disorder were more likely to self-report anti-social behaviour, more likely to be disruptive during observational assessment and to have behavioural and educational difficulties by the age of 7. Drawing data from multiple sources – interviews with the children’s mothers, teacher questionnaires, observations and self-report – all strengthened the Concurrent Validity of the diagnoses.


Lahey et al (2006) found good Predictive Validity with regard to social and academic functioning over a 6-year period for children diagnosed with ADHD.


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