Diagnostic and statistical manual of mental disorders

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vatsala Sharma, M.B.B.S., M.D.

Overview

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication by the American Psychiatric Association that lists different categories and the diagnostic criteria for mental disorders. There are multiple revisions of the DSM since it was first published in 1952. These revisions have made changes in the subsequent editions through the inclusion and removal of a number of psychiatric diagnostic entities. The lastest revision is in the form of DSM-5. International Classification of Diseases (ICD) by WHO, is another commonly used classification system in psychiatry. Both DSM and ICD use hierarchical and categorical classification systems. Hierarchical classification is based on the idea that one diagnostic entity wins over the other. Categorical classification is based on the fact that every diagnosis is distinct. DSM is used worldwide by clinicians, researchers, insurance companies, pharmaceutical companies, legal systems, and policymakers. It has attracted praise, controversy, as well as criticism.

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 United States military, and from a survey of the views of 10% of APA members.[1]
  • The manual was 130 pages long and had 106 categories of mental disorders.
  • The DSM-II was published in 1968; it listed 182 disorders, and contained 134 pages. [2]
  • Symptoms were not specified in detail for specific disorders but were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, and rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was also incorporated in a model that did not emphasize a clear boundary between normality and abnormality.[3]
  • In 1974, the decision to create a new revision of the DSM was taken, and Robert Spitzer was elected 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). [4]
  • The goal was to improve the reliability of psychiatric diagnosis. The practices of mental health professionals, especially in different countries, were not uniform. The establishment of specific criteria was also an attempt to facilitate mental health research. The multiaxial system attempted to yield a more complete picture of the patient, rather than just a simple diagnosis.
  • Through DSM-III, an attempt was made to base categorization on description rather than assumptions of etiology. The psychodynamic view was abandoned, 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.
  • The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced. 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 the deletion of the concept of neurosis and the mainstreaming of psychoanalytic theory. 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. In 1980, the DSM-III was published, with 494 pages and had 265 diagnostic categories. The DSM-III rapidly came into widespread international use by multiple stakeholders and had been termed a revolution in psychiatry.[2][3]
  • In 1987, under the direction of Spitzer DSM-III was revised to DSM-III-R. Categories were renamed, reorganized, and significant changes in criteria were made. Controversial diagnoses such as premenstrual dysphoric disorder and masochistic personality disorder were discarded. DSM-III-R contained 567 pages and 292 diagnostic categories.
  • 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 workgroups of 5–16 members. Each workgroup had approximately 20 advisers. The workgroups 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. Finally, they conducted multicenter field trials relating diagnoses to clinical practice.[5][6]
  • 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 criteria for diagnosis remained unchanged.[7] 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.
  • DSM-5 made significant changes in the overall structure. The diagnostic criteria for some categories were modified as well. A major change in DSM-5 from previous versions was the inclusion of a clinical significance criterion to almost half of the categories, which required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”.[8]
  • Changes to the DSM were mainly due to the advances in neuroscience, clinical, and public health need. The problems found with the classification system and criteria in the DSM‐IV also necessitated the development of DSM-5. The decision‐making was also aimed at a better alignment with the 11th edition of the International Classification of Diseases (ICD‐11).[9]

DSM and politics

  • Following controversy and protests from activists at APA annual conferences from 1970 to 1973, the seventh printing of the DSM-II (1974) no longer listed homosexuality as a disorder. 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, and confirmation by the wider APA membership in 1974, the diagnosis was replaced by a milder category of "sexual orientation disturbance". In 1980, this was further substituted by the diagnosis of ego-dystonic homosexuality in the DSM-III and was removed in 1987 with the release of the DSM-III-R.[2][10][11]
  • A category of "sexual disorder not otherwise specified" continued in the DSM-IV, which mainly included persistent and marked distress about one’s sexual orientation. This could apply to any sexual orientation. [12]
  • Removal of the diagnosis of homosexuality from the DSM led to an important shift of focus from treatment to satisfaction of the mental health needs of this population.[13]

Categorization

  • The DSM 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 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.[14]
  • 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.
  • Each category of disorder has a numeric code used for health service (including insurance) administrative purposes.

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: acute medical conditions and physical disorders
  • Axis IV: psychosocial and environmental factors contributing to the disorder
  • Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children under the age of 18. (on a scale from 100 to 0)

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.

Cautions

  • The DSM 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. [15]
  • 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 for psychiatric treatment.
  • Further, people sharing the same diagnosis may not have the same etiology or require the same treatment. The DSM contains no information regarding treatment.
  • 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.

DSM-5

  • The DSM‐5 was formulated with the goal of addressing the drawbacks of the DSM‐IV while combining the latest scientific and clinical evidence. [9]
  • Between 2003 to 2008, 13 international research conferences were held to draft the guidelines. These conferences involved nearly 400 experts from 13 countries, representing disciplines of psychiatry, psychology, neurology, pediatrics, primary care, epidemiology, research methodology, and statistics.[9]
  • DSM‐5 was published in May 2013. [9]
  • DSM-5 has a clear-cut movement toward the dimensional conceptualization of disorders and there is dissolution of the multiaxial system.[16]
  • In addition, DSM-5 includes a piece of well-systematic information regarding gender and culture for each diagnostic category.[16]

Changes from DSM-IV to DSM-5

  • In DSM-5, somatoform disorders are now called somatic symptom and related disorders.[17]
  • The diagnosis of hypochondriasis has been replaced by illness anxiety disorder in DSM-5. Individuals with high health anxiety without somatic symptoms receive this diagnosis.[18]
  • Criteria for conversion disorder of DSM-IV are modified in DSM-5 to emphasize the importance of the neurological examination. Conversion disorder is called functional neurological symptom disorder in DSM-5.[19]
  • In DSM-5, the diagnosis of intellectual disability emphasizes the level of adaptive functioning. DSM-IV’s importance to Intelligence Quotient (IQ) only led to problematic outcomes.[20]
  • Autism spectrum disorder is a new diagnostic category in DSM-5 that encompasses the DSM-IV's autistic disorder, asperger’s disorder, and childhood disintegrative disorders.[20]
  • A new category of specific learning disorder combines all the DSM-IV learning-disorder diagnoses, reflecting that these conditions often occur together.[20]
  • DSM-IV's dementia and amnestic disorder are combined in a new major neurocognitive disorder category. DSM-5 also adds a new category of mild neurocognitive disorder for the minimally diminished cognitive functioning.[20]

Criticism

There have been a number of persistent critical debates about the DSM.

  • There have been continuing scientific discussions concerning the construct validity and practical reliability of the diagnostic criteria and categories in the DSM, even though they have been increasingly standardized to improve inter-rater agreement in controlled research.[21][22][23] It has been argued that the DSM's claims to being empirically founded are overstated.
  • Psychiatric diagnosis continues to suffer from relatively low reliability in the clinical settings, and diagnoses in DSM-5 continue to be dependant on clinical phenomenology rather than on biomarkers. [8]
  • On the contrary, some clinicians believe that psychiatry is in crisis and the descriptions of mental disorders in the DSM do not match clinical observations. In addition to acknowledging the role of brain sciences and psychopharmacology, these authors believe that psychiatry should move beyond the current, technological paradigm. Although mental health issues have a biological basis, they also involve social, cultural, and psychological dimensions.[24][8]
  • 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 between normal and abnormal. Some authors argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[25][26][27][28]
  • It has been argued that purely symptom-based diagnostic criteria fail to adequately take into account the context in which a person is living. It also sidelines the demarcation between a disorder and a response to an ongoing situation.[29][30] It is claimed that the use of distress and disability as additional criteria for many disorders has not solved this false-positives problem, because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors.[31]
  • The political context of the DSM is a topic of controversy, including its use by drug and insurance companies. The potential for conflict of interest has been raised because according to evidence, some of the authors who previously selected and defined the DSM psychiatric disorders have had financial relationships with pharmaceutical industries and drug companies.[32]
  • Some argue that the expansion of disorders in the DSM has been influenced by profit motives and represents an increasing medicalization of normal human behavior, while others argue that mental health problems are still under-recognized and under-treated. [33]

See also

References

  1. ↑ Grob, GN. (1991) Origins of DSM-I: a study in appearance and reality Am J Psychiatry. Apr;148(4):421–31.
  2. ↑ 2.0 2.1 2.2 Mayes, R. & Horwitz, AV. (2005) DSM-III and the revolution in the classification of mental illness. J Hist Behav Sci 41(3):249–67.
  3. ↑ 3.0 3.1 Wilson, M. (1993) DSM-III and the transformation of American psychiatry: a history. Am J Psychiatry. 1993 Mar;150(3):399–410.
  4. ↑ Speigel, A. (2005) The Dictionary of Disorder: How one man revolutionized psychiatry The New Yorker, issue of 2005-01-03.
  5. ↑ Allen Frances, Avram H. Mack, Ruth Ross, and Michael B. First (2000) The DSM-IV Classification and Psychopharmacology.
  6. ↑ Schaffer, David (1996) A Participant's Observations: Preparing DSM-IV Can J Psychiatry 1996;41:325–329.
  7. ↑ APA Summary of Practice-Relevant Changes to the DSM-IV-TR.
  8. ↑ 8.0 8.1 8.2 Stein, Dan J.; Lund, Crick; Nesse, Randolph M. (2013). "Classification systems in psychiatry". Current Opinion in Psychiatry. 26 (5): 493–497. doi:10.1097/YCO.0b013e3283642dfd. ISSN 0951-7367.
  9. ↑ 9.0 9.1 9.2 9.3 Regier, Darrel A.; Kuhl, Emily A.; Kupfer, David J. (2013). "The DSM-5: Classification and criteria changes". World Psychiatry. 12 (2): 92–98. doi:10.1002/wps.20050. ISSN 1723-8617.
  10. ↑ "The diagnostic status of homosexuality in DSM-III: a reformulation of the issues", by R.L. Spitzer, Am J Psychiatry 1981; 138:210-215
  11. ↑ Spiegel, Alix. (18 January 2002.) "81 Words". In Ira Glass (producer), This American Life. Chicago: Chicago Public Radio.
  12. ↑ Silverstein, Charles (2008). "The Implications of Removing Homosexuality from the DSM as a Mental Disorder". Archives of Sexual Behavior. 38 (2): 161–163. doi:10.1007/s10508-008-9442-x. ISSN 0004-0002.
  13. ↑ Drescher, Jack (2015). "Out of DSM: Depathologizing Homosexuality". Behavioral Sciences. 5 (4): 565–575. doi:10.3390/bs5040565. ISSN 2076-328X.
  14. ↑ Maser, JD. & Patterson, T. (2002) Spectrum and nosology: implications for DSM-V Psychiatric Clinics of North America, Dec, 25(4)p855-885
  15. ↑ http://www.psych.org/research/dor/dsm/dsm_faqs/faq81301.cfm
  16. ↑ 16.0 16.1 Kress, Victoria E.; Barrio Minton, Casey A.; Adamson, Nicole A.; Paylo, Matthew J.; Pope, Verl (2014). "The Removal of the Multiaxial System in the DSM-5: Implications and Practice Suggestions for Counselors". The Professional Counselor. 4 (3): 191–201. doi:10.15241/vek.4.3.191. ISSN 2164-3989.
  17. ↑ "Highlights of Changes from DSM-IV to DSM-5". FOCUS. 11 (4): 525–527. 2013. doi:10.1176/appi.focus.11.4.525. ISSN 1541-4094.
  18. ↑ "Highlights of Changes from DSM-IV to DSM-5". FOCUS. 11 (4): 525–527. 2013. doi:10.1176/appi.focus.11.4.525. ISSN 1541-4094.
  19. ↑ "Highlights of Changes from DSM-IV to DSM-5". FOCUS. 11 (4): 525–527. 2013. doi:10.1176/appi.focus.11.4.525. ISSN 1541-4094.
  20. ↑ 20.0 20.1 20.2 20.3 Wakefield, Jerome C. (2013). "DSM-5: An Overview of Changes and Controversies". Clinical Social Work Journal. 41 (2): 139–154. doi:10.1007/s10615-013-0445-2. ISSN 0091-1674.
  21. ↑ Kendell R, Jablensky A. (2003) Distinguishing between the validity and utility of psychiatric diagnoses.Am J Psychiatry. Jan;160(1):4-12. PMID 12505793
  22. ↑ Baca-Garcia E, Perez-Rodriguez MM, Basurte-Villamor I, Fernandez del Moral AL, Jimenez-Arriero MA, Gonzalez de Rivera JL, Saiz-Ruiz J, Oquendo MA. (2007) Diagnostic stability of psychiatric disorders in clinical practice. Br J Psychiatry. Mar;190:210-6. PMID 17329740
  23. ↑ Pincus et al. (1998) "Clinical Significance" and DSM-IV Arch Gen Psychiatry.1998; 55: 1145
  24. ↑ Bracken, Pat; Thomas, Philip; Timimi, Sami; Asen, Eia; Behr, Graham; Beuster, Carl; Bhunnoo, Seth; Browne, Ivor; Chhina, Navjyoat; Double, Duncan; Downer, Simon; Evans, Chris; Fernando, Suman; Garland, Malcolm R.; Hopkins, William; Huws, Rhodri; Johnson, Bob; Martindale, Brian; Middleton, Hugh; Moldavsky, Daniel; Moncrieff, Joanna; Mullins, Simon; Nelki, Julia; Pizzo, Matteo; Rodger, James; Smyth, Marcellino; Summerfield, Derek; Wallace, Jeremy; Yeomans, David (2018). "Psychiatry beyond the current paradigm". British Journal of Psychiatry. 201 (6): 430–434. doi:10.1192/bjp.bp.112.109447. ISSN 0007-1250.
  25. ↑ Spitzer, Robert L, M.D., Williams, Janet B.W, D.S.W., First, Michael B, M.D., Gibbon, Miriam, M.S.W., Biometric Research
  26. ↑ Maser, JD & Akiskal, HS. et al. (2002) Spectrum concepts in major mental disorders Psychiatric Clinics of North America, Vol. 25, Special issue 4
  27. ↑ Krueger, RF., Watson, D., Barlow, DH. et al. (2005) Toward a Dimensionally Based Taxonomy of Psychopathology Journal of Abnormal Psychology Vol 114, Issue 4
  28. ↑ Bentall, R. (2006) Madness explained : Why we must reject the Kraepelinian paradigm and replace it with a 'complaint-orientated' approach to understanding mental illness Medical hypotheses, vol. 66(2), pp. 220-233
  29. ↑ Chodoff, P. (2005) Psychiatric Diagnosis: A 60-Year Perspective Psychiatric News June 3, 2005 Volume 40 Number 11, p17
  30. ↑ Jerome C. Wakefield, PhD, DSW; Mark F. Schmitz, PhD; Michael B. First, MD; Allan V. Horwitz, PhD (2007) Extending the Bereavement Exclusion for Major Depression to Other Losses: Evidence From the National Comorbidity Survey Arch Gen Psychiatry. 2007;64:433-440.
  31. ↑ Spitzer RL, Wakefield JC. (1999) DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? Am J Psychiatry. 1999 Dec;156(12):1856-64. PMID 10588397
  32. ↑ Cosgrove, Lisa, Krimsky, Sheldon,Vijayaraghavan, Manisha, Schneider, Lisa,Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry
  33. ↑ Kirk, A.S. (2005) Are we all going mad, or are the experts crazy? August 14 edition of the Los Angeles Times.


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