Diagnostic and Statistical Manual of Mental Disorders
Nature and purposes
The Diagnostic and Statistical Manual of Mental Disorders is a reference work consulted by psychiatrists, psychologists, physicians in clinical practice, social workers , medical and nursing students, pastoral counselors, and other professionals in health care and social service fields. The book's title is often shortened to DSM , or an abbreviation that also indicates edition, such as DSM-IV-TR, which indicates fourth edition, text revision of the manual, published in 2000. The DSM-IV-TR provides a classification of mental disorders, criteria sets to guide the process of differential diagnosis , and numerical codes for each disorder to facilitate medical record keeping. The stated purpose of the DSM is threefold: to provide "a helpful guide to clinical practice"; "to facilitate research and improve communication among clinicians and researchers"; and to serve as "an educational tool for teaching psychopathology."
The multi-axial system
The third edition of DSM , or DSM-III , which was published in 1980, introduced a system of five axes or dimensions for assessing all aspects of a patient's mental and emotional health. The multi-axial system is designed to provide a more comprehensive picture of complex or concurrent mental disorders. According to the DSM-IVTR, the system is also intended to "promote the application of the biopsychosocial model in clinical, educational and research settings." The reference to the biopsychosocial model is significant, because it indicates that the DSM-IV-TR does not reflect the view of any specific "school" or tradition within psychiatry regarding the cause or origin (also known as "etiology") of mental disorders. In other words, the DSM-IV-TR is atheoretical in its approach to diagnosis and classification— the axes and categories do not represent any overarching theory about the sources or fundamental nature of mental disorders.
The biopsychosocial approach was originally proposed by a psychiatrist named George Engel in 1977 as a way around the disputes between psychoanalytically and biologically oriented psychiatrists that were splitting the field in the 1970s. The introduction to DSM-IV-TR is quite explicit about the manual's intention to be "applicable in a wide variety of contexts" and "used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, inter-personal, family/systems)."
The atheoretical stance of DSM-IV-TR is also significant in that it underlies the manual's approach to the legal implications of mental illness. DSM notes the existence of an "imperfect fit between questions of ultimate concern to the law and the information contained in a clinical diagnosis." What is meant here is that the DSM-IV-TR diagnostic categories do not meet forensic standards for defining a "mental defect," "mental disability," or similar terms. Because DSM-IV-TR states that "inclusion of a disorder in the classification ... does not require that there be knowledge about its etiology," it advises legal professionals against basing decisions about a person's criminal responsibility, competence, or degree of behavioral control on DSM diagnostic categories.
The five diagnostic axes specified by DSM-IV-TR are:
- Axis I: Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.
- Axis II: Personality disorders and mental retardation . This axis includes notations about problematic aspects of the patient's personality that fall short of the criteria for a personality disorder.
- Axis III: General medical conditions. These include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient's mood or functioning; or that influence the choice of medications for treating the mental disorder.
- Axis IV: Psychosocial and environmental problems. These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder. DSM-IV-TR lists the following categories of problems: family problems; social environment problems; educational problems; occupational problems; housing problems; economic problems; problems with access to health care; problems with the legal system; and other problems (war, disasters, etc.).
- Axis V: Global assessment of functioning. Rating the patient's general level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress. The primary scale for Axis V is the Global Assessment of Functioning (GAF) Scale, which measures level of functioning on a scale of 1–100. DSM-IV-TR includes three specialized global scales in its appendices: the Social and Occupational Functioning Assessment Scale (SOFAS); the Defensive Functioning Scale; and the Global Assessment of Relational Functioning (GARF) Scale. The GARF is a measurement of the maturity and stability of the relationships within a family or between a couple.
The Axis I clinical disorders are divided among 15 categories: disorders usually first diagnosed in infancy, childhood, or adolescence; delirium , dementia , amnestic, and other cognitive disorders; medical disorders due to a general medical condition; substance-related disorders; schizophrenia and other psychotic disorders; mood disorders; anxiety disorders; somatoform disorders; factitious disorders; dissociative disorders; sexual and gender identity disorders; eating disorders; sleep disorders ; impulse control disorders not elsewhere classified; and adjustment disorders.
The diagnostic categories of DSM-IV-TR are essentially symptom-based, or, as the manual puts it, based "on criteria sets with defining features." Another term that is sometimes used to describe this method of classification is phenomenological . A phenomenological approach to classification is one that emphasizes externally observable phenomena rather than their underlying nature or origin.
Another important characteristic of DSM-IV-TR's classification system is its dependence on the medical model of mental disorders. Such terms as "psychopathology," "mental illness," "differential diagnosis," and "prognosis" are all borrowed from medical practice. One should note, however, that the medical model is not the only possible conceptual framework for understanding mental disorders. Historians of Western science have observed that the medical model for psychiatric problems was preceded by what they term the supernatural model (mental disorders understood as acts of God or the result of demon possession), which dominated the field until the late seventeenth century. The supernatural model was followed by the moral model, which was based on the values of the Enlightenment and regarded mental disorders as bad behaviors deliberately chosen by perverse or ignorant individuals.
The medical model as it came to dominate psychiatry can be traced back to the work of Emil Kraepelin, an eminent German psychiatrist whose Handbuch der Psychiatrie was the first basic textbook in the field and introduced the first nosology, or systematic classification, of mental disorders. By the early 1890s Kraepelin's handbook was used in medical schools across Europe. He updated and revised it periodically to accommodate new findings, including a disease that he named after one of his clinical assistants, Alois Alzheimer. The classification in the 1907 edition of Kraepelin's handbook includes 15 categories, most of which are still used nearly a century later. Kraepelin is also important in the history of diagnostic classification because he represented a biologically based view of mental disorders in opposition to the psychoanalytical approach of Sigmund Freud. Kraepelin thought that mental disorders could ultimately be traced to organic diseases of the brain rather than disordered emotions or psychological processes. This controversy between the two perspectives dominated psychiatric research and practice until well after the Second World War.
Background of DSM
The American Diagnostic and Statistical Manual of Mental Disorders goes back to the 1840s, when the United States Bureau of the Census attempted for the first time to count the numbers of patients confined in mental hospitals. Isaac Ray, superintendent of the Butler Hospital in Rhode Island, presented a paper at the 1849 meeting of the Association of Medical Superintendents of American Institutions for the Insane (the forerunner of the present American Psychiatric Association) in which he called for a uniform system of naming, classifying and recording cases of mental illness. The same plea was made in 1913 by Dr. James May of New York to the same organization, which by then had renamed itself the American Medico-Psychological Association. In 1933, the New York Academy of Medicine and the Medico-Psychological Association compiled the first edition of the Statistical Manual for Mental Diseases , which was also adopted by the American Neurological Association. The Statistical Manual went through several editions between 1933 and 1952, when the first edition of the Diagnostic and Statistical Manual of Mental Disorders appeared. The task of compiling mental hospital statistics was turned over to the newly formed National Institute of Mental Health in 1949.
DSM-I and DSM-II
DSM-I , which appeared in 1952, maintained the coding system of earlier American manuals. Many of the disorders in this edition were termed "reactions," a term borrowed from a German psychiatrist named Adolf Meyer. Meyer viewed mental disorders as reactions of an individual's personality to a combination of psychological, social, and biological factors. DSM-I also incorporated the nomenclature for disorders developed by the United States Army and modified by the Veterans Administration to treat the postwar mental health problems of service personnel and veterans. The VA classification system grouped mental problems into three large categories: psychophysiological, personality, and acute disorders.
DSM-II, which was published in 1968, represented the first attempt to coordinate the American Diagnostic and Statistical Manual of Mental Disorders with the World Health Organization's (WHO) International Classification of Diseases , or ICD . DSM-II appeared before the ninth edition of the ICD , or ICD-9, which was published in 1975. DSM-II continued DSM-I's psychoanalytical approach to the etiology of the nonorganic mental disorders and personality disorders.
DSM-III, DSM-III-R and DSM-IV
DSM-III, which was published in 1980 after six years of preparatory work, represented a major break with the first two editions of DSM. DSM-III introduced the present descriptive symptom-based or phenomenological approach to mental disorders, added lists of explicit diagnostic criteria, removed references to the etiology of disorders, did away with the term "neurosis," and established the present multi-axial system of symptom evaluation. This sweeping change originated in an effort begun in the early 1970s by a group of psychiatrists at the medical school of Washington University in St. Louis to improve the state of research in American psychiatry. The St. Louis group began by drawing up a list of "research diagnostic criteria" for schizophrenia, a disorder that can manifest itself in a variety of ways. The group was concerned primarily with the identification of markers for schizophrenia that would allow the disease to be studied at other research sites without errors introduced by using different types of patients in different centers. What happened with DSM-III, DSM-III-R, and DSM-IV, however, was that a tool for scholarly investigation of a few mental disorders was transformed into a diagnostic method applied to all mental disorders without further distinction. The leaders of this transformation were biological psychiatrists who wanted to empty the diagnostic manual of terms and theories associated with hypothetical or explanatory concepts. The transition from an explanatory approach to mental disorders to a descriptive or phenomenological one in the period between DSM-II and DSM-III is sometimes called the "neo-Kraepelinian revolution" in the secondary literature. Another term that has been applied to the orientation represented in DSM-III and its successors is empirical , which denotes reliance on experience or experiment alone, without recourse to theories or hypotheses. The word occurs repeatedly in the description of "The DSM-IV Revision Process" in the Introduction to DSM-IV-TR.
DSM-IV built upon the research generated by the empirical orientation of DSM-III. By the early 1990s, most psychiatric diagnoses had an accumulated body of published studies or data sets. Publications up through 1992 were reviewed for DSM-IV, which was published in 1994. Conflicting reports or lack of evidence were handled by data reanalyses and field trials. The National Institute of Mental Health sponsored 12 DSM-IV field trials together with the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The field trials compared the diagnostic criteria sets of DSM-III, DSM-III-R, ICD-10 (which had been published in 1992), and the proposed criteria sets for DSM-IV. The field trials recruited subjects from a variety of ethnic and cultural backgrounds, in keeping with a new concern for cross-cultural applicability of diagnostic standards. In addition to its inclusion of culture-specific syndromes and disorders, DSM-IV represented much closer cooperation and coordination with the experts from WHO who had worked on ICD-10. A modification of ICD-10 for clinical practitioners, the ICD-10-CM, is scheduled to be introduced in the United States in 2004.
Textual revisions in DSM-IV-TR
DSM-IV-TR does not represent either a fundamental change in the basic classification structure of DSM-IV or the addition of new diagnostic entities. The textual revisions that were made to the 1994 edition of DSM-IV fall under the following categories:
- correction of factual errors in the text of DSM-IV
- review of currency of information in DSM-IV
- changes reflecting research published after 1992, which was the last year included in the literature review prior to the publication of DSM-IV
- improvements to enhance the educational value of DSM-IV
- updating of ICD diagnostic codes, some of which were changed in 1996
Critiques of DSM-IV and DSM-IV-TR
A number of criticisms of DSM-IV have arisen since its publication in 1994. They include the following observations and complaints:
- The medical model underlying the empirical orientation of DSM-IV reduces human beings to one-dimensional sources of data; it does not encourage practitioners to treat the whole person.
- The medical model perpetuates the social stigma attached to mental disorders.
- The symptom-based criteria sets of DSM-IV have led to an endless multiplication of mental conditions and disorders. The unwieldy size of DSM-IV is a common complaint of doctors in clinical practice— a volume that was only 119 pages long in its second (1968) edition has swelled to 886 pages in less than thirty years.
- The symptom-based approach has also made it easier to politicize the process of defining new disorders for inclusion in DSM or dropping older ones. The inclusion of post-traumatic stress disorder (PTSD) and the deletion of homosexuality as a disorder are often cited as examples of this concern for political correctness.
- The criteria sets of DSM-IV incorporate implicit (implied but not expressly stated) notions of human psychological well-being that do not allow for ordinary diversity among people. Some of the diagnostic categories of DSM-IV come close to defining various temperamental and personality differences as mental disorders.
- The DSM-IV criteria do not distinguish adequately between poor adaptation to ordinary problems of living and true psychopathology. One byproduct of this inadequacy is the suspiciously high rates of prevalence reported for some mental disorders. One observer remarked that "... it is doubtful that 28% or 29% of the population would be judged [by managed care plans] to need mental health treatment in a year."
- The 16 major diagnostic classes defined by DSM-IV hinder efforts to recognize disorders that run across classes. For example, PTSD has more in common with respect to etiology and treatment with the dissociative disorders than it does with the anxiety disorders with which it is presently grouped. Another example is body dysmorphic disorder , which resembles the obsessive-compulsive disorders more than it does the somatoform disorders.
- The current classification is deficient in acknowledging disorders of uncontrolled anger, hostility, and aggression. Even though inappropriate expressions of anger and aggression lie at the roots of major social problems, only one DSM-IV disorder ( intermittent explosive disorder ) is explicitly concerned with them. In contrast, entire classes of disorders are devoted to depression and anxiety.
- The emphasis of DSM-IV on biological psychiatry has contributed to the widespread popular notion that most problems of human life can be solved by taking pills.
A number of different nosologies or schemes of classification have been proposed to replace the current descriptive model of mental disorders. Three of them will be briefly described.
The dimensional model
Dimensional alternatives to DSM-IV would replace the categorical classification now in use with a recognition that mental disorders lie on a continuum with mildly disturbed and normal behavior, rather than being qualitatively distinct. For example, the personality disorders of Axis II are increasingly regarded as extreme variants of common personality characteristics. In the dimensional model, a patient would be identified in terms of his or her position on a specific dimension of cognitive or affective capacity rather than placed in a categorical "box."
The holistic model
The holistic approach to mental disorders places equal emphasis on social and spiritual as well as pharmacological treatments. A biochemist who was diagnosed with schizophrenia and eventually recovered compared the reductionism of the biological model of his disorder with the empowering qualities of holistic approaches. He stressed the healing potential in treating patients as whole persons rather than as isolated collections of nervous tissue with chemical imbalances: "The major task in recovering from mental illness is to regain social roles and identities. This entails focusing on the individual and building a sense of responsibility and self-determination."
The essential or perspectival model
The third and most complex alternative model is associated with the medical school of Johns Hopkins University, where it is taught as part of the medical curriculum. This model identifies four broad "essences" or perspectives that can be used to identify the distinctive characteristics of mental disorders, which are often obscured by the present categorical classifications.
The four perspectives are:
- Disease. This perspective works with categories and accounts for physical diseases or damage to the brain that produces psychiatric symptoms. It accounts for such disorders as Alzheimer's disease or schizophrenia.
- Dimensions. This perspective addresses disorders that arise from the combination of a cognitive or emotional weakness in the patient's constitution and a life experience that challenges their vulnerability.
- Behaviors. This perspective is concerned with disorders associated with something that the patient is doing (alcoholism, drug addiction , eating disorders, etc.) that has become a dysfunctional way of life.
- Life story. This perspective focuses on disorders related to what the patient has encountered in life, such as events that have injured his or her hopes and aspirations.
In the Johns Hopkins model, each perspective has its own approach to treatment: the disease perspective seeks to cure or prevent disorders rooted in biological disease processes; the dimensional perspective attempts to strengthen constitutional weaknesses; the behavioral perspective seeks to interrupt the problematic behaviors and assist patients in overcoming their appeal; and the life story perspective offers help in "rescripting" a person's life narrative, usually through cognitive behavioral treatment.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Freeman, Hugh, ed. A Century of Psychiatry. St. Louis, MO: Mosby, 1999.
Kihlstrom, John F. "To Honor Kraepelin...: From Symptoms to Pathology in the Diagnosis of Mental Illness." In Alternatives to the DSM, edited by L. E. Beutler and M. L. Malik. Washington, DC: American Psychological Association, 2000.
World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.
Collins, Geneva. "Radical Makeover Proposed for DSM." Clinical Psychiatry News 29 (August 2001): 1.
Diamond, Ellen A. "A Conceptual Structure for Diagnoses." Psychiatric Times 18 (November 2001): 4-5.
Fisher, Daniel B. "Recovering from Schizophrenia." Clinical Psychiatry News 29 (November 2001): 30.
Kutchins, H., and S. A. Kirk. "DSM-III-R: The Conflict Over New Psychiatric Diagnoses." Health and Social Work 14 (May 1989): 91-101.
McHugh, Paul R. "How Psychiatry Lost Its Way." Commentary 108 (December 1999): 67-72.
McHugh, Paul R. "A Structure for Psychiatry at the Century's Turn: The View from Johns Hopkins." Journal of the Royal Society of Medicine 85 (1992): 483-487.
Ozarin, Lucy D., MD. "DSM: A Brief Historical Note." Psychatric News (April 3, 1998).
"Psychiatrists Call for Overhaul of Unwieldy DSM." Clinical Psychiatry News 29 (October 2001): 20.
Widiger, T. A. "Adult Psychopathology: Issues and Controversies." Annual Review of Psychology (2000).
American Psychiatric Association. 1400 K Street, NW,
Washington, DC 20005. <www.psych.org> .
National Institute of Mental Health. 6001 Executive
Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov> .
Young, Robert M. "Between Nosology and Narrative: Where
Should We Be?" Lecture delivered to the Toronto Psychoanalytic Society, Toronto, Canada, 8 January 1999.
Rebecca J. Frey, Ph.D.