Diagnostic and Statistical Manual of Mental Disorders



The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, is the handbook used most often in diagnosing mental disorders in the United States and internationally. The International Statistical Classification of Diseases and Related Health Problems (ICD) is a commonly-used alternative.

Some psychologists have stated that they use DSM primarily for completing forms for the government or insurance companies, some of which require a patient to be classified by a diagnosis.

Development
The criteria and classification system of the DSM are based on the majority opinion of people who represent American mental health specialists. Therefore, the content of the DSM does not reflect all opinions on the subject of psychopathology, nor are there any objective standards to which it can adhere. The criteria, and the way they are applied by individual clinicians are at least to some extent influenced by cultural variables. What is and what is not considered a mental disorder changes over time. For example, several decades ago homosexuality was commonly considered a mental disorder, and it was listed in the DSM as such. Today, homosexuality is seen by most psychologists and psychiatrists as a normal sexual orientation. It is also known that diagnosis of some mental disorders is influenced by gender role expectations. That is, while diagnostic criteria do not mention gender, clinicians diagnose women's and men's behaviour in different ways.1

The categories do not represent a complete list of all psychiatric disorders or research topics. For instance, the DSM does not categorize mental disorders that are specific to other (i.e. non-American) cultures, such as koro, susto, or taijin kyofusho. The DSM categories do not include many uncommon or rare syndromes although at times they are mentioned in the text.

Brief history
Users should be reminded that the manual is, to an extent, a historical document.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 categorisation 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. This would allow for the modular treatment of different sets of symptoms, for instance prescribing antidepressants for a deficit of serotonin and tranquillisers to deal with acute anxiety.


 * The first edition (DSM-I) was published in 1952, and had about 60 different disorders.


 * DSM-II was published in 1968.
 * Both of these editions were strongly influenced by the psychodynamic approach, which provides no sharp distinction between normal and abnormal. All disorders are considered reactions to environmental events, with mental disorders existing on a continuum of behavior.  In this sense, everyone is more or less abnormal. The people with more severe abnormalities have more severe difficulties with functioning.


 * The classificatory structure of early editions of the DSM was rooted in a distinction between two poles of mental disorder, psychosis and neurosis. A psychosis is a severe mental disorder characterized by a disconnection from reality. Psychoses typically involve hallucinations, delusions, and illogical thinking. A neurosis, however, is a milder mental disorder characterized by distortions of reality, but not a complete break with reality. Neuroses typically involve anxiety and depression.


 * Among the most noted examples of controversial diagnoses is the classifying in the DSM-II of homosexuality as a mental disorder, a classification that was removed by vote of the APA in 1973 after three years of various gay activists groups demonstrating at APA meetings (see also homosexuality and psychology).


 * In 1980, with DSM-III, the psychodynamic view was abandoned and the biomedical model became the primary approach, introducing a clear distinction between normal and abnormal. The DSM became atheoretical since it had no preferred etiology for mental disorders.


 * In 1987 the DSM-III-R appeared as a revision of DSM-III. Many criteria were changed.


 * In 1994, it evolved into DSM-IV. This work is currently in its fourth edition.


 * The most recent version is the 'Text Revision' of the DSM-IV, also known as the DSM-IV-TR, published in 2000. The vast majority of the criteria for the diagoses were not changed from DSM-IV. The text in between the criteria was updated.


 * DSM-V, is tentatively scheduled for publication in 2011, with initial planning having begun in 1999. The APA Division of Research expects to begin forming DSM development workgroups in 2007.

A multiaxial approach
The Diagnostic and Statistical Manual of Mental Disorders, presently in its fourth revised (IV-TR, 2000) edition, systemizes psychiatric diagnosis in five axes:
 * Axis I: major mental disorders, developmental disorders and learning disabilities
 * Axis II: underlying pervasive or personality conditions, as well as mental retardation
 * Axis III: any nonpsychiatric medical condition ("somatic")
 * Axis IV: social functioning and impact of symptoms
 * Axis V: Global Assessment of Functioning (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, and mild mental retardation.

The contents of the DSM are determined by experts whose mandate is to create a set of diagnoses that are replicable and meaningful. While the classification system was originally intended to enhance research into both diagnosis and treatment, the nomenclature is now widely used by both clinicians and insurance companies.

Limitations
The DSM is intended for use by mental health professionals, and for use in research and administration. Appropriate use of the diagnostic criteria requires clinical training, and its contents "cannot simply be applied in a cookbook fashion". APA notes that diagnostic labels are primarily for use as a "convenient shorthand" among professionals for the same symptoms. Further, people sharing the same diagnosis/label may not have the same etiology (cause), or require the same treatment (the DSM contains no information on treatment or cause for this reason).

Criticism
The DSM is routinely attacked for being non-scientific. Columbia University acknowledges the unscientific nature of 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 interesting fact that the most commonly diagnosed personality disorder is 301.9, Personality Disorder not Otherwise Specified.

"The field of mental health is highly subjective, capricious, and dominated by whims, mythologies, and public relations. In many ways it is a pop culture with endless fads but with no real substance." – Dr. Walter Fisher, Assistant Superintendent, Elgin State Hospital.

Reference
1 Ford, M. R. & Widiger, T. A. (1989) Sex bias in the diagnosis of histrionic and antisocial personality disorder. Journal of Consulting and Clinical Psychology, 57, 301-305.