Diagnostic and Statistical Manual of Mental Disorders
 |
The Diagnostic and Statistical Manual published by the American Psychiatric Association |
The
Diagnostic and Statistical Manual of Mental Disorders (
DSM-IV-TR), published by the
American Psychiatric Association, is the handbook used most often in diagnosing
mental disorders in the
United States. The
' (ICD) is a commonly-used alternative internationally. The DSM tends to be the more specific of the two. Both assume medical concepts and terms, and state that there are categorical disorders that can be diagnosed by set lists of criteria. It is controversial and some mental health professionals and others question the utility of this classification system.
The DSM has gone though five revisions (II, III, III-R, IV, IV-TR) since it was first published. The next version will be the DSM V, due in approximately 2010.
The DSM-IV-TR warns that, because the Diagnostic and Statistical Manual of Mental Disorders' (DSM'') is produced for mental health specialists, its use by people without clinical training can lead to inappropriate application of its contents. They generally advise 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.
The DSM was initially developed to give more objective terms for psychiatric research. Before the DSM, communication between psychiatrists, 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 are based on a process of consultation and committee meetings involving primarily psychiatrists. Therefore, the content of the DSM does not reflect all opinions on the subject of psychopathology, emotional distress and social functioning. Nor are there any objective, biological verifiable standards to which it adheres. The criteria, and the way they are applied by individual clinicians are at least to some extent influenced by cultural variables and are periodically altered to reflect the contemporary social landscape. What is and what is not considered a mental disorder changes over time. For example, before a psychiatric
plebiscite in 1973,
homosexuality was listed in the DSM as a diagnosable mental illness. It is also known that the diagnosis of some mental disorders is influenced by
gender role expectations. That is, while diagnostic criteria do not mention gender, clinicians may diagnose women's and men's behaviour in different ways
[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.].
Users should be reminded that the manual is, to an extent, an 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 106 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 continuoum 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
1986 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 diagnosis 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 [
1].
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.
The DSM is intended for use by mental health professionals, and for use in research and administration. Appropriate use of the diagnostic criteria requires extensive clinical training, and its contents "cannot simply be applied in a cookbook fashion" [
2]. 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). The range and breadth of the DSM represents an extensive scope. Impotence, premature ejaculation, jet lag, caffeine addiction, and bruxism are examples of surprising inclusions and are but only several that non-psychiatrists might not consider to be mental illnesses.
The DSM is routinely attacked as being unscientific, even though it is intended as a tool for measurement. Columbia University acknowledges a similar concern about 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.
Dr. Paula J. Caplan is a clinical and research psychologist and co-author of
[Bias in Psychiatric Diagnosis].[
3] She has called for Congressional hearings regarding DSM labeling and created a website criticizing the unscientific nature of DSM labels and purports that these labels have caused harm.
Another question is the potential bias of DSM authors who define psychiatric disorders, and whether or not there is a vested financial interest in diagnosis. According to
The Washington Post, a recent analysis published in
Psychotherapy and Psychosomatics found:
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. (
see)
This report also noted 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", and did not discuss whether or not the financial ties were limited to research-funding (which might pose a conflict of interest, but might not).
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. Critics claim that this may have exacerbated the ever-expanding number of disease categories. It may also cause people to be labeled with "illness" for the purpose of re-imbursement. All physician services in the United States require an ICD code for health insurance payment, regardless if the patient has a definable illness or not. This is equally true of mental or physical complaints.
*
*
Complete List of DSM-IV Codes*
GAF Scale*
Chinese Classification and Diagnostic Criteria of Mental Disorders*
DSM home page at APPI*
DSM-IV-TR online
