Diagnostic and Statistical Manual of Mental Disorders

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 International Statistical Classification of Diseases and Related Health Problems (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 2011.

Development

The DSM was initially developed to give more objective terms for psychiatric research. Previous to 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 waysFord, 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..

Brief history

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 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 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 ^*.

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 extensive 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). 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.

Criticism

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 in Psychiatric Diagnosis.^* 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.

Reference

External links

Medical manuals | Mental illness diagnosis by DSM and ICD | Psychology | Classification systems

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