The Diagnostic And Statistical Manual of Mental Disorders (DSM) is a diagnostic manual used by clinicians and psychiatrists to diagnose mental disorders in the United States.
What Is The DSM?
It is a medical diagnostic manual published by the American Psychiatric Association (APA) and it covers all the categories of mental disorders for both adults and children. A 2013 study 1 explains that it “provides the standard language by which clinicians, researchers, and public health officials in the United States communicate about mental disorders.” The manual is regarded as the most valuable document for the classification and diagnosis of psychiatric disorders. Although other diagnostic approaches and criteria are available, like the Psychodynamic Diagnostic Manual (PDM) and the International Statistical Classification of Diseases (ICD), the Diagnostic and Statistical Manual Mental Disorders is primarily considered as “the gold standard 2 for mental health diagnosis.”
The Manual contains descriptions, symptoms, and other criteria necessary for diagnosing mental health disorders. It also contains statistics related to which gender is most affected by the illness, the typical age of the onset, the effects of treatment, and common treatment approaches. Like other medical conditions, the government and many insurance companies require a specific diagnosis so that the payment can be approved for further treatment. Therefore, in addition to being used for psychiatric diagnosis and treatment recommendations, this manual is also used to classify patients with specific diagnoses for billing purposes.
History Of The DSM
Research 3 reveals that a manual containing categories and classifications on mental health conditions was first published in 1918 by the American Medico-Psychological Association, which was later known as the APA in 1921. Although a manual of medical illnesses, known as Medical 203 that was prepared by the US army during the Second World War, the APA published the first DSM in 1952 consisting of valuable statistics and nomenclature. Titled simply as the Diagnostic and Statistical Manual of Mental Disorders, the document did not include any numbers like the later revisions as the authors probably did not realize that it would get revised occasionally. However, the next edition was published in 1968 and was titled the Diagnostic and Statistical Manual of Mental Disorders, Second Edition. The pattern of adding a roman suffix to the latest versions of the DSM started with the third edition in 1980.
The Diagnostic and Statistical Manual of Mental Disorders was updated seven times since it was first published in 1952.
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The newest version of this manual was published in May of 2013 known as the DSM 5. The latest version had a lot of controversies. This included the ongoing questions concerning the reliability and validity of many diagnoses, the use of the arbitrary dividing lines between mental illness and normality, cultural bias, and the medicalization of human distress. One of the major issues with the manual has been around validity 4 . In this case, the National Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a modern classification system that is more biologically based and is helpful to arrive at the correct diagnosis.
However, later, NIMH director, Thomas Insel and APA president, Jeffery Lieberman issued a joint statement stating that the Diagnostic and Statistical Manual of Mental Disorders, fifth edition “represents the best information currently available for clinical diagnosis of mental disorders”. They also added that the fifth edition and the RDoC represent “complementary, not competing frameworks” for the classification of mental health disorders. The recent edition is based on standardizing psychiatric disorders with an emphasis on empirical evidence rather than theory-based standardization as in DSM III.
Various Editions Of The DSM
The Diagnostic and Statistical Manual of Mental Disorders has been amended over the years. The chronological editions are mentioned below:
1. First Edition
The APA committee was assigned to develop a version of Medical 203 that would specifically be used in the United States. This involved a mere collection of demographic data by the Bureau of the Census. It was originally published in 1952 and had a total of 106 diagnoses. These were accordingly subcategorized into two major groups of mental disorders:
- Conditions caused by organic brain dysfunction
- Conditions presumed to result from the effects of socio-environmental stressors on an individual’s biological constitution and patient’s inability to adapt to such pressures
The DSM was first created as a mental health policy 5 for the treatment of institutionalized mentally ill people rather than for diagnostic purposes.
2. Second Edition
This version was published in 1968 with a total of 182 diagnoses. In this version, there were two major content modifications. The first was a further expansion of the definitions of mental illness. The second was an increased systematic categorization and specificity that suggested a return to the Kraepelinian tradition 6 . It also involved multiple subdivisions of former disorder categories such as the addition of eight new “alcoholic brain syndromes” and an increased number of qualifiers from four to nine namely acute, chronic, not psychotic, mild, moderate, severe, in remission. Another alteration was the removal of the psychodynamic term “reaction”, referring to the maladaptive response of an individual to socio-environmental sources of distress.
3. Third Edition
The DSM-III was published in 1988 and had a total of 265 diagnoses. In this version, one of the major alterations was the official removal of the psychodynamic term “neurosis”. It was further decided to include the term parenthetically as “neurotic disorder”. In addition to this, an explanation 7 of the distinction between “neurosis” as an etiological explanation and the expression “neurotic disorder” as a discrete entity was underscored in the introduction of this third version.
4. Fourth Edition
The fourth edition published more than 250 mental disorders and was originally published in 1994. This version had five major changes that includes:
- A theoretical shift in the conceptualization of mental disorders from a biopsychosocial model to a research-oriented medical model
- Development of the multiaxial diagnostic system that facilitated a rise in biomedical findings based upon the five axes and the relationship between them
- The inclusion of new disorders and expansion of previously defined disorders
- A lateral reorganization of disorders into discrete broad categories that involved merging a number of disorders while eliminating others
- A neo-Kraepelinian paradigm shift that reinforced descriptive and somatic orientation
The updated version, called the DSM IV-TR, was published in 2000. This version used a multiaxial or multidimensional approach for diagnosing mental disorders. The multidimensional approach was used to help clinicians make effective evaluations of the patient since mental illnesses often impact various areas of life. This manual describes disorders using five DSM “axes” or dimensions that ensure that all factors are taken into consideration. These factors included psychological, biological, and environmental aspects that are essential for making a mental health diagnosis. The “axes” are described below:
A. Axis I: Clinical Syndromes
Axis I involves clinical syndromes consisting of mental health and substance use disorders that can cause significant impairment in all areas of life. Disorders are grouped into different categories, such as mood disorders, anxiety disorders, or eating disorders.
B. Axis II: Personality Disorders and Mental Retardation
Axis II involves personality disorders and mental retardation, such as antisocial personality disorder and histrionic personality disorder. Personality disorders can cause significant impairment in how a person connects and relates to the world around them. On the other hand, mental retardation involves intellectual deficits in significant life areas, such as self-care and interpersonal skills.
C. Axis III: General Medical Conditions
Axis III involves the codification of mental conditions that significantly influence Axis I or Axis II disorders. These examples include HIV/AIDS and brain injuries
D. Axis IV: Psychosocial and Environmental Problems
Axis IV involves any psychosocial or environmental problems that impact Axis I or Axis II disorders. This axis includes things, such as unemployment, relocation, divorce, or the death of a loved one.
E. Axis V: Global Assessment of Functioning
Axis V is the assessment phase of the diagnostic process wherein the clinicians give their impression of the patient’s overall level of functioning. On the basis of this meeting, clinicians can have an overall understanding of how the four axes interacted and impacted the individual’s life and mental health.
5. Fifth Edition: The Classification of Mental Disorders
This manual reflects the current state of knowledge and consensus among experts in their relative fields. It contains 947 pages, divided into three sections and an appendix.
A. Section I
Section I contains the basics and introduction, instructions regarding the usage, and a chapter on the cautionary statements for forensic use of DSM 5.
B. Section II
Section II of the manual lays out the diagnostic criteria and codes of 22 diagnostic categories. The DSM 5 contains a single axis format and considers the relevance of age, gender, and culture. The manual also lists the International Classification of Diseases 9 (ICD 9) Clinical Modification (CM) and ICD 10 CM codes for each diagnostic category.
C. Section III
Section III is on emerging measures and models. This covers self-rated cross-cutting symptom measures for children, adults, and adolescents between age 6 and 17 years; WHO Disability Assessment Schedule 2, an alternative fifth edition model for personality disorders, and a list of conditions for further study.
DSM 5 Research & Planning
The Research and Planning Conference of 1999 8 was held to devise the DSM 5 under the joint sponsorship of the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH) and to set research priorities for future editions of the Diagnostic Manual. The conference included eminent experts in family and twin studies, molecular genetics, basic and clinical neurosciences, cognitive and behavioral sciences, and covered issues in development throughout the lifespan and disability. The conference was primarily focused on resolving the issues in the fourth edition’s system of classification, disability, and impairment, newer insights from the research in neuroscience, the need for improved nomenclature, and the impact of cross-cultural issues. Participants involved in developing the DSM IV were not invited in the process of developing 9 the DSM 5.
In the year 2008, the Executive Director of the American Psychiatric Institute for Research Education, Dr. Darrel A Reiger, leaders from the World Health Organisation (WHO) and the World Psychiatric Association (WPA), and 397 participants, that included half from outside the US, were involved in developing the fifth edition. All the group members were reviewed for potential conflict of interest and approved by the APA Board of Trustees. The fifth edition is a joint effort of the following establishments –
- The APA
- The National Institute of Health USA
- National Institute of Drug Abuse
- National Institute of Alcoholism and Alcohol Abuse
- The WHO
- The WPA
The entire process maintained transparency by publishing minutes of every meeting and monographs of their proceedings on the APA website, presentations at scientific conferences with QNA sessions at countless national and international conferences. They also held grand rounds at leading university medical centers and presented posters and papers at the annual meetings of APA.
Elimination Of The Multiaxial System
The fifth edition eliminated the multiaxial system. It lists categories of disorders along with a number of different related disorders. Examples of categories in the fifth edition include anxiety disorders, bipolar and related disorders, depressive disorders, feeding and eating disorders, obsessive compulsive and related disorders, and personality disorders.
Some of the changes that were also included in DSM 5 are as follows:
- Asperger’s disorder was removed and incorporated under the category of autism spectrum disorders.
- Disruptive mood dysregulation disorder was added in part to decrease overdiagnosis of childhood bipolar disorders.
- Several diagnoses were also officially added to the manual including binge eating disorder, hoarding disorder, and premenstrual dysphoric disorder.
Fifth Edition: The Diagnostic Tool
The DSM 5 doesn’t claim to be the final word in the classification of mental disorders. Although the Diagnostic and Statistical Manual is an important tool for diagnosing mental health conditions, only those who have specialized training and possess sufficient experience are qualified to diagnose and treat people with mental illnesses with the help of this manual.
- Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM-5: Classification and criteria changes. World psychiatry : official journal of the World Psychiatric Association (WPA), 12(2), 92–98. https://doi.org/10.1002/wps.20050
- Khoury, B., Langer, E. J., & Pagnini, F. (2014). The DSM: mindful science or mindless power? A critical review. Frontiers in psychology, 5, 602. https://doi.org/10.3389/fpsyg.2014.00602
- Vahia V. N. (2013). Diagnostic and statistical manual of mental disorders 5: A quick glance. Indian journal of psychiatry, 55(3), 220–223. https://doi.org/10.4103/0019-5545.117131
- Oskooilar N. (2006). The Reliability of DSM. Psychiatry (Edgmont (Pa. : Township), 3(3), 22.
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