The Diagnostic and Statistical Manual of Mental Disorders (DSM)

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), offers a common language and standard criteria for the classification of mental disorders.

1. The Diagnostic and Statistical Manual of Mental Disorders (DSM) Ms. Hemangi Narvekar M.Phil. Clinical Psychology National Institute for empowerment of persons with multiple disabilities (NIEPMD), chennai

2. CONTENTS Introduction History DSM – I DSM – II DSM – III DSM-III-R DSM – IV DSM – IV - TR

3. Introduction The Diagnostic and Statistical Manual of Mental Disorders ( DSM ), published by the American Psychiatric Association (APA), offers a common language and standard criteria for the classification of mental disorders. It is used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers together with alternatives such as the International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO). Since the initial publication of the DSM, there have been five subsequent editions of this manual published.

4. History By the end of World War II, psychiatrists faced a problem regarding the nomenclature for psychopathology. Within the United States, there were three different classification systems for mental illness in use. The first was the Standard Classified Nomenclature of Disease - 1942 revision. The second was the Armed Forces Nomenclature (Medical 203 ). Third was the  Veterans Administration Nomenclature which was a slightly different version of the Medical 203. To add to the confusion, none of these classification systems matched the systems used by hospitals for reporting purposes (APA, 1952; Houts , 2000).  Thus, the representatives from all areas met to begin forming the new classification system (APA, 1952).

5. History George N. Raines, chair of the APA Committee on Nomenclature and Statistics wrote the forward for the DSM-I in which he outlines the revision process and creation of the new DSM nomenclature. As the release date of the DSM approached, the committee sent it for review to approximately 10 percent  of the APA membership. Of the surveys that were returned, almost all (93%) approved of the DSM-I draft. The second draft was then approved by the APA membership in 1951 ( Houts , 2000). The Diagnostic and Statistical Manual of Mental Disorders was, thus, published in 1952.

6. DSM - I The DSM-I was 145 pages long and included a total of 106 disorders (APA 1952 ). The structure and conceptual framework were the same as in Medical 203, and many passages of text identical. B oth relied heavily on psych-dynamic concepts of diagnosing psychopathology.  The DSM-I and Medical 203 divided psychological pathology into the standard psychoanalytic categories of neurotic, psychotic, and character disorders. The only differences in between the structure of the two documents was that the DSM-I placed somatization reactions in a separate category where the Medical 203 placed these disorders in the psycho-neurotic division ( Houts , 2000).

7. DSM - I The DSM-I also added an additional six somatization disorders that were not included in the Medical 203. One of the hallmark features of the DSM-I was the use of the term "reaction" throughout the manual (APA, 2000 ). The concept that life circumstances could produce mental illness started in the Medical 203 system and became fully incorporated into the DSM-I. Interestingly, neither system dedicated space for childhood specific disorders.

8. DSM - II The DSM-II was published in 1968 . It was only 136 pages long, but it now included 182 disorders (APA, 1968). This edition of the DSM retained the overall approach used in the DSM-I and continued to conceptualize psychopathology from a psychodynamic perspective (First, 2010 ). This was the first edition to include a section on the behavioral disorders of childhood and adolescence. Withdrawing reaction, Overanxious reaction, Runaway reactions, Unsocialized aggressive reaction, Group deliquent reaction, and other reaction of childhood were listed within this section.  The DSM–II also included a new section on Sexual deviations. Homosexuality, Fetishism, Pedophilia, Transvestism , Exhibitionism, Voyeurism, Sadism, and Masochism were listed as official forms of mental illness.

9. DSM - II The term "reaction" was dropped, but the term "neurosis" was retained. The idea that personality disorders did not involve emotional distress was discarded . The main problem with DSM-II was the lack of an objective and reliable system for describing psychopathology and determining diagnoses . Symptoms were not specified in detail for specific disorders. Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality .

10. DSM - II Since the APA listed homosexuality in the DSM as a sociopathic personality disturbance, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations. Presented with data from researchers, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".

11. DSM - III In 1974, the APA appointed the Task Force on Nomenclature and Statistics to begin work on DSM-III. Emphasis was placed on increasing reliability and clinical utility. The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced, while some were deleted or changed. Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry.

12. DSM - III Innovations in DSM - III Provided a definition of the term “mental disorder” Presented diagnostic criteria for each disorder Introduced the multiaxial diagnostic format Redefined a number of major disorders (e.g., elimination of “neurosis”) Added new diagnostic categories (e.g., personality disorders) Presented a hierarchical organization of diagnostic categories Presented a systematic description of each disorder Provided decision trees for differential diagnosis Provided a glossary of technical terms Published reliability data from field trials Utilized a descriptive, atheoretical approach

13. DSM–III-R DSM-III-R was published in 1987, as a result of on-going research and resulting progress in the understanding of the diagnostic categories . Categories were renamed and reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Altogether , the DSM-III-R contained 292 diagnoses and was 567 pages long.

14. DSM - IV In 1994, DSM – IV was published, listing 297 disorders in 886 pages . A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning ”. Some personality disorder diagnoses were deleted or moved to the appendix.

15. DSM - IV T he DSM-IV organized each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability: Axis I : All psychological diagnostic categories except mental retardation and personality disorder Axis II : Personality disorders and mental retardation Axis III : General medical condition; acute medical conditions and physical disorders Axis IV : Psychosocial and environmental factors contributing to the disorder Axis V : Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

16. DSM-IV TR A "Text Revision" of the DSM-IV, known as the DSM – IV TR was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD . Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes . The DSM-IV-TR was also organized into a five-part axial system. Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder.

17. References American Psychiatric Association. (2013). Diagnostic and Statistical Manual for Mental Disorders (5th ed.). Washington: APA. Blashfield , R.K., Keeley, J.W., Flanagan, E. H., & Miles, S.R. (2014). The Cycle of Classification: DSM-I Through DSM-5. Annual Review of Clinical Psychology , 10, 25-51. DOI: 10.1146/annurev-clinpsy-032813-153639 History of the DSM. Retrieved on October 31, 2016 from https:// sites.google.com/site/psych54000/early-dsm at 11.45 am. Kawa , S., & Giordano, J. (2011). A brief historicity of the Diagnostic and Statistical Manual of Mental Disorders : Issues and implications for the future of psychiatric canon and practice. Philosophy, Ethics, and Humanities in Medicine , 201-272.

18. THANK YOU