The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 38,000 members are mainly American but some are international. The association publishes various journals and pamphlets, as well as the Diagnostic and Statistical and provides diagnostic criteria for mental disorders A mental disorder or mental illness is a psychological or behavioral pattern that occurs in an individual and is thought to cause distress or disability that is not expected as part of normal development or culture. The recognition and understanding of mental disorders has changed over time and across cultures. Definitions, assessments, and. It is used in the United States The United States of America is a federal constitutional republic comprising fifty states and a federal district. The country is situated mostly in central North America, where its forty-eight contiguous states and Washington, D.C., the capital district, lie between the Pacific and Atlantic Oceans, bordered by Canada to the north and Mexico to the and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance Health insurance is insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis or purchased by companies, pharmaceutical companies The pharmaceutical industry develops, produces, and markets drugs licensed for use as medications. Pharmaceutical companies can deal in generic and/or brand medications. They are subject to a variety of laws and regulations regarding the patenting, testing and marketing of drugs and policy makers.

The DSM has attracted controversy and criticism as well as praise. There have been five revisions since it was first published in 1952, gradually including more disorders, though some have been removed and are no longer considered to be mental disorders. It initially evolved out of systems for collecting census and psychiatric hospital A psychiatric hospital is a hospital specializing in the treatment of serious mental illness, usually for relatively long-term inpatients statistics, and from a manual developed by the US Army The United States Army is the branch of the United States armed forces responsible for land-based military operations. It is the largest and oldest established branch of the U.S. military and is one of seven uniformed services. The modern Army has its roots in the Continental Army which was formed on 14 June 1775, before the establishment of the. The last major revision was the fourth edition ("DSM-IV"), published in 1994, although a "text revision" was produced in 2000. The fifth edition ("DSM-V") is currently in consultation, planning and preparation, due for publication in May 2012.^[1] An early draft will be released for comment in 2009. ^[2] The mental disorders section of the International Statistical Classification of Diseases and Related Health Problems The International Statistical Classification of Diseases and Related Health Problems provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six (ICD) is another commonly-used guide, used more often in some parts of the world. The coding system Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders. The coding system utilized by the DSM-IV is designed to correspond with codes from the International Classification used in the DSM-IV is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously.

Uses

Many mental health professionals use this book to determine and help communicate a patient's diagnosis after an evaluation; hospitals, clinics, and insurance companies also generally require a 'five axis' DSM diagnosis of all the patients treated. The DSM can be used to establish a diagnosis or categorize patients using diagnostic criteria. The DSM may also be used in mental health research. Studies done on specific diseases often recruit patients whose symptoms match the criteria listed in the DSM for that disease. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.^[3]

The DSM, including DSM-IV, is a registered trademark belonging to the American Psychiatric Association The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 38,000 members are mainly American but some are international. The association publishes various journals and pamphlets, as well as the Diagnostic and Statistical.^[4]

History

The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census which used a single category, "idiocy/insanity". The 1880 census distinguished among seven categories: mania Mania is a severe medical condition characterized by extremely elevated mood, energy, unusual thought patterns and sometimes psychosis. There are several possible causes for mania including drug abuse and brain tumors, but it is most often associated with bipolar disorder, where episodes of mania alternate with episodes of major depression. These, melancholia Melancholia (from Greek μελαγχολία - melancholia, also lugubriousness, from the Latin lugere, to mourn; moroseness, from the Latin morosus, self-willed, fastidious habit; wistfulness, from old English wist: intent, or saturnine, see Saturn ), in contemporary usage, is a mood disorder of non-specific depression, characterized by low, monomania In psychiatry, monomania is a type of paranoia in which the patient has only one idea or type of ideas. Emotional monomania is that in which the patient is obsessed with only one emotion or several related to it; intellectual monomania is that which is related to only one kind of delirious idea or ideas, paresis Paresis is a condition typified by partial loss of movement, or impaired movement. When used without qualifiers, it usually refers to the limbs, but it also can be used to describe the muscles of the eyes and also the stomach (gastroparesis). Neurologists use the term paresis to describe weakness, and plegia to describe paralysis in which all, dementia Dementia is a non-specific illness syndrome in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed; cognitive dysfunction which has been seen only over shorter times, particularly less than weeks, must be termed delirium. In all types, dipsomania Dipsomania is a historical term describing a medical condition involving an uncontrollable craving for alcohol. It was used in the 19th century to describe a variety of alcohol-related problems, most of which are most commonly today conceptualized as alcoholism, but it is occasionally still used to describe a particular condition of periodic,, and epilepsy Epilepsy is a common chronic neurological disorder characterized by recurrent unprovoked seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or synchronous neuronal activity in the brain. About 50 million people worldwide have epilepsy, with almost 90% of these people being in developing countries. Epilepsy is more. In 1917, a "Committee on Statistics" from what is now known as the American Psychiatric Association The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 38,000 members are mainly American but some are international. The association publishes various journals and pamphlets, as well as the Diagnostic and Statistical (APA), together with the National Commission on Mental Hygiene, developed a new guide for mental hospitals called the "Statistical Manual for the Use of Institutions for the Insane", which included 22 diagnoses. This was subsequently revised several times by APA over the years. APA, along with the New York Academy of Medicine The New York Academy of Medicine was founded in 1847 by a group of leading New York City metropolitan area physicians as a voice for the medical profession in medical practice and public health reform. The Academy quickly established the Metropolitan Board of Health, the first modern municipal public health authority in the United States, also provided the psychiatric nomenclature The classic English translation of De re metallica includes an appendix detailing problems of nomenclature in weights and measures subsection of the US medical guide, the "Standard Classified Nomenclature of Disease", referred to as the "Standard".^[5]

World War II World War II, or the Second World War , was a global military conflict which involved a majority of the world's nations, including all of the great powers, organized into two opposing military alliances: the Allies and the Axis. The war involved the mobilization of over 100 million military personnel, making it the most widespread war in history saw the large-scale involvement of US psychiatrists in the selection, processing, assessment and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist and brigadier general A brigadier general in the United States Army, Air Force, and Marine Corps, is a one-star general officer, with the pay grade of O-7. Brigadier general ranks above a colonel and below major general. Brigadier general is equivalent to the rank of rear admiral in the other uniformed services William C. Menninger William Claire Menninger was a co-founder with his brother Karl and his father of The Menninger Foundation in Topeka, Kansas, which is an internationally known center for treatment of behavioral disorders developed a new classification scheme called Medical 203, issued in 1943 as a "War Department Technical Bulletin" under the auspices of the Office of the Surgeon General The Surgeon General of the United States is the operational head of the Public Health Service Commissioned Corps and thus the leading spokesperson on matters of public health in the federal government. The Surgeon General's office and staff are known as the Office of the Surgeon General (OSG).^[6] The foreword to the DSM-I states the US Navy The United States Navy is the sea branch of the U.S. Armed Forces. It is one of the seven uniformed services of the United States. As of 31 December 2008, the U.S. Navy had about 331,682 personnel on active duty and 124,000 in the Navy Reserve. It operates 283 ships in active service and more than 3,700 aircraft. The U.S. Navy is the largest in had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces", and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is responsible for administering programs of veterans’ benefits for veterans, their families, and survivors. The benefits provided include disability compensation, pension, education, home loans, life insurance, also adopted a slightly modified version of Medical 203.

In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD) which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature." An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950 the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system and the Standard's Nomenclature, to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in it being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text identical.^[6] The manual was 130 pages long and listed 106 mental disorders.^[7]

Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to also go ahead with a revision of the DSM. It was also published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. The term “reaction” was dropped but the term “neurosis Neurosis refers to a class of functional mental disorder involving distress but not delusions nor hallucinations, where behavior is not outside socially acceptable norms. It is also known as psychoneurosis or neurotic disorder. Once a common psychiatric diagnosis, the term is no longer part of mainstream psychiatric terminology in the United” was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry,^[8] although they also included biological perspectives and concepts from Kraepelin's Emil Kraepelin was a German psychiatrist. The Encyclopedia of Psychology by H. J. Eysenck identifies him as the founder of contemporary scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated the system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis Neurosis refers to a class of functional mental disorder involving distress but not delusions nor hallucinations, where behavior is not outside socially acceptable norms. It is also known as psychoneurosis or neurotic disorder. Once a common psychiatric diagnosis, the term is no longer part of mainstream psychiatric terminology in the United and psychosis Psychosis , with adjective psychotic, literally means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality". People suffering from psychosis are said to be psychotic (roughly, anxiety/depression broadly in touch with reality, or hallucinations A hallucination, in the broadest sense, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space. The latter/delusions A delusion, in everyday language, is a fixed belief that is either false, fanciful, or derived from deception. Psychiatry defines the term more specifically as a belief that is pathological . As a pathology, it is distinct from a belief based on false or incomplete information, apperception, illusion, or other effects of perception appearing disconnected from reality). Sociological and biological knowledge was also incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.^[9]

Following controversy and protests from gay activists at APA annual conferences from 1970 to 1973, as well as the emergence of new data from researchers such as Alfred Kinsey Alfred Charles Kinsey was an American biologist and professor of entomology and zoology, who in 1947 founded the Institute for Research in Sex, Gender and Reproduction at Indiana University, now called the Kinsey Institute for Research in Sex, Gender, and Reproduction. Kinsey's research on human sexuality - foundational to the modern field of and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. But through the efforts of psychiatrist Robert Spitzer Dr. Robert L. Spitzer is a Professor of Psychiatry at Columbia University in New York City, United States and is on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He was chair of the task force of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of, who had led the DSM-II development committee, 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".^[10]

In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer Dr. Robert L. Spitzer is a Professor of Psychiatry at Columbia University in New York City, United States and is on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He was chair of the task force of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems The International Statistical Classification of Diseases and Related Health Problems provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six (ICD), published by the World Health Organization The World Health Organization is a specialized agency of the United Nations (UN) that acts as a coordinating authority on international public health. Established on 7 April 1948, and headquartered in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health Organization, which had been an agency of the. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members.^[11] One goal was to improve the uniformity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment The Rosenhan experiment was a famous experiment into the validity of psychiatric diagnosis conducted by David Rosenhan in 1972. It was published in the journal Science under the title "On being sane in insane places.". There was also a perceived need to standardize diagnostic practices within the US and with other countries. The establishment of these criteria was also an attempt to facilitate the pharmaceutical regulatory process.

The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria The Feighner Criteria is the informal name given to diagnostic criteria for use in psychiatry research. The criteria were first presented in a scientific paper published in 1972 of which John Feighner was the principal author. Fourteen conditions were defined including primary affective disorders, schizophrenia, anxiety neurosis and antisocial, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University Washington University in St. Louis is a nonsectarian, private research university located in St. Louis, Missouri. Founded in 1853 and named for George Washington, the university has students and faculty from all fifty U.S. states and more than one hundred and twenty five nations. Twenty-two Nobel laureates have been associated with Washington and the New York State Psychiatric Institute The New York State Psychiatric Institute, established in 1895 and located on Riverside Drive at the foot of Washington Heights, the far upper west side of Manhattan in New York City, was one of the first institutions in the United States to integrate teaching, research and therapeutic approaches to the care of patients with mental illnesses. Other criteria, and potential new categories of disorder, were established by a consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by Federal administrative offices), rather than assumptions of etiology Etiology is the study of causation. The word is derived from the Greek αἰτιολογία, aitiologia, "giving a reason for" (αἰτία, aitia, "cause"; and -λογία, -logia), although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian Emil Kraepelin was a German psychiatrist. The Encyclopedia of Psychology by H. J. Eysenck identifies him as the founder of contemporary scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated the”). The psychodynamic The original concept of "psychodynamics" was developed by Sigmund Freud. Freud suggested that psychological processes are flows of psychological energy in a complex brain, establishing "psychodynamics" on the basis of psychological energy, which he referred to as libido or physiologic Physiology is the study of the mechanical, physical, and biochemical functions of living organisms. Physiology has traditionally been divided between plant physiology and animal and all living things physiology but the principles of physiology are universal, no matter what particular organism is being studied. For example, what is learned about view was abandoned, in favor of a regulatory Regulation refers to "controlling human or societal behaviour by rules or restrictions." Regulation can take many forms: legal restrictions promulgated by a government authority, self-regulation, social regulation , co-regulation and market regulation. One can consider regulation as actions of conduct imposing sanctions (such as a fine) or legislative A legislature is a type of representative deliberative assembly with the power to create and change laws. The law created by a legislature is called legislation or statutory law. Legislatures are known by many names, the most common being parliament and congress, although these terms also have more specific meanings model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis In medicine, diagnosis is the process of identifying a medical condition or disease by its signs, symptoms, and from the results of various diagnostic procedures. The conclusion reached through this process is called a diagnosis. The term "diagnostic criteria" designates the combination of signs, symptoms, and test results that allows. Spitzer argued, “mental disorders are a subset of medical disorders” but the task force decided on the DSM statement: “Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.”^[8]

The first draft of the DSM-III The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides diagnostic criteria for mental disorders. It is used in the United States and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical was prepared within a year. Many new categories of disorder were introduced; a number of the unpublished documents that aim to justify them have recently come to light.^[12] Field trials sponsored by the U.S. National Institute of Mental Health The National Institute of Mental Health is part of the federal government of the United States and the largest research organization in the world specializing in mental illness. It is one of the 27 component organizations of the National Institutes of Health (NIH), which is in turn part of the U.S. Department of Health and Human Services. It was (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, so the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity, a political compromise reinserted the term in parentheses after the word “disorder” in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".

Finally published in 1980, the DSM-III was 494 pages long and listed 265 diagnostic categories. It rapidly came into widespread international use by multiple stakeholders and has been termed a revolution or transformation in psychiatry.^[8][9]. In 1987 the DSM-III-R was published as a revision of DSM-III, under the direction of Spitzer. Categories were renamed, reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were considered and discarded. "Sexual orientation disturbance" was also removed, but was largely subsumed under "sexual disorder not otherwise specified" which can include "persistent and marked distress about one’s sexual orientation."^[8][13] Altogether, DSM-III-R contained 292 diagnoses and was 567 pages long.

In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three step process. First, each group conducted an extensive literature review of their diagnoses. Then they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative. Finally, they conducted multicenter field trials relating diagnoses to clinical practice.^[14][15] 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”.

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.^[16] 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.

DSM-IV-TR - The Current Version

Categorization

The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries...” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance.^[17] Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:

• Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders
• Axis II: underlying pervasive or personality conditions, as well as mental retardation
• Axis III: 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

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, Autism, phobias, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder, and mental retardation.

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

Cautions

The DSM-IV-TR states, because it is produced for the completion of Federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”.^[18] The APA notes diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis/label may have different etiologies (causes) or require different treatments; the DSM contains no information regarding treatment or cause for this reason. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered “illnesses”.

Sourcebooks

The DSM-IV doesn't specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials.^{[19][20][21][22]} The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.^[23][24]

Criticism

Beginning with the problem that there is no single objective diagnostic test for a mental illness in the field of psychiatry — a problem the DSM sidesteps by referring only to "mental disorders", defined modestly as dysfunctional psychological or behavioral patterns — the DSM-IV has come under various criticisms over the years.

Validity and reliability

The most fundamental criticism of the DSM concerns the construct validity and reliability of its diagnostic categories and criteria.^[25][26][27] Although increasingly standardized, critics argue that the DSM's claim of an empirical foundation is overstated.^[23] A reliance on operational definitions necessitates that intuitive concepts such as depression be operationally defined before they can be used in scientific investigation. Such definitions are used as a follow up to a conceptual definition, in which the specific concept is defined as a measurable occurrence. John Stuart Mill pointed out the dangers of believing anything that could be given a name must refer to a thing and Stephen Jay Gould and others have criticized psychologists for doing just that. A committed operationalist would respond that speculation about the thing in itself, or noumenon, should be resisted as meaningless, and would comment only on phenomena using operationally defined terms and tables of operationally defined measurements. This line of criticism has also appeared in non-specialist venues. In 1997, Harper's Magazine published an essay, ostensibly a book review of the DSM-IV, that criticized the lack of hard science and the proliferation of disorders. The language of the DSM was described as "simultaneously precise and vague", and the manual itself compared to "a militia's Web page, insofar as it constitutes an alternative reality under siege," and a "fertilizer bomb" against hard science.^[28]

Symptomatological bias

By design, the DSM is primarily concerned with the symptoms of mental disorders, it does not attempt to analyze or explain the conditions it lists or even to discuss possible patterns or relationships between them. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages.^[29] The lack of causative or explanatory material, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiactric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."^[30] The DSM's apparent superficiality is therefore largely a result of necessity, since there is no agreement on a more explanatory classification system.

Despite the lack of consensus, advocates for specific psychopathlogical paradigms have nonetheless faulted the current diagnostic scheme for not incorporating the innovations of their particular model; the most recent example being evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology.^[31][32][33]

Reductionist bias

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and between normal and abnormal. Although the DSM-V may move away from this categorical approach in some limited areas, some argue that a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.^{[34][35][36][37]} Similarly, the current individual symptom-based approach has been argued to not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual or a psychological response to adverse situations.^[38][39] Because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the standard of distress or disability can often produce false positives. ^[40]

Some psychiatrists also argue that current diagnostic standards rely on an exagerated intepretation of neurophysiological findings and so understate the scientific importance of social-psychological variables.^[41] Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers.^[42]. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only prove consistency, not legitimacy.^[41] Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal.^[43] Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misintepreted or misrepresented.^[44] Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has opined that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only signficant to specific symptom presentations.^[41]

It has also been suggested that the apparent reductionism of the DSM, as well as its substantial expansions, are representative of an increasing medicalization of human nature, a result of disease mongering by drug companies, whose influence on psychiatry has dramatically grown in recent decades.^[45] Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had had a financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest.^[46] In 2008, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".^[47]

Political controversies

There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias (sexual fetishes) and hypoactive sexual desire disorder (low sex drive). Critics of these and other controversial diagnoses often cite the DSM's previous inclusion of homosexuality, as well as the APA's eventual decision to remove it, as a precedent for current disputes.^[48] That 1974 decision, however, is still challenged by many conservative and religious groups who maintain that homosexuality is in fact a mental disorder.^[49] The fact that this diagnostic revision continues to be passionately disputed, so many years after the fact, underscores that any reevaluation of controversial disorders must be viewed as a political as well as scientific decision. Indeed, even Robert Spitzer (psychiatrist), a leading proponent of continued inclusion, conceded that a significant reason that certain diagnoses are not removed from the DSM is because "it would be a public relations disaster for psychiatry".^[50]

DSM-V - the next version

The DSM-V is tentatively scheduled for publication in 2012.^[1] In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-IV,^[51] and the resulting work and recommendations were reported in an APA monograph^[52] and peer-reviewed literature.^[53] There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children.^[54] The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.^[55]

On July 23 2007, the APA announced the task force that will oversee the development of DSM-V. The DSM-V Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Revision of the DSM will continue over the next five years. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.^[56]

Owing to criticism over the perceived proliferation of diagnoses in the current edition of the DSM, David Kupfer, who is shepherding the DSM's revision, said in an interview: "One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis."^[57]

Criticism

Robert Spitzer, the head of the DSM-III task force, has publicly criticized the American Psychiatric Association for mandating that DSM-V task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: “When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.”^[58]

Although the American Psychiatric Association has since instituted a disclosure policy for DSM-V task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a recent Point/Counterpoint article,^[59] Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed." David Kupfer, MD, chair of the DSM-V task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-V is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on www.dsm5.org.

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, has led to an internet petition^[60] to remove them.^[61] According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career."^[62] According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse."^[63] Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views."^[63] Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"^[62]

See also

• Relational disorder (proposed DSM-V new diagnosis)
• Classification of mental disorders
• Chinese Classification and Diagnostic Criteria of Mental Disorders
• DSM-IV Codes
• GAF Scale
• Psychodynamic Diagnostic Manual
• Structured Clinical Interview for DSM-IV (SCID)

References

1. ^ ^{a b} DSM-V: The Future Manual
2. ^ Internet addictions: A real medical menace?, Yahoo Tech Blog: christopher Null: the Working Guy, 3/24/08.
3. ^ Mezzich, Juan E. (2002). "International Surveys on the Use of ICD-10 and Related Diagnostic Systems" (guest editorial, abstract). Psychopathology 35 (2-3): 72–75. doi:10.1159/000065122. http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=65122&Ausgabe=228600&ProduktNr=224276. Retrieved on 2008-09-02.
4. ^ "Trademark Electronic Search System (TESS)". http://tess2.uspto.gov/bin/showfield?f=doc&state=k7tj8q.2.1. Retrieved on 2008-02-08.
5. ^ Greenberg SA, Shuman DW, Meyer RG. (2004) Unmasking forensic diagnosis. Int J Law Psychiatry. 2004 January-February;27(1):1-15. doi=10.1016/j.ijlp.2004.01.001
6. ^ ^{a b} Houts, A.C. (2000) Fifty years of psychiatric nomenclature: Reflections on the 1943 War Department Technical Bulletin, Medical 203. Journal of Clinical Psychology, 56 (7), Pages 935 - 967
7. ^ Grob, GN. (1991) Origins of DSM-I: a study in appearance and reality Am J Psychiatry. April;148(4):421–31.
8. ^ ^{a b c d} Mayes, R. & Horwitz, AV. (2005) DSM-III and the revolution in the classification of mental illness. J Hist Behav Sci 41(3):249–67.
9. ^ ^{a b} Wilson, M. (1993) DSM-III and the transformation of American psychiatry: a history. Am J Psychiatry. 1993 March;150(3):399–410.
10. ^ "The diagnostic status of homosexuality in DSM-III: a reformulation of the issues", by R.L. Spitzer, Am J Psychiatry 1981; 138:210-215
11. ^ Speigel, A. (2005) The Dictionary of Disorder: How one man revolutionized of 2005-01-03.
12. ^ Lane, Christopher (2007). Shyness: How Normal Behavior Became a Sickness. Yale University Press. pp. 263. ISBN 0300124465.
13. ^ Spiegel, Alix. (18 January 2002.) "81 Words". In Ira Glass (producer), "This American Life." Chicago: Chicago Public Radio.
14. ^ Allen Frances, Avram H. Mack, Ruth Ross, and Michael B. First (2000) The DSM-IV Classification and Psychopharmacology.
15. ^ Schaffer, David (1996) A Participant's Observations: Preparing DSM-IV Can J Psychiatry 1996;41:325–329.
16. ^ APA Summary of Practice-Relevant Changes to the DSM-IV-TR.
17. ^ Maser, JD. & Patterson, T. (2002) Spectrum and nosology: implications for DSM-V Psychiatric Clinics of North America, December, 25(4)p855-885
18. ^ DSM FAQ
19. ^ DSM-IV Sourcebook Volume 1
20. ^ DSM-IV Sourcebook Volume 2
21. ^ DSM-IV Sourcebook Volume 3
22. ^ DSM-IV Sourcebook Volume 4
23. ^ ^{a b} Poland, JS. (2001) Review of Volume 1 of DSM-IV sourcebook
24. ^ Poland, JS. (2001) Review of vol 2 of DSM-IV sourcebook
25. ^ Kendell R, Jablensky A. (2003) Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry. January;160(1):4-12. PMID 12505793
26. ^ Baca-Garcia E, Perez-Rodriguez MM, Basurte-Villamor I, Fernandez del Moral AL, Jimenez-Arriero MA, Gonzalez de Rivera JL, Saiz-Ruiz J, Oquendo MA. (2007) Diagnostic stability of psychiatric disorders in clinical practice. Br J Psychiatry. March;190:210-6. PMID 17329740
27. ^ Pincus et al. (1998) "Clinical Significance" and DSM-IV Arch Gen Psychiatry.1998; 55: 1145
28. ^ L.J. Davis (February 1997). "'The Encyclopedia of Insanity — A Psychiatric Handbook Lists a Madness for Everyone.'". Harpers Magazine. http://alumnus.caltech.edu/~rbell/EncyclopediaOfInsanity.html.gz.
29. ^ Paul R. McHugh (2005) Striving for Coherence: Psychiatry’s Efforts Over Classification JAMA. 2005;293(no.20)2526-2528.
30. ^ Spitzer and First (2005) Classification of Psychiatric Disorders. JAMA.2005; 294: 1898-1899.
31. ^ Dominic Murphy, PhD; Steven Stich, PhD (1998) Darwin in the Madhouse [1]
32. ^ Leda Cosmides, PhD; John Tooby, PhD (1999) Toward an Evolutionary Taxonomy of Treatable Conditions "J of Abnormal Psychology." 1999;108(3):453-464. [2]
33. ^ McNally RJ. (2001) On Wakefield's harmful dysfunction analysis of mental disorder. Behav Res Ther. 2001 March;39(3):309-14. PMID 11227812
34. ^ Spitzer, Robert L, M.D., Williams, Janet B.W, D.S.W., First, Michael B, M.D., Gibbon, Miriam, M.S.W., Biometric Research
35. ^ Maser, JD & Akiskal, HS. et al. (2002) Spectrum concepts in major mental disorders Psychiatric Clinics of North America, Vol. 25, Special issue 4
36. ^ Krueger, RF., Watson, D., Barlow, DH. et al. (2005) Toward a Dimensionally Based Taxonomy of Psychopathology Journal of Abnormal Psychology Vol 114, Issue 4
37. ^ Bentall, R. (2006) Madness explained : Why we must reject the Kraepelinian paradigm and replace it with a 'complaint-orientated' approach to understanding mental illness Medical hypotheses, vol. 66(2), pp. 220-233
38. ^ Chodoff, P. (2005) Psychiatric Diagnosis: A 60-Year Perspective Psychiatric News June 3, 2005 Volume 40 Number 11, p17
39. ^ Jerome C. Wakefield, PhD, DSW; Mark F. Schmitz, PhD; Michael B. First, MD; Allan V. Horwitz, PhD (2007) Extending the Bereavement Exclusion for Major Depression to Other Losses: Evidence From the National Comorbidity Survey Arch Gen Psychiatry. 2007;64:433-440.
40. ^ Spitzer RL, Wakefield JC. (1999) DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? Am J Psychiatry. 1999 December;156(12):1856-64. PMID 10588397
41. ^ ^{a b c} Widiger TA, Sankis LM (2000). "Adult psychopathology: issues and controversies". Annu Rev Psychol 51: 377–404. doi:10.1146/annurev.psych.51.1.377. PMID 10751976.
42. ^ Shankar Vedantam, Psychiatry's Missing Diagnosis: Patients' Diversity Is Often Discounted Washington Post: Mind and Culture, June 26
43. ^ Kleinman A (1997). "Triumph or pyrrhic victory? The inclusion of culture in DSM-IV". Harv Rev Psychiatry 4 (6): 343–4. doi:10.3109/10673229709030563. PMID 9385013.
44. ^ Bhugra, D. & Munro, A. (1997) Troublesome Disguises: Underdiagnosed Psychiatric Syndromes Blackwell Science Ltd
45. ^ Healy D (2006) The Latest Mania: Selling Bipolar Disorder PLoS Med 3(4): e185.
46. ^ Cosgrove, Lisa, Krimsky, Sheldon,Vijayaraghavan, Manisha, Schneider, Lisa, Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry
47. ^ Sharfstein, SS. (2005) Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly Psychiatric News August 19, 2005 Volume 40 Number 16
48. ^ Alexander, B. (2008) What's ‘normal’ sex? Shrinks seek definition Controversy erupts over creation of psychiatric rule book's new edition MSNBC Today, May.
49. ^ [3]
50. ^ Kleinplatz, P.J & Moser, C. (2005). Politics versus science: An addendum and response to Drs. Spitzer and Fink. Journal of Psychology and Human Sexuality, 17(3/4), 135-139.
51. ^ First, M. (2002) A Research Agenda for DSM-V: Summary of the DSM-V Preplanning White Papers Published in May 2002
52. ^ Kupfer, First & Regier (2002) A Research Agenda for DSM-V
53. ^ Regier DA, Narrow WE, First MB, Marshall T (2002). "The APA classification of mental disorders: future perspectives". Psychopathology 35 (2-3): 166–70. doi:10.1159/000065139. PMID 12145504. http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=0254-4962&title=Psychopathology&volume=35&issue=2-3&spage=166&atitle=The%20APA%20classification%20of%20mental%20disorders:%20future%20perspectives.&aulast=Regier&date=2002.
54. ^ DSM-5 Research Planning
55. ^ APA DSM-V Research Planning Activities
56. ^ Regier, MD, MPH, Darrel A. (2007). "Somatic Presentations of Mental Disorders: Refining the Research Agenda for DSM-V" (pdf). Psychosomatic Medicine (Lippincott Williams and Wilkins) 69: 827–828. doi:10.1097/PSY.0b013e31815afbe4. http://www.psychosomaticmedicine.org/cgi/reprint/69/9/827.pdf. Retrieved on 2007-12-21.
57. ^ Grossman, Ron (December 27, 2008). "Psychiatric manual's update needs openness, not secrecy, critics say". Chicago Tribune. http://www.chicagotribune.com/features/lifestyle/health/chi-dsm-controversy-26-dec27,0,3080538.story.
58. ^ Carey, Benedict (December 17, 2008). "Psychiatrists Revise the Book of Human Troubles". New York Times. http://www.nytimes.com/2008/12/18/health/18psych.html?pagewanted=all.
59. ^ [Cosgrove L, Bursztajn HJ, Kupfer DJ, Regier DA. "Toward Credible Conflict of Interest Policies in Clinical Psychiatry" Psychiatric Times 26:1.]
60. ^ "Objection to DSM-V Committee Members on Gender Identity Disorders," last accessed 22.55GMT 10 May 2008.
61. ^ Lou Chibbaro Jr. (2008-05-30). "Activists alarmed over APA: Head of psychiatry panel favors ‘change’ therapy for some trans teens". Washington Blade.
62. ^ ^{a b} Alexander, Brian (2008-05-22). "What's ‘normal’ sex? Shrinks seek definition: Controversy erupts over creation of psychiatric rule book's new edition". MSNBC. http://www.msnbc.msn.com/id/24664654/. Retrieved on 2008-06-14.
63. ^ ^{a b} Osborne, Duncan (2008-05-15). "Flap Flares Over Gender Diagnosis". Gay City News. http://www.gaycitynews.com/site/news.cfm?newsid=19693908&BRD=2729&PAG=461&dept_id=568864&rfi=6. Retrieved on 2008-06-14.

External links

• DSM-IV-TR Official Site - American Psychiatric Association
• DSM-V Prelude Project - DSM-V Prelude Review Project by American Psychiatric Association
• Topic Center: DSM-V
• Reproduction of Medical 203
• The DSM-II
• Sections of the DSM-IV-TR on Google Books.
• Widiger: Review DSM-IV Source Book

Categories: Medical manuals | Mental illness diagnosis by DSM and ICD | Abnormal psychology | Clinical psychology | Classification systems

See Also:

• Diagnostic and Statistical Manual of Mental Disorders
• Mental Health
• Mental Illness
• Mental Disorder
• Mental Disorders

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