Diagnostic and Statistical Manual of Mental Disorders

Nature and purposes

Background of DSM

Critiques of DSM-IV and DSM-IV-TR

Alternative nosologies

Resources

Nature and purposes

The Diagnostic and Statistical Manual of Mental Disorders is a reference work consulted by psychiatrists, psychologists, physicians in clinical practice, social workers , medical and nursing students, pastoral counselors, and other professionals in health care and social service fields. The book’s title is often shortened to DSM, or an abbreviation that also indicates edition, such as DSM-IV-TR, which indicates fourth edition, text revision of the manual, published in 2000. The DSM-IV-TR provides a classification of mental disorders, criteria sets to guide the process of differential diagnosis , and numerical codes for each disorder to facilitate medical record-keeping. The stated purpose of the DSM is threefold: to provide “a helpful guide to clinical practice”; “to facilitate research and improve communication among clinicians and researchers”; and to serve as “an educational tool for teaching psychopathology.”

The multi-axial system

The third edition of DSM, or DSM-III, which was published in 1980, introduced a system of five axes or dimensions for assessing all aspects of a patient’s mental and emotional health. The multi-axial system is designed to provide a more comprehensive picture of complex or concurrent mental disorders. According to the DSM-IV-TR, the system is also intended to “promote the application of the biopsychosocial model in clinical, educational and research settings.” The reference to the biopsychosocial model is significant, because it indicates that the DSM-IV-TR does not reflect the view of any specific “school” or tradition within psychiatry regarding the cause or origin (also known as “etiology”) of mental disorders. In other words, the DSM-IV-TR is atheoretical in its approach to diagnosis and classification—the axes and categories do not represent any overarching theory about the sources or fundamental nature of mental disorders.

The biopsychosocial approach was originally proposed by a psychiatrist named George Engel in 1977 as a way around the disputes between psychoanalytically and biologically oriented psychiatrists that were splitting the field in the 1970s. The introduction to DSM-IV-TR is quite explicit about the manual’s intention to be “applicable in a wide variety of contexts” and “used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems).”

The atheoretical stance of DSM-IV-TR is also significant in that it underlies the manual’s approach to the legal implications of mental illness. DSM notes the existence of an “imperfect fit between questions of ultimate concern to the law and the information contained in a clinical diagnosis.” What is meant here is that the DSM-IV-TR diagnostic categories do not meet forensic standards for defining a “mental defect,” “mental disability,” or similar terms. Because DSM-IV-TR states that “inclusion of a disorder in the classification … does not require that there be knowledge about its etiology,” it advises legal professionals against basing decisions about a person’s criminal responsibility, competence, or degree of behavioral control on DSM diagnostic categories.

The five diagnostic axes specified by DSM-IV-TR are:

• Axis I: Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.
• Axis II: Personality disorders and mental retardation. This axis includes notations about problematic aspects of the patient’s personality that fall short of the criteria for a personality disorder.
• Axis III: General medical conditions. These include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient’s mood or functioning; or that influence the choice of medications for treating the mental disorder.
• Axis IV: Psychosocial and environmental problems. These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient’s mental disorder. DSM-IV-TR lists the following categories of problems: family problems; social environment problems; educational problems; occupational problems; housing problems; economic problems; problems with access to health care; problems with the legal system; and other problems (war, disasters, etc.).
• Axis V: Global assessment of functioning. Rating the patient’s general level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress. The primary scale for Axis V is the Global Assessment of Functioning (GAF) Scale, which measures level of functioning on a scale of 1-100. DSM-IV-TR includes three specialized global scales in its appendices: the Social and Occupational Functioning Assessment Scale (SOFAS); the Defensive Functioning Scale; and the Global Assessment of Relational Functioning (GARF) Scale. The GARF is a measurement of the maturity and stability of the relationships within a family or between a couple.

Diagnostic categories

The Axis I clinical disorders are divided among 15 categories: disorders usually first diagnosed in infancy, childhood, or adolescence; delirium, dementia , amnestic, and other cognitive disorders; medical disorders due to a general medical condition; substance-related disorders; schizophrenia and other psychotic disorders; mood disorders; anxiety disorders; somatoform disorders; factitious disorders; dissociative disorders; sexual and gender identity disorders; eating disorders; sleep disorders; impulse control disorders not elsewhere classified; and adjustment disorders.

The diagnostic categories of DSM-IV-TR are essentially symptom-based, or, as the manual puts it, based “on criteria sets with defining features.” Another term that is sometimes used to describe this method of classification is phenomenological. A phenomenological approach to classification is one that emphasizes externally observable phenomena rather than their underlying nature or origin.

Another important characteristic of DSM-IV-TR’s classification system is its dependence on the medical model of mental disorders. Such terms as “psychopathology,” “mental illness,” “differential diagnosis,” and “prognosis” are all borrowed from medical practice. One should note, however, that the medical model is not the only possible conceptual framework for understanding mental disorders. Historians of Western science have observed that the medical model for psychiatric problems was preceded by what they term the supernatural model (mental disorders understood as acts of God or the result of demon possession), which dominated the field until the late seventeenth century. The supernatural model was followed by the moral model, which was based on the values of the Enlightenment and regarded mental disorders as bad behaviors deliberately chosen by perverse or ignorant individuals.

The medical model as it came to dominate psychiatry can be traced back to the work of Emil Kraepelin, an eminent German psychiatrist whose Handbuch der Psychiatrie was the first basic textbook in the field and introduced the first nosology, or systematic classification, of mental disorders. By the early 1890s Kraepelin’s handbook was used in medical schools across Europe. He updated and revised it periodically to accommodate new findings, including a disease that he named after one of his clinical assistants, Alois Alzheimer. The classification in the 1907 edition of Kraepelin’s handbook includes 15 categories, most of which are still used nearly a century later. Kraepelin is also important in the history of diagnostic classification because he represented a biologically based view of mental disorders in opposition to the psychoanalytical approach of Sigmund Freud. Kraepelin thought that mental disorders could ultimately be traced to organic diseases of the brain rather than disordered emotions or psychological processes. This controversy between the two perspectives dominated psychiatric research and practice until well after World War II.

Background of DSM

The American Diagnostic and Statistical Manual of Mental Disorders goes back to the 1840s, when the United States Bureau of the Census attempted for the first time to count the numbers of patients confined in mental hospitals. Isaac Ray, superintendent of the Butler Hospital in Rhode Island, presented a paper at the 1849 meeting of the Association of Medical Superintendents of American Institutions for the Insane (the forerunner of the present American Psychiatric Association) in which he called for a uniform system of naming, classifying and recording cases of mental illness. The same plea was made in 1913 by Dr. James May of New York to the same organization, which by then had renamed itself the American Medico-Psychological Association. In 1933, the New York Academy of Medicine and the Medico-Psychological Association compiled the first edition of the Statistical Manual for Mental Diseases, which was also adopted by the American Neurological Association. The Statistical Manual went through several editions between 1933 and 1952, when the first edition of the Diagnostic and Statistical Manual of Mental Disorders appeared. The task of compiling mental hospital statistics was turned over to the newly formed National Institute of Mental Health in 1949.

DSM-I and DSM-II

DSM-I, which appeared in 1952, maintained the coding system of earlier American manuals. Many of the disorders in this edition were termed “reactions,” a term borrowed from a German psychiatrist named Adolf Meyer. Meyer viewed mental disorders as reactions of an individual’s personality to a combination of psychological, social, and biological factors. DSM-I also incorporated the nomenclature for disorders developed by the United States Army and modified by the Veterans Administration (VA) to treat the postwar mental health problems of service personnel and veterans. The VA classification system grouped mental problems into three large categories: psychophysiological, personality, and acute disorders.

DSM-II, which was published in 1968, represented the first attempt to coordinate the American Diagnostic and Statistical Manual of Mental Disorders with the World Health Organization’s (WHO) International Classification of Diseases, or ICD. DSM-II appeared before the ninth edition of the ICD, or ICD-9, which was published in 1975. DSM-II continued DSM-I’s psychoanalytical approach to the etiology of the nonorganic mental disorders and personality disorders.

DSM-III, DSM-III-R and DSM-IV

DSM-III, which was published in 1980 after six years of preparatory work, represented a major break with the first two editions of DSM. DSM-III introduced the present descriptive symptom-based or phenomenological approach to mental disorders, added lists of explicit diagnostic criteria, removed references to the etiology of disorders, did away with the term “neurosis,” and established the present multi-axial system of symptom evaluation. This sweeping change originated in an effort begun in the early 1970s by a group of psychiatrists at the medical school of Washington University in St. Louis to improve the state of research in American psychiatry. The St. Louis group began by drawing up a list of “research diagnostic criteria” for schizophrenia, a disorder that can manifest itself in a variety of ways. The group was concerned primarily with the identification of markers for schizophrenia that would allow the disease to be studied at other research sites without errors introduced by using different types of patients in different centers. What happened with DSM-III, DSM-III-R, and DSM-IV, however, was that a tool for scholarly investigation of a few mental disorders was transformed into a diagnostic method applied to all mental disorders without further distinction. The leaders of this transformation were biological psychiatrists who wanted to empty the diagnostic manual of terms and theories associated with hypothetical or explanatory concepts. The transition from an explanatory approach to mental disorders to a descriptive or phenomenological one in the period between DSM-II and DSM-III is sometimes called the “neo-Kraepelinian revolution” in the secondary literature. Another term that has been applied to the orientation represented in DSM-III and its successors is empirical, which denotes reliance on experience or experiment alone, without recourse to theories or hypotheses. The word occurs repeatedly in the description of “The DSM-IV Revision Process” in the Introduction to DSM-IV-TR.

DSM-IV built upon the research generated by the empirical orientation of DSM-III. By the early 1990s, most psychiatric diagnoses had an accumulated body of published studies or data sets. Publications up through 1992 were reviewed for DSM-IV, which was published in 1994. Conflicting reports or lack of evidence were handled by data reanalyses and field trials. The National Institute of Mental Health sponsored 12 DSM-IV field trials together with the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The field trials compared the diagnostic criteria sets of DSM-III, DSM-III-R, ICD-10 (which had been published in 1992), and the proposed criteria sets for DSM-IV. The field trials recruited subjects from a variety of ethnic and cultural backgrounds, in keeping with a new concern for cross-cultural applicability of diagnostic standards. In addition to its inclusion of culture-specific syndromes and disorders, DSM-IV represented much closer cooperation and coordination with the experts from WHO who had worked on ICD-10. A modification of ICD-10 for clinical practitioners, the ICD-10-CM, was introduced in the United States in 2004.

Textual revisions in DSM-IV-TR

DSM-IV-TR does not represent either a fundamental change in the basic classification structure of DSM-IV or the addition of new diagnostic entities. The textual revisions that were made to the 1994 edition of DSM-IV fall under the following categories:

• correction of factual errors in the text of DSM-IV
• review of currency of information in DSM-IV
• changes reflecting research published after 1992, which was the last year included in the literature review prior to the publication of DSM-IV
• improvements to enhance the educational value of DSM-IV
• updating of ICD diagnostic codes, some of which were changed in 1996

Critiques of DSM-IV and DSM-IV-TR

A number of criticisms of DSM-IV have arisen since its publication in 1994. They include the following observations and complaints:

• The medical model underlying the empirical orientation of DSM-IV reduces human beings to one-dimensional sources of data; it does not encourage practitioners to treat the whole person.
• The medical model perpetuates the social stigma attached to mental disorders.
• The symptom-based criteria sets of DSM-IV have led to an endless multiplication of mental conditions and disorders. The unwieldy size of DSM-IV is a common complaint of doctors in clinical practice—a volume that was only 119 pages long in its second (1968) edition has swelled to 886 pages in less than thirty years.
• The symptom-based approach has also made it easier to politicize the process of defining new disorders for inclusion in DSM or dropping older ones. The inclusion of post-traumatic stress disorder (PTSD) and the deletion of homosexuality as a disorder are often cited as examples of this concern for political correctness.
• The criteria sets of DSM-IV incorporate implicit (implied but not expressly stated) notions of human psychological well-being that do not allow for ordinary diversity among people. Some of the diagnostic categories of DSM-IV come close to defining various temperamental and personality differences as mental disorders.
• The DSM-IV criteria do not distinguish adequately between poor adaptation to ordinary problems of living and true psychopathology. One by-product of this inadequacy is the suspiciously high rates of prevalence reported for some mental disorders. One observer remarked that “… it is doubtful that 28% or 29% of the population would be judged [by managed care plans] to need mental health treatment in a year.”
• The 16 major diagnostic classes defined by DSM-IV hinder efforts to recognize disorders that run across classes. For example, PTSD has more in common with respect to etiology and treatment with the dissociative disorders than it does with the anxiety disorders with which it is presently grouped. Another example is body dysmorphic disorder, which resembles the obsessive-compulsive disorders more than it does the somatoform disorders.
• The current classification is deficient in acknowledging disorders of uncontrolled anger, hostility, and aggression. Even though inappropriate expressions of anger and aggression lie at the roots of major social problems, only one DSM-IV disorder (intermittent explosive disorder) is explicitly concerned with them. In contrast, entire classes of disorders are devoted to depression and anxiety.
• The emphasis of DSM-IV on biological psychiatry has contributed to the widespread popular notion that most problems of human life can be solved by taking pills.

Alternative nosologies

A number of different nosologies or schemes of classification have been proposed to replace the current descriptive model of mental disorders.

The dimensional model

Dimensional alternatives to DSM-IV would replace the categorical classification now in use with a recognition that mental disorders lie on a continuum with mildly disturbed and normal behavior, rather than being qualitatively distinct. For example, the personality disorders of Axis II are increasingly regarded as extreme variants of common personality characteristics. In the dimensional model, a patient would be identified in terms of his or her position on a specific dimension of cognitive or affective capacity rather than placed in a categorical “box.”

The holistic model

The holistic approach to mental disorders places equal emphasis on social and spiritual as well as pharmacological treatments. A biochemist who was diagnosed with schizophrenia and eventually recovered compared the reductionism of the biological model of his disorder with the empowering qualities of holistic approaches. He stressed the healing potential in treating patients as whole persons rather than as isolated collections of nervous tissue with chemical imbalances: “The major task in recovering from mental illness is to regain social roles and identities. This entails focusing on the individual and building a sense of responsibility and self-determination.”

The essential or perspectival model

The third and most complex alternative model is associated with the medical school of Johns Hopkins University, where it is taught as part of the medical curriculum. This model identifies four broad “essences” or perspectives that can be used to identify the distinctive characteristics of mental disorders, which are often obscured by the present categorical classifications.

The four perspectives are:

• Disease. This perspective works with categories and accounts for physical diseases or damage to the brain that produces psychiatric symptoms. It accounts for such disorders as Alzheimer’s disease or schizophrenia.
• Dimensions. This perspective addresses disorders that arise from the combination of a cognitive or emotional weakness in the patient’s constitution and a life experience that challenges their vulnerability.
• Behaviors. This perspective is concerned with disorders associated with something that the patient is doing (alcoholism, drug addiction, eating disorders, etc.) that has become a dysfunctional way of life.
• Life story. This perspective focuses on disorders related to what the patient has encountered in life, such as events that have injured his or her hopes and aspirations.

In the Johns Hopkins model, each perspective has its own approach to treatment: the disease perspective seeks to cure or prevent disorders rooted in biological disease processes; the dimensional perspective attempts to strengthen constitutional weaknesses; the behavioral

KEY TERMS

Atheoretical —Unrelated to any specific theoretical approach or conceptual framework. The classification system of DSM-IV-TR is atheoretical.

Differential diagnosis —The process of distinguishing one disorder from other, similar disorders.

Empirical —Verified by actual experience or by scientific experimentation.

Etiology —The cause or origin of a disease or disorder. The word is also used to refer to the study of the causes of disease.

Forensic —Pertaining to courtroom procedure or evidence used in courts of law.

Holistic —An approach to health care that emphasizes the totality of an individual’s well-being, spiritual and psychological as well as physical; and that situates a disease or disorder within that totality.

Implicit —Implied or suggested without being clearly stated. Some critics of DSM-IV-TR maintain that its contributors based the criteria sets for certain disorders on an implicit notion of a mentally healthy human being.

Medical model —The basic conceptual framework in the West since the nineteenth century for understanding, researching, and classifying mental disorders.

Nosology —The branch of medicine that deals with the systematic classification of diseases and disorders.

perspective seeks to interrupt the problematic behaviors and assist patients in overcoming their appeal; and the life story perspective offers help in “rescripting” a person’s life narrative, usually through cognitive behavioral treatment.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Freeman, Hugh, ed. A Century of Psychiatry. St. Louis, MO:Mosby, 1999.

Kihlstrom, John F. “To Honor Kraepelin …: From Symptoms to Pathology in the Diagnosis of Mental Illness.” In Alternatives to the DSM, edited by L. E. Beutler and M. L. Malik. Washington, DC: American Psychological Association, 2000.

World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.

PERIODICALS

Collins, Geneva. “Radical Makeover Proposed for DSM.” Clinical Psychiatry News 29 (August 2001): 1.

Diamond, Ellen A. “A Conceptual Structure for Diagnoses.” Psychiatric Times 18 (November 2001): 4-5.

Fisher, Daniel B. “Recovering from Schizophrenia.” Clinical Psychiatry News 29 (November 2001): 30.

Kutchins, H., and S. A. Kirk. “DSM-III-R: The Conflict Over New Psychiatric Diagnoses.” Health and Social Work 14 (May 1989): 91-101.

McHugh, Paul R. “How Psychiatry Lost Its Way.” Commentary 108 (December 1999): 67–72.

McHugh, Paul R. “A Structure for Psychiatry at the Century’s Turn: The View from Johns Hopkins.” Journal of the Royal Society of Medicine 85 (1992): 483–487.

Ozarin, Lucy D., MD. “DSM: A Brief Historical Note.” Psychatric News (April 3, 1998).

“Psychiatrists Call for Overhaul of Unwieldy DSM.” Clinical Psychiatry News 29 (October 2001): 20.

Widiger, T. A. “Adult Psychopathology: Issues and Controversies.” Annual Review of Psychology (2000).

ORGANIZATIONS

American Psychiatric Association. 1400 K Street, NW, Washington, DC 20005. <www.psych.org>.

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (301) 443-4513. <www.nimh.nih.gov>

OTHER

Young, Robert M. “Between Nosology and Narrative: Where Should We Be?” Lecture delivered to the Toronto Psychoanalytic Society, Toronto, Canada. January 8, 1999.

Rebecca J. Frey, Ph.D.

Diagnostic and Statistical Manual of Mental Disorders

Nature and purposes

The Diagnostic and Statistical Manual of Mental Disorders is a reference work consulted by psychiatrists, psychologists, physicians in clinical practice, social workers , medical and nursing students, pastoral counselors, and other professionals in health care and social service fields. The book's title is often shortened to DSM, or an abbreviation that also indicates edition, such as DSM-IV-TR, which indicates fourth edition, text revision of the manual, published in 2000. The DSM-IV-TR provides a classification of mental disorders, criteria sets to guide the process of differential diagnosis , and numerical codes for each disorder to facilitate medical record keeping. The stated purpose of the DSM is threefold: to provide "a helpful guide to clinical practice"; "to facilitate research and improve communication among clinicians and researchers"; and to serve as "an educational tool for teaching psychopathology."

The multi-axial system

The third edition of DSM, or DSM-III, which was published in 1980, introduced a system of five axes or dimensions for assessing all aspects of a patient's mental and emotional health. The multi-axial system is designed to provide a more comprehensive picture of complex or concurrent mental disorders. According to the DSM-IVTR, the system is also intended to "promote the application of the biopsychosocial model in clinical, educational and research settings." The reference to the biopsychosocial model is significant, because it indicates that the DSM-IV-TR does not reflect the view of any specific "school" or tradition within psychiatry regarding the cause or origin (also known as "etiology") of mental disorders. In other words, the DSM-IV-TR is atheoretical in its approach to diagnosis and classification— the axes and categories do not represent any overarching theory about the sources or fundamental nature of mental disorders.

The biopsychosocial approach was originally proposed by a psychiatrist named George Engel in 1977 as a way around the disputes between psychoanalytically and biologically oriented psychiatrists that were splitting the field in the 1970s. The introduction to DSM-IV-TR is quite explicit about the manual's intention to be "applicable in a wide variety of contexts" and "used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, inter-personal, family/systems)."

The atheoretical stance of DSM-IV-TR is also significant in that it underlies the manual's approach to the legal implications of mental illness. DSM notes the existence of an "imperfect fit between questions of ultimate concern to the law and the information contained in a clinical diagnosis." What is meant here is that the DSM-IV-TR diagnostic categories do not meet forensic standards for defining a "mental defect," "mental disability," or similar terms. Because DSM-IV-TR states that "inclusion of a disorder in the classification ... does not require that there be knowledge about its etiology," it advises legal professionals against basing decisions about a person's criminal responsibility, competence, or degree of behavioral control on DSM diagnostic categories.

The five diagnostic axes specified by DSM-IV-TR are:

• Axis I: Clinical disorders, including anxiety disorders, mood disorders, schizophrenia and other psychotic disorders.
• Axis II: Personality disorders and mental retardation . This axis includes notations about problematic aspects of the patient's personality that fall short of the criteria for a personality disorder.
• Axis III: General medical conditions. These include diseases or disorders that may be related physiologically to the mental disorder; that are sufficiently severe to affect the patient's mood or functioning; or that influence the choice of medications for treating the mental disorder.
• Axis IV: Psychosocial and environmental problems. These include conditions or situations that influence the diagnosis, treatment, or prognosis of the patient's mental disorder. DSM-IV-TR lists the following categories of problems: family problems; social environment problems; educational problems; occupational problems; housing problems; economic problems; problems with access to health care; problems with the legal system; and other problems (war, disasters, etc.).
• Axis V: Global assessment of functioning. Rating the patient's general level of functioning is intended to help the doctor draw up a treatment plan and evaluate treatment progress. The primary scale for Axis V is the Global Assessment of Functioning (GAF) Scale, which measures level of functioning on a scale of 1–100. DSM-IV-TR includes three specialized global scales in its appendices: the Social and Occupational Functioning Assessment Scale (SOFAS); the Defensive Functioning Scale; and the Global Assessment of Relational Functioning (GARF) Scale. The GARF is a measurement of the maturity and stability of the relationships within a family or between a couple.

Diagnostic categories

The Axis I clinical disorders are divided among 15 categories: disorders usually first diagnosed in infancy, childhood, or adolescence; delirium , dementia , amnestic, and other cognitive disorders; medical disorders due to a general medical condition; substance-related disorders; schizophrenia and other psychotic disorders; mood disorders; anxiety disorders; somatoform disorders; factitious disorders; dissociative disorders; sexual and gender identity disorders; eating disorders; sleep disorders ; impulse control disorders not elsewhere classified; and adjustment disorders.

The diagnostic categories of DSM-IV-TR are essentially symptom-based, or, as the manual puts it, based "on criteria sets with defining features." Another term that is sometimes used to describe this method of classification is phenomenological. A phenomenological approach to classification is one that emphasizes externally observable phenomena rather than their underlying nature or origin.

Another important characteristic of DSM-IV-TR's classification system is its dependence on the medical model of mental disorders. Such terms as "psychopathology," "mental illness," "differential diagnosis," and "prognosis" are all borrowed from medical practice. One should note, however, that the medical model is not the only possible conceptual framework for understanding mental disorders. Historians of Western science have observed that the medical model for psychiatric problems was preceded by what they term the supernatural model (mental disorders understood as acts of God or the result of demon possession), which dominated the field until the late seventeenth century. The supernatural model was followed by the moral model, which was based on the values of the Enlightenment and regarded mental disorders as bad behaviors deliberately chosen by perverse or ignorant individuals.

The medical model as it came to dominate psychiatry can be traced back to the work of Emil Kraepelin, an eminent German psychiatrist whose Handbuch der Psychiatrie was the first basic textbook in the field and introduced the first nosology, or systematic classification, of mental disorders. By the early 1890s Kraepelin's handbook was used in medical schools across Europe. He updated and revised it periodically to accommodate new findings, including a disease that he named after one of his clinical assistants, Alois Alzheimer. The classification in the 1907 edition of Kraepelin's handbook includes 15 categories, most of which are still used nearly a century later. Kraepelin is also important in the history of diagnostic classification because he represented a biologically based view of mental disorders in opposition to the psychoanalytical approach of Sigmund Freud. Kraepelin thought that mental disorders could ultimately be traced to organic diseases of the brain rather than disordered emotions or psychological processes. This controversy between the two perspectives dominated psychiatric research and practice until well after the Second World War.

Background of DSM

The American Diagnostic and Statistical Manual of Mental Disorders goes back to the 1840s, when the United States Bureau of the Census attempted for the first time to count the numbers of patients confined in mental hospitals. Isaac Ray, superintendent of the Butler Hospital in Rhode Island, presented a paper at the 1849 meeting of the Association of Medical Superintendents of American Institutions for the Insane (the forerunner of the present American Psychiatric Association) in which he called for a uniform system of naming, classifying and recording cases of mental illness. The same plea was made in 1913 by Dr. James May of New York to the same organization, which by then had renamed itself the American Medico-Psychological Association. In 1933, the New York Academy of Medicine and the Medico-Psychological Association compiled the first edition of the Statistical Manual for Mental Diseases, which was also adopted by the American Neurological Association. The Statistical Manual went through several editions between 1933 and 1952, when the first edition of the Diagnostic and Statistical Manual of Mental Disorders appeared. The task of compiling mental hospital statistics was turned over to the newly formed National Institute of Mental Health in 1949.

DSM-I and DSM-II

DSM-I, which appeared in 1952, maintained the coding system of earlier American manuals. Many of the disorders in this edition were termed "reactions," a term borrowed from a German psychiatrist named Adolf Meyer. Meyer viewed mental disorders as reactions of an individual's personality to a combination of psychological, social, and biological factors. DSM-I also incorporated the nomenclature for disorders developed by the United States Army and modified by the Veterans Administration to treat the postwar mental health problems of service personnel and veterans. The VA classification system grouped mental problems into three large categories: psychophysiological, personality, and acute disorders.

DSM-II, which was published in 1968, represented the first attempt to coordinate the American Diagnostic and Statistical Manual of Mental Disorders with the World Health Organization's (WHO) International Classification of Diseases, or ICD. DSM-II appeared before the ninth edition of the ICD, or ICD-9, which was published in 1975. DSM-II continued DSM-I's psychoanalytical approach to the etiology of the nonorganic mental disorders and personality disorders.

DSM-III, DSM-III-R and DSM-IV

DSM-III, which was published in 1980 after six years of preparatory work, represented a major break with the first two editions of DSM. DSM-III introduced the present descriptive symptom-based or phenomenological approach to mental disorders, added lists of explicit diagnostic criteria, removed references to the etiology of disorders, did away with the term "neurosis," and established the present multi-axial system of symptom evaluation. This sweeping change originated in an effort begun in the early 1970s by a group of psychiatrists at the medical school of Washington University in St. Louis to improve the state of research in American psychiatry. The St. Louis group began by drawing up a list of "research diagnostic criteria" for schizophrenia, a disorder that can manifest itself in a variety of ways. The group was concerned primarily with the identification of markers for schizophrenia that would allow the disease to be studied at other research sites without errors introduced by using different types of patients in different centers. What happened with DSM-III, DSM-III-R, and DSM-IV, however, was that a tool for scholarly investigation of a few mental disorders was transformed into a diagnostic method applied to all mental disorders without further distinction. The leaders of this transformation were biological psychiatrists who wanted to empty the diagnostic manual of terms and theories associated with hypothetical or explanatory concepts. The transition from an explanatory approach to mental disorders to a descriptive or phenomenological one in the period between DSM-II and DSM-III is sometimes called the "neo-Kraepelinian revolution" in the secondary literature. Another term that has been applied to the orientation represented in DSM-III and its successors is empirical, which denotes reliance on experience or experiment alone, without recourse to theories or hypotheses. The word occurs repeatedly in the description of "The DSM-IV Revision Process" in the Introduction to DSM-IV-TR.

DSM-IV built upon the research generated by the empirical orientation of DSM-III. By the early 1990s, most psychiatric diagnoses had an accumulated body of published studies or data sets. Publications up through 1992 were reviewed for DSM-IV, which was published in 1994. Conflicting reports or lack of evidence were handled by data reanalyses and field trials. The National Institute of Mental Health sponsored 12 DSM-IV field trials together with the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The field trials compared the diagnostic criteria sets of DSM-III, DSM-III-R, ICD-10 (which had been published in 1992), and the proposed criteria sets for DSM-IV. The field trials recruited subjects from a variety of ethnic and cultural backgrounds, in keeping with a new concern for cross-cultural applicability of diagnostic standards. In addition to its inclusion of culture-specific syndromes and disorders, DSM-IV represented much closer cooperation and coordination with the experts from WHO who had worked on ICD-10. A modification of ICD-10 for clinical practitioners, the ICD-10-CM, is scheduled to be introduced in the United States in 2004.

Textual revisions in DSM-IV-TR

DSM-IV-TR does not represent either a fundamental change in the basic classification structure of DSM-IV or the addition of new diagnostic entities. The textual revisions that were made to the 1994 edition of DSM-IV fall under the following categories:

• correction of factual errors in the text of DSM-IV
• review of currency of information in DSM-IV
• changes reflecting research published after 1992, which was the last year included in the literature review prior to the publication of DSM-IV
• improvements to enhance the educational value of DSM-IV
• updating of ICD diagnostic codes, some of which were changed in 1996

Critiques of DSM-IV and DSM-IV-TR

A number of criticisms of DSM-IV have arisen since its publication in 1994. They include the following observations and complaints:

• The medical model underlying the empirical orientation of DSM-IV reduces human beings to one-dimensional sources of data; it does not encourage practitioners to treat the whole person.
• The medical model perpetuates the social stigma attached to mental disorders.
• The symptom-based criteria sets of DSM-IV have led to an endless multiplication of mental conditions and disorders. The unwieldy size of DSM-IV is a common complaint of doctors in clinical practice— a volume that was only 119 pages long in its second (1968) edition has swelled to 886 pages in less than thirty years.
• The symptom-based approach has also made it easier to politicize the process of defining new disorders for inclusion in DSM or dropping older ones. The inclusion of post-traumatic stress disorder (PTSD) and the deletion of homosexuality as a disorder are often cited as examples of this concern for political correctness.
• The criteria sets of DSM-IV incorporate implicit (implied but not expressly stated) notions of human psychological well-being that do not allow for ordinary diversity among people. Some of the diagnostic categories of DSM-IV come close to defining various temperamental and personality differences as mental disorders.
• The DSM-IV criteria do not distinguish adequately between poor adaptation to ordinary problems of living and true psychopathology. One byproduct of this inadequacy is the suspiciously high rates of prevalence reported for some mental disorders. One observer remarked that "... it is doubtful that 28% or 29% of the population would be judged [by managed care plans] to need mental health treatment in a year."
• The 16 major diagnostic classes defined by DSM-IV hinder efforts to recognize disorders that run across classes. For example, PTSD has more in common with respect to etiology and treatment with the dissociative disorders than it does with the anxiety disorders with which it is presently grouped. Another example is body dysmorphic disorder , which resembles the obsessive-compulsive disorders more than it does the somatoform disorders.
• The current classification is deficient in acknowledging disorders of uncontrolled anger, hostility, and aggression. Even though inappropriate expressions of anger and aggression lie at the roots of major social problems, only one DSM-IV disorder (intermittent explosive disorder ) is explicitly concerned with them. In contrast, entire classes of disorders are devoted to depression and anxiety.
• The emphasis of DSM-IV on biological psychiatry has contributed to the widespread popular notion that most problems of human life can be solved by taking pills.

Alternative nosologies

A number of different nosologies or schemes of classification have been proposed to replace the current descriptive model of mental disorders. Three of them will be briefly described.

The dimensional model

Dimensional alternatives to DSM-IV would replace the categorical classification now in use with a recognition that mental disorders lie on a continuum with mildly disturbed and normal behavior, rather than being qualitatively distinct. For example, the personality disorders of Axis II are increasingly regarded as extreme variants of common personality characteristics. In the dimensional model, a patient would be identified in terms of his or her position on a specific dimension of cognitive or affective capacity rather than placed in a categorical "box."

The holistic model

The holistic approach to mental disorders places equal emphasis on social and spiritual as well as pharmacological treatments. A biochemist who was diagnosed with schizophrenia and eventually recovered compared the reductionism of the biological model of his disorder with the empowering qualities of holistic approaches. He stressed the healing potential in treating patients as whole persons rather than as isolated collections of nervous tissue with chemical imbalances: "The major task in recovering from mental illness is to regain social roles and identities. This entails focusing on the individual and building a sense of responsibility and self-determination."

The essential or perspectival model

The third and most complex alternative model is associated with the medical school of Johns Hopkins University, where it is taught as part of the medical curriculum. This model identifies four broad "essences" or perspectives that can be used to identify the distinctive characteristics of mental disorders, which are often obscured by the present categorical classifications.

The four perspectives are:

• Disease. This perspective works with categories and accounts for physical diseases or damage to the brain that produces psychiatric symptoms. It accounts for such disorders as Alzheimer's disease or schizophrenia.
• Dimensions. This perspective addresses disorders that arise from the combination of a cognitive or emotional weakness in the patient's constitution and a life experience that challenges their vulnerability.
• Behaviors. This perspective is concerned with disorders associated with something that the patient is doing (alcoholism, drug addiction , eating disorders, etc.) that has become a dysfunctional way of life.
• Life story. This perspective focuses on disorders related to what the patient has encountered in life, such as events that have injured his or her hopes and aspirations.

In the Johns Hopkins model, each perspective has its own approach to treatment: the disease perspective seeks to cure or prevent disorders rooted in biological disease processes; the dimensional perspective attempts to strengthen constitutional weaknesses; the behavioral perspective seeks to interrupt the problematic behaviors and assist patients in overcoming their appeal; and the life story perspective offers help in "rescripting" a person's life narrative, usually through cognitive behavioral treatment.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Freeman, Hugh, ed. A Century of Psychiatry. St. Louis, MO: Mosby, 1999.

Kihlstrom, John F. "To Honor Kraepelin...: From Symptoms to Pathology in the Diagnosis of Mental Illness." In Alternatives to the DSM, edited by L. E. Beutler and M. L. Malik. Washington, DC: American Psychological Association, 2000.

World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.

PERIODICALS

Collins, Geneva. "Radical Makeover Proposed for DSM." Clinical Psychiatry News 29 (August 2001): 1.

Diamond, Ellen A. "A Conceptual Structure for Diagnoses." Psychiatric Times 18 (November 2001): 4-5.

Fisher, Daniel B. "Recovering from Schizophrenia." Clinical Psychiatry News 29 (November 2001): 30.

Kutchins, H., and S. A. Kirk. "DSM-III-R: The Conflict Over New Psychiatric Diagnoses." Health and Social Work 14 (May 1989): 91-101.

McHugh, Paul R. "How Psychiatry Lost Its Way." Commentary 108 (December 1999): 67-72.

McHugh, Paul R. "A Structure for Psychiatry at the Century's Turn: The View from Johns Hopkins." Journal of the Royal Society of Medicine 85 (1992): 483-487.

Ozarin, Lucy D., MD. "DSM: A Brief Historical Note." Psychatric News (April 3, 1998).

"Psychiatrists Call for Overhaul of Unwieldy DSM." Clinical Psychiatry News 29 (October 2001): 20.

Widiger, T. A. "Adult Psychopathology: Issues and Controversies." Annual Review of Psychology (2000).

ORGANIZATIONS

American Psychiatric Association. 1400 K Street, NW,

Washington, DC 20005. <www.psych.org>.

National Institute of Mental Health. 6001 Executive

Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov>.

OTHER

Young, Robert M. "Between Nosology and Narrative: Where

Should We Be?" Lecture delivered to the Toronto Psychoanalytic Society, Toronto, Canada, 8 January 1999.

Rebecca J. Frey, Ph.D.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

The Diagnostic and Statistical Manual of Mental Disorders (DSM) represents the most influential effort in the field of mental health to identify psychological and psychiatric abnormalities for the purposes of treatment. The extent to which this effort has been pursued in a rigorously scientific manner, and the ethical issues surrounding the distinction between normal and abnormal mental functioning, are important questions for clarification and debate.

The DSM, which has been compiled and published by the American Psychiatric Association (APA) since its first publication in 1952, is intended to serve as a standard tool for mental health professionals in the diagnosis of mental illness. In addition to providing the field with a definition of the term mental disorder, the fourth edition of the manual (DSM-IV-TR; APA 2000) contains a catalog of the clinical symptoms of 365 different mental disorders (for example, obsessive–compulsive disorder, borderline personality disorder), which are organized into sixteen major diagnostic classes (such as anxiety disorders, personality disorders, and so on).

With each subsequent edition, the classifications provided by the DSM have become more widely referenced in the field of psychopathology. In addition, the DSM system of diagnosis has become increasingly central to the communication between mental health professionals and those outside the field, such as lawyers, insurance companies, and the media. Nevertheless, the system remains highly controversial, even among those who have contributed to its development. Some of this controversy surrounds the general issue of whether or not the diagnosis of mental illness is a scientific endeavor at all. More specific criticism has also been leveled, however, at the specific approaches the DSM has taken over its history to describe or explain mental disorders. In both cases, the debate over the DSM has often raised fundamental questions about the nature and diagnosis of mental illness.

The Origins and History of the DSM

As Gerald N. Grob (1991) has detailed, psychiatrists of the early 1900s were largely uncomfortable with the idea that the symptoms of mental illness could be broken down into any meaningful classification scheme. The professionals of this period tended to view the individual case as highly unique and subject to a wide variety of interrelated personal and environmental variables. Various classification schemes were proposed between 1900 and 1920, including a collaborative effort of the U.S. Bureau of the Census and the existing version of the American Psychiatric Association that produced a taxonomy of twenty-two categories of mental disorder, most of which were predicated on a particular form of biological abnormality. Such systems, however, were largely irrelevant in clinical practice or research. Instead, they served primarily to provide gross survey categories for hospitals and local governments to use in the compilation of statistics on rates of mental illness among different demographic and ethnic groups and on standards of care across different communities.

During World War II, however, mental health professionals began caring for large numbers of patients (i.e., soldiers) who did not require long-term confinement in a hospital. These patients showed psychophysical, personality, and acute stress disorders that were not well documented and that added significant variety to the existing classifications of mental illness. Inspired by these circumstances, the APA formed a committee of experts to establish a diagnostic system that expanded upon systems developed for the U.S. armed forces and adapted the international statistical classification of diseases, injuries, and causes of death, developed by the World Health Organization, for use in the United States. This process involved a significant expansion and reorganization of the existing systems and culminated in the publication of the first DSM (DSM-I) in 1952. The DSM-I (and the subsequent DSM-II, published in 1968) represented a major turning point in the nature and purpose of a taxonomy of mental disorders. For one thing, it was the first attempt to standardize psychiatric diagnoses according to a particular theory of mental illness (that is, psychoanalytic theory). Moreover, the DSM was proposed to advance the science, and not just the administration, of mental health services. By providing mental health professionals with a common diagnostic language and by grounding the descriptions of the disorders in the prevailing psycho-analytic theory, the DSM was intended to further stimulate and synthesize research into the nature of mental illness.

These first two editions of the DSM, however, were not received with unequivocal support. The two primary complaints mental health professionals voiced against the DSM concerned the lack of evidence for the distinctions it made among various disorders and the small number of experts involved in determining the classification scheme. The reliance on psychoanalytic concepts was also increasingly questioned given the rise of more empirical and behavioral approaches in clinical settings. In response the APA took a distinctively different approach to developing the third (DSM-III, 1980) and fourth (DSM-IV, 1994) editions. For each of these editions, expert researchers and clinicians were organized into work groups for each category of disorders (e.g., anxiety disorders, substance-abuse disorders). These groups conducted reviews of the available literature to determine whether or not the criteria for each disorder and the distinctions among disorders were supported by empirical evidence. Although the findings from the work groups continued to be compiled and reviewed by committee, the emphasis on research increased both the objectivity of the decision-making process and the number of professionals who could influence the final product. The manual also became accessible to a wider range of professionals by abandoning a central theoretical perspective and adopting a focus on clinically observable symptoms such as thoughts of suicide or repetitive behaviors.

Current Issues in the Development and Application of the DSM

The primary purpose for the development of the DSM has always been its use as a clinical tool for guiding the assessment and treatment of mental disorders. Perhaps the greatest strength of the DSM is its usefulness in differential diagnosis. For example, a patient's complaint of feeling down or depressed can be evaluated in light of other clinical symptoms that are present and compared with the criteria for disorders such as Major Depressive Episode and Adjustment Disorder with Depressed Mood. Although disorders such as these share some common features, distinctions among them with regard to etiology (cause) and prognosis may provide important guidance for treatment planning. In fact, some clinicians argue that the future of mental health as a science depends heavily on the ability of professionals to distinguish among treatments that are or are not effective for specific diagnoses. Such an approach ultimately leads to the matching of treatment with diagnosis based on support from available research.

An important problem with such an approach, however, is that patients with distinctly different symptoms and clinical presentations can receive the same diagnosis. In the DSM-IV, for example, each disorder is characterized by a set of equally weighted criteria. Patients need not meet all criteria for a given disorder in order to fit the diagnosis. This flexibility allows for more reliable diagnosis across clinicians, but it can also lead to minimal overlap in symptoms between any two patients with the same diagnosis. Often, symptoms that these patients do not share play a major role in treatment planning and clinical management.

A similar problem concerns the frequency with which patients meet criteria for more than one disorder at a given time (known as comorbidity). As Lee Anna Clark, David Watson, and Sarah Reynolds (1995) have noted, more than half of all individuals with a DSM diagnosis also meet criteria for another disorder. In many cases, the presence of a second disorder is a significant issue that has a dramatic effect on a patient's response to a given treatment.

A third problem with the use of the DSM in treatment planning is the lack of a coherent theoretical framework for understanding the causes and progressions of the various disorders. This limitation is ironic, given that a descriptive, symptom-focused approach was deliberately adopted in the DSM-III and DSM-IV to make the manual accessible to a range of professionals with different theoretical orientations. Clinicians inevitably rely on a particular theoretical framework in assessment and treatment planning, however, and so a purely descriptive manual cannot help but appear removed from reality in clinical settings.

Beyond its clinical utility, the DSM has also been developed to facilitate research and communication among professionals regarding the nature of mental illness. Prior to the development of the DSM, clinicians developed colloquial classification schemes that did not generalize far beyond their immediate setting. Although many professionals of the time considered such an approach to be unavoidable, they also recognized the difficulties this posed for efforts to increase or disseminate their base of knowledge. The DSM has certainly increased systematic research into mental illness and placed that research in a framework that is accessible to a broader scientific community. A prominent example is the dramatic increase of research in personality disorders that has occurred because these disorders were given special emphasis in the DSM-III (Widiger and Shea 1991).

The question remains, however, whether this proliferation in research has resulted in any real increases in scientific knowledge concerning mental illness. For instance, critics have noted that as the DSM classifications have become more widely adopted, they have begun to take on the nature of assumptions rather than scientific problems to be investigated. Thus, researchers may rely on DSM criteria instead of independent, theoretically driven criteria in selecting research participants. In this way, the DSM has become a somewhat self-perpetuating framework.

In addition, it is important to keep in mind that the ultimate decisions about making changes to the manual are not purely empirical exercises. Such decisions must appeal to fundamental assumptions about principles concerning the nature of mental illness and the goals of the system itself. Along these lines, Arthur C. Houts (2002) has argued that it is unlikely that the continual expansion of the DSM from 106 disorders in 1952 to 365 disorders in 1994 represents real scientific advance in the ability to detect and diagnose mental illness. In particular, this expansion of labels has not occurred alongside the necessary solidification of a limited number of "covering" or "synthesizing" laws that would explain how all these new disorders relate to one another. A more specific and highly publicized example of this problem concerns the removal of homosexuality as a mental disorder in the third edition of the DSM. Regardless of whether or not homosexuality should be included in the DSM as a mental disorder, even the leadership of the revision process has admitted that the decision was ultimately based more on social pressures than on the weight of scientific evidence (Spitzer, Williams, and Skodol 1980).

A third central purpose for the development of the DSM concerns the justification of professional services and judgments. Particularly in the arenas of insurance reimbursement and legal proceedings, mental health professionals are expected to demonstrate that their evaluations and treatment plans meet some standard of common practice in the profession. With respect to insurance, however, it continues to be difficult to justify treatment decisions based on a particular diagnostic picture. Because of the heterogeneity of patients who can share a given diagnosis and because the DSM continues to explicitly require clinical judgment in assigning a diagnosis and planning treatment, the assignment of a particular diagnosis to a patient can have very little impact on the clinical services provided to that patient. Furthermore, clinicians often use DSM diagnoses for purely instrumental reasons (e.g., to promote or protect the relationship with the patient, to obtain services from a resistant insurance provider). In a common example, clinicians, in order to avoid stigmatizing or scandalizing a patient, will often diagnose the person with adjustment disorder (which connotes a more transient and normative reaction to stress) instead of a more serious disorder even though the patient meets the criteria for the latter. With regard to the courts, mental health professionals cannot assume that a particular DSM diagnosis of mental illness bears any correspondence to the legal definition of "mental disease" or "mental defect." Thus, questions of diagnosis are often abandoned altogether in the courtroom in favor of more straightforward comparisons of symptoms and states of mind with legal definitions of sanity.

Future Directions for the DSM

Shortly after publication of the DSM-IV, clinicians began expressing hopes that future editions would address several fundamental flaws in the current classification scheme, in addition to those mentioned above. Perhaps the most common desire is to move away from categorical (i.e., yes or no) diagnosis of mental disorders and toward a system of rating patients on a small number of basic, personological dimensions (e.g., personality traits). Proponents argue that such a system would have greater value in guiding differential diagnosis, would help consolidate the growing number of disorders, and would more validly reflect the dynamic nature of the individual. A less radical revision that, presumably, would also reduce the degree of disparate diagnoses is John F. Kihlstrom's (2002) proposal that the current phenomenological groupings of symptoms be replaced with diagnoses based on laboratory findings such as characteristic cognitive or affective deficits. Finally, Thomas A. Widiger and Lee Anna Clark (2000) recommend that greater attention be paid to the most basic element of the diagnostic system: the establishment of meaningful boundaries between normal and abnormal psychological functioning. Common to all these proposals is a need for the DSM to develop a more unified and coherent framework of mental illness that is more validly rooted in the fundamental nature of the human person.

Central to the ongoing debates surrounding the DSM, then, is the role of values and metaphysical assumptions in defining psychological normality and, thus, providing a foundation for the identification and treatment of abnormality. Whereas empirical science may be invaluable in describing the mental, emotional and physical processes underlying psychological disorders, interpretation of these descriptions inevitably proceeds from a framework containing statements about the nature of human abilities, the kind of life worth living, and the ideal form of relationships among persons or between persons and their environment. As Daniel Robinson (1997) has argued, any theory of psychological disorder and therapy that is divorced from these questions fails to answer the question, "therapy for what?" because it will fail to account for the kind of healing or remediation that is necessary. These kinds of metaphysical issues, which are also assuming an increasingly central role in the ethics of the biological and genetic sciences, bring into clearer relief the nature and limits of a scientific attempt to identify problems or deficiencies in the psychological life of persons.

CARLETON A. PALMER

SEE ALSO Homosexuality Debate;Psychology.

BIBLIOGRAPHY

American Psychiatric Association (APA). (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th edition, text revision. Washington, DC: Author. This most recent revision updates the text of the DSM-IV to include the results of research conducted after 1992. The revision is intended to maintain the usefulness of the DSM as an educational resource between major editions.

Clark, Lee Anna, David Watson, and Sarah Reynolds. (1995). "Diagnosis and Classification of Psychopathology: Challenges to the Current System and Future Directions." Annual Review of Psychology 46: 121–153. The authors review the purposes of a diagnostic taxonomy and consider alternatives to the current, descriptive approach. Research failing to support categorical diagnosis of psychopathology is highlighted.

Grob, Gerald N. (1991). "Origins of DSM-I: A Study in Appearance and Reality." American Journal of Psychiatry 148(4): 421–431. Examines the social and political context in which the DSM-I was developed.

Houts, Arthur C. (2002). "Discovery, Invention, and the Expansion of the Modern Diagnostic and Statistical Manuals of Mental Disorders." In Rethinking the DSM: A Psychological Perspective, ed. Larry E. Beutler and Mary L. Malik. Washington, DC: American Psychological Association. Analyzes the assumption that the proliferation of DSM diagnostic labels across editions represents actual scientific progress in the assessment and differentiation of psychological disorders.

Kihlstrom, John F. (2002). "To Honor Kraepelin … : From Symptoms to Pathology in the Diagnosis of Mental Illness." In Rethinking the DSM: A Psychological Perspective, ed. Larry E. Beutler and Mary L. Malik. Washington, DC: American Psychological Association. Argues that a taxonomy based on laboratory observations would advance the science of psychopathology and return the practice of psychological diagnosis to its historical roots.

Robinson, Daniel N. (1997). "Therapy as Theory and as Civics." Theory and Psychology 7(5): 675–681. The author suggests that fitness for the moral and civic aspects of human life provides the grounding for any theories of mental disorder and any attempts at psychotherapy.

Spitzer, Robert L., Janet B. W. Williams, and Andrew E. Skodol. (1980). "DSM-III: The Major Achievements and an Overview." American Journal of Psychiatry 137(2): 151–164. Leaders from the task force on DSM-III describe the origins of its development and the reasons for the major transition toward an atheoretical approach to defining and classifying mental disorders.

Widiger, Thomas A., and Lee Anna Clark. (2000). "Toward DSM-V and the Classification of Psychopathology." Psychological Bulletin 126(6): 946–963. Discusses the more significant issues of disagreement and debate surrounding the DSM-IV and recommends continued exploration of alternatives to the current perspective.

Widiger, Thomas A., and Tracie Shea. (1991). "Differentiation off Axis I and Axis II Disorders. Journal of Abnormal Psychology 100(3): 399–406. Suggests that the distinction between personality and symptomatic disorders first introduced in DSM-III ignores important relationships between them and instances of significant overlap in symptomatology.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

A reference work developed by the American Psychiatric Association and designed to provide guidelines for the diagnosis and classification of mental disorders.

The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders, widely referred to as DSM-IV, a reference work designed

CLASSIFICATION OF MENTAL DISORDERS

DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD, OR ADOLESCENCE

• Mental retardation
• Learning disorders
• Motor skill disorder
• Communication disorders
• Pervasive developmental disorders
• Attention-deficit and disruptive behavior disorders
• Feeding and eating disorders of infancy or early childhood
• Tic disorders
• Elimination disorders
• Other disorders of infancy, childhood, or adolescence

DELIRIUM, DEMENTIA, AND AMNESTIC AND OTHER COGNITIVE DISORDERS

• Delirium
• Dementia
• Amnestic disorders
• Other cognitive disorders

MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION NOT ELSEWHERE CLASSIFIED

SUBSTANCE-RELATED DISORDERS

• Alcohol-related disorders
• Amphetamine use disorders
• Amphetamine-induced disorders
• Caffeine-related disorders
• Cannabis-related disorders
• Cocaine-related disorders
• Hallucinogen-related disorders
• Inhalent-related disorders
• Nicotine-related disorders
• Opioid-related disorders

PHENCYCLIDINE-RELATED DISORDERS

• Sedative-, hypnotic-, or anxiolytic-related disorders
• Polysubstance-related disorder
• Other, or unknown substance-related disorder

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

MOOD DISORDERS

• Depressive disorders
• Bipolar disorders

ANXIETY DISORDERS

• Somatoform disorders
• Factitious disorders
• Dissociative disorders

SEXUAL AND GENDER IDENTITY DISORDERS

• Sexual dysfunctions
• Paraphilias
• Gender identity disorders

EATING DISORDERS

SLEEP DISORDERS

• Primary sleep disorders
• Sleep disorders related to another mental disorder

IMPULSE-CONTROL DISORDERS NOT ELSEWHERE CLASSIFIED

ADJUSTMENT DISORDERS

PERSONALITY DISORDERS

OTHER CONDITIONS

to provide guidelines for psychologists and others to use in the diagnosis and classification of mental disorders. The latest edition, DSM-IV, serves as a reference to psychiatrists, other physicians and mental health professionals, psychologists, social workers, and others in clinical, educational, and social service settings.

First published in 1917, each new edition of Diagnostic and Statistical Manual of Mental Disorders has added new categories. With the third edition, published in 1980, the DSM began recommending assessment of mental disorders according to five axes, or dimensions, that together establish an overall picture of a person's mental, emotional, and physical health, providing as complete a context as possible in which to make a proper diagnosis. The diagnostician evaluates the patient according to criteria for each axis to produce a comprehensive assessment of the patient's condition; the multiaxial system addresses the complex nature of more mental disorders.

Axis I lists 14 major clinical syndromes. These include disorders usually first diagnosed in childhood or adolescence (hyperactivity, mental retardation , autism ); dementia , amnesia , and other cognitive disorders; substance-related disorders; schizophrenia and other conditions characterized by abnormalities in thinking, perception, and emotion ; and sexual and gender identity disorders. Also listed in Axis I are mood , anxiety, somatoform, dissociative, eating, sleep , impulse control, and adjustment disorders , as well as factitious (false) disorders.

Axis II is for assessment of personality disorders— lifelong, deeply ingrained patterns of behavior that are destructive to those who display them or to others. Some examples are narcissistic, dependent, avoidant, and antisocial personality types. This axis also includes developmental disorders in children.

Axis III considers any organic medical problems that may be present. The fourth axis includes any environmental or psychosocial factors affecting a person's condition (such as the loss of a loved one, sexual abuse , divorce , career changes, poverty, or homelessness).

In Axis V, the diagnostician assesses the person's level of functioning within the previous 12 months on a scale of 1 to 100.

One notable feature of DSM-IV is that it dispenses with two previously ubiquitous terms in the field of psychology—" neurosis " and "psychosis "—because they are now considered too vague. The term "neurosis" was generally used for a variety of conditions that involved some form of anxiety, whereas "psychosis" referred to conditions in which the patient had lost the ability to function normally in daily life and/or had lost touch with reality. Conditions that would formerly have been described as neurotic are now found in five Axis I classifications: mood disorders, anxiety disorders, somatoform disorders, dissociative identity disorder s, and sexual disorders. Conditions formerly referred to as psychotic are now found in Axis I as well. Besides diagnostic criteria, the DSM-IV also provides information about mental and emotional disorders, covering areas such as probable cause, average age at onset, possible complications, amount of impairment, prevalence, gender ratio, predisposing factors, and family patterns.

DSM-IV contains the results of a comprehensive and systematic review of relevant published literature, including

MULTIAXIAL CLASSIFICATION SYSTEM

• Axis I – Clinical disorders; other conditions that may be a focus of clinical attention
• Axis II – Personality disorders; mental retardation
• Axis III – General medical conditions
• Axis IV – Psychosocial and enviromental problems
• Axis V – Global assessment of functioning.

earlier editions of DSM. In cases where the evidence of a literature review was found to be insufficient to resolve a particular question, data sets were reanalyzed and issue-focused field trials were conducted. These literature reviews, data reanalyses, and field trials that form the basis of DSM-IV have been fully documented, condensed, and published separately as a reference record in a five-volume set entitled DSM-IV Sourcebook. The DSM-IV Sourcebook also contains executive summaries of the rationales for the final decisions relative to inclusion in DSM-IV.

Further Reading

Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994.

DSM-IV Sourcebook. Washington, DC: American Psychiatric Association, 1994. In five volumes, contains documentation of all work leading to criteria published in DSM-IV, and includes executive summaries of the rationales for final decisions made in compiling the work.