History of the Diagnostic Manual (DSM)

 

A Brief Overview

 

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the primary text used in the United States and several other nations for classifying and diagnosing people with mental health conditions. Previously, in the 1920's, institutions (colleges, universities, hospitals, military services, etc.) had begun to develop their own systems of categorizing mental health conditions that they would use on a local level.

 

As people moved from job to job and from city to city it became clear that there was too much discrepancy and difficulty communicating between institutions using different manuals, different symptom lists, and different names for the various conditions. There was clearly a need for a single manual that could be used throughout the country. 

 

In 1928 a national conference led to the creation of a manual that was published in 1933 called the "Standard Classified Nomenclature of Disease". This initial publication was used primarily to facilitate communication and encourage the sharing of information about conditions between professionals (as opposed to the text itself being all that informative). It did so by provided a common language that different professionals would use when discussing cases and conditions. It was revised twice, the last time being in 1942. Although this was not the only available publication of its type at the time, it became the basis for what became the DSM, which is still used today.

 

DSM-I

In 1952, the American Psychiatric Association (APA) published the first version of the Diagnostic and Statistical Manual, or DSM for short, which included wording from the original Standard Classified Nomenclature of Disease. The DSM-I emphasized the gathering of statistical information as much as categorizing (naming) mental health conditions. For instance, it encouraged institutions to collect information about the people admitted into their program including their age, sex, race, marital status, dates of family visits, dates of escapes and returns, etc. in an effort to better understand the conditions they were treating.

Some of the conditions listed in the DSM-I included the following:

 

  • Acute brain syndrome with intracranial infection

  • Chronic brain syndrome associated with Mongolism

  • Paranoia

  • Obsessive compulsive reaction

  • Schizophrenic reactions

  • Phobic reaction

  • Depressive reaction

  • Emotionally unstable personality

  • Passive-aggressive personality

  • Inadequate personality 

As you can see, some of the language that was used in the original DSM is still used to a certain degree today, while other terms and conditions are no longer used and/or are considered insensitive, if not outright offensive. But this does help us to see where some modern days terms (and in some cases insults) originated from. 

 

DSM-II

The second edition of the DSM was published in 1968 to keep pace with the revisions of another manual, the International Classification of Diseases (ICD), used primarily outside of the United States. The DSM-II changed some wording such as removing the term "reaction" from certain conditions. Wording changes such as these were made to avoid "unacceptable implications". It also provided a greater emphasis on subcategories of various conditions.

 

The DSM-II was 119 pages long and listed approximately 50 additional conditions compared to the 132 page DSM-I that listed just over 100 conditions. The DSM-II sought to differentiate itself from the ICD only enough to where the APA felt it would be more applicable to US society. One of the main areas where they sought differentiation was in avoiding what were called "unspecified" subcategories in an attempt to "reduce confusion and ambiguity". Ironically perhaps, the DSM-5 actually reintroduced unspecified categories in recognition of the inherent uniqueness of people.

Some of the conditions listed in the DSM-II included the following:

 

  • Mental retardation

    • Following infection or intoxication

    • Following trauma or physical agent

  • Senile dementia

  • Psychosis with childbirth

  • Schizophrenia

  • Manic-Depressive illness

  • Hysterical personality

  • Sexual deviations

    • Homosexuality

    • Pedophilia

    • Voyeurism

  • Behavior disorders of childhood and adolescence

  • Marital maladjustment

 

Again we can see some of the development of our language. The terms hysterical and senile were first used in this edition, mental retardation was included with some believed causes listed as subtypes, and running away in reaction to a threatening environment was also listed as a disorder. Additionally, homosexuality was first introduced into the manual; a move that would later cause a lot of controversy.

 

DSM-III

Published in 1980, this new and much larger manual was 494 pages long and included several new diagnoses and categories as well as expanded descriptions. While some diagnoses were removed, the new edition still had over 250 diagnoses. Descriptions in the first two editions were typically a sentence to a paragraph long. The new descriptions found in the third edition included a narrative explanation, similar diagnoses to rule out so as to avoid misdiagnosing patients, and statistical information gathered from previous editions and research. Statistical information might include things like the typical age a condition is first seen, if more men or women are diagnosed, how common the condition is, possible hereditary information, and other factors (besides the actual symptoms) that may be commonly, but not always seen in those with a particular diagnosis.

 

Another major change in the DSM-III was what was called a "multiaxial" evaluation tool. Simply put, this means that mental health professionals would now be asked to look at the person in a more holistic way. In the first two editions, diagnoses were simply given based upon the symptoms a person showed. With the multiaxial approach short-term disorders were distinguished from long-term disorders (known as personality disorders). Physical issues like being sick and social-environmental factors (e.g. stressful family situations or unemployment) could also be included as they affected the condition being diagnosed.

 

Some of the new or altered conditions listed in the DSM-III included the following:

 

  • Attention Deficit Disorder

    • with hyperactivity

    • without hyperactivity

  • Eating Disorders

    • Anorexia Nervosa

    • Bulimia

  • Infantile Autism

  • Developmental Disorders

  • Delirium, Dementia, and Amnesia

  • Substance Use Disorders

  • Bipolar Disorder

  • Agoraphobia

  • Panic Disorder

  • Post-traumatic Stress Disorder

  • Hypochondriasis

  • Multiple Personality

  • Psychosexual Disorders

  • Personality Disorders

    • Borderline Personality Disorder

    • Narcissistic Personality Disorder

    • Dependent Personality Disorder

    • Histrionic Personality Disorder

Additional changes included renaming marital maladjustment "Marital Problems" in an effort to clarify that marital issues are not necessarily due to a mental disorder, as well as removing "Runaway reaction" and "Psychosis with childbirth". Homesexuality was adjusted such that it was only deemed a disorder if it caused distress. Also, the capitalization was changed with the third edition and is presented on this page in such a way as to accurately depict how it was used in each edition.

 

DSM-III-R

The 567-page DSM-III-R is a "revised" edition of the DSM-III, and was published in 1987. The goals of the revision were to accommodate new research findings, address inconsistencies and contradictions, and otherwise provide further clarification. A revision was published because the DSM-III had become much more widely accepted and used (compared to earlier editions), but the American Psychiatric Association was not yet ready to publish a DSM-IV. Although intended primarily as a manual for the United States, the DSM was translated and now widely used in several other, mostly European, nations.

 

Continuing in line with the DSM-III, the DSM-III-R also provided specific symptoms (criteria) that could be observed and documented as an aid to help is making a diagnosis.

Infantile autism was renamed Autistic Disorder with the option to specify "childhood onset" if diagnosed before a person's third birthday. Attention Deficit Disorder (ADD) was renamed Attention-deficit Hyperactivity Disorder (ADHD), Anorexia was renamed Anorexia Nervosa, and Transvestism was changed to Transvestic Fetishism emphasizing that cross-dressing involves sexual excitement.

 

Gender Identity Disorders was introduced as a group to address individuals who felt a disconnect between their biological sex and the way in which they view themselves internally. Gender Identity Disorder of Children consisted of children who felt discomfort with their assigned sex and possibly a desire to become or "grow into" the opposite-sex.

For those who have reached puberty, the label Transsexualism continued to be used and would describe a person who wished to actively change or remove their genitals. Those who had already reached puberty but did not wish to actively change or remove their genitals would be given the diagnosis Gender Identity Disorder of Adolescence or Adulthood, nontranssexual type. While others who did not fully fall into the above descriptions but still maintained some level of distress around their gender may have been given the label Gender Identity Disorder Not Otherwise Specified. 

 

Although homosexuality was formally removed in the DSM-III-R, some mental health professionals would still use another diagnosis to describe a person who was attracted to or who had distress about an attraction to members of the same sex.

 

Additionally, Alzheimer's was introduced as a type of dementia. Specifically, Primary Degenerative Dementia of the Alzheimer Type was used to  describe those individuals with dementia where a specific biological cause could not be determined.

 

DSM-IV

As with the DSM-III-R, the DSM-IV added a lot in the way of descriptive information about the various diagnoses it contained. The fourth edition was an impressive 886 pages long and published in 1994. It placed a much higher emphasis on research findings than did earlier editions. There was also a particular focus placed on cultural factors and diagnoses affecting older adults. A glossary was included listing several Culture-Bound Syndromes.

 

The American Psychiatric Association also sought input from over 60 different agencies and organizations including the developers of the International Classification of Diseases (ICD). Unlike its predecessors, the DSM-IV focused less on adding and deleting different diagnoses and more on emphasizing the process of diagnosing, along with incorporating research studies into the descriptions and lists of symptoms provided for each condition.

 

The authors of the DSM-IV also made a point of spelling out that the term "mental disorder" is not ideal. They stated that the term suggests that a distinct difference exists between mental and physical ailments, where in reality mental and physical symptoms and conditions typically occur together. For instance, you may feel anxiety (a mental condition) because of a recent diagnosis requiring invasive surgery (a physical condition).

 

The authors also point out that using categories to label people is a convenient way to understand what a person is experiencing, but that not all people with a particular diagnosis will have the same symptoms. Likewise, in some cases two or more diagnoses may seem like a good fit without either standing out as the obvious diagnosis. They emphasize that for reasons such as this it is important that only trained professionals make a diagnosis and that lay persons should not attempt to diagnosis themselves.

 

Some specific changes in the diagnoses includes clearer subtypes of ADHD and the cleaning up of disorders usually associated with children and adolescents. For instance, eating disorders and anxiety disorders were given their own categories. Various types of dementia were given their own separate diagnoses. Also, Multiple Personality Disorder as it was called in the DSM-III-R was renamed Dissociative Identity Disorder.

 

Finally, the DSM-IV made a point of adding that for most conditions it was necessary that the person affected must be impacted in such a way that the condition causes significant distress in their life in order to qualify for a diagnosis. In other words, even if a person theoretically had all of the symptoms of a condition they should not be diagnosed with that condition if the symptoms had no real effect on their day to day life.

 

DSM-IV-TR

As was the case with the original DSM-IV the DSM-IV-TR focused less on changing diagnoses and more on updating information to stay consistent with recent research findings.  The "TR" stands for "text revision". This edition of the manual was published in 2000 and consisted of 943 pages.

 

A "text revision" was created because the American Psychiatric Association was not yet ready to publish a fifth edition, but recognized that a significant amount of time had passed since their last publication. As such, they wanted to keep up to date with current research and with other comparable manuals such as the International Classification of Diseases (ICD). 

 

In the introduction to the text revision it states that "no substantive changes in the criteria sets were considered, nor were any proposals entertained for new disorders..."  Instead they limited all changes to the narrative descriptions and the statistical information that accompany each disorder. For example, changes were made based on research findings about the ratio of men to women diagnosed with a particular disorder, the typical age that a particular disorder first occurs, and the overall frequency that a disorder generally occurs amongst the entire population.

 

DSM-5

The DSM-5 was published in 2013 and was the largest yet at 991 pages. Since the previous version was only a "text revision" and not a completely new version, in a sense this edition is the first full and true update of the DSM since 1994. Thus it shouldn't be a surprise to see some major changes in this new edition.

 

The first change that might have caught your eye is that roman numerals have been removed such that what was originally expected to be the DSM-V is now the DSM-5. This was done to be consistent with modern technology and to allow for the option of making smaller, more frequent changes and updates, just like is done with software. Thus instead of having a DSM-V-R (revised), we will more likely see a DSM-5.1, a DSM-5.2, and so on.

 

But perhaps the biggest change is the elimination of the multiaxial system where personality disorders, environmental and social factors, and medical issues were separated from other diagnoses. There was also an axis devoted exclusively to an overall assessment of functioning. In the DSM-5 the axes have essentially been combined.

 

Additional changes have been made in the organization of the manual and in the way that diagnoses are made. To the non-professional these may be thought of as nuances, though changes such as these were designed to make things easier for mental health professionals and to be more realistic.

 

For a more in depth review of the DSM-5, please click here.

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