Diagnostic and Statistical Manual of Mental Disorders

From Wikipedia, the free encyclopedia

The Diagnostic and Statistical Manual published by the American Psychiatric Association

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the handbook used most often in diagnosing mental disorders in the United States. The International Statistical Classification of Diseases and Related Health Problems (ICD) is a commonly-used alternative internationally. The DSM tends to be the more specific of the two. Both assume medical concepts and terms, and state that there are categorical disorders that can be diagnosed by set lists of criteria. It is controversial and some mental health professionals and others question the utility of this classification system.

The DSM has gone through five revisions (II, III, III-R, IV, IV-TR) since it was first published. The next version will be the DSM V, due for publication in approximately 2011. ^[1]

The DSM-IV-TR warns that, because it is produced for mental health specialists, its use by people without clinical training can lead to inappropriate application of its contents. They generally advise that laypersons should consult the DSM only to obtain information, not to make diagnoses, and that people who may have a mental disorder should be referred to psychiatric counseling or treatment.

1 Development
2 A multiaxial approach
3 Special Considerations
4 Criticism
5 See also
6 Reference
7 External Links

[edit] Development

The Diagnostic and Statistical Manual of Mental Disorders (DSM) was initially developed to give more objective terms for psychiatric research. Before the DSM, communication between psychiatrists, especially in different countries, was not uniform. The establishment of specific criteria was also an attempt to facilitate mental health research. The multiaxial system attempts to yield a more complete picture of the patient, rather than just a simple diagnosis.

The criteria and classification system of the DSM are based on a process of consultation and committee meetings involving primarily psychiatrists. Therefore, the content of the DSM does not reflect all opinions on the subject of psychopathology, emotional distress and social functioning. Nor are there any objective, biological verifiable standards to which it adheres. The criteria, and the way they are applied by individual clinicians are at least to some extent influenced by cultural variables and are periodically altered to reflect the contemporary social landscape. What is and what is not considered a mental disorder changes over time. For example, before a psychiatric plebiscite in 1973, homosexuality was listed in the DSM as a diagnosable mental illness. It is also known that the diagnosis of some mental disorders is influenced by gender role expectations. That is, while diagnostic criteria do not mention gender, clinicians may diagnose women's and men's behavior in different ways^[2].

Users should be reminded that the manual is, to an extent, a historical document. The science used to create categories, taxonomies, and diagnoses is based on statistical models. These systems are thus subject to the limitations of the methods used to create them. Deconstructive critics assert that DSM invents illnesses and behaviors. Detractors of DSM argue that patients frequently fail to fit into any particular category or fall into several, that time limits and numbers of clinical characteristics required for a categorization are arbitrary and that attention directed towards finding a suitable DSM category for a patient would be better spent discussing possible life-history events that precipitated a mental disturbance or monitoring treatment. Since effective treatment is the aim of the psychiatric profession they would argue that it makes more sense to regard ailments on the basis of how they should be treated rather than on deciding what clinically irrelevant differences place them in one category and not another. This would allow for the modular treatment of different sets of symptoms, for instance prescribing antidepressants for a deficit of serotonin and tranquillizers to deal with acute anxiety.

The first edition (DSM-I) was published in 1952, and had about 106 different disorders.

DSM-II was published in 1968 with a growth to 140 disorders.

Both of these editions were strongly influenced by the psychodynamic approach, which provides no sharp distinction between normal and abnormal. All disorders are considered reactions to environmental events, with mental disorders existing on a continuum of behavior. In this sense, everyone is more or less abnormal, and inclusion in the manual presumes abnormality. The people with more severe abnormalities have more severe difficulties with functioning.

Already in the DSM-II version, the editor, Robert Spitzer, subsumes many physical and medical findings as mental illness abnormalities. .0 indicates that reported symptoms follow infection or intoxication; .1 are symptoms that follow trauma or a physical agent; .2 is related to disorders of metabolism, etc. until .7 and up, when true psychiatric findings are specified. Acute alcohol intoxication, speech disturbance, and enuresis are all listed as specific mental illness manifestations in this version of the DSM.

The classificatory structure of early editions of the DSM was rooted in a distinction between two poles of mental disorder, psychosis and neurosis. A psychosis is a severe mental disorder characterized by a disconnection from reality. Psychoses typically involve hallucinations, delusions, and illogical thinking. A neurosis, however, is a milder mental disorder characterized by distortions of reality, but not a complete break with reality. Neuroses typically involve anxiety and depression.

Among the most noted examples of controversial diagnoses is the classifying in the DSM-II of homosexuality as a mental disorder, a classification that was removed by vote of the APA in 1973 after three years of various gay activists groups demonstrating at APA meetings (see also homosexuality and psychology).

In 1980, with DSM-III, the psychodynamic view was abandoned and the biomedical model became the primary approach, introducing a clear distinction between normal and abnormal. The DSM became atheoretical since it had no preferred etiology for mental disorders. The criteria for many of the mental disorders were expanded from the Research Diagnostic Criteria (RDC) and Feighner Criteria which had been developed for psychiatry research in the 1970s.

In 1986 the DSM-III-R appeared as a revision of DSM-III. Many criteria were changed.

In 1994, it evolved into DSM-IV. This is the most current edition.

The most recent version is the 'Text Revision' of the DSM-IV, also known as the DSM-IV-TR, published in 2000. The vast majority of the criteria for the diagnosis were not changed from DSM-IV. The text in between the criteria was updated.

DSM-V is tentatively scheduled for publication in 2011, with initial planning having begun in 1999. The APA Division of Research expects to begin forming DSM development workgroups in 2007. ^[3]

[edit] A multiaxial approach

The Diagnostic and Statistical Manual of Mental Disorders, presently in its fourth revised (IV-TR, 2000) edition, systemizes psychiatric diagnosis in five axes:

Axis I: major mental disorders, clinical disorders
Axis II: underlying pervasive or personality conditions, developmental disorders and learning disabilities, as well as mental retardation
Axis III: medical conditions contributing to the disorder
Axis IV: psychosocial and environmental factors contributing to the disorder
Axis V: Global Assessment of Functioning (on a scale from 100 to 0)

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, and schizophrenia. Common Axis II disorders include borderline personality disorder, schizotypal personality disorder, antisocial personality disorder, narcissistic personality disorder, and mild mental retardation.

The contents of the DSM are determined by experts whose mandate is to create a set of diagnoses that are replicable and meaningful. While the classification system was originally intended to enhance research into both diagnosis and treatment, the nomenclature is now widely used by both clinicians and insurance companies.

[edit] Special Considerations

The DSM is intended for use by mental health professionals in clinical, research, and administration settings. Appropriate use of the diagnostic criteria requires extensive clinical training, and its contents "cannot simply be applied in a cookbook fashion."^[4] The APA notes that diagnostic labels are primarily for use as a "convenient shorthand" among professionals for the same symptoms. Further, people sharing the same diagnosis/label may not have the same etiology (cause) or require the same treatment (the DSM contains no information on treatment or cause for this reason). The range and breadth of the DSM represents an extensive scope of psychiatric and psychological issues, and it is not exclusive to what one may consider "illnesses." Impotence, premature ejaculation, jet lag, and caffeine intoxication are examples of inclusions that some readers in the general public might find surprising and are among several disorders that are not normally considered to be mental illnesses.

[edit] Criticism

The DSM has seen criticisms through the years. A Columbia University team headed by Robert Spitzer, one of the creators of the DSM, acknowledges a concern about the DSM in their annual report of 2001, “Problems with the current DSM-IV categorical (present vs. absent) approach to the classification of personality disorders have long been recognized by clinicians and researchers.” Among the problems, they list “arbitrary distinction between normal personality, personality traits and personality disorder” and point out the fact that the most commonly diagnosed personality disorder is 301.9, Personality Disorder not Otherwise Specified.^[5]

There have also been questions of potential bias of DSM authors who define psychiatric disorders. According to The Washington Post, an analysis published in Psychotherapy and Psychosomatics^[6] pointed out that "every psychiatric expert involved in writing the standard diagnostic criteria for disorders such as depression and schizophrenia has had financial ties to drug companies that sell medications for those illnesses."^[7] However, an important limitation of this study was that the analysis did not reveal the extent of their relationships with industry or whether those ties preceded or followed their work on the manual.

In the United States, health insurance typically will not pay for psychological or psychiatric services unless a DSM-IV mental disease diagnosis accompanies the insurance claim. Critics claim that this may have exacerbated the ever-expanding number of disease categories. It may also cause people to be labeled with "illness" for the purpose of reimbursement. All physician services in the United States require an ICD code for health insurance payment, regardless if the patient has a definable illness or not. This is equally true of mental or physical complaints.

The website of the DSM-V Prelude Project^[8] covers shortcomings of the DSM-IV that may be subject for improvements for the DSM-V.