The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the product of decades of effort by hundreds of international experts in all aspects of mental health.
Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research.
History of DSM
Pre-World War Two
In the United States of America (US), the initial stimulus for developing a classification of mental disorders was the need to collect statistical information.
What might be considered the first official attempt to gather information about mental health in the US was the recording of the frequency of “idiocy/insanity” in the 1840 census.
By the 1880 census, seven categories of mental health were distinguished:
In 1917, the American Medico-Psychological Association, together with the National Commission on Mental Hygiene, developed a plan adopted by the Bureau of the Census for gathering uniform health statistics across mental hospitals.
Although this system devoted more attention to clinical usefulness than did previous systems, it was still primarily an administrative classification.
In 1921, the American Medico-Psychological Association changed its name to the APA. It subsequently collaborated with the New York Academy of Medicine to develop a nationally acceptable psychiatric classification that would be incorporated within the first edition of the American Medical Association’s Standard Classified Nomenclature of Disease.
This system was designed primarily for diagnosing inpatients with severe psychiatric and neurological disorders.
Post-World War Two
A much broader classification system was later developed by the US Army (and modified by the Veterans Administration) to better incorporate the outpatient presentations of World War II servicemen and veterans (e.g. psychophysiological, personality, and acute disorders).
At the same time, the World Health Organisation (WHO) published the sixth edition of the International Classification of Diseases (ICD), which, for the first time, included a section for mental disorders. ICD-6 was heavily influenced by the Veterans Administration classification and included:
- 10 categories for psychoses and psychoneuroses; and
- 7 categories for disorders of character, behaviour, and intelligence.
The APA Committee on Nomenclature and Statistics developed a variant of the ICD-6 that was published in 1952 as the first edition of DSM.
DSM contained a glossary of descriptions of the diagnostic categories and was the first official manual of mental disorders to focus on clinical use.
The use of the term “reaction” throughout DSM reflected the influence of Adolf Meyer’s psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors.
In part because of the lack of widespread acceptance of the mental-disorder listings contained in ICD-6 and ICD-7, the WHO sponsored a comprehensive review of diagnostic issues, conducted by the British psychiatrist Erwin Stengel.
His report inspired many advances in diagnosis – especially the need for explicit definitions of disorders as a means of promoting reliable clinical diagnoses.
However, the next round of revisions, which led to DSM-II and ICD-8, did not follow Stengel’s recommendations to any great degree. DSM-II was similar to DSM but eliminated the term “reaction.”
Development of DSM-III
As had been the case for the DSM and DSM-II, the development of the third edition (DSM-III) was coordinated with the development of the next version of the ICD, ICD-9, which was published in 1975 and implemented in 1978. Work began on DSM-III in 1974, with publication in 1980.
DSM-III introduced a number of important innovations, including explicit diagnostic criteria, a multi-axial diagnostic assessment system, and an approach that attempted to be neutral with respect to the causes of mental disorders. This effort was aided by extensive work on constructing and validating the diagnostic criteria and developing psychiatric interviews for research and clinical uses.
ICD-9 did not include diagnostic criteria or a multi-axial system largely because the primary function of this international system was to outline categories for the collection of basic health statistics.
In contrast, DSM-III was developed with the additional goal of providing precise definitions of mental disorders for clinicians and researchers.
Because of dissatisfaction across all of medicine with the lack of specificity in ICD-9, a decision was made to modify it for use in the US, resulting in ICD-9-CM (for Clinical Modification).
Development of DSM-III-Rand/DSM-IV
Experience with DSM, Third Edition (DSM-III) revealed inconsistencies in the system and instances in which the diagnostic criteria were not clear. Therefore, APA appointed a work group to revise DSM-III, which developed the revisions and corrections that led to the publication of DSM-III-R in 1987.
DSM-IV was published in 1994. It was the culmination of a six-year effort that involved more than 1,000 individuals and numerous professional organisations.
Much of the effort involved conducting a comprehensive review of the literature to establish a firm empirical basis for making modifications. Numerous changes were made to the classification (e.g. disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text.
Developers of DSM-IV and the 10th edition of the ICD worked closely to coordinate their efforts, resulting in increased congruence between the two systems and fewer meaningless differences in wording. ICD-10 was published in 1992.
DSM’s Three Major Components
DSM consists of three major components:
- The diagnostic classification:
- The diagnostic classification is the official list of mental disorders recognised in DSM.
- Each diagnosis includes a diagnostic code, which is typically used by individual providers, institutions, and agencies for data collection and billing purposes.
- These diagnostic codes are derived from the coding system used by all US healthcare professionals, (currently) known as the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM).
- The diagnostic criteria sets:
- For each disorder included in DSM, a set of diagnostic criteria indicates symptoms that must be present (and for how long) as well as a list of other symptoms, disorders, and conditions that must first be ruled out to qualify for a particular diagnosis.
- While these criteria help increase diagnostic reliability (i.e. the likelihood that two doctors would come up with the same diagnosis when using DSM to assess a patient), it is important to remember that these criteria are meant to be used by trained professionals using clinical judgement; they are not meant to be used by the general public in a cookbook fashion.
- The descriptive text:
- The third area of DSM is the descriptive text that accompanies each disorder.
- The text of DSM-5 provides information about each disorder under the following headings:
- Diagnostic Features.
- Associated Features Supporting Diagnosis.
- Subtypes and/or Specifiers.
- Development and Course.
- Risk and Prognostic Factors.
- Diagnostic Measures.
- Functional Consequences.
- Culture-Related Diagnostic Issues.
- Gender-Related Diagnostic Issues.
- Differential Diagnosis.
- Recording Procedures.
Iterations of DSM
- DSM: Published in 1952.
- DSM-II: Published in 1968 and reprinted in 1974.
- DSM-III: Work started in 1974 and published in 1980.
- DSM-III-Rand (DSM-III-R): Published in 1987.
- DSM-IV: Published in 1994.
- DSM-IV-TR: Published in 2000.
- DSM 5: Work started in 2000,with DSM-5 Task force established in 2007, and published in May 2013.
Further information about DSM can be found at the American Psychiatric Association’s website here.