DSM (The Diagnostic and Statistical Manual of Mental Disorders)

Tonight we are doing something a little different. We are not going anywhere creepy. We aren't talking about UFOs, cryptids, or ghosts. You may have noticed our love of unsolved murders and true crime, as well. Well, tonight we are looking at one of the most revolutionary tools used in diagnosing those criminals. We are talking about the DSM. This is going to be a little nerdy, but definitely interesting.


What is the DSM 5?


The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) is the product of more than 10 years 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.


DSM 1


The DSM 1 was released by the American psychiatric association in 1952. It contained 60 recognized disorders and was very different from the current DSM. The objective of DSM I was to create a single nomenclature for psychopathology. Three separate diagnostic systems were in use, none of which matched systems used by hospitals for reporting purposes:

Standard Nomenclature of Disease, (1942 revision)

War Department Technical Bulletin (Medical 203), 1943 (US Navy)

Veteran's Administration (modified version of Medical 203)

rooted in Adolf Meyer's psychobiology: all disorders considered to be reactions to stress (e.g., depressive reaction)


psychoanalytic (i.e., Fruedian) which was constructed by sending questionnaires to 10% of APA members, 46% of whom responded.


Final approval obtained from vote of full APA membership


There were three broad classes of psychopathology:


organic brain syndromes (e.g., Korsakoff's syndrome, epilepsy)


functional disorders (e.g., depression, schizophrenia)


mental deficiency (mental retardation [now called intellectual disability])


one childhood disorder, adjustment reaction of childhood/adolescence.


The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The APA listed homosexuality in the DSM as a sociopathic personality disturbance. In 1956, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a heroine to many gay men and lesbians, Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. Unfortunately homosexuality remained in the DSM until May 1974. DSM was criticized for its reliability and validity. The major limitation of the DSM was that the concept had not been scientifically tested. Also, all of the disorders listed were considered to be reactions to events occurring in an individual’s environment. Another problem was that there really was no distinction between abnormal and normal behavior. Despite this, it gained acceptance.


DSM 2


This second edition was released in 1969 by the APA. This edition featured a jump to 182 disorders. There were few changes in either process or philosophy (still psychoanalytic)


For the first time, international treaty dictated that the DSM and International Classification of Diseases (version 8; World Health Organization, 1966) be compatible.


Another primary objective was to improve communication among psychiatrists. Major psychiatric classes were expanded from 3 to 11 and several child and adolescent disorders added. They were: group delinquent reaction, hyperkinetic reaction, overanxious reaction, runaway reaction, unsocialized aggressive reaction, withdrawing reaction. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry,[24] although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). The idea that personality disorders did not involve emotional distress was discarded. There was still a disconnect between many doctors on whether the DSM was a reliable diagnostic tool. Robert Spitzer and Joseph L. Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".


DSM 2: 7TH PRINTING


Homosexuality was removed as a mental disorder following protests by gay rights activists at the 1974 annual convention of the APA in San Francisco


This landmark event illustrates several important points about conceptualization and diagnosis of mental illness:


1. diagnostic systems such as the DSM, which are constructed by social institutions, reflect social values


2. Psychiatry and related disciplines reinforce prevailing social values, which can lead to stigmatization, with considerable potential for negative effects on mental health.


3. As a social institution, the APA is not indifferent to socio political influence.


DSM 3


The DSM 3 was released in 1980 and showed a radical shift in philosophy from earlier versions. It contained 265 disorders. Available (albeit limited) research weighted heavily for the first time. It was designed to be descriptive and atheoretical in order to appeal to professionals across theoretical orientations (e.g., social workers, psychologists) instead of just psychiatrists. Psychoanalytic paradigm was supplanted by the 'biological psychiatry' perspective. A major objective was to make psychiatry more scientific, bringing it into mainstream medicine. There was a pretty big problem though. There were low inter-rater agreements in psychiatric diagnosis, the major dependent variable in psychiatry. The US-UK Cross National Diagnostic Project revealed much higher rates of schizophrenia diagnoses in NY and much higher rates of mood disorder diagnoses in London, despite nearly identical symptoms among psychiatric admissions. A meta analysis by Spitzer and Fleiss (1974) revealed the following kappa (κ) statistics for major psychiatric disorders:


depression: .41


mania: .33


anxiety: .45


schizophrenia: .57


alcoholism: .71


In general κs greater than .6 are unacceptable, so basically what this is saying is that these numbers are too high and there's too much disagreement in diagnosis. Low agreement was attributed to two sources, criterion variance and information variance.


criterion variance is when diagnosticians are using different criteria when rendering diagnoses. Information variance is when diagnosticians are obtaining different information when interviewing patients. Both of these things led to major breakthroughs in diagnosis techniques but we're getting nerdy and scientific enough, and frankly we don't have the time… Just know they were important! The DSM-III also introduced multi-axial classification:


Axis I: clinical disorders, and conditions that need clinical attention (e.g., schizophrenia, major depression, bipolar disorder, panic disorder)


Axis II: personality disorders and mental retardation (e.g., antisocial personality disorder, borderline personality disorder, autism spectrum disorder)


Axis III: general medical conditions (e.g., hypothyroidism, Huntington's disease)


Axis IV: psychosocial and environmental problems (e.g., homelessness, child abuse)


Axis V: global assessment of functioning scale (0-100)


DSM 3-R


The revision of the DSM 3 was released in 1987. It added a few more disorders bringing the number to 292. The explicit goal was to revise diagnostic criteria that were inconsistent, unclear, or were contradicted by subsequent research.


It eliminated most exclusion criteria, thereby doing away with implementing diagnostic hierarchies, which simplify diagnosis.


pre- DSM-III-R:


1. organic brain syndrome (i.e., illness attributable to CNS disease, brain trauma, etc.); if absent, then


2. schizophrenia; if absent, then


3. mood disorders; if absent, then


4. personality disorders


Eliminating diagnostic hierarchies resulted in a major increase in prevalence of disorders, and on rates of comorbidity.


DSM 4


The DSM 4 was released in 1994. The DSM 4 contained 365 disorders. A new version was needed to be compatible with the ICD 10. It is more data driven than any previous version. Some of the things done to collect now data were as follows: 13 work groups, populated with experts in each domain (e.g., anxiety disorders, eating disorders, mood disorders, multi-axial issues, etc.)


review papers commissioned


12 multisite field trials to collect new data with 5-10 sites per field trial with 70 total sites involving 6000 participants


workgroups were to use data from the field trials to "compare alternative options and to study the possible impact of suggested changes"


McArthur foundation funding for re-analysis of existing datasets


publication of a multivolume DSM Sourcebook


Side note: looking into different sources, the number of disorders and diagnosis in each edition vary from source to source. For example three different sources list the the amount of disorders for the DSM 4 at 297, 365, and 410 respectively. If you've been listening and say this point are like: these idiots can't even get the number right… Well we're doing our best goddammit, and as we like to say, Blame the internet!.


Ok back to it


DSM 4 TR


A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses. The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM .


Ok so that covers the first four editions and their revisions. And yes, for those of you who knows your DSMs, there is much more to editions 3 and 4 that we didn't go into. We are aware of this. But for the sake of time and sanity we did it the way we felt best… So back off.


That brings us to the present edition, the one that had piqued Jons interest so much, the DSM 5.


Turns it the joke may be on Jon as big changes were anticipated but few were implemented. A similar revision process to that used for DSM IV was used including:


11 expensive field trails at medical/academic sites to assess "...reliability, feasibility, and clinical utility of select revisions"


19 expert work/study groups


re-analyses of large datasets


Here are done of the major highlights:


autism spectrum disorder (ASD) subsumes what were autistic disorder, Asperger's disorder, childhood disintegrative disorder, and PDD NOS


ADHD placed in the neurodevelopmental disorders category (with intellectual developmental disorder, ASD, specific LDs, motor disorders, etc.)


a schizophrenia spectrum is now recognized


disruptive mood dysregulation disorder added to depressive disorders


several new obsessive compulsive disorders added (e.g., hoarding, skin-picking, substance-induced)


gender dysphoria added


gambling disorder added to the the substance-related and addictive disorders chapter


ALMOST NO CHANGES TO THE PERSONALITY DISORDERS!


Multi-axial classification that characterized the DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR was abandoned.


The DSM spawned the five factor model, or FFM. The FFM came about as an idea that it could be used to describe and understand the official personality disorder (PD) constructs from the American Psychiatric Association's diagnostic manuals. The FFM while spawned from the DSM is not exactly the same thing they are often confused and many think they are the same thing. The five factor model (FFM) is based on five personality factors, often referred to by the acronym OCEAN for Openness, Conscientiousness, Extraversion, Agreeableness and Neuroticism. They are measured on continua, whereby an individual may be highly extraverted, low in extraversion (introverted) or somewhere between these two extremes.

It enables the analysis of human personality based on observations carried out from clinical practices. Psychologist Lewis Goldberg referred to these as the ‘Big Five’ factors of personality, and developed the International Personality Item Pool (IPIP) - an inventory of descriptive statements relating to each trait. Within each factor, a set of individual traits relate to more specific aspects of personality.


FIVE FACTORS AT A GLANCE:


Openness to Experience

The openness to experience dimension of personality is characterised by a willingness to try new activities. Openness to experience is often associated with intelligence when measuring personality factors.


Individuals who score highly on verbal/crystallized intelligence measures have been found to also report being more open to experience.


CONSCIENTIOUSNESS:


People who are conscientious are more aware of their actions and the consequences of their behavior than people who are unconscientious. They feel a sense of responsibility towards others and are generally careful to carry out the duties assigned to them.Conscientious individuals like to keep a tidy environment and are well-organized. They are keen to maintain good timekeeping. People with high conscientious levels also exhibit more goal-oriented behavior. Low levels of conscientiousness are reflected in less motivated behavior. Unconscientious individuals are less concerned by tidiness and punctuality. Unconscientious people tend to engage in more impulsive behavior. They will act on a last-minute whim rather than considering the consequences of their choices. Research suggests that both environmental factors and heritability may influence conscientiousness.


EXTRAVERSION:


Extraversion is characterised by outgoing, socially confident behavior. Extraverts are sociable, talkative and often forward in social situations. They enjoy being the center of a group and will often seek the attention of others.This personality trait is measured on an introversion-extraversion continuum. Individuals who fit in the middle of the two traits are described as ambiverts. Introverts are people with low levels of extraversion, display contrasting behavior. They are quieter and often feel shy around other people. They may feel intimidated being in large groups such as parties, and will often try to avoid demanding social gatherings.


AGREEABLENESS:


Individuals who score highly on agreeableness measures are friendly and co-operative. Often considered more likeable by their peers and colleagues, agreeable people are trusting of others and are more altruistic, willing to help others during times of need. Their ability to work with others means that they often work well as members of a team. Individuals who are disagreeable score lower on this dimension of personality. They are less concerned with pleasing other people and making friends. Disagreeable individuals are more suspicious of other people’s intentions and are less charitable. As with some of the other ‘Big Five’ personality factors, our agreeableness levels are fluid throughout our lives, tending to increase as we grow older.


Neuroticism

This personality dimension is measured on a continuum ranging from emotional stability to emotional instability, or neuroticism. People with high neuroticism scores are often persistent worriers. They are more fearful and often feel anxious, over-thinking their problems and exaggerating their significance. Rather than seeing the positive in a situation, they may dwell on its negative aspects.People with low neuroticism scores are less preoccupied by these negative concerns. They are able to remain more calm in response to stressful situations, and view problems in proportion to their importance. As a result, they tend to worry about such problems to a lesser extent. A person’s neuroticism can have repercussions in terms of their relationship with others. A study found that people in relationships were less happy than other couples if their partner scored highly on the personality trait.


These 5 major traits contain facets, and within these facets are the 18 items that experts link with psychopathy.


We started with the DSM 5 which led us to the FFM, which brings us to psychos. There were so many damn case studies and legal papers from law students, this shit was hard to research past the basic explanations. As for both being used in legal settings that is an even more gigantic pile of stinky shit to wade through. There were at least 6 pages worth of google his about the misuses of both in diagnosing criminals for court cases. A good amount of the misuses were dealing with trying to use the dsm 5 and the FFM as proof for an insanity plea. Not necessarily a misuse, but it seems that even when these are used to help determine personality and/or mental illness, even these are rarely convincing enough to actually grant an insanity ruling. The FFM can help determine a person's personality and possibly if they are a psychopath, but even being a psychopath won't automatically guarantee any kind of insanity defence. The DSM 5 can help identify any mental disorders, but mental disorders alone don't call for an automatic insanity defence. Even put together, personality profile and any underlying mental disorders, they are not necessarily a recipe insanity. Successful insanity defenses are rare. While rates vary from state to state, on average 0.85 percent actually raises the insanity defense nationwide. Interestingly, states with higher rates of insanity defenses tend to have lower success rates for insanity defenses; the percentage of all defendants found NGRI is fairly constant, at around 0.26 percent.


Another reason that it is hard to use the dsm5 in insanity defences is the factor of the many differing opinions on how the dsm5 is applied. We saw earlier in the episode that there was a large amount of different diagnosis on patients that had the same symptoms.


After all this we then looked into the DSM as it pertains to profiling as Jon had mentioned. It turns out profilers don't really use the dsm 5 to help them. Which maybe they should, seeing as how profilers are right only around 66%, they could probably use all the help they can get. Some, however, believe by using the dsm 5 you can find the common mental illness of serial killers and use that to help determine a profile. Speaking of mental illness, let's look at the top three mental illnesses most commonly found in serial killers. First up schizophrenia. Schizophrenia is a severe mental disorder that affects how a person thinks, feels and behaves. Symptoms range from hallucinations and delusions to emotional flatness and catatonia. It is one of the most common mental disorders diagnosed among criminals, especially serial killers. David Berkowitz, Richard Chase, James holmes, and Ed Vein all had schizophrenia. Next up, Borderline Personality Disorder.

Characterized by impulsive behaviors, intense mood swings, feelings of low self-worth and problems in interpersonal relationships, borderline personality disorder seems more common among female criminals. Jeffrey Dahmer, Kristin H Gilbert, and Aileen Wuornos were all found to have borderline personality. Antisocial Personality Disorder is the third major illness. Known in the past as “psychopathy,” this mental disorder is characterized by a total lack of remorse and disregard of the feelings of others. People with APD may lie, act out violently, or break the law. While it’s reported that APD only affects 0.6% of the population, it may affect up to 47% of male inmates and 21% of female inmates. It’s also been diagnosed among three of the most ruthless serial killers. So we know that we just said that it was formerly known as psychopathy but turn out they may be two distinct things. There's actually pushback from both sides that there are traits of each that are distinct from the other. Charles Manson, Ted Bundy, and John Wayne Gacy were all diagnosed with antisocial Personality Disorder. These determinations of the diagnoses were carried out using the dsm5 guidelines for determining illnesses. So while it may not be used in profiling so to speak, you can use it to gather information to help see the traits of other people like the one they are looking for.


The DSM has been a valuable tool for mental health development and treatment. Every mental health professional uses the DSM in his or her own way. Some practitioners rigidly stick to the manual, developing treatment plans for each client based solely on the book's diagnoses. Others use the DSM as a guideline—a tool to help them conceptualize cases while focusing on each client's unique set of circumstances.


Despite its flaws, the DSM is uniquely helpful for several reasons.


Standardization

Beyond billing and coding, standardization provides a number of important benefits to the clinician and the client. Standardization of diagnoses helps ensure that clients receive appropriate, helpful treatment regardless of location, social class, or ability to pay. It provides a concrete assessment of issues and helps therapists develop specific goals of therapy, as well as assess the effectiveness of treatment.4


Research Guidance

In addition, the DSM helps guide research in the mental health field. The diagnostic checklists help ensure that different groups of researchers are studying the same disorder—although this may be more theoretical than practical, as so many disorders have such widely varying symptoms.



Therapeutic Guidance

For the mental health professional, the DSM eliminates a lot of guesswork. Proper diagnosis and treatment of mental illness remains an art, but the DSM diagnostic criteria serve as a sort of map.