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.
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.
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, 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.
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:
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)
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.
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.
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