History of the Diagnostic and Statistical Manual of Mental Disorders (DSM)

Understanding the DSM-5Crystal Weaver, CRC, MT-BC

TermsNosology: the branch of medical science dealing with the classification of diseasesDemarcating: separate or distinguish fromEmpirical: based on, concerned with, verifiable by observation or experience rather than theory or pure logicPositivistic: a doctrine contending that sense perceptions are the only admissible basis of human knowledge and precise thoughtPsychodynamics: the interaction of various conscious and unconscious mental or emotional processes, especially as they influence personality, behavior, and attitudesICD: The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States in 1994. The 11th revision of the classification has already started and will continue until 2015Part One: The History of the DSM

Why Learn the History of the DSM?Understanding the history of the DSM can help practitioners and researchers:Better understand the diagnostic language they are usingIdentify future directions for an improved nosologyBetter understand the DSMs strengths and limitationsFor example, many of the diagnostic criteria are not based on empirical research but on expert consensus and, in some cases, political appeasement

Before the DSMNumerous nosologies in North America preceded the development of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)Having divergent classification systems impeded communication between researchers and practitionersA standardized classification system was needed to:Minimize confusionCreate a consensus among the fieldHelp mental health professionals communicate using a common diagnostic languagePrecursor to the DSMThe advent of institutionalization provided substantial opportunity to collect data and learn about mental disorders in clinical contextsMental disorder began to be viewed through a medical lensIndividual nosologies put forth by psychiatrists in the late 19th and early 20th centuries had the advantage of being holistic and centered on the individualChallenges of different nosologies:Different diagnostic languages were spoken, impeding communication between psychiatristsPrevalence rates of mental disorders could not be determinedGreat confusion and variability in diagnoses of mental disordersPrecursor to the DSM (cont)In 1917, the Committee on Statistics of the American Medico-Psychological Association (now the American Psychiatric Association) recommended a uniform classification system of mental diseaseThis committee feared that having a disordered way of classifying mental diseases would discredit the field of psychiatryPublished the Statistical Manual for the Use of Institutions for the InsaneThis manual separated mental disorders into 22 groupsThis manual went through 10 editions until 1942Opponents To A Psychiatric NosologyAdolf Meyer, former president of the APAOpposed to a nosology demarcating a one-word diagnosis marking the individualViewed mental illness in holistic terms and was a proponent of understanding the life histories of patients to understand the etiologies of mental disordersBelieved each psychiatric case was unique and should be studied on its own termsWorld War IIA significant shift in psychiatric nosology occurred in the U.S. as a result of World War IIPsychiatrists serving in the military found that environmental stressors contribute to mental illnessNew terminology focused less on biological bases of behavior and more on developmental, environmental, and relational factorsTherefore, further updates to the Statistical Manual for the Use of Institutions were put on hold and the army made extensive revisions to the standard nomenclatureInternational Statistical ClassificationIn 1948, the 6th revision of the International Statistical Classification (ICD) was producedIncluded a section on mental disordersAt this time, at least three nomenclatures were widely used in North AmericaNone of which were in line with the International Statistical ClassificationDiagnostic and Statistical Manual of Mental Disorders, First EditionThe first edition of the DSM, published in 1952, was an important development toward a standard nosology of mental disordersThis manual offered:A new classification in conformity with newer scientific and clinical knowledgeSimpler structureEasier to useVirtually identical with other national and international nomenclatures

Diagnostic and Statistical Manual of Mental Disorders, First Edition (cont)DSM-I featured descriptions of 106 disorders, which were referred to as reactionsDisorders were split into two groups based on causalityDisorders caused by or associated with impairment of brain tissue functionAcute brain disordersChronic brain disordersMental deficiencyDisorders of psychogenic origin or without clearly defined physical cause or structural change in the brain Psychotic disordersPsychophysiologic autonomic and visceral disordersPsychoneurotic disordersPersonality disordersTransient situational personality disordersDiagnostic and Statistical Manual of Mental Disorders, First Edition (cont)Highly influenced by the prevalence of psychodynamic theory in North AmericaAfter its publication, it became necessary to coordinate DSM with future editions of the ICDProved to be a daunting task based on the different orientation and purposes of the manualsDiagnostic and Statistical Manual of Mental Disorders, Second EditionBoth the DSM-I and the DSM-II held similar theoretical stances, which were grounded in psychodynamicsNoteworthy differences between the DSM-I and the DSM-IIIn the DSM-II nomenclature was carefully selected to avoid terms implying causalityThe term reaction was removed from diagnostic labels in the DSM-II because it implied causality and referred to psychoanalysisThe DSM-II increased the number of disorders to 182Between the Second and Third Editions of the DSMBy the 1960s, psychiatry as a profession was predominantly psychodynamicWhich resulted in some unrealistic thinkingSuccess in returning soldiers to the front in World War II created perhaps an unrealistic expectation of the curability of mental illnessThe reliability of diagnosis came under scrutinyThere was growing public contempt in the U.S.Particularly over conflicting testimonies of psychiatrists in insanity defense pleasNeo-KraepeliniansThe profession of psychiatry underwent significant theoretical changes toward an empirical, positivistic orientationThe field reverted to an orientation based on the ideas of Emil KraepelinKraepelins core ideas include:Relating psychiatry with medicineUsing descriptive languageObserving psychiatry through an empirical lensBiology and genetics play a key role in mental disordersDistinguishing between schizophrenia and bipolar disorderNeo-Kraepelinians (cont)Kraepelins influence on psychiatry reemerged in the 1960s, about 40 years after his death, with a small group of psychiatrists at Washington University in St. Louis, MO, who were dissatisfied with psychodynamically oriented American psychiatryThey were dissatisfied with:The lack of clear diagnoses and classificationLow interrater reliability among psychiatristsBlurred distinction between mental health and illnessTo address these fundamental concerns and to avoid speculating on etiology, these psychiatrists advocated descriptive and epidemiological work in psychiatric diagnosis In 1972, John Feighner and his neo-Kraepelinian colleagues published a set of diagnostic criteria based on a synthesis of research, pointing out that the criteria were not based on opinion or traditionDiagnostic and Statistical Manual of Mental Disorders, Third EditionThe DSM-III appeared to adopt a neo-Kraepelinian standpoint and in the process revolutionized psychiatry in North AmericaThe DSM-III, published in 1980, dropped the psychodynamic perspective in favor of empiricismThe DSM-III expanded to 494 pages with 265 diagnostic categories

Diagnostic and Statistical Manual of Mental Disorders, Third Edition (cont)The DSM-III:Presented psychiatry in a medical modelEmphasized follow-upEmphasized family historiesSought to increase the reliability of diagnosisSought to facilitate communication among mental health professionalsDiagnostic and Statistical Manual of Mental Disorders, Third Edition (cont)The introduction of the DSM-III emphasizes the importance of having a common diagnostic language:Clinicians and researchers must have a common language with which to communicate about the disorders for which they have professional responsibilityThe efficacy of various treatment modalities can be compared only if patient groups are described using diagnostic terms that are clearly defined. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (cont)The DSM-III featured a multiaxial format, which addressed:Mental disorderPersonalityMedical causesEnvironmental factorsGeneral functioning in diagnoses Contrary to a neo-Kraepelinian standpoint, expert consensus was often used to inform diagnostic criteriaEmpirical research was used when possible, but much of the categorization was based on clinical judgmentDiagnostic and Statistical Manual of Mental Disorders, Third Edition (cont)A revised edition of the DSM-III was published in 1987, which included:Some revised descriptions of diagnostic criteria Descriptions of field trials assessing the validity and reliability of disordersAn appendix of Proposed Diagnostic Categories Needing Further StudyDiagnostic and Statistical Manual of Mental Disorders, Fourth EditionThe structure and theoretical orientation of the DSM-IV was largely unchanged from the DSM-IIIThe number of mental disorders increased to more than 300 in the DSM-IVThe threshold for approval or a diagnosis in the DSM-IV was more conservative, requiring more empirical backingThe DSM-IV-TR was published to ensure that information in the DSM-IV remained up-to-dateNo substantive changes were made to the diagnostic criteria set out in the DSM-IV No new disorders nor new subtypes were considered

The DSM-IV-TR and the ICDThe DSM-IV-TR and ICD-10 represented the dominant diagnostic languages in the worldTraditionally, revisions to the DSMs and ICDs have occurred relatively independentlyMost disorders in both manuals have differences between them21% having conceptually based differencesDifferences in these two manuals can undermine the credibility of the field of psychiatry, and having two different classification systems can impede international collaboration effects

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition PredictionsThe initial phase of the DSM-5 planning process began in 1999 with a series of conference cosponsored by APA and the National Institute of Mental Health Task force of 28 peopleWork groups had over 130 people in 13 workgroups400 advisorsStrong international representation (39 countries)Harmonization of the DSM and ICD was identified as an important goal of the revisions of both manualsOne step that had been proposed for the DSM-5 was the amalgamation of Axes I, II, and III into one axis that contains all psychiatric and general medical conditionsThis would bring the DSM more in line with ICD approachDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont)Perhaps the most revolutionary idea is to adopt a dimensional rather than categorical approach to classificationIn contrast with the categorical approach used in the DSM-IV-TR, where dichotomous diagnostic decisions regarding the presence/absence of a disorder are made based on meeting a certain number/pattern of criteria, a dimensional approach would involve quantitative ratings of patients on characteristics or features of the disorderUsing this method, important clinical information can be communicated for patients above and below current diagnostic thresholdsDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont)In February 2010, the APA released Proposed Draft Revisions to DSM Disorders and Criteria. Many of these proposed changes reflected a shirt toward etiologically based, dimensional diagnosesOne proposed change was the inclusion of an anxiety dimension across all mood disordersIn the categorical approach in DSM-III and DSM-IV, anxiety is identified as a separate and distinct construct from other mood disorders, whereas the proposed changes in DSM-5 suggest that anxiety may be a common underlying factor

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Predictions (cont)Other proposed changes for the DSM-5:Autistic disorder, Aspergers disorder, and PDD-not otherwise specified (NOS) were distinct categories in the DSM-IV-TR. The proposed changes would eliminate these categories and place these disorders within the classification autism spectrum disorderWith Personality Disorders, diagnoses may be based on underlying traits (which requires a dimensional approach)Part Two: The DSM-5

Why Are Clients Diagnosed?To provide better treatment for the clientTo obtain reimbursementTo stimulate researchTo guide treatmentTo better understand the client The BasicsThe DSM-5 was released at the American Psychiatric Associations annual conference in San Francisco in May, 2013There are criticisms and controversies surrounding the DSM-5Pathology-based, not strengths-basedConcerns about overprescribing medicationsNo treatment suggestionsElectronic version available

DevelopmentTask force of 28 peopleWork groups had over 130 people in 13 workgroups400 advisorsInternational representation (39 countries)Process began in 1999Goals and PurposeGoals: Improve diagnostic accuracyAdd severity scalesAdd dimensional assessmentsReduce not otherwise specified (NOS) usageAlign with ICD (International Classification of Diseases)Purpose:Tool for cliniciansEducational resource for studentsReference for researchersProvide a common languageAssist in compiling public health statisticsHelp assess people objectivelyDefining Mental DisorderThe definition of mental disorder is essentially the same as the DSM-IV definition:A syndrome of clinically significant disturbance in cognition, emotion regulation, or behavior, that is associated with distress, disability, or significant impairment in important areas of functioningSeveral categories give the option of medication-induced __________ disorder or substance-induced __________ disorderGuidance on UseA diagnosis should not be made for behaviors that are an expected or culturally sanctioned response to a particular eventConsider cultural context: Section 3 has a chapter on cultural formulation with a structured interviewThese are conditions a person may have but the conditions should not define the personThese disorders are often early life coping or defense mechanisms that are now dysfunctional and causing distressConditions may or may not be medical or biological illnesses

No More Multiaxial SystemNo more Axis I- VNo more GAFNo listing of psychosocial and environmental problemsNo listing of contributing medical conditions

Diagnostic GroupingsNeurodevelopmental DisordersSchizophrenia Spectrum and Other Psychotic DisordersBipolar and Related DisordersDepressive DisorderAnxiety DisordersObsessive-Compulsive and Related DisordersTrauma and Stressor-Related DisordersDissociative DisordersSomatic Symptom and Related DisordersFeeding and Eating DisordersElimination DisordersSleep-Wake DisordersSexual DysfunctionsGender DysphoriaDisruptive, Impulse Control, and Conduct DisordersSubstance-Related and Addictive DisordersNeurocognitive DisordersPersonality DisordersParaphilic DisordersNeurodevelopmental DisordersCategory includes:Intellectual DisabilityGlobal Developmental Delay (under age 5)Communication DisordersAutism Spectrum DisorderADHDSpecific Learning DisorderMotor DisordersAutism Spectrum Disorder (ASD)Aspergers disorder is now absorbed into Autism Spectrum Disorder (ASD)Aspergers, Childhood Disintegrative Disorder, Retts Disorder, and Pervasive Developmental Disorder (PDD) are goneThe reliability and validity of these disorders are very poorThere is no evidence to support their continued separationAutism Spectrum Disorder (cont)People with a well-established DSM-IV diagnosis of ASD, Aspergers, or PDD will probably qualify for the diagnosis of ASDIf the person does not meet criteria, an evaluation for Social (Pragmatic) Communication Disorder may be doneDramatic rise in the prevalence of ASD:2007 (1 in 150)2009 (1 in 110)2013 (1 in 88)Autism Spectrum Disorder (cont)Three domains in DSM-IV will become two domains in the DSM-5:DSM-IVQualitative impairment in social interactionQualitative impairment in communicationRestricted repetitive and stereotyped patterns of behavior, interests, and activitiesDSM-5Social and communication deficitsRestricted repetitive behaviors, interests, and activities (RRBs)

Autism Severity(Severity specifiers should not be used to determine eligibility for services)Severity LevelSocial CommunicationRestricted Interests, Repetitive BehaviorsLevel 3Requiring very substantial supportSevere deficits in verbal and nonverbal communication, limited social interactionPreoccupations interfere with functioning in all areas. Distress when rituals are interruptedLevel 2Requiring substantial supportMarked deficits even with supports, limited initiation of social interactions, abnormal responsesRituals appear frequently enough that a casual observer notices. Some interference with functionLevel 1Requiring supportWithout support, deficits cause impairment. Difficulty with social interactionRepetitive behaviors interfere with some functioning. Resists redirectionAutism Spectrum Disorder (cont)Typical presentation includes:Inappropriate responses in conversationMisreading nonverbal interactionsDifficulty building friendships appropriate to ageOverly dependent on routinesHighly sensitive to changes in environmentIntensely focused on inappropriate itemsCore features are usually obvious by age 2Regression or plateau in language or social development is present in 20-30% by age 2There is no blood test or biological markerAutism Spectrum Comorbidities71%: Oppositional Defiant Disorder (ODD)62%: Anxiety50-73%: Significant motor delays (especially handwriting)40-85%: Sleep problems (10x higher rate of insomnia)41%: ADHD37%: Obsessive-Compulsive Disorder (OCD)22-70%: GI complaints13%: Depression10%: Speech problems9%: Tourettes/tic disorders Autism Spectrum Disorder (cont)70% have one other mental health diagnosis41% have two or more other mental health diagnosesParents may have increased stress and poorer healthSiblings may have more anxiety and depressionThere is no link between vaccines and autismConclusive studies done by:Centers for Disease Control and PreventionFood and Drug AdministrationInstitute for MedicineWorld Health OrganizationAmerican Academy of PediatricsDepressive DisorderCategory includes:Disruptive Mood Dysregulation Disorder (new) Major Depressive DisorderSymptom list has not changedPersistent Depressive Disorder (new)Premenstrual Dysphoric Disorder (new)

Anxious Distress SpecifierDepression/anxiety link:29% have history of panic attacks62% have moderate anxietyAnxious Distress Specifier:Keyed up/tenseUnusually restlessDecreased concentrationFear of something awful happeningFear of losing controlDepression with Anxious Distress Specifier:Takes longer to recover fromGreater suicide riskMore complaints of medication side effectsGreater recurrenceGreater impairmentBereavement ExclusionBeginning in DSM-III, if someone is grieving the loss of a loved one, they can not be diagnosed with depression for the first 2 monthsPrognosis is bad if someone has bereavement and major depression at the same timesBereavement can induce great suffering, but does not typically induce major depressionGrief vs. Depression:Less psychomotor retardationLess worthlessness or self-loathingLess suicidal ideationFewer symptomsPeople see symptoms as normal and expected given the lossBereavement Exclusion (cont)Grief:Painful feelings come in waves, often mixed with positive memories of the deceasedProminent feelings of emptiness and lossPerson feels that symptoms are due to the lossDepression:Mood and ideation are almost constantly negativeMood is persistently depressed with an inability to anticipate happiness or pleasurePerson may not have any idea why they feel so badDisruptive Mood Dysregulation Disorder (DMDD)New diagnosisSimilar to Bipolar Disorder with extreme temper and ragePrevalence: 2-5% more in males than femalesSimilar to Oppositional Defiant Disorder (ODD), but more severe:DMDD requires impairment across two settings, once of which is severeDMDD has higher symptom threshold than ODD

Disruptive Mood Dysregulation Disorder (cont)

Severe recurrent temper outbursts:Verbal or behavioralInconsistent with developmental levelMood between outbursts is persistently irritable or angryPresent in a least 2 settings, severe in at least oneFrequency: at least 3 times weeklyDuration: 12 months, no more than 3 months symptom-freeCan not diagnosis before age 6 or after age 18Anxiety DisordersPost-Traumatic Stress Disorder (PTSD) and Obsessive Compulsive Disorder (OCD) are no longer in this categoryPanic attack is now just a specifier, not a diagnosisCategory includes:Separation Anxiety DisorderCan diagnose with adult onsetSelective MutismSpecific PhobiaSocial Anxiety DisorderPanic DisorderAgoraphobiaNow a stand-along diagnosis, does not need to be linked with Panic DisorderGeneralized Anxiety DisorderObsessive-Compulsive and Related DisordersObsessive-Compulsive Disorder (OCD) is a stand alone categoryCategory includes:OCDBody Dysmorphic Disorder (now listed under OCD instead of Somatoform Disorders)Hoarding Disorder (new)TrichotillomaniaExcoriation (new)Obsessive-Compulsive and Related Disorders (cont)Insight specifier with OCD, Hoarding, and Body Dysmorphic DisorderDSM-IV required the person with OCD to realize the obsessions and compulsions were unreasonable, that is not required in the DSM-530% have a Tic Disorder25% of OCD starts by age 14Suicide and OCD:Ideation in 50%Attempts in 25%Trauma and Stressor-Related DisordersCategory includes:Reactive Attachment DisorderDisinhibited Social Engagement DisorderPost-Traumatic Stress Disorder (PTSD)Acute Stress DisorderAdjustment DisordersPost Traumatic Stress Disorder (PTSD)Specifically includes sexual violence as a trigger eventPTSD no longer requires that an individual have a subjective experience of fear or horrorWell-trained emergency workers and military personnel often do not report subjective feelings of fear and horrorAt one year, 14% have dissociative symptomsMilitary leaders through that the word disorder made military people resistant to asking for helpthey wanted to rename PTSD to Post-Traumatic Stress InjuryThe task force felt that injury was imprecise and that the military environment needs to changePTSD:Symptom ClustersDSM-IV: 3 symptom clustersRe-experiencing and intrusive symptomsAvoidance and numbingArousal and reactivityDSM-5: 4 symptom clustersRe-experiencing and intrusive symptomsAvoidance and numbingArousal and reactivityNegative alterations in cognitions and moodPTSD:Symptom Clusters (cont)Negative cognitions and mood:Inability to remember important aspects of the traumaNegative beliefs about self, others, or the worldPersistent distorted blame of self or othersPervasive negative emotional stateDiminished interest in significant activitiesFeeling detachment from othersInability to experience positive emotionsPTSD:Symptom Clusters (cont)Re-experiencing and intrusive symptoms:Recurrent memories of the traumatic eventRecurrent distressing dreams related to the traumaFlashbacks or other intense prolonged psychological distressAvoidance:Avoiding distressing memories, thoughts, feelings, or external reminders of the eventArousal and reactivity:Aggressive, reckless, or self-destructive behaviorSleep disturbanceHypervigilanceIrritability and angerSubstance Use and Addictive DisordersThis is by far the largest category in the DSM-5Only three qualifiers are used in the categoryUse (replaces both abuse and dependence)IntoxicationWithdrawal Nicotine-related renamed tobacco usePolysubstance categories discontinuedGambling added to this category

Substance Use and Addictive Disorders (cont)Substance use disorder replaces both abuse and dependenceDependence was misused when describing the normal physical reactions that can occur during appropriate medication use, such as antidepressant discontinuation syndromeAbuse was more reliably assessed than dependenceNicotine was changed to tobaccoDo not want people on nicotine replacement to get confused and think they are doing something riskyTobacco is the harmful agent with significant health risksSubstance Use and Addictive Disorders (cont)Symptoms:Taken in larger amounts or for a longer period than intendedPersistent desire or unsuccessful efforts to cut down or control useGreat deal of time is spent obtaining, using, or recoveringCraving or a strong desire or urge to useRecurrent use results in failure to fulfill major role obligations at work, school, or homeContinued use in spite of social or interpersonal problemsImportant activities are given up or reduced because of useRecurrent use when it is physically hazardousContinued use in spite of physical problemsTolerancewithdrawalSubstance Use and Addictive Disorders (cont)Severity:Mild = 2-3 symptomsModerate = 4-5 symptomsSevere = 6 or more symptomsGamblingMoved to substance use and addictive disorders section from disruptive, impulse control, and conduct disorders sectionOnly behavioral addiction in the manualIndividuals who are pathological gamblers: show tolerance, dependence, and withdrawalThe brains reward system and neural circuits react in similar waysSimilar to substance use disorders in:Clinical expressionBrain originComorbidityFrontal lobe dysfunctionTreatment (Cognitive-Behavioral Therapy, 12-step program, motivational, brief)Impulse dysregulationGenetics In ConclusionThe DSM has frequently been referred to as the gold standard for psychiatric diagnosisThe DSM is used in clinical and research contexts throughout the world, and few texts match its influential powerThere are a number of factors that spurred the development of the first edition of the DSM, with perhaps the most important being the need for a common diagnostic languageFrom the beginning, there were fundamental differences between the DSM and the ICDAs international collaboration becomes increasingly more common, continued harmonization of the DSM and ICD is neededIn Conclusion (cont)The development of DSM, from beginning to present, resembles a historic pendulum, from DSM-I on the one hand emphasizing psychodynamics and causality to DSM-III and DSM-IV emphasizing empiricism and logical positivismEtiological- and dimensional-based classification for DSM-5 appear to represent a shift toward the center

ReferencesSanders, J. L. (2011). A distinct language and a historic pendulum: The evolution of the diagnostic and statistical manual of mental disorders. Archives of Psychiatric Nursing, 25, 394-403.Teater, M. (2013). Using the DSM-5 for Revolutionizing Diagnosis & Treatment. Eau Claire, Wisconsin: CMI Education.DSM-5 Press Briefing at the APA Annual Meeting in San FranciscoMay 18, 2013Speaker: DSM Task Force Chair David Kupfer, MD American Psychiatric Association:www.dsm5.orgwww.psychiatry.org/dsm5