History of Diagnosing in Psychiatry
Early History.
Medicine’s, including psychiatry’s, diagnostic systems are tied to concepts. In ancient times concepts
were usually tied to religious beliefs. The Hippocratic school [460-375 BC] broke away from concepts tied to
religion and adopted secular concepts, such as a humoral theories. Galen [129-200 AD] combined the
works of the Greek schools with his studies of animal anatomy which he took to be the same as human
anatomy. His diagnostic system continued the humoral of the Greeks along with many other secular
concepts. Galen’s thinking would hold true in some parts of the world into the 18th century.
In most of Europe during the Middle Ages, there was a return to diagnosing that was tied to religious
beliefs, although Arabic countries preserved much of the Roman and Greek thinking. In Europe, for the
mentally ill, a separate system was developed the MALLEUS MALEFICARUM [The Witches Hammer],
1487, which clarified the degree to which the mentally ill were possessed by the Devil. This book went
through many editions into the 1700s.
In the 15th century, some parts of Europe began to rediscover the Roman and Greek medical concepts.
In the 16th century, a sense that returning to the concepts of the past was inadequate. For example,
Andreas Vesalius [1514-1564] description of human anatomy undermined Galen’s work. In the 18th
Century, autopsies led to conceptualizing gross pathological findings to signs and symptoms the person had
prior to death. In the 19th century this expanded to microscopic pathological findings, and in the 20th to
genetics and other physiological abnormalities. In addition to finding ties between pathology and signs and
symptoms, it also became acceptable to includes in the diagnostic system syndromes of signs and
symptoms that empirically seemed to go together even though no pathology was identified.
As medicine’s vast growth of pathological diagnosing, “scientific diagnosing,” grew in the 19th century,
psychiatric leaders attempted to find abnormalities in the brain to keep pace with the rest of medicine, but
this often failed. So, Emil Kraepelin [1856 – 1926] turned to a prognostic-based system that led him to
formulate dementia praecox and manic-depression as core disorders in about 1896, a distinction preserved,
roughly, ever since, with a change in terms to schizophrenia [coined by Eugene Bleuler, 1857-1939, in 1911]
and to bipolar disorder, coined by K. Leonhard [1957]. In the first half of the 20th century, psychiatric
diagnosing was sometimes tied to theories of the mind.
APA and Diagnostic Systems.
APA was party to classification systems of psychiatric disorders almost from APA’s inception. Most
of the APA’s contributions were within medical classifications. The APA influenced the US Census Office to
use the terms [1880]: mania, melancholia, monomania, general paralysis of the insane, dementia,
dipsomania. In 1918, American Medico-Psychological Association [older name for APA] issued the
“Statistical Manual for the Use of Institutions for the Insane,” with 22 diagnostic categories.
The first international classification of disease [ICD] was developed in 1893, and there has been a
new edition about every 10 to 15 years. ICD-10 was in 1993, but has yet to be implemented in the US
because of the potential expense of the change to governments and the private sector. IICD-10 is now
scheduled for 2013. ICD-11 may be ready in about 2015.
During WW-II, the use of the US medical system diagnostic system was found to be inadequate,
and the APA decided after the war to develop their own separate mental health diagnostic system, leading
to the DSMs.
DSM-I, 1952
-- Described terms, for example, Schizophrenic Reactions was defined as: “It represents a group of
psychotic disorders characterized by fundamental disturbances in reality relationships and concept
formations, with affective, behavioral, and intellectual disturbances in varying degrees and mixtures. The
disorders are marked by strong tendency to retreat from reality, by emotional disharmony, unpredictable
disturbances in stream of thought, regressive behavior, and in some, a tendency to ‘deterioration.’”
-- Had 94% changes in nomenclature from the prior system. Seventy terms used “Reaction,” e.g.,
Schizophrenic Reaction. This included reaction to internal mental conflicts.
-- While the typical historiany of the DSMs indicates that DSM-I was psychoanalytic, actually, there was very
1
little in the way of psychoanalytic content in DSM-I. “Unconscious” was mentioned a few times in describing
psychoneurotic disorders, nothing more.
-- Chair: George Raines
-- Process: Raines, Psychiatry Chair at Georgetown, after career in Navy psychiatry, wrote a document
drawing on several classifications developed in the military in the 1940s, got improvements from the other
six members of the APA Nomenclature and Statistics Committee, then distributed a draft to about 500 APA
members, 10% of the membership, half of whom responded, and of that half, over 90% approved. With
comments in hand, a final draft was written that became DSM-I.
DSM-II, 1968:
-- Described terms
-- 94% changes in nomenclature from DSM-I.
Goal of using terms that coincided with ICD-8's.
Removed all “Reactions.”
-- Took an atheoretical position: “In the case of diagnostic categories about which there is current
controversy concerning the disorder’s nature or cause, the Committee has attempted to select terms which it
thought would least bind the judgment of the user. … Inevitably some users of the Manual will read into it
some general view of the nature of mental disorders. The Committee can only aver that such interpretations
are, in fact, unjustified.”
-- Chair: Ernest Gruenberg.
-- Process: The Nomenclature and Statistics Committee developed a draft, sent it to 120 psychiatrists for
reactions, then rewrote and sent to APA, parts of which had to be rewritten at APA Headquarters. Forward
to DSM-II states principles of facilitating communications and avoiding terms that imply causation, principles
which subsequent DSMs would follow.
Post-DSM-II, 1973, “Homosexuality” replaced with “Egodystonic Homosexuality.” This was an APA
Board of Trustee decision. A membership-wide vote to overturn the Board’s decision failed.
DSM-III, 1980: Adopted many new subjects to the Manual:
-- Criteria sets, to increase reliability.
-- Five axes, to assure a comprehensive evaluation of the pt.
-- Vast increase in background information about each disorder, making it a text for psychopathology, by
adding:
Diagnostic features
Associated features
Cultural and gender features
Prevalence
Course
Familiar patterns
Differential Dx
-- Decision trees,
-- Glossary,
-- Field trials,
-- 93% changes in nomenclature.
-- Chair: Robert Spitzer
-- Process: Many work groups were established of which Spitzer was a member of each. A draft edition
was available to many and reactions were encouraged and addressed by the work groups. Many were
invited to provide input; probably the total eventually exceeded a thousand APA members. Assembly
demanded successfully to be part of the approval process.
DSM-IIIR, 1987,
--------
Modifications of some criteria sets,
removed “Egodystonic Homosexuality,”
established a category of Disorders to Be Studied,
contained a symptom index,
had 45% changes in nomenclature.
Chair: Robert Spitzer
Process: Much like DSM-III.
2
DSM-IV, 1994:
-- Modifications of some criteria sets,
-- removed “organic” as a concept and replaced with conditions related to “General Medical Conditions,”
-- removed Self-defeating and Sadistic Personality Disorder from Disorders to be Studied.
-- removed symptom index.
-- allowed non-Axial system as opposed to implying, as DSM-III and DSM-IIIR did that everyone should use
multiaxial system
-- 48% changes in nomenclature.
-- Chair: Allan Frances,
Co-Chair: Harold Pincus
Editor: Michael First
-- Process: Much like DSM-III with greater international involvement and more involvement of other mental
health organizations. Criteria for change included a] empirical justifications and b] the wish to coincide with
ICD-10 [which was being developed concurrently].
DSM-IV-TR, 2000, virtually no changes in criteria sets or nomenclature. Text was vastly improved.
Chair: Michael First. Co-Chair: Harold Pincus.
Process. With switch in Chair form Frances to First, used DSM-IV structure and Task Force members to
rapidly make text accurate and current. No massive involvement of APA membership was necessary.
DSM-5, 2012. Values outlined so far:
A. Recommendations should be guided by research evidence.
B. Continuity with previous editions should be maintained.
C. No a priori constraints on the degree of change between DSM-IV and DSM-V.
D. Cross-cutting issues should be addressed when looking at all criteria:
1. Developmental, prevention, dimensional, gender, and race/ethnicity
2. Cross-cultural applications
3. Operationalization of “clinical significant.”
E. A living document that can advance with the state of the research should be produced.
DSM-5 Task Force Members
Chair: David Kupfer;
Co-Chair: Darrell Regier.
Other Members:
William T. Carpenter, Jr. MD, Chairs Psychosis Work Group
Wilson M. Comptom, MD, MPE,
F. Xavier Castellanos, MD, Chairs Externalizing Disorders Work Group
Joel E. Dimsdale, MD, Chairs Somatoform Disorders Work Group
Javier I. Escobar, MD
Jan Fawcett, MD, Chairs Mood Disorders Work Group
Steven E. Hyman, MD, Chairs Spectrum Study Group and is liaison to World Health Organization
Dilip V. Jester, MD, Chairs Cognitive Work Group
Helena C. Kraemer, Ph.D.
Jan Fawcett, MD, Chairs Mood Disorders Work Group
Daniel T. Mamah, MD
James P. McNulty, AB, ScB, Consumer Representative
Howard B. Moss, MD
William E. Narrow, MD, MPH
Charles O'Brien, PhD Chairs Substance-Related Disorders Work Group
Roger Peele, MD, Liaison to the Assembly
Katharine Phillips, MD, Chairs Anxiety Disorders Work Group
Charles F. Reynolds, MD, Chairs Sleep Disorders Work Group
Norman Sartorius, MD, Ph.D., International Consultant.
Maritza Rubio-Stipec, Sc.D. Statistics and Methods Director
Andrew Skodol, MD, Chairs Personality Disorders Work Group
Susan Swedo, MD, Chairs Development Disorders Work Group
3
Timothy Walsh, MD, Chairs Eating Disorders Work Group
Philip Wang, MD
William Womack, MD, Liaison to the Board of Trustees
Kimberly Yonkers, MD, Chairs Gender and Cross-Cultural Study Group
Kenneth Zucker, MD, Chairs, Sexual and Gender Disorders
WORK GROUP MEMBERS:
ADHD and Disruptive Behavior Disorders:
F. Xavier Castellanos, M.D. (Chair)
Glorisa Canino, Ph.D.
Paul J. Frick, Ph.D.
Terrie Moffitt, Ph. D.
Joel T. Nigg, Ph.D.
Luis Augusto Rohde, M.D., Sc. D.
Rosemary Tannock, Ph. D.
Richard Todd, Ph. D., M.D.
Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders:
Katharine Phillips, M.D. (Chair)
Gavin Andrews, M.D.
Susan M. Bogels, Ph. D.
Michelle Craske, Ph. D.
Matthew J. Friedman, M.D., Ph. D.
Eric Hollander, M.D.
Roberto Lewis-Fernandez, M.D.
Scott L. Rauch, M.D.
Dan J. Stein, M.D., Ph. D.
Robert J. Ursano, M.D.
Hans Ulrich Wiitchen, Ph. D.
Disorders in Childhood and Adolescence Work Group:
Daniel Pine, M. D. (Chair)
E. Jane Costello, Ph. D.
Ronald E. Dahl, M.D.
Rachel Klein, Ph. D.
Regina Smith James, M.D.
James Leckman, M.D.
Ellen Leibenluft, M.D.
Judith Rapoport, M.D.
David Shaffer, M.D., FRCP
Eric Taylor, MB
Charles Zeanah, M.D.
Eating Disorders Work Group:
B. Timothy Walsh, M. D. (Chair)
Evelyn Attia, M.D.
Anne E. Becker, M.D., Ph. D., Sc. M.
Prof. Hans Wijbrand Hoek, M.D. Ph. D.
Richard E. Kriepe, M.D.
Marsha D. Marcus, Ph. D.
James E. Mitchell, M.D.
Ruth Striegel-Moore, Ph. D.
G. Terence Wilson, Ph. D.
Barbara E. Wolfe, Ph. D. APRN, FAAN
Stephen Wonderlich, Ph. D.
Mood Disorders:
Jan A. Fawcett, M.D. (Chair)
William Coryell, M.D.
J. Raymond DePaulo, M.D.
Ellen Frank, Ph. D.
4
Sir David Goldberg, M.D.
James Jackson, Ph.D.
Kenneth Kendler, M.D., Ph. D.
Mario Maj, M.D., Ph.D.
Husseini K. Manji, M.D.
Michael R. Phillips, M.D.
Trisha Suppes, M.D., Ph. D.
Carlos Zarate, M.D.
Neurocognitive Disorders Work Group:
Dilip V. Jeste, M.D. (Chair)
Deborah Blacker, M.D., Sc. D.
Dan Blazer, M.D., Ph. D., M.P.H.
Warachal Faison, M.D.
Mary Ganguli, M.D., M.P.H.
Igor Grant, M.D., FRCP
Jane S. Paulsen, Ph. D.
Ronald Petersen, Ph. D., M.D.
Perminder Sachdev M.D., Ph. D., FRAZCP
Neurodevelopment Disorders:
Susan Swedo, M.D. (Chair)
Edwin H. Cook Jr., M.D.
Francesca G. Happe, Ph. D.
Walter E. Kaufmann, M.D.
Bryan H. King, M.D.
Catherine E. Lord, Ph. D.
Joseph Piven, M.D.
Sally J. Rogers, Ph. D.
Sarah J. Spence, M.D., Ph. D.
Poul Thorsen, M.D., Ph. D.
Fred Volkmar, M.D.
Amy Wetherby, Ph. D.
Harry H. Wright, M.D.
Personality and Personality Disorders:
Andrew E. Skodol, M.D.(Chair)
Renato D. Alarcon, M.D., M.P.H.
Carl C. Bell, M. D.
Donna S. Bender, Ph. D.
Lee Anna Clark, Ph. D.
Robert Krueger, Ph. D.
W. John Livesly, M.D., Ph.D.
Leslie Morey, Ph. D.
John M. Oldham, M.D.
Larry J. Siever, M.D.
Roel Verheul, Ph. D.
Psychotic Disorders:
William T. Carpenter, Jr., M.D. (Chair)
Deanna Barch, Ph. D.
Juan R. Bustillo, M.D.
Raquel E. Gur, M.D., Ph. D.
Stephan H. Heckers, M.D.
Michael Owen, Ph. D., M.D.
Susan K. Schultz, M.D.
Rajiv Tandon, M.D.
Ming T. Tsuang, M.D., Ph. D.
Jim van Os, M.D.
Sexual and Gender Identity Disorders:
Kenneth J. Zucker, Ph. D. (Chair)
5
Irving M. Binik, Ph. D.
Ray Blanchard, Ph. D.
Peggy T. Cohen-Kettenis, Ph. D.
Jack Drescher, M.D.
Cynthia Graham, Ph. D.
Richard B. Krueger, M.D.
Niklas Langstrom, M.D., Ph. D.
Heino F. L. Meyer-Bahlburg, Dr.rer.nat.
Robert Taylor Segraves, M.D., Ph. D.
Sleep-Wake Disorders:
Charles F. Renolds III, M.D. (Chair)
Charles Morin, Ph. D.
Ruth M. O'hara, Ph. D.
Alan I. pack, Ph. D.
Kathy P. Packer, R.N., C.S., Ph. D.
Susan Redline, M.D., M.P.H.
Dieter Riemann, Ph. D.
Somatic Distress Disorders:
Joel E. Dimsdale, M.D. (Chair)
Arthur J. Barsky III, M.D.
Francis Creed, M.D.
Nancy Frasure-Smith, Ph. D.
Michael R. Irwin, M.D.
Francis J. Keefe, Ph. D.
Sing Lee, M.D.
James L. Levenson, M.D.
Michael Sharpe, M.D.
Lawson R. Wulsin, M.D.
Substance-Related Disorders:
Charles O'Brien, M.D., Ph. D. (Chair)
Marc Auriacombe, M.D.
Guilherme Borges, M.D., DrSc
Kathleen Bucholz, Ph. D.
Alan Budney, Ph. D.
Thomas Crowley, M.D.
Bridget Grant, Ph. D., Ph.D.
Deborah Hasin, Ph. D.
Walter Ling, M.D.
Spero M. Manson, Ph. D.
A. Thomas McLellan, Ph. D.
Nancy Petry, Ph. D.
Marc A. Schuckit, M.D.
Wim van den Brink, M.D.
Impact of the DSMs:
1. Access to care and treatment. DSMs “is the cornerstone in the edifice of mental health care”
[Sadler, 2006].
2. Access to entitlements. Defines the responsibilities of public agencies accountable for the
psychiatrically ill. Reimbursements are administered on the basis of the DSM [in an overlap with ICDs]. Even
the location within DSM can have an impact on access, e.g., the Axis II location, some claim, decreases
access.
3. Approved treatments.
[Some see this as having a negative consequence. Edward Shorter, medical historian: “the pipeline [of
medication development] is empty at this moment [2004] despite spending billions of dollars on
psychopharmacology,” a stall he traces largely to the effects of using DSM-III/IIIR/IV in defining disease
indications for medication approval. DSM disorders, he believes, have not provided specific treatment
6
targets. [Assembly passed motion in 2006 saying that FDA should consider signs/symptoms for approval,
not just dx categories].
4. Research [see #3 supra]
5. Education. The teaching of psychopathology in the United States and many other countries follows the
DSM.
6. Legal and criminal decisions. Despite disclaimer within the DSMs, the DSMs are often used to answer
legal questions.
7. Society’s concept of mental illness, of normality. Some examples:
Conceptualizes homosexuality as normal.
-- 1973, substituted “egodystonic homosexuality” for “homosexuality”
-- 1987, DSM-IIIR, abolished “egodystonic homosexuality”
Many DSM terms have become part of the American discourse, for example, “ADHD.”
8. Defines psychiatry. While DSM-IV-TR has a 147 word definition of mental illness, which is not used, the
aggregation of disorders in the DSMs tends to define psychiatry. However, the openness of DSM-IV’s
NOSs, has created unclear boundaries as to “normal” and “illness.”
Roger Peele, MD, DLFAPA, 2May2012
7