History of the DSM
Cornelia Pinnell, Ph.D.
Argosy University/Phoenix
Lecture Outline
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Why classification? A rationale.
Classification of mental disorders –
a historical account of classification systems
– Census
– Military
– World Health Organization (ICDs)
– DSM
– Other classification systems
Mental Disorders
“Mental disorders
are easily described
but
not easily defined.”
Castillo (1996)
Purposes of classification
systems in psychiatry
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To distinguish between different
categories (for accurate diagnosis and
treatment decision)
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To provide a common language
among mental health professionals
Historical background
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Hippocrates (5th century BC)
introduced the terms mania and
hysteria
Historical background
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1840 census (population count) One category of mental illness:
illness:
idiocy/insanity
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1880 census - 7 categories of
mental illness: mania; melancholia;
monomania; paresis; dementia;
dipsomania; epilepsy
Historical background
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1917 - the Bureau of the Census
adopted a statistical system developed
by the American MedicoMedico-Psychological
Association & the National Commission
on Mental Hygiene
Historical background
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1948 - Nomenclature developed by
the US Army & modified by the
Veterans Administration to cover the
presentation of outpatient
servicemen and veterans of WW II.
Classification systems
n
Taxonomy = The study of the general
principles of systematic classification
n
Nosology = The branch of medical
science that deals with the systematic
classification of diseases
Classification systems
n
Medical classification systems are used
for a variety of applications (e.g.,
diagnostic, procedural codes):
– Statistical analysis of diseases and
therapeutic actions
– Reimbursement
– Epidemiological research
International
Classification Of Disease
n
International Statistical Classification
of Diseases and Related Health
Problems (ICD) provides codes to
classify diseases and a wide variety of
signs, symptoms, abnormal findings,
complaints, social circumstances, and
external causes of injury or disease.
International
Classification Of Disease
ICD – an effort of the WHO
International Classification of Causes
of Death (1900 – 1st edition)
/International Classification of Disease
/International Classification of
Functioning, Disability and Health
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– Revisions approximately every 10 years
ICDs
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n
n
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ICD
ICD--2
ICD
ICD--3
ICD
ICD--4
ICD
ICD--5
ICD
ICD--6
in
in
in
in
in
1910
1921
1930
1939
1949
International
Classification Of Disease
n
The Manual of International Statistical
Classification of Diseases, Injuries and
Causes of Death. ICD
ICD--6th edition
– included for the first time a section
on mental disorders
§
The ICDICD-6 was considered to be
inadequate for use in USA.
International
Classification Of Disease
Beginning with the ICDICD-7,
a series of adaptations/modifications of
the WHO publication
were developed
each containing a section for
the classification of procedures
ICDs
n
International Classification of
Diseases, Adapted for Indexing
Hospital Records by Diseases and
Operations (ICDA or ICDAICDA-7) -7th rev
(1958).
n
International Classification of Disease
Adapted for Use in the United States
(ICDA--8) – 8th rev. (1968)
(ICDA
ICDs
n
The ICDICD-9 was published by the WHO in
1977 and in the US in 1979
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International Classification of Diseases,
Clinical Modification (ICD
(ICD--9-CM) is a
classification used in assigning codes to
diagnoses associated with inpatient,
outpatient, and physician office utilization in
the U.S. It is based on the ICDICD-9 but
provides for additional morbidity detail and
is annually updated on October 1.
ICDs
n
ICD
ICD--10 was completed in 1992
n
On January 1st, 1999 the ICDICD-10
(without clinical extensions) was
adopted for reporting mortality,
but ICDICD-9-CM is still used for
morbidity.
Other systems
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Current Procedural Terminology (CPT)
code set is maintained by the
American Medical Association (AMA)
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International Classification of
Headache Disorders
International Classification of Sleep
Disorders
Other Classification Systems
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Other classification systems for mental
disorders:
– Psychodynamic Diagnostic Manual
– Chinese Classification of Mental Disorders
DSM
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The need for a uniform
nomenclature for mental health
professionals in the US created the
impetus for the creation of the
Diagnostic and Statistical Manual for
Mental Disorders (DSM) – an American
classification system
DSM-I (1952) –
based on Adolf Meyer’s
biopsychosocial model
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Variant of ICDICD-6
First official manual for clinical use – etiological
Contained a glossary
(descriptions of diagnostic categories)
View that mental disorders were “reactions” to
biological, psychological and social factors
Treatment = psychodynamic
DSM--I
DSM
n
Assumptions for DSM I (1952):
1.
‘Quantitative spectrum’ of mental illness (MI) -
2.
continuum of severity
Fluid boundaries between health & illness,
3.
4.
normal & abnormal
Psychogenesis is involved in etiology of MI
The mixture of noxious environment &
psychic conflict causes mental illness
The anti
anti--psychiatry
movement
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Erving Goffman - Asylum patients learn to be
institutionalized
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Thomas Szasz - Mental illness is a myth, a
problem of labeling – “problems in living”
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Thomas Scheff - Nonconformity is labeled
‘deviant’ by the social group
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Fuller Torrey – Most patients treated by
psychiatrists have ‘problems in living’
DSM-II (1968)
DSM– begins a paradigm shift –
‘biomedical’ model
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Added certain ICDICD-8 diagnostic categories
and deleted others
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Eliminated the term ‘reaction’
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Low reliability;
reliability; diagnoses based on clinical
experience were highly subjective
Websites of interest
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Thomas Szasz on mental health
http://www.youtube.com/watch?v=IJI6Yuu
HB3c&feature=related
Thomas Szasz exposes psychiatry
http://www.youtube.com/watch?v=Lk4hW
WPv9EY&feature=related
Stephen Wiseman response to Szasz
http://www.youtube.com/watch?v=hk691rH
IrkE&feature=related
ICD--9-CM, 1979
ICD
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n
International Classification of
Diseases,, 9th edition, Clinical
Diseases
modification for use in US
Official system for recording all
“diseases, injuries, impairments,
symptoms, and causes of death”
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Expands 44-digit ICDICD-9 codes to 55-digit
codes for greater specificity
DSM-III (1980
DSM(1980):
):
disease--centered psychiatry
disease
(organicity prevails)
Assumptions for the DSMDSM-III
n Mental disorders are based in brain disease
n Each disorder can be defined accurately &
narrowly & classified by descriptive
patterns of symptoms
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Atheoretical and descriptive
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No information provided on etiology,
management of the disorder, or treatment
planning.
DSM--III (1980)
DSM
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Designed to increase diagnostic reliability &
improve communication among clinicians
and researchers
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Empirically based nosology – field trials
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Categorical, hierarchical, multiaxial system
Hierarchical
conceptualization
1)
SYMPTOM = ‘target behavior’ (affect,
cognition, overt behavior, perception)
2)
SYNDROME = constellation of
concomitant symptoms (sxs covariation)
3)
DISORDER = clustering of syndromes
DISEASE = known etiology (underlying
4)
mechanisms and processes)
DSM--III Multiaxial system
DSM
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Axis I: Clinical Syndromes and V Codes
Axis II: Personality Disorders &
Developmental Disorders
Axis III: Medical/Physical Disorders and
Conditions
Axis IV: Psychosocial Stressors
Axis V: Highest Global Level of Functioning
Criticisms of the multiaxial
system in the DSMDSM-III
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Axis I : Uncontrolled proliferation of
unvalidated diagnostic criteria
Axis II: Overlap between personality
disorders; sexist
Axis III: Difficult to determine what to
include
Axis IV: No definitions of stress; arbitrary
Axis V: Need to assess more than 1 year of
premorbid functioning
Research Diagnostic Criteria
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Research Diagnostic Criteria (RDC) were
developed as a reaction to the DSMDSM-III.
This system identified specific symptoms
and indicated that a subset of symptoms
was sufficient for a particular diagnosis to
be met.
http://www.garfield.library.upenn.edu/classics1989/A1989U30
9700001.pdf
http://archpsyc.ama--assn.org/cgi/content/ abstract/39/
http://archpsyc.ama
11/1283
DSM-IIIDSMIII-R (1987) –
medical model
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Minor revisions
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Designed to eliminate inconsistencies
and increase reliability among
clinicians and researchers
DSM--IV (1994)
DSM
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The “offspring” of the DSMDSM-III, it
disease--centered paradigm.
retains the disease
It was expanded to include social and
cultural factors under the influence of
psychiatric anthropology and
postmodern thought.
Concerns regarding the validity of the
various diagnostic categories.
Spitzer – the main architect
of the DSMDSM-IV
Described the procedural ‘gold standard’
for establishing a diagnosis:
LEAD
1) L = Longitudinal observations
2) E = Expert clinician
3) A = All available data
4) D = Empirical data
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Field trials
Field trials would provide empirical basis & assess:
n Reliability of diagnosis = agreement among
diagnosticians (inter(inter-rater reliability)
n Face validity = acceptability of criteria
n Feasibility of criteria = if easily understood &
applied by clinicians/researchers
n Generalizability of criteria = if applicable in various
settings
n Coverage = goodness of fit with patients
n Construct validity = descriptive, concurrent,
predictive
DSM-IV (1994) – beginnings
DSMof a cultural paradigm shift
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Coordinated with ICDICD-10 to be used
internationally & applicable crosscross-culturally.
Mental disorders viewed as psychobiological
adaptations to emotional stress and trauma.
Concern regarding the ontological status
(validity) of the nosological categories.
Multiaxial format maintained
DSM--IV (1994)
DSM
Basic Features:
Features:
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Descriptive approach
Specific diagnostic criteria to increase
reliability
Systematic description
DSM-IV
DSMMutiaxial Assessment
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Axis I:
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Axis II: Personality Disorders & Mental
Clinical Syndromes & Other Conditions
That May Be A Focus of Clinical
Attention
Retardation
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n
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental
Problems
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Axis V:
Global Assessment of Functioning (GAF)
DSM-IV
DSMMultiaxial Assessment
n
Axis I:
n
Axis II: Personality Disorders & Mental
Clinical Syndromes & Other Conditions
That May Be A Focus of Clinical
Attention
Retardation
n
n
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental
Problems
n
Axis V:
Global Assessment of Functioning (GAF)
DSM-IV
DSMNew Axes recommended
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Vulnerability
Family functioning
Coping style & defense mechanisms
Response to therapy
DSM--IVDSM
IV-TR (2000)
Minor (text) revisions of the DSMDSM-IV
Lists 365 disorders in 17 sections
DSM-IVDSMIV-TR
Multiaxial Assessment
n
Axis I:
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Axis II: Personality Disorders & Mental
Clinical Disorders & Other Conditions
That May Be A Focus of Clinical
Attention
Retardation; habitual use of a particular
defense mechanism
DSM-IVDSMIV-TR
Multiaxial Assessment
n
Axis III: General Medical Conditions – can be
causative or a result of a mental disorder
(when causative, the mental disorder is
listed on Axis I and the medical
condition on Axis III)
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Axis IV: Psychosocial and Environmental
Problems
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Axis V:
Global Assessment of Functioning (GAF)
– social, occupational and psychological
DSM--V
DSM
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Initially scheduled to be published
sometime between 2010 and 2012;
now it is expected to be published in
2013
Information on the DSMDSM-V revision is
available at http://www.dsmv.org
Websites of interest
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Open Yale Courses website:
http://open.yale.edu/courses
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What Happens When Things Go Wrong:
Mental Illness, Part I & II–
II– Yale University
http://www.youtube.com/watch?v=rW79Zw
DPKsY&feature=related
http://www.youtube.com/watch?v=4wtl3q8
7Rn8&feature=channel
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