The DSM: 97 Yrs of History and Controversy

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, offers a common language and standard criteria for the classification of mental disorders. Basically, it’s the organized language of disorder. Often referred to as the therapist’s bible, it’s used, or relied upon, by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policy makers together with alternatives such as the International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO). The DSM is now in its fifth edition, DSM-5, published on May 18, 2013.

The DSM evolved from systems for collecting census and psychiatric hospital statistics, and from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, although also removing those no longer considered to be mental disorders.

The International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO), is the other commonly used manual for mental disorders. It is distinguished from the DSM in that it covers health as a whole. It is in fact the official diagnostic system for mental disorders in the US, but is used more widely in Europe and other parts of the world. The coding system used in the DSM is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously.

While the DSM has been praised for standardizing psychiatric diagnostic categories and criteria, it has also generated controversy and criticism. Critics, including the National Institute of Mental Health, argue that the DSM represents an unscientific and subjective system. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from ‘normality’; possible cultural bias; medicalization of human distress. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically totaling over $100 million.

Many mental health professionals use the manual to determine and help communicate a patient’s diagnosis after an evaluation; hospitals, clinics, and insurance companies in the US also generally require a DSM diagnosis for all patients treated. The DSM can be used clinically in this way, and also to categorize patients using diagnostic criteria for research purposes. Studies done on specific disorders often recruit patients whose symptoms match the criteria listed in the DSM for that disorder. An international survey of psychiatrists in 66 countries comparing use of the ICD-10 and DSM-IV found the former was more often used for clinical diagnosis while the latter was more valued for research.

DSM-5, and all previous editions, are registered trademarks owned by the American Psychiatric Association (APA).

The current version of the DSM characterizes a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress…or disability…or with a significant increased risk of suffering.” It also notes that “…no definition adequately specifies precise boundaries for the concept of ‘mental disorder’…different situations call for different definitions”. It states that “there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder” (APA, 1994 and 2000). There are attempts to adjust the wording for the upcoming DSM-V.

The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category, “idiocy/insanity”. Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives stating that “the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation” and pointing out that in many towns African-Americans were all marked as insane, and the statistics were essentially useless.

The Association of Medical Superintendents of American Institutions for the Insane was formed in 1844, changing its name in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association (APA).

Edward Jarvis and later Francis Amasa Walker helped expand the census, from 2 volumes in 1870 to 25 volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume called “Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880)” (published 1888). Wines used seven categories of mental illness: dementiadipsomania (uncontrollable craving for alcohol), epilepsymaniamelancholiamonomania and paresis. These categories were also adopted by the Association.

In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the APA developed a new guide for mental hospitals called the “Statistical Manual for the Use of Institutions for the Insane”. This included 22 diagnoses and would be revised several times by the APA over the years. Along with the New York Academy of Medicine, the APA also provided the psychiatric nomenclature subsection of the US general medical guide, the Standard Classified Nomenclature of Disease, referred to as the “Standard.”

1952: DSM-I

World War II saw the large-scale involvement of US psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. A committee headed by psychiatrist Brigadier General William C. Menninger developed a new classification scheme called Medical 203, that was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the US Navy had itself made some minor revisions but “the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present day concepts of mental disturbance. This nomenclature eventually was adopted by all Armed Forces”, and “assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty.” The Veterans Administration also adopted a slightly modified version of Medical 203. In 1949, the World Health Organization published the sixth revision of the International Statistical Classification of Diseases (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this “categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature.” An APA Committee on Nomenclature and Statistics was empowered to develop a version specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the VA system, and the Standard’s Nomenclature to approximately 10% of APA members. 46% replied, of which 93% approved, and after some further revisions (resulting in its being called DSM-I), the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of “personality disturbance”, generally distinguished from “neurosis” (nervousness, egodystonic). In 1952, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality, 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 widely influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study that compared 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 hero to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.

1968: DSM-II

In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued that mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was merely another example of how society labels and controls non-conformists; from behavioral psychologists who challenged psychiatry’s fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA’s listing of homosexuality as a mental disorder. A study published in Scienceby Rosenhan received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.

Although the APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968), it decided to go ahead with a revision of the DSM. It was published in 1968, listed 182 disorders, and was 134 pages long. It was quite similar to the DSM-I. 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 they 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, rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, or hallucinations/delusions appearing disconnected from reality). Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.

An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool.They found that different practitioners using the DSM-II were rarely in agreement when diagnosing patients with similar problems. In reviewing previous studies of 18 major diagnostic categories, Fleiss and Spitzer 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”.

1974: DSM-II (7th printing)

As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate against the APA’s convention. At the 1971 conference, Kameny grabbed the microphone and yelled, “Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you.”

This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations.

Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of “sexual orientation disturbance”.

1980: DSM-III

In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD), published by the World Health Organization. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also a need to standardize diagnostic practices within the US and with other countries after research showed that psychiatric diagnoses differed markedly between Europe and the USA. The establishment of these criteria was an attempt to facilitate the pharmaceutical regulatory process.

The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University in St. Louis and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language (which would be easier to use by federal administrative offices), rather than assumptions of etiology, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as “neo-Kraepelinian”). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislativemodel. A new “multiaxial” system attempted to yield a picture more amenable to a statistical population census, rather than just a simple diagnosis. Spitzer argued that “mental disorders are a subset of medical disorders” but the task force decided on the DSM statement: “Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.” The personality disorders were placed on axis II along with mental retardation.

The first draft of the DSM-III was prepared within a year. Many new categories of disorder were introduced, while some were deleted or changed. A number of the unpublished documents discussing and justifying the changes have recently come to light.[34] Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity; a political compromise reinserted the term in parentheses after the word “disorder” in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of “sexual orientation disturbance”.

Finally published in 1980, the DSM-III was 494 pages and listed 265 diagnostic categories. It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry. However, Robert Spitzer later criticized his own work on it in an interview with Adam Curtis, saying it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems.

When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:

Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator…

1987: DSM-III-R

In 1987, the DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, and significant changes in criteria were made. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. “Sexual orientation disturbance” was also removed and was largely subsumed under “sexual disorder not otherwise specified”, which can include “persistent and marked distress about one’s sexual orientation.”Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated that for at least some disorders, “particularly the Personality Disorders, the criteria require much more inference on the part of the observer.” 

1994: DSM-IV

In 1994, DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances. A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. Some personality disorder diagnoses were deleted or moved to the appendix.

2000: DSM-IV-Text Revision (TR)

A “text revision” of the DSM-IV, known as the DSM-IV-TR, was published in 2000. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. The DSM-IV-TR was organized into a five-part axial system. The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.

2013: DSM-5 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-V, was approved by the Board of Trustees of the American Psychiatric Association (APA) on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in twenty years, and the Roman numerals numbering system has been discontinued to allow for greater clarity in regard to revision numbers. A significant change in the fifth edition is the proposed deletion of the subtypes of schizophrenia. During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.

Categories

The DSM-V is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning,” although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Classifications

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step (“Axis IV”) for outlining “Psychosocial and environmental factors contributing to the disorder” once someone is diagnosed with that particular disorder.

Because an individual’s degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM’s standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptomology may nevertheless experience comparable distress or disability in their life.

Welcome to Your Axis

The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:

  • Axis I: All psychological diagnostic categories except mental retardation and personality disorder
  • Axis II: Personality disorders and mental retardation
  • Axis III: General medical condition; acute medical conditions and physical disorders
  • Axis IV: Psychosocial and environmental factors contributing to the disorder
  • Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children and teens under the age of 18

Common Axis I disorders include depressionanxiety disordersbipolar disorderADHDautism spectrum disordersanorexia nervosabulimia nervosa, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorderschizoid personality disorderschizotypal personality disorder,borderline personality disorderantisocial personality disordernarcissistic personality disorderhistrionic personality disorderavoidant personality disorder,dependent personality disorderobsessive-compulsive personality disorder; and intellectual disabilities.

Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

WARNINGS (kind of)

The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”. The APA notes diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered “illnesses”.

Citations, please.

The DSM-IV does not specifically cite its sources, but there are four volumes of “sourcebooks” intended to be APA’s documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials. The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.

How do We Know This is Reliable?

The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. It was argued that a science of psychiatry can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about a diagnosis with a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with “tweaking” the diagnostic criteria. Unfortunately, neither the issue of reliability (accurate measurement) or validity (do these disorders really exist) was settled. However, most psychiatric education post DSM-III focused on issues of treatment—especially drug treatment—and less on diagnostic concerns. In fact, Thomas R. Insel, M.D., Director of the NIMH, has recently stated the agency would no longer fund research projects that rely exclusively on DSM criteria due to its lack of validity.

Superficial Symptoms

By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, “little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology.”

The DSM’s focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system.  Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.

Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists’ criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology. Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that “Instead of replacing ‘metaphysical’ terms such as ‘desire’ and ‘purpose’, they used it to legitimize them by giving them operational definitions…the initial, quite radical operationalist ideas eventually came to serve as little more than a ‘reassurance fetish’ for mainstream methodological practice.”

A 2013 review published in the European archives of psychiatry and clinical neuroscience states “that psychiatry targets the phenomena of consciousness, which, unlike somatic symptoms and signs, cannot be grasped on the analogy with material thing-like objects.” As an example of the problem of the superficial characterization of psychiatric signs and symptoms, the authors gave the example of a patient saying they “feel depressed, sad, or down,” showing that such a statement could indicate various underlying experiences: “not only depressed mood but also, for instance, irritationanger, loss of meaning, varieties of fatigueambivalenceruminations of different kinds, hyper-reflectivitythought pressure, psychic anxiety, varieties of depersonalization, and even voices with negative content, and so forth.” The structured interview comes with “danger of over confidence in the face value of the answers, as if a simple ‘yes’ or ‘no’ truly confirmed or denied the diagnostic criterion at issue.” The authors gave an example: A patient who was being administered theStructured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a “conversational, phenomenological interview,” a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: That the patient didn’t “recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question,” or the experience didn’t “fully articulate itself” until the patient started talking about his experiences.

Bias

Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as “culture-bound”, whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman’s negative view toward the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One of the results was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM to treat African and African American patients.

Medical Model + Financial Conflicts of Interest: Follow the Money

It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half have had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. The same article concludes that the connections between panel members and the drug companies were particularly strong in those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. In 2005, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had “allowed the biopsychosocial model to become the bio-bio-bio model” referring to a significant focus on biology (medical model) vs social and psychological influences.

However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients. William Glasser (founder of Reality Therapy and Choice Therapy), however, refers to the DSM as “phony diagnostic categories”, arguing that “it was developed to help psychiatrists – to help them make money”. In addition, the publishing of the DSM, with tightly guarded copyrights, has in itself earned over $100 million for the American Psychiatric Association.

Consumer v Client: Terms of Resentment

A “consumer” is a person who accesses psychiatric services and may have been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, while a “survivor” self-identifies as a person who has endured a psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). Some individuals are relieved to find that they have a recognized condition that they can apply a name to and this has led to many people self-diagnosing. Others, however, question the accuracy of the diagnosis, or feel they have been given a “label” that invites social stigma and discrimination (the terms “mentalism” and “sanism” have been used to describe such discriminatory treatment).

Diagnoses can become internalized and affect an individual’s self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, and/or against the DSM system in general. The Mad Pride movement has been particularly vocal in its criticism of the DSM. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple “comorbid” diagnoses) or chronicity.

Criticism 

Psychiatrist Allen Frances has been critical of proposed revisions to the DSM-5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, it will “medicalize normality and result in a glut of unnecessary and harmful drug prescription.” In a December 2, 2012 blog post in Psychology Today, Frances lists the ten “most potentially harmful changes” to DSM-5:

  • Disruptive Mood Dysregulation Disorder, for temper tantrums
  • Major Depressive Disorder, includes normal grief
  • Minor Neurocognitive Disorder, for normal forgetting in old age
  • Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
  • Binge Eating Disorder, for excessive eating
  • Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
  • First time drug users will be lumped in with addicts
  • Behavioral Addictions, making a “mental disorder of everything we like to do a lot.”
  • Generalized Anxiety Disorder, includes everyday worries
  • Post-traumatic stress disorder, changes opening “the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.”

Frances and others have published debates on what they see as the six most essential questions in psychiatric diagnosis:

  • are they more like theoretical constructs or more like diseases
  • how to reach an agreed definition
  • whether the DSM-5 should take a cautious or conservative approach
  • the role of practical rather than scientific considerations
  • the issue of use by clinicians or researchers
  • whether an entirely different diagnostic system is required.

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 14,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen otherAmerican Psychological Association divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.

We hope this history of the DSM provides some thought-provoking information you can use to become a more educated consumer or advocate for someone with mental health issues. 

Mental Health Diagnoses: A (Nearly) Complete History of Mental Illness

If you are not a mental health professional, the weird names and stranger numbers we throw around may seem like a secret language. In many ways, diagnostic discussions are kind of like a language that can have very real and important implications in peoples’ lives. Today, we examine where our understanding of mental illness and mental health diagnoses come from.  

Like many scientific inquiries, our understanding of mental health disorders evolved over time. The various classification systems used to diagnose and describe mental health disorders, during different periods of history, were bound by the knowledge, social attitudes, and the scientific paradigms available during the historical period in which they were conceived.  An understanding of this historical context strengthens our ability to fully appreciate the research advancements that have informed our current understanding of these disorders. These scientific advancements subsequently guided the development of successful treatment approaches. Let’s start a REALLY long time ago…

3500 BC – 30 BC

Ancient Egyptian documents known as the Ebers papyrus appear to describe disordered states of concentration and attention, and emotional distress in the heart or mind. Some of these have been interpreted as indicating what would later be termed hysteria and melancholy. Somatic treatments typically included applying bodily fluids while reciting magical spells. Hallucinogens may have been used as part of healing rituals. Religious temples may have been used as therapeutic retreats, possibly for the induction of receptive states to facilitate sleep and the interpreting of dreams. In ancient China, mental disorders were treated mainly under Traditional Chinese Medicine by herbs, acupuncture or “emotional therapy”. The Inner Canon of the Yellow Emperor described symptoms, mechanisms and therapies for mental illness, emphasizing connections between bodily organs and emotions. Conditions were thought to comprise five stages or elements and imbalance between Yin and yang.

400 BC

During the 4th century BC, Hippocrates described all disease as an imbalance of the four bodily humors – phlegm, blood, yellow bile, and black bile. Variations in the levels of these fluids were believed to be connected to changes in people’s moods and behavior. Treatments were often terrible. The Greek physician Asclepiades (c. 124 – 40 BC), who practiced in Rome, discarded it and advocated humane treatments, and had insane persons freed from confinement and treated them with natural therapy, such as diet and massages. Arateus (ca AD 30–90) argued that it is hard to pinpoint where a mental illness comes from. However, Galen (AD 129 – ca. 200), practicing in Greece and Rome, revived humoral theory. Galen, however, adopted a single symptom approach rather than broad diagnostic categories, for example studying separate states of sadness, excitement, confusion and memory loss.

100 – 1300s

Well in advance of their European and African counterparts Persian and Arabic scholars were heavily involved in translating, analyzing and synthesizing Greek texts and concepts. As the Muslim world expanded, Greek concepts were integrated with religious thought and over time, new ideas and concepts were developed. Arab texts from this period contain discussions of melancholia, mania, hallucinations, delusions, and other mental disorders. Mental disorder was generally connected to loss of reason, and writings covered links between the brain and disorders, and spiritual/mystical meaning of disorders. Muslim scholars often wrote about fear and anxiety, anger and aggression, sadness and depression, and obsessions.

Authors who wrote on mental disorders and/or proposed treatments during this period include Al-BalkhiAl-RaziAl-FarabiIbn-SinaAl-MajusiAbu al-Qasim al-ZahrawiAverroes, and Unhammad

Ready to have your mind blown? Under Islam, the mentally ill were considered incapable yet deserving of humane treatment and protection. For example, Sura 4:5 of the Qur’an states “Do not give your property which God assigned you to manage to the insane: but feed and cloth the insane with this property and tell splendid words to him.” Some thought mental disorder could be caused by possession by a djin (genie), which could be either good or demon-like. There were sometimes beatings to exorcise djin, or alternatively over-zealous attempts at cures. Islamic views often merged with local traditions. In Morocco the traditional Berber people were animists and the concept of sorcery was integral to the understanding of mental disorder; it was mixed with the Islamic concepts of djin and often treated by religious scholars combining the roles of holy man, sage, seer and sorcerer.

The first psychiatric hospital ward was founded in Baghdad in 705, and insane asylums were built in Fes in the early 8th century, Cairo in 800 and in Damascus and Aleppo in 1270. Insane patients were treated using baths, drugs, music and activities. In the centuries to come, The Muslim world would eventually serve as a critical way station of knowledge for Renaissance Europe, through the Latin translations of many scientific Islamic texts. Ibn-Sina’s (Avicenna’s) Canon of Medicine became the standard of medical science in Europe for centuries, together with works of Hippocrates and Galen.

Meanwhile, conceptions of madness in Europe were a mixture of the divine, diabolical, magical and transcendental. Theories of the four humors (black bile, yellow bile, phlegm, and blood) were applied, sometimes separately (a matter of “physic”) and sometimes combined with theories of evil spirits (a matter of “faith”). Arnaldus de Villanova (1235–1313) combined “evil spirit” and Galen-oriented “four humours” theories and promoted trephining as a cure to let demons and excess humours escape. Other bodily remedies in general use included purges, bloodlettingand whipping. Madness was often seen as a moral issue, either a punishment for sin or a test of faith and character. Christian theology endorsed various therapies, including fasting and prayer for those estranged from God and exorcism of those possessed by the devil. Thus, although mental disorder was often thought to be due to sin, other more mundane causes were also explored, including intemperate diet and alcohol, overwork, and grief.[20] The Franciscan monk Bartholomeus Anglicus (ca. 1203 – 1272) described a condition which resembles depression in his encyclopedia, De Proprietatibis Rerum, and he suggested that music would help. A semi-official tract called the Praerogativa regis distinguished between the “natural born idiot” and the “lunatic”. The latter term was applied to those with periods of mental disorder; deriving from either Roman mythology describing people “moonstruck” by the goddess Luna or theories of an influence of the moon.

Episodes of mass dancing mania are reported from the Middle Ages, “which gave to the individuals affected all the appearance of insanity”. This was one kind of mass delusion or mass hysteria/panic that has occurred around the world through the millennia.

The care of lunatics was primarily the responsibility of the family. In England, if the family were unable or unwilling, an assessment was made bycrown representatives in consultation with a local jury and all interested parties, including the subject himself or herself. The process was confined to those with real estate or personal estate, but it encompassed poor as well as rich and took into account psychological and social issues. Most of those considered lunatics at the time probably had more support and involvement from the community than people diagnosed with mental disorders today. As in other eras, visions were generally interpreted as meaningful spiritual and visionary insights; some may have been causally related to mental disorders, but since hallucinations were culturally supported they may not have had the same connections as today.

1500s – 1700s

It was not uncommon for mentally disturbed people to become victims of the witch-hunts that spread in waves in early modern Europe. However, those judged insane were increasingly admitted to local workhouses, poorhouses and jails (particularly the “pauper insane”) or sometimes to the new private madhouses. Restraints and forcible confinement were used for those thought dangerously disturbed or potentially violent to themselves, others or property. The latter likely grew out of lodging arrangements for single individuals (who, in workhouses, were considered disruptive or ungovernable) then there were a few catering each for only a handful of people, then they gradually expanded (e.g. 16 in London in 1774, and 40 by 1819). By the mid-19th century there would be 100 to 500 inmates in each. The development of this network of madhouses has been linked to new capitalist social relations and a service economy, that meant families were no longer able or willing to look after disturbed relatives.

By the end of the 17th century and into the Enlightenment, madness was increasingly seen as an organic physical phenomenon, no longer involving the soul or moral responsibility. The mentally ill were typically viewed as insensitive wild animals. Harsh treatment and restraint in chains was seen as therapeutic, helping suppress the animal passions. There was sometimes a focus on the management of the environment of madhouses, from diet to exercise regimes to number of visitors. Severe somatic treatments were used, similar to those in medieval times. Madhouse owners sometimes boasted of their ability with the whip. Treatment in the few public asylums was also barbaric, often secondary to prisons. The most notorious was Bedlam where at one time spectators could pay a penny to watch the inmates as a form of entertainment.

Concepts based in humoral theory gradually gave way to metaphors and terminology from mechanics and other developing physical sciences. Complex new schemes were developed for the classification of mental disorders, influenced by emerging systems for the biological classification of organisms and medical classification of diseases.

Towards the end of the 18th century, a moral treatment movement developed, that implemented more humane, psychosocial and personalized approaches. Notable figures included the medic Vincenzo Chiarugi in Italy under Enlightenment leadership; the ex-patient superintendent Pussinand, the Quakers in England, led by businessman William Tuke; and later, in the United States, campaigner Dorothea Dix. Philippe Pinel observed there were a group of patients who behaved in irrational ways even though they seemed to be in touch with reality and were aware of the irrationality of their actions. Pinel’s documented observations during this period appear to be one of the first explicit attempts at describing what we would nowadays call a personality disorder.

1800s – 1950s

By the early 1900s, European diagnostic systems were beginning to describe different temperaments and personality types. At this point in history, mental conditions and disorders were not very well defined because the scientific professions of psychology and psychiatry were still in their infancy. Most psychiatrists were purely focused on describing the phenomena of mental illness and disturbances they observed. From these early descriptions we can determine that much of what was observed and described would today be considered a personality disorder. However, at that time, the symptoms that were observed were thought to be something else, namely the early stages of some other, more severe mental illnesses such as manic depression (now called Bipolar Disorder).

During the 1920’s and 30’s Sigmund Freud and his colleagues were one of the first to move beyond mere descriptive categorization of mental disorders. Instead, Freud and his camp theorized the etiology (causes) of behavioral and emotional problems.  Although our modern understanding of personality disorders has advanced significantly beyond these earlier theories of Sigmund Freud, he is still often credited as the “father of psychology.”

Freud and his followers began to theorize how character types and emotional issues developed. Freud’s theory proposed the existence of unconscious mental processes that influence our character development and subsequent behavior. He explained these unconscious mental processes as consisting of three competing component parts. He named these three parts the Id, the Ego, and the Superego. The Id referred to a collection of instinctual impulses and drives, seeking immediate gratification. The Superego referred to a set of moral values and self-critical attitudes. The term “Ego” was used to describe a set of regulatory functions intended to keep the Id under control by preventing the Id from indulging its every whim. The Ego’s purpose was to mediate a balance between the impulsive Id and the harsh, moralistic Superego. In Freudian theory, the goals of these three mental components were in conflict with each other, causing anxiety. The Ego relied on “defense mechanisms” to keep such conflicts from entering our conscious awareness so as to reduce this anxiety.

Freud and his colleagues were also interested in exploring infantile sexual development.   It was theorized that we are born with the Id, so that every infant has the inborn raw impulses that seek immediate gratification. Over time, the Ego develops and keeps the Id in check, trying to keep the person anchored in reality. The Superego consisted of moral values and harbored a concept of an ideal self. It was thought to develop last.  The psychoanalysts (as followers of Freud’s theory and his methods came to be known) believed that during childhood, we undergo different stages of psychosexual maturation. Frustrations, or conversely overindulgences, experienced during particular stages of development, could cause a person to become stuck, or “fixated” at that particular developmental stage.   This fixation interfered with the proper and timely development of the Ego or Superego.   As a result, the normal and appropriate Ego balance of Id and Superego energies could not be achieved.  Some psychoanalysts viewed personality disorders (or “character disorders” as they were once called) as fixations that emerged during early developmental stages.  At this point in history, character disorders were considered to be difficult to treat and quite resistant to change.

In Nazi Germany, the institutionalized mentally ill were among the earliest targets of sterilization campaigns and covert “euthanasia” programs. It has been estimated that over 200,000 individuals with mental disorders of all kinds were put to death, although their mass murder has received relatively little historical attention. Despite not being formally ordered to take part, psychiatrists and psychiatric institutions were at the center of justifying, planning and carrying out the atrocities at every stage, and “constituted the connection” to the later annihilation of Jews and other “undesirables” such as homosexuals in the Holocaust.

1950s – Present

By the 1950s, the concept of “character disorders” had become widely accepted within the psychoanalytic community, and psychoanalytic clinicians were distinguishing character disorders from the more severe forms of mental illnesses that cause people to lose touch with reality (i.e., to become psychotic). But, character disorders were not viewed as legitimate mental illnesses in their own right. Instead, they were typically understood as weaknesses of character or willfully deviant behavior caused by problems in a person’s upbringing. Some of these patients were treated in psychoanalysis (psychotherapy based on Freud’s theories) where they typically regressed and got worse. The term “Borderline” dates back to this historical time period, as these character disordered patients were thought to be functioning at the borderline between the psychoses (disorders characterized mainly by suspended reality testing such as Schizophrenia), and the neuroses (disorders characterized mainly by anxiety arising from the conflict among the Id, Ego, and Superego).

Theories and models of the mental components and fixations of psychosexual development laid the foundation for conceptually understanding “character disorders” and their causes. However, these theories were not themselves formal diagnoses. It was not until the 1950s, with the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM), that the character disorders became formally recognized. The original DSM, devised to reduce confusion surrounding psychiatric diagnosis and diagnostic systems prevalent at the time, defined the personality disorders as patterns of behavior that were quite resistant to change, but not connected to a lot of anxiety or personal distress on part of the patient. This first DSM relied heavily on the psychoanalytic tradition and Freud’s ideas which were the prevailing view of that time period.

DSM II, published in 1968, reflected an attempt to make the American psychiatric classification system compatible with the International Classification of Diseases devised by the World Health Organization. It also reflected an attempt to adopt neutral language that did not endorse specific and controversial theoretical viewpoints (such as Freudian, psychoanalytic theories). In DSM II, personality disorders were described as follows, “This group of disorders is characterized by deeply ingrained, maladaptive patterns of behavior that are perceptibly different in quality from psychotic and neurotic symptoms.” Then each disorder was briefly described by a few short sentences. The names of these disorders, and their brief descriptions, bear only a slight resemblance to what we know today as personality disorders.

The third incarnation, DSM III, was published in 1980. At this time, the fields of psychology and psychiatry were struggling to establish themselves as scientific fields of study. This new version of the DSM reflected the fact that newer, more contemporary models of mental illness and treatment were emerging. More importantly, these newer models rested upon evidence-based practices: i.e., these models were not based on unproven or un-testable theories, but instead rested upon scientific evidence.

It is important to understand that scientific study cannot proceed without a means for measuring what is being studied.  Thus, in order for the scientific study of mental disorders to proceed, these disorders had to be defined in such a way as to make them observable, and therefore measurable. Freud’s concepts did not lend themselves to measurement. For instance, one cannot observe, nor measure the Id.  Therefore, the DSM III removed these abstract Freudian concepts that could not be measured. They were replaced with observed behaviors and/or reported  thoughts as these concepts were more easily measurable.

These newer and more contemporary models of mental illness reflected a significant paradigm shift within psychology and psychiatry during the 1970s and 80s. This shift represented the declining influence of psychoanalysis and Freudian theory, and the ascendance of the cognitive-behavioral model within psychology (emphasizing the observable, behavioral manifestations of disorders), and the medical model within psychiatry (cataloging pathological symptoms and their biological causes).

As the name suggests, cognitive-behavioral theory was principally concerned with people’s thoughts and behaviors.  Thoughts were easily reported, and people’s behaviors were easily observed. As such, the cognitive-behavioral theory was perfectly suited to measurement and research, and met the scientific requirements of the day.  Treatments for mental conditions took the form of interventions designed to help people learn better and more effective, healthy ways to think and behave in order to relieve their distress.

Psychoanalytic theory’s fell from grace. This was because it could not be tested or proven using the scientific methods and technologies available at that time. Unfortunately, it merely theorized the causes of mental distress. These theorized causes were completely invisible; and therefore, not measurable. This included the invisible Id, Ego, and Super-Ego; the invisible conflicts between these invisible mental structures; and the invisible psycho-sexual stages of developments. In contrast, the cognitive-behavioral theory restricted itself to addressing only the observable and measurable causes of distress.  Caught in the crossfire between these two influential, psychological theories, one waxing and the other waning, and the rising role of pharmacological treatments within psychiatry, the authors of DSM III attempted to stay out of the conflict by making their document atheoretical.  They achieved this by ensuring that their disorder definitions were primarily descriptive.  They refrained from endorsing one particular theory accounting for the origin and cause of mental disorders over another. 

The goal of DSM III was to outline the diagnostic criteria for as many conditions as possible, and to rely on, and to foster research on mental disorders. The biggest change in DSM III was the introduction of a multi-axial (multi-dimensional) format for making diagnoses. This multi-axial system placed personality disorders onto a separate axis called Axis II.  This Axis II was separated personality disorders from the rest of the major mental disorders and clinical syndromes (such as Major Depression, Schizophrenia, and Bipolar Disorder, to name but a few).  These disorders were described using the first axis (Axis I), while the personality disorders, and developmental conditions such intellectual disabilities were  described on the Axis II.

The goal of this separation of diagnostic dimensions was to enable clinicians to record a person’s current state and prevailing difficulties on Axis I while simultaneously describing a person’s lifelong and pervasive personality characteristics on Axis II.  In other words, Axis I disorders were thought to be transient conditions, while personality disorders and other developmental conditions, described on Axis II, were thought to be permanent conditions.  The rationale was that it was necessary to describe these “permanent” conditions on a separate diagnostic dimension in order to highlight them so that they would not otherwise be overshadowed by the more acute Axis I clinical syndromes.  This multi-axial system remained in place from 1980 until 2013 when it was abandoned with the introduction of DSM-5 due to numerous problems and controversies.

Prior to DSM III, personality disorders were only vaguely described categories that did not lend themselves to research.  However, the publication DSM III (APA, 1980) changed all that.  Personality disorders were now recognized as a distinct and separate category of disorders in their own right. As such, research on personality disorders flourished.   Researchers developed assessment methods facilitating the systematic study of the personality disorders. This new research resulted in the refinement of the criteria sets for personality disorder diagnoses present in DSM-III-RDSM-IVDSM-IV-TR, and DSM-5.  The most recent version of the diagnostic manual, DSM-5, proposes an entirely different model of personality disorders for future research.  Depending on the outcome of that research, we may someday assess personality disorders using a dimensional system of various personality traits.  The current, prevailing diagnostic method and this proposed dimensional system will be compared and discussed in another section.

As a result of ongoing research, people with personality disorders are no longer seen as people with untreatable moral weakness, or willfully bad behavior.  Personality disorders are now recognized as deeply troubling, and legitimate conditions, that have a large negative impact on people’s lives, and in most cases, can be successfully treated.

Mental health and illness have had a fascinating history. Without understanding the context of mental illness and it’s subsequent treatments, we are at risk of oversimplifying the complex. Mental health and how cultures responded over history tells a story of compassion, resiliency as well as some pretty ugly choices. But the story continues to unfold as research, treatment and even religion turn the page on the next chapter.