Mental disorders are easily described. not easily defined. Castillo (1996)

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1 History of the DSM Cornelia Pinnell, Ph.D. Argosy University/Phoenix

2 Lecture Outline Why classification? A rationale. Classification of mental disorders a historical account of classification systems Census Military World Health Organization (ICDs) DSM Other classification systems

3 Mental Disorders Mental disorders are easily described but not easily defined. Castillo (1996)

4 Purposes of classification systems in psychiatry To distinguish between different categories (for accurate diagnosis and treatment decision) To provide a common language among mental health professionals

5 Historical background Hippocrates (5 th century BC) introduced the terms mania and hysteria

6 Historical background 1840 census (population count) - One category of mental illness: idiocy/insanity 1880 census - 7 categories of mental illness: mania; melancholia; monomania; paresis; dementia; dipsomania; epilepsy

7 Historical background the Bureau of the Census adopted a statistical system developed by the American Medico-Psychological Association & the National Commission on Mental Hygiene

8 Historical background Nomenclature developed by the US Army & modified by the Veterans Administration to cover the presentation of outpatient servicemen and veterans of WW II.

9 Classification systems Taxonomy = The study of the general principles of systematic classification Nosology = The branch of medical science that deals with the systematic classification of diseases

10 Classification systems 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

11 International Classification Of Disease 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.

12 International Classification Of Disease ICD an effort of the WHO International Classification of Causes of Death ( st edition) /International Classification of Disease /International Classification of Functioning, Disability and Health Revisions approximately every 10 years

13 ICDs ICD-2 in 1910 ICD-3 in 1921 ICD-4 in 1930 ICD-5 in 1939 ICD-6 in 1949

14 International Classification Of Disease The Manual of International Statistical Classification of Diseases, Injuries and Causes of Death. ICD-6 th edition included for the first time a section on mental disorders The ICD-6 was considered to be inadequate for use in USA.

15 International Classification Of Disease Beginning with the ICD-7, a series of adaptations/modifications of the WHO publication were developed each containing a section for the classification of procedures

16 ICDs International Classification of Diseases, Adapted for Indexing Hospital Records by Diseases and Operations (ICDA or ICDA-7) -7 th rev (1958). International Classification of Disease Adapted for Use in the United States (ICDA-8) 8 th rev. (1968)

17 ICDs The ICD-9 was published by the WHO in 1977 and in the US in 1979 International Classification of Diseases, Clinical Modification (ICD-9-CM) 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 ICD-9 but provides for additional morbidity detail and is annually updated on October 1.

18 ICDs ICD-10 was completed in 1992 On January 1 st, 1999 the ICD-10 (without clinical extensions) was adopted for reporting mortality, but ICD-9-CM CM is still used for morbidity.

19 Other systems Current Procedural Terminology (CPT) code set is maintained by the American Medical Association (AMA) International Classification of Headache Disorders International Classification of Sleep Disorders

20 Other Classification Systems Other classification systems for mental disorders: Psychodynamic Diagnostic Manual Chinese Classification of Mental Disorders

21 DSM 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

22 DSM-I (1952) based on Adolf Meyer s biopsychosocial model Variant of ICD-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

23 DSM-I Assumptions for DSM I (1952): 1. Quantitative spectrum of mental illness (MI) - continuum of severity 2. Fluid boundaries between health & illness, normal & abnormal 3. Psychogenesis is involved in etiology of MI 4. The mixture of noxious environment & psychic conflict causes mental illness

24 The anti-psychiatry movement Erving Goffman - Asylum patients learn to be institutionalized Thomas Szasz - Mental illness is a myth, a problem of labeling problems in living Thomas Scheff - Nonconformity is labeled deviant by the social group Fuller Torrey Most patients treated by psychiatrists have problems in living

25 DSM-II (1968) begins a paradigm shift biomedical model Added certain ICD-8 diagnostic categories and deleted others Eliminated the term reaction reaction Low reliability; diagnoses based on clinical experience were highly subjective

26 Websites of interest Thomas Szasz on mental health HB3c&feature=related Thomas Szasz exposes psychiatry WPv9EY&feature=related Stephen Wiseman response to Szasz IrkE&feature=related

27 ICD-9-CM, CM, 1979 International Classification of Diseases, 9th edition, Clinical modification for use in US Official system for recording all diseases, injuries, impairments, symptoms, and causes of death Expands 4-digit ICD-9 codes to 5-digit codes for greater specificity

28 DSM-III (1980): disease-centered psychiatry (organicity prevails) Assumptions for the DSM-III Mental disorders are based in brain disease Each disorder can be defined accurately & narrowly & classified by descriptive patterns of symptoms Atheoretical and descriptive No information provided on etiology, management of the disorder, or treatment planning.

29 DSM-III (1980) Designed to increase diagnostic reliability & improve communication among clinicians and researchers Empirically based nosology field trials Categorical, hierarchical, multiaxial system

30 Hierarchical conceptualization 1) SYMPTOM = target behavior (affect, cognition, overt behavior, perception) 2) SYNDROME = constellation of concomitant symptoms (sxs covariation) 3) DISORDER = clustering of syndromes 4) DISEASE = known etiology (underlying mechanisms and processes)

31 DSM-III Multiaxial system 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

32 Criticisms of the multiaxial system in the DSM-III 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

33 Research Diagnostic Criteria Research Diagnostic Criteria (RDC) were developed as a reaction to the DSM-III. This system identified specific symptoms and indicated that a subset of symptoms was sufficient for a particular diagnosis to be met pdf assn.org/cgi/content/ abstract/39/ 11/1283

34 DSM-III-R (1987) medical model Minor revisions Designed to eliminate inconsistencies and increase reliability among clinicians and researchers

35 DSM-IV (1994) The offspring of the DSM-III, it retains the disease-centered paradigm. 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.

36 Spitzer the main architect of the DSM-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

37 Field trials Field trials would provide empirical basis & assess: Reliability of diagnosis = agreement among diagnosticians (inter-rater rater reliability) Face validity = acceptability of criteria Feasibility of criteria = if easily understood & applied by clinicians/researchers Generalizability of criteria = if applicable in various settings Coverage = goodness of fit with patients Construct validity = descriptive, concurrent, predictive

38 DSM-IV (1994) beginnings of a cultural paradigm shift Coordinated with ICD-10 to be used internationally & applicable cross-culturally. 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

39 DSM-IV (1994) Basic Features: Descriptive approach Specific diagnostic criteria to increase reliability Systematic description

40 Axis I: DSM-IV Mutiaxial Assessment Clinical Syndromes & Other Conditions That May Be A Focus of Clinical Attention Axis II: Personality Disorders & Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Axis V: Problems Global Assessment of Functioning (GAF)

41 Axis I: DSM-IV Multiaxial Assessment Clinical Syndromes & Other Conditions That May Be A Focus of Clinical Attention Axis II: Personality Disorders & Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Axis V: Problems Global Assessment of Functioning (GAF)

42 DSM-IV New Axes recommended Vulnerability Family functioning Coping style & defense mechanisms Response to therapy

43 DSM-IV-TR (2000) Minor (text) revisions of the DSM-IV Lists 365 disorders in 17 sections

44 DSM-IV-TR Multiaxial Assessment Axis I: Clinical Disorders & Other Conditions That May Be A Focus of Clinical Attention Axis II: Personality Disorders & Mental Retardation; habitual use of a particular defense mechanism

45 DSM-IV-TR Multiaxial Assessment Axis III: General Medical Conditions 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) Axis IV: Psychosocial and Environmental Axis V: Problems Global Assessment of Functioning (GAF) social, occupational and psychological

46 DSM-V Initially scheduled to be published sometime between 2010 and 2012; now it is expected to be published in 2013 Information on the DSM-V revision is available at

47 Websites of interest Open Yale Courses website: What Happens When Things Go Wrong: Mental Illness, Part I & II Yale University DPKsY&feature=related 7Rn8&feature=channel