Diagnostic and Statistical Manual of Mental Disorders (DSM)

DSM is published by the American Psychiatric Association and is the classification used most often in diagnosing mental disorders in USA. The International Classification of Diseases (ICD) is a commonly-used alternative internationally.

The first edition (DSM-I) was published in 1952. DSM-II was published in 1968. DSM-III in 1980 and DSM-III-R as a revision in 1986. The current  fourth edition, DSM-IV was first published in 1994. A text revision known as DSM-IV-TR appeared in 2000. Work is being done in order to publish a new fifths edition in the future.

DSM-I and DSM-II were strongly influenced by the psychodynamic approach to mental disorders, but with DSM-III, the psychodynamic view was abandoned and the biomedical model became the primary approach, introducing a clear distinction between normal and abnormal. The DSM became atheoretical since it had no preferred etiology for mental disorders. When DSM-III was first published in 1980 it embodied a radical, new method for identifying psychiatric illness. DSM-III was often referred to as the "psychiatric Bible," and it was used to challenge the pervasive criticism that psychiatric diagnoses were unreliable and invalid.

Kirk & Kutchins (1992) is a critical book of DSM. A reviewer wrote:

"Chapters 2 and 3 present the political and scientific context in which DSM-III developed.  The historical progression is described along with the manner in which the APA (American Psychiatric Association) was manipulated to produce and endorse this product.  The history includes tracing the development and use of the new statistic, kappa, to shift the issue of reliability from a serious conceptual, scientific problem to a relatively innocuous technical issue.

    Chapter 4 presents the step-by-step account of how a small band of research psychiatrists accomplished such remarkable success in influencing the course of American psychiatry.  Chapters 5 and 6 are the meat of the book.  The authors demonstrate that careful analysis of the data from the field trials used in developing DSM-III indicates that these trials do not show what it is claimed they show.  Rather than improving the reliability of psychiatric diagnosis, DSM-III either does not show any better reliability or is worse than DSM-II.  The few studies of reliability that have been done after DSM -III show a high level of unreliability." (Underwager, 1993).

Spasser (1998) writes that psychiatric classification is a profoundly important activity that directs subsequent treatment decisions, assumptions about etiology, and prognostic considerations. While the ideal classification scheme would be clear, concise, comprehensively inclusive of, and hospitable to, the entities under consideration, in practice, all classification systems reflect trade-offs and embody flawed structures. Accordingly, it is essential to be fully cognizant of the shortcomings, biases, and tacit assumptions of extant systems so that classifications can be improved and so that misrepresentations will not be blindly repeated or reproduced. Modern psychiatric classification and diagnosis are almost exclusively defined within the context of the nomenclature and diagnostic categories of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). He uses Giddens’s (1984) theory of "structuration" to explain how at least some of the consequences of relying on the DSM for classification result in unexamined conditions of its use and unintentionally reproduced its underlying assumptions. This article uses the DSM to explicate agency in structuration theory and structuration theory to illuminate the structure and use of the DSM. Finally, Spasser suggests that several prominent issues and concerns in psychiatric nosology resonate profoundly with those that have concerned, and continue to interest, library classificationists.

Dunne & Chute (1999) report on a project aimed at parsing the rubric criteria of the DSM to extract the clinically detailed signs, symptoms, findings, and conditions that are present. These are seen as a "latent terminology" implicit within the DSM which is highly granular and clinically specific. The article describes the content of these terms that heretofore existed sub rosa, though it is recognized that during the authorship of the DSM such terms were constructed deliberately and systematically. Relevant characteristics of the classification system are briefly reviewed. Summary results of parsing the defining criteria for the 400 JCD-9 Codes enumerated in DSM-IV are presented.

"The Diagnostic and Statistical Manual of Mental Disorders is important, but it is also controversial. While its publishers claim that the D.S.M. is a scientific classification system based on sound data, many have doubts. Big business has interests in the D.S.M. Perhaps the D.S.M. has been distorted by pressures stemming from insurance companies, or from pharmaceutical companies? Others are concerned that whether a condition is classified as a mental disorder depends too greatly on social and political factors. More conceptual worries are also frequent. If classification requires a theory, and if mental disorders are poorly understood, then a sound classification system may be presently unobtainable. Possibly even attempting to construct a classification system that cuts nature at the joints is conceptually naïve. Maybe types of mental disorder are radically unlike, say, chemical elements, and simply fail to have a natural structure. Cooper (2005) offers a sustained philosophical critique of the D.S.M. that addresses these concerns. The first half of the book asks whether the project of constructing a classification of mental disorders that reflects natural distinctions makes sense. I conclude that it does. The second half of the book addresses epistemic worries. Even supposing a natural classification system to be possible in principle, there may be reasons to be suspicious of the categories included in the D.S.M. I examine the extent to which the D.S.M. depends on psychiatric theory, and look at how it has been shaped by social and financial factors. I aim to be critical of the D.S.M. without being antagonistic towards it. Ultimately, however, I am forced to conclude that although the D.S.M. is of immense practical importance, it is not on track to become the best possible classification of mental disorders." (Cooper, 2005).
 

Literature:

American Psychiatric Association Task Force on DSM-IV. (1994). Diagnostic and statistical manual of mental disorders 4th ed.; DSM-IV. Washington, DC: American Psychiatric Association.

Cooper, Rachel (2005). Classifying Madness: A Philosophical Examination of the Diagnostic and Statistical Manual of Mental Disorders. Berlin: Springer.  (Philosophy and Medicine).

Dunne, D. & Chute, C. G. (1999). Detailed content and terminological properties of DSM-IV. Journal of the American Medical Informatics Association, S, 57-61.
 

Kirk, S. A. & Kutchins, H. (1992). The Selling of DSM: The Rhetoric of Science in Psychiatry. New Brunswick, NJ:  Aldine Transaction. 

Kupfer, D. J.; First, M. B. & Regier, D. A. (Eds.). (2002). A research  agenda  for DSM-V. Washington, D.C.: American Psychiatric Association.

Spasser, Mark A. (1998). Psychiatrists make Diagnoses, but not in Circumstances of Their Own Choosing: Agency and Structure in the DSM. Library Trends, 47(2), 313-337.  http://findarticles.com/p/articles/mi_m1387/is_2_47/ai_54050966/pg_1

Underwager, R. (1993). [Book review of] The Selling of DSM: The Rhetoric of Science in Psychiatry. Issues In Child Abuse Accusations, 5(2), available at:  http://www.ipt-forensics.com/journal/volume5/j5_2_br7.htm

Wikipedia. The free encyclopedia. (2006). Diagnostic and Statistical Manual of Mental Disorders. http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders

See also:  Psychiatry

Birger Hjørland

Last edited: 24-01-2008

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