How the DSM Developed: What You Might Not Know
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is widely known as the bible of psychiatry and psychology.
But not many people know how this powerful and influential book came to be. Here’s a brief look at the DSM’s evolution and where we are today.
The Need for Classification
The origins of the DSM date back to 1840 — when the government wanted to collect data on mental illness. The term “idiocy/insanity” appeared in that year’s census.
Forty years later, the census expanded to feature these seven categories: “mania, melancholia, monomania, paresis, dementia, dipsomania and epilepsy.”
But there was still a need to gather uniform stats across mental hospitals. In 1917, the Bureau of the Census embraced a publication called the Statistical Manual for the Use of Institutions for the Insane. It was created by the Committee on Statistics of the American Medico-Psychological Association (now the American Psychiatric Association) and the National Commission on Mental Hygiene. The committees separated mental illness into 22 groups. The manual went through 10 editions until 1942.
DSM-I is Born
Before the DSM, there were several different diagnostic systems. So there was a real need for a classification that minimized the confusion, created a consensus among the field and helped mental health professionals communicate using a common diagnostic language.
Published in 1952, DSM-I featured descriptions of 106 disorders, which were referred to as “reactions.” The term reactions originated from Adolf Meyer, who had a “psychobiological view that mental disorders represented reactions of the personality to psychological, social and biological factors” (from the DSM-IV-TR).
The term reflected a psychodynamic slant (Sanders, 2010). At the time, American psychiatrists were adopting the psychodynamic approach.
Here’s a description of “schizophrenic reactions”:
It represents a group of psychotic disorders characterized by fundamental disturbances in reality relationships and concept formations, with affective, behavioral, and intellectual disturbances in varying degrees and mixtures. The disorders are marked by strong tendency to retreat from reality, by emotional disharmony, unpredictable disturbances in stream of thought, regressive behavior, and in some, a tendency to ‘deterioration.’”
Disorders also were split into two groups based on causality (Sanders, 2010):
(a) disorders caused by or associated with impairment of brain tissue function and (b) disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain…. The former grouping was subdivided into acute brain disorders, chronic brain disorders, and mental deficiency. The latter was subdivided into psychotic disorders (including affective and schizophrenic reactions), psychophysiologic autonomic and visceral disorders (psychophysiologic reactions, which appear related to somatization), psychoneurotic disorders (including anxiety, phobic, obsessive–compulsive, and depressive reactions), personality disorders (including schizoid personality, antisocial reaction, and addiction), and transient situational personality disorders (including adjustment reaction and conduct disturbance).
Oddly enough, as Sanders points out: “…learning and speech disturbances are categorized as special symptom reactions under personality disorders.”
A Significant Shift
In 1968, the DSM-II came out. It was only slightly different from the first edition. It increased the number of disorders to 182 and eliminated the term “reactions” because it implied causality and referred to psychoanalysis (terms like “neuroses” and “psychophysiologic disorders” remained, though).
When DSM-III was published in 1980, however, there was a major shift from its earlier editions. DSM-III dropped the psychodynamic perspective in favor of empiricism and expanded to 494 pages with 265 diagnostic categories. The reason for the big shift?
Not only was psychiatric diagnosis viewed as unclear and unreliable but suspicion and contempt about psychiatry started brewing in America. Public perception was far from favorable.
The third edition (which was revised in 1987) leaned more toward German psychiatrist Emil Kraepelin’s concepts. Kraepelin believed that biology and genetics played a key role in mental disorders. He also distinguished between “dementia praecox”—later renamed schizophrenia by Eugen Bleuler—and bipolar disorder, which before that were viewed as the same version of psychosis.
From Sanders (2010):
Kraepelin’s influence on psychiatry reemerged in the 1960s, about 40 years after his death, with a small group of psychiatrists at Washington University in St. Louis, MO, who were dissatisfied with psychodynamically oriented American psychiatry. Eli Robins, Samuel Guze, and George Winokur, who sought to return psychiatry to its medical roots, were called the neo-Kraepelinians (Klerman, 1978). They were dissatisfied with the lack of clear diagnoses and classification, low interrater reliability among psychiatrists, and blurred distinction between mental health and illness. To address these fundamental concerns and to avoid speculating on etiology, these psychiatrists advocated descriptive and epidemiological work in psychiatric diagnosis.
In 1972, John Feighner and his “neo-Kraepelinian” colleagues published a set of diagnostic criteria based on a synthesis of research, pointing out that the criteria were not based on opinion or tradition. In addition, explicit criteria were used to increase reliability (Feighner et al., 1972). The classifications therein became known as the “Feighner criteria.” This became a landmark article, eventually becoming the most cited article pub- lished in a psychiatric journal (Decker, 2007). Blashfield (1982) suggests that Feighner’s article was highly influential, but that the large number of citations (more than 140 per year at that point, compared with an average of about 2 per year) may have been in part due to a disproportionate number of citations from within the “invisible college” of the neo-Kraepelinians.
The change in the theoretical orientation of American psychiatry toward an empirical foundation is perhaps best reflected in the third edition of the DSM. Robert Spitzer, Head of the Task Force on DSM-III, was previously associated with the neo- Kraepelinians, and many were on the DSM-III Task Force (Decker, 2007), but Spitzer denied being neo- Krapelinian himself. In fact, Spitzer facetiously resigned from “the neo-Kraepelinian college” (Spitzer, 1982) on account that he did not subscribe to some of the tenets of the neo-Kraepelinian credo presented by Klerman (1978). Nevertheless, the DSM-III appeared to adopt a neo-Kraepelinian standpoint and in the process revolutionized psychiatry in North America.
It’s not surprising that the DSM-III looked quite different from earlier versions. It featured the five axes (e.g., Axis I: disorders such as anxiety disorders, mood disorders and schizophrenia; Axis II: personality disorders; Axis III: general medical conditions) and new background information for each disorder, including cultural and gender features, familial patterns and prevalence.
Here’s an excerpt from the DSM-III about manic-depression (bipolar disorder):
Manic-depressive illnesses (Manic-depressive psychoses)
These disorders are marked by severe mood swings and a tendency to remission and recurrence. Patients may be given this diagnosis in the absence of a previous history of affective psychosis if there is no obvious precipitating event. This disorder is divided into three major subtypes: manic type, depressed type, and circular type.
296.1 Manic-depressive illness, manic type ((Manic-depressive psychosis, manic type))
This disorder consists exclusively of manic episodes. These episodes are characterized by excessive elation, irritability, talkativeness, flight of ideas, and accelerated speech and motor activity. Brief periods of depression sometimes occur, but they are never true depressive epi- sodes.
296.2 Manic-depressive illness, depressed type ((Manic-depressive psychosis, depressed type))
This disorder consists exclusively of depressive episodes. These episodes are characterized by severely depressed mood and by mental and motor retardation progressing occasionally to stupor. Uneasiness, apprehension, perplexity and agitation may also be present. When illusions, hallucinations, and delusions (usually of guilt or of hypochondriacal or paranoid ideas) occur, they are attributable to the dominant mood disorder. Because it is a primary mood dis- order, this psychosis differs from the Psychotic depressive reaction, which is more easily attributable to precipitating stress. Cases in- completely labelled as “psychotic depression” should be classified here rather than under Psychotic depressive reaction.
296.3 Manic-depressive illness, circular type ((Manic-depressive psychosis, circular type))
This disorder is distinguished by at least one attack of both a depressive episode and a manic episode. This phenomenon makes clear why manic and depressed types are combined into a single category. (In DSM-I these cases were diagnosed under “Manic depressive reaction, other.”) The current episode should be specified and coded as one of the following:
296.33* Manic-depressive illness, circular type, manic*
296.34* Manic-depressive illness, circular type, depressed*
296.8 Other major affective disorder ((Affective psychosis, other))
Major affective disorders for which a more specific diagnosis has not been made are included here. It is also for “mixed” manic-depressive illness, in which manic and depressive symptoms appear almost simultaneously. It does not include Psychotic depressive reaction (q.v.) or Depressive neurosis (q.v.). (In DSM-I this category was included under “Manic depressive reaction, other.”)
(You can check out the entire DSM-III here.)
Not much changed from DSM-III to DSM-IV. There was another increase in the number of disorders (over 300), and this time, the committee was more conservative in their approval process. In order for disorders to be included, they had to have more empirical research to substantiate the diagnosis.
DSM-IV was revised once, but the disorders remained unchanged. Only the background information, such as prevalence and familial patterns, was updated to reflect current research.
The DSM-5 is slated for publication in May 2013 — and it’s going to be quite an overhaul. Here are posts from Psych Central for more information about the revision:
- A Look at the DSM-5 Draft
- A Review of the DSM-5 Draft
- Personality Disorders Shake-Up in DSM-5
- Overdiagnosis, Mental Disorders and the DSM-5
- DSM-5 Sleep Disorders Overhaul
- You Do Make a Difference in the DSM-5
- The Two Worlds of Grief and Depression
Sanders, J.L., (2010). A distinct language and a historic pendulum: The evolution of the diagnostic and statistical manual of mental disorders. Archives of Psychiatric Nursing, 1–10.
The DSM story, Los Angeles Times.
History of the DSM from the American Psychiatric Association.
Tartakovsky, M. (2011). How the DSM Developed: What You Might Not Know. Psych Central. Retrieved on July 31, 2015, from http://psychcentral.com/blog/archives/2011/07/02/how-the-dsm-developed-what-you-might-not-know/