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.