DSM Dilemma: Issue 1

The Diagnostic and Statistical Manual of Mental Disorder (DSM) is used practically by all psychiatrists and other practitioners as a guide to diagnose psychiatric disorders. This manual is a guide to the way the field communicates and the way in which scientific evidence is standardized. Recently, the American Psychiatric Association released the fifth edition of DSM amidst much controversies and criticism. Cipla's DSM Dilemma endeavors to bring to light DSM-5's biggest changes and the possible impact they may have on mental health care. Before we begin the discussion on DSM-5 and its controversies, it is worthwhile to reflect on the history behind this psychiatric manual. The history of classification will enable us to contextualize the multiple changes that have affected this field. Therefore, the first issue of DSM Dilemma attempts to cover the journey of DSM from DSM-I to DSM-5. Please note that terms such as 'asylum' and 'insane' are used to indicate their historical context and are in no way meant to stigmatize medical conditions.

Before the Diagnostic and Statistical Manual of Mental Disorder (DSM), each mental institution had its own system for classification of mental illness. Therefore, in the early 19th century, the American Psychiatric Association (APA) committee was formed, and they developed the first classification system for mental illness. The Statistical Manual for the use of Institutions for the Insane. The volume included 21 diagnostic categories. However, the manual was widely criticized for being too narrow in scope (meant only for patients in asylum), illogical and inconsistent (same symptoms spanned several diagnoses). Therefore, the manual was ignored by most clinicians.¹ A need for a more elaborate and logical classification was indeed evident.

"The Statistical Manual for the use of Institutions for the Insane, the first classification system for mental illness, was widely criticized for being too narrow in scope, illogical and inconsistent."

During World War II, America needed to employ a huge number of military psychiatrists. These psychiatrists were successful in treating the army men from the stressful situations of war. This success lead to the speculation that these treatment modalities might work outside the war zone. Psychiatrists wondered whether there were some similar stressful conditions in American society that could be removed to cure the underlying mental illness. Thus, having gained a new perspective of the field, post-war American psychiatrists found the existing diagnostic scheme even more inadequate.¹

Another important development taking place in the field was the rapid acceptance of psychodynamic theory (reflecting the work conducted by Adolf Meyer, a renowned neurologist turned psychiatrist) with the American Board of Psychiatry formally recognizing it as the leading school of thought.²

"The first edition of DSM (DSM-I) was released in 1952 and included 102 broadly-construed diagnostic categories."

Given the changing scenario in this field, the APA Committee on Nomenclature and Statistics sought to create a new classification system. The first edition of DSM (DSM-I) was released in 1952. The manual included 102 broadly-construed diagnostic categories that were subdivided into two major groups of mental disorders: 1) conditions associated with somatic disturbances such as intoxication, trauma, or a variety of physiological diseases, and 2) conditions supposedly caused due to socio-environmental stressors on individuals biological constitution and patients inability to adapt to such pressures. The latter group was further segregated into psychoses (relatively severe conditions e.g. manic-depressive disorder or schizophrenia) and psychoneuroses (conditions such as anxiety, depressive disorders, and personality disorders).²

Although the DSM-I did set the stage for increasingly standardized categorization(s) of mental illness, it had several shortcomings: for example, all mental illnesses were referred to as 'reactions'. Accordingly, patients were thought to respond differently only because their life histories differed. Consequently, within the same individual, stress initially manifests as a depressive reaction and could manifest as a schizophrenic reaction later in life. Next, there was a hierarchy of diagnoses that prohibited certain combinations owing to the belief that certain comorbid conditions were just expression of the primary disorder and did not need separate diagnosis. For example, a psychotic disorder and a psychoneurotic disorder could not be diagnosed in the same individual at the same time nor could two psychoneurotic disorders.1 The second edition of the Diagnostic and Statistical Manual of Mental Disorders was released in 1968 to address these alleged shortcomings of the previous edition.²

DSM-II had 10 main divisions and the order of the groups was very specific. It was planned such that the categories could be studied one after the other until the patient was diagnosed.¹ There were some major changes that occurred in the content. First, definitions of mental illness were expanded to include mild conditions seen in the general population. For e.g., diagnostic categories were expanded to include individuals who were psychiatrically normal but warrant examination by a psychiatrist; patients with disturbances of psychotic proportion, which are considered clearly transitory reactions to overwhelming environmental stress. Secondly, there was an increased systematic categorization and specificity as was evidenced by multiple subdivisions of former disorder categories. For e.g., the manual added 8 new alcoholic brain syndromes and an increased number of 'qualifiers' from four to nine. Another important alteration in the DSM-II was the removal of the psychodynamic term 'reaction', referring to the maladaptive response of an individual to socioenvironmental causes of distress.²

The 1960s and 70s witnessed various changes in the psychiatric field which created a need for the next edition of the DSM DSMIII, which is believed to be the defining moment in psychiatry. First, due to lack of clear and distinguished differences between mental health and illness, psychiatric diagnoses were deemed unreliable by both from within the psychiatry community and from without.2 A paper read at the 1975 APA annual meeting, and later published in the American Journal, argued that one of the main problems with psychiatric diagnosis was a large amount of variance because of the lack of discrete boundaries between illnesses.1 Second, there was also a paradigm shift in the school of thoughts among psychiatrists with biologically-oriented ideology gaining more acceptance than the much criticized psychodynamic approach. Next, owing to the progress in psychometric instruments, use of psychometric assessments scales and checklists had become something of a standard in practice. Lastly, progress in psychopharmocology led to development of several mood and behavior-altering agents with psychiatrists regularly prescribing these for treatment.²

The DSM-III was published in 1980 and was huge compared to the preceding issues (almost 500 pages). By defining what a mental disorder is, the manual took an extremely important step in bringing genuineness to psychiatry as a medical specialty. Further to improve diagnostic reliability, the manual used checklists of features and introduced the multiaxial system (Axis I to Axis V) designed to bring the clinician's attention to different areas. Axis I included clinical syndromes; Axis II included personality disorders and academic skills disorders; Axis III contained physical disorders; Axis IV represented the severity of psychosocial stressors; and Axis V was the rating of the highest level of adaptive function.¹

It considerably expanded the section on childhood and adolescent disorders and added eating disorders, attention deficit disorders, and pervasive developmental disorders. Some other important changes included: substance use disorders had its own section, whereas alcohol and drug-related intoxication or withdrawal were listed as organic mental disorders; schizophrenic disorders, paranoid disorders and psychotic

"Checklists of features and the multiaxial system (Axis I to Axis V) designed to bring the clinician's attention to different areas were introduced in DSM-III".

disorders not classified elsewhere were a section unto themselves. For the first time, manic-depressive disorder (renamed as bipolar disorder) was listed under an affective disorders section rather than as a psychotic disorder.¹

The DSM-III was hugely popular; however, it was revised (to DSM-III-R) to reexamine the utility of the DSM-III from the point of view of the clinicians.¹

Only 1 year after the publication of the DSM-III-R, the APA appointed a task force to prepare the DSM-IV to coincide with the scheduled publication of a new International Classification of Diseases (ICD) manual in 1993. There were mental health professionals who objected to the planned publication of DSM-IV claiming that it would be problematic to have three different DSMs in 12 years. Notwithstanding the criticism, the work on the DSM-IV was begun.¹

DSM-IV was a bulky 886 pages with only a few significant changes compared with DSM-III-R. The term Cognitive disorders now replaced organic mental disorders such as dementia and delirium. To increase the reliability, diagnoses was focused on duration: e.g., specifying that a month of positive symptoms were required for schizophrenia versus 1 week in DSM-III-R. Some diagnoses were added (notably, Rett's disorder, Asperger's disorder, and narcolepsy); some were removed or included under other categories (notably, cluttering, identity disorder, transsexualism). The multiaxialsystem was also modified in DSM-IV.¹

In the mid-1990s, the WHO announced that it would no longer update the ICD on a regular 10-year cycle. Thus, there was to be no modification of diagnostic criteria until DSM-5 which was scheduled for publication in 2010. However, the APA made the decision to update the text associated with each diagnosis on the basis of research conducted from 1992 to 1998. To avoid confusion with DSM-IV, and to prevent it from being considered a complete revision, it was called DSM-IV-TR for “Text Revision”.¹

In 2006, APA task force was formed to direct the development of DSM-5. The task in hand was to review the research and literature base to form the content for DSM-5. Between 2007 and 2012, the work group analyzed DSM-IV's strengths and problems. After developing research questions and hypotheses and thorough analysis of literature reviews and existing data, the work group developed the draft DSM-5 diagnostic criteria. The final,

"The latest DSM, DSM-5, was released in May 2013 at APA's Annual Meeting amongst much controversies and debate."

approved DSM-5 was released in May 2013 at APA's Annual Meeting3 amongst much controversies and debate. Do read the second issue of this newsletter that intends to give a comprehensive outlook on DSM-5.³