DSM (The Diagnostic and Statistical Manual of the American Psychiatric Association) - Where did it come from?

I've been reading about the history of classification of mental illness – especially in relation to the DSM – and I’ve learnt a few things that I thought might be worth sharing many of which I found in an article highlighted in my Medscape daily news feed.

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It seems that in America in the mid-19th Century many psychiatric diagnoses were made by the US marshals who collected census details across the country. The tenth national census, in 1888, reported on seven different classes of mental illness that the marshals had been charged with identifying. These were dementia, epilepsy (no wonder epilepsy has been so stigmatised for so long), dipsomania (that’s alcoholism to the rest of us), mania, melancholia, monomania and paresis. A mixed bag of “psychiatric” diagnoses if ever there was one!

Enter the American Psychiatric Association…

By 1917 those seven diagnoses had expanded to 22 in the new Statistical Manual for the Use of Institutions for the Insane published by the American Medico-Psychological Association (which would later become the American Psychiatric Association). I’m pretty sure the US marshals were no longer in charge of making diagnoses by then. Over the years, as the Association’s classification was developing, another classification system was also being developed by the US Army to meet the mental health needs of servicemen. This latter system of classification, called Medical 203 with its 52 disorders divided into 5 categories became the template for the APAs Diagnostic and Statistical Manual (DSM)

The DSM I was published in 1952. The process the APA chose to classify mental illnesses was to circulate proposals for categorisation amongst its members and decide on the content of the DSM by what really was a fairly unscientific “consensus method” based on the opinions of the many. To a large extent that consensus method has remained the same ever since. 

DSM II was published in 1968 so a lot had happened between iterations and there were now 182 disorders categorised in its pages. DSM I and II functioned as reference guides for clinicians and researchers - they were considered unreliable as diagnostic tools in many quarters and in the early 1970s a movement began to make some scientifically based improvements to the DSM.

The Turning Point

Through the late 1970s twenty-five expert committees under the leadership of psychiatrist Prof Robert Spitzer took on the task of overcoming the barriers to scientific classification of mental illness in the face of a paucity of psychiatric research and the continuing dominance of psychoanalysts over biological psychiatrists in American psychiatry. DSM III, published in 1980, was the result. There followed DSM IV in 1987 with its by then 410 disorders and DSM 5 in 2013.

Despite the warm embrace of health insurers and clinicians the DSM remains controversial and criticism grew with each iteration. Many saw it as unnecessarily “labelling” people who would do better with more individualised treatment or medicalising conditions that really fell into the spectrum of normality. Some, like Prof Allen Frances who had previously chaired the DSM IV task force, worried that DSM 5 contained changes that were unsafe and scientifically unsound. Frances wrote a book, “Changing Normal, an insider’s revolt against out-of-control psychiatric diagnosis, DSM 5, big pharma and the medicalisation of ordinary life”. Frances implored clinicians to view the DSM as “a guide, not a bible”.

Whatever you think of the DSM classification system, it is entrenched in western mental health care, so familiarity with it is important for all mental health professionals. It does have its uses. Communication between mental health professionals is easier when disorders can be clearly categorised. Research can be replicated with confidence. Health insurers and bureaucracies can be clear about what their clients are dealing with.

Where to from here?

I understand that in the future the APA will no longer produce full revisions of the whole manual but will revise it section by section in response to relevant advances in the science and publish those revisions online. We will have to keep our eyes out for the changes.

Let’s hope that future iterations of the DSM will lean towards science rather than opinion. Let’s hope too, that the experts putting the revisions together are able to stay safe from lobbyists with commercial agendas. That’s a danger that those US marshals probably never dreamed of.

References

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Dr Jan Orman

Jan is Sydney GP, private psychological medicine practitioner in Sydney’s inner west and a GP educator for Black Dog Institute.

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