Distinction from ICDAn alternate, widely used classification publication is the '' '' (ICD) is produced by the (WHO). The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 5 of the ICD specifically covers mental and behavioural disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM. The (4th. ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated. Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other. Mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients. Health-care researchers use the DSM to categorize patients for research purposes. An international survey of psychiatrists in sixty-six countries compared the use of the and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research. DSM-5, and the abbreviations for all previous editions, are owned by the American Psychiatric Association.
Census data and report (1840–1888)The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the , which used a single category: " / ". Three years later, the made an official protest to the , stating that "the most glaring and remarkable errors are found in the statements respecting , prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns were all marked as insane, and calling the statistics essentially useless. The was formed in 1844; it has since changed its name twice before the new millennium: in 1892 to the American Medico-Psychological Association, and in 1921 to the present American Psychiatric Association (APA). Edward Jarvis and later helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880. Frederick H. Wines was appointed to write a 582-page volume, published in 1888, called ''Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880)''. Wines used seven categories of mental illness, which were also adopted by the American Medico-Psychological Association: , (uncontrollable craving for alcohol), , , , , and .
American Psychiatric Association Manual (1917)In 1917, together with the National Commission on Mental Hygiene (now ), the American Medico-Psychological Association developed a new guide for mental hospitals called the ''Statistical Manual for the Use of Institutions for the Insane''. This guide included twenty-two diagnoses and would be revised several times by the Association and its successor, the American Psychiatric Association (APA), over the years. Along with the , the APA provided the psychiatric subsection of the U.S. general medical guide, the ''Standard Classified Nomenclature of Disease'', referred to as the ''Standard''.
Medical 203 (1943)saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. Under the direction of , a committee headed by psychiatrist William C. Menninger, with the assistance of the Mental Hospital Service, developed a new classification scheme called Medical 203, which was issued in 1943 as a War Department Technical Bulletin under the auspices of the Office of the Surgeon General. The foreword to the DSM-I states the had itself made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance. This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature introduced into many clinics and hospitals by psychiatrists returning from military duty." The also adopted a slightly modified version of Medical 203.
ICD-6 (1949)In 1949, the published the sixth revision of the (ICD), which included a section on mental disorders for the first time. The foreword to DSM-1 states this "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature".
Early versions (20th century)
DSM-1 (1952)An APA Committee, on Nomenclature and Statistics, was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the ''Standard''s nomenclature, and the VA system's modifications of the ''Standard'' to approximately 10% of APA members: 46% of whom replied, with 93% approving the changes. After some further revisions (resulting in its being called DSM-I), the ''Diagnostic and Statistical Manual of Mental Disorders'' was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, ). In 1952, the APA listed homosexuality in the DSM as a personality disturbance. ''Homosexuality: A Psychoanalytic Study of Male Homosexuals'', a large-scale 1962 study of homosexuality by and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. In 1956, however, the psychologist performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a heroine to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.
DSM-II (1968)In the 1960s, there were many challenges to the concept of itself. These challenges came from psychiatrists like , who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as , who said mental illness was another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in ''Science'', the , received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis. The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term " " was retained. Both the DSM-I and the DSM-II reflected the predominant psychiatry, although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and (roughly, anxiety/depression broadly in touch with reality, as opposed to or disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded. An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and and is poor for the remaining categories".
Seventh printing of the DSM-II (1974)As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by activists against the APA began in 1970, when the organization held its convention in . The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist worked with the collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you." This gay activism occurred in the context of a broader movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists. Taking into account data from researchers such as and , the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".
DSM-III (1980)In 1974, the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous . There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States. The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process. The criteria adopted for many of the mental disorders were taken from the (RDC) and , which had just been developed by a group of research-orientated psychiatrists based primarily at and the . Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as " neo-Kraepelinian"). The or physiologic view was abandoned, in favor of a or model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple . Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." were placed on axis II along with mental retardation. The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance". Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry. When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:
Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalisability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator...
DSM-III-R (1987)In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" . xxiii
DSM-IV (1994)In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multicenter field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix.
DSM-IV DefinitionsThe DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom" It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder."
DSM-IV CategorizationThe DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from s and several of the s due to their nature. Each category of disorder has a numeric code taken from the , used for health service (including insurance) administrative purposes.
DSM-IV multi-axial systemThe DSM-IV was organized into a five-part axial system. Axis I provided information about clinical disorders, or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM-V as mental retardation. Those were both covered on Axis II. Axis III covered medical conditions that could impact a person's disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person. Axis V was the GAF, or global assessment of functioning, which was basically a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life.
DSM-IV SourcebooksThe DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials. The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification.Poland, JS. (2001
DSM-IV-TR (2000)A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses. The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM .
DSM-5 (2013)The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in 20 years. A significant change in the fifth edition is the deletion of the subtypes of : , disorganized, , undifferentiated, and residual. The deletion of the subsets of Autism spectrum, autistic spectrum disorder—namely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified—was also implemented, with specifiers regarding intensity: mild, moderate, and severe. Severity is based on social communication impairments and restricted, repetitive patterns of behaviour, with three levels: # requiring support # requiring substantial support # requiring very substantial support During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.
Future revisions and updatesBeginning with the fifth edition, it is intended that subsequent revisions will be added more often, to keep up with research in the field. It is notable that DSM-5 uses Hindu–Arabic numeral system, Arabic rather than Roman numerals. During the DSM-5 development process, the APA planned to use decimals to identify future incremental updates (e.g., DSM-5.1, DSM-5.2) and whole numbers for new editions (e.g., DSM-5, DSM-6), similar to the scheme used for software versioning. However, the forthcoming revision of the DSM-5 follows a more traditional path and is called DSM-5-TR (Text Revision) and is scheduled for publication release in March of 2022.
Reliability and validityThe revisions of the DSM from the 3rd Edition forward have been mainly concerned with Inter-rater reliability, diagnostic reliability—the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Unfortunately, neither the issue of reliability or validity was settled. In 2013, shortly before the publication of DSM-5, the director of the (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response." Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability Cohen's kappa, kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78. The criticisms motivated the development of the Hierarchical Taxonomy of Psychopathology, a dimensional alternative to the classification of mental disorders.
Superficial symptomsBy design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiology, pathophysiological processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology." "The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is necessary at all), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per a DSM or ICD-based diagnosis." "Despite the lack of consensus on underlying causation, advocates for specific psychopathology, psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychology, evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology but one that is widely challenged within general psychology." Another example is the strong Operationalization, operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts like Depression (mood), depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice." A 2013 review published in the ''European Archives of Psychiatry and Clinical Neuroscience'' stated "that psychiatry targets the phenomenology (psychology), phenomena of consciousness, which, unlike somatic symptom disorder, somatic symptoms and medical sign, signs, cannot be grasped on the analogy with material thing-like objects." As an example of the problem of the superficial characterization of psychiatric signs and symptoms, the authors gave the example of a patient saying they "feel depressed, sad, or down," showing that such a statement could indicate various underlying experiences: "not only depression (mood), depressed mood but also, for instance, irritability, irritation, anger, loss of meaning, varieties of fatigue (medical), fatigue, ambivalence, rumination (psychology), ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even auditory hallucination, voices with negative content, and so forth." The structured interview comes with a "danger of over confidence in the face value of the answers, as if a simple 'yes' or 'no' truly confirmed or denied the diagnostic criteria, diagnostic criterion at issue." The authors gave an example: A patient who was being administered the Structured Clinical Interview for DSM-IV, Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenology (psychology), phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusion, delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own qualia, experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the qualia, experience did not "fully articulate itself" until the patient started talking about his experiences.
OverdiagnosisDr. Allen Frances, an outspoken critic of DSM-5, stated that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggested that the "DSM-5 threatens to provoke several more [epidemics]." Some researchers stated that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and Autism spectrum, autism spectrum disorder. Bruchmüller, et al. (2012) suggested that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics.
Dividing linesDespite caveats in the introduction to the DSM, it has long been argued that its Classification of mental disorders, system of classification makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence. In addition, it has been argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM-V no longer includes a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder, a step which was previously present in the DSM-IV. Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.
Cultural biasPsychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell (physician), Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatry, Cross-cultural psychiatrist Arthur Kleinman contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Mainstream psychiatrists have been dissatisfied with these culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posited that the culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo in 1989 as an alternative to the DSM in treating patients of the African diaspora. Historically, the DSM tended to avoid issues involving religion; the DSM-5 relaxed this attitude somewhat.
Medicalization and financial conflicts of interestThere was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing of human nature, very possibly attributable to disease mongering by psychiatrists and , the power and influence of the latter having grown dramatically in recent decades. In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model". It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct Conflict of interest#Relationship to medical research, conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry. William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million. The article’s closing words: "it [the APA] will be laughing all the way to the bank." However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients.
Clients, survivors, and consumersA client is a person who accesses psychiatric services and may have been given a diagnosis from the DSM, while a survivor self-identifies as a person who has endured a psychiatric intervention and the mental health system (which may have involved involuntary commitment and involuntary treatment). A term adopted by many users of psychiatric services is "consumer". This term was chosen to eliminate the "patient" label and restore the person to an active role as a user or consumer of services. Some individuals are relieved to find that they have a recognized condition that they can apply a name to and this has led to many people Self-diagnosis, self-diagnosing. Others, however, question the accuracy of the diagnosis, or feel they have been given a Labeling theory, label that invites social stigma and discrimination (the terms "mentalism (discrimination), mentalism" and "sanism" have been used to describe such discriminatory treatment).Sanism in Theory and Practice
Critiques of DSM-5Psychiatrist was critical of the proposed revisions to the DSM-5. In a 2012 ''New York Times'' editorial, Frances warned that if this DSM version was issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription." In a December 2012 blog post on ''Psychology Today'', Frances provided his "list of DSM 5's ten most potentially harmful changes:" * Disruptive Mood Dysregulation Disorder, for temper tantrums * Major Depressive Disorder, includes normal grief * Minor Neurocognitive Disorder, for normal forgetfulness in old age * Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants * Binge Eating Disorder, for excessive eating * Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services * First-time drug users will be lumped in with addicts * Behavioral Addictions, making a "mental disorder of everything we like to do a lot." * Generalized Anxiety Disorder, includes everyday worries * Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings." A group of 25 psychiatrists and researchers, among whom were Frances and , published debates on what they saw as the six most essential questions in psychiatric diagnosis: * Are they more like theoretical constructs or more like diseases? * How to reach an agreed definition? * Should the DSM-5 take a cautious or conservative approach? * What is the role of practical rather than scientific considerations? * How should it be used by clinicians or researchers? * Is an entirely different diagnostic system required? In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other APA divisions have endorsed the petition. Robbins noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.
See also* Chinese Classification and Diagnostic Criteria of Mental Disorders * Classification of mental disorders * Diagnostic classification and rating scales used in psychiatry * DSM-IV Codes * Global Assessment of Functioning, Global Assessment of Functioning (GAF) Scale * International Statistical Classification of Diseases and Related Health Problems, International Statistical Classification of Diseases and Related Health Problems (ICD) * Kraepelinian dichotomy * Psychodynamic Diagnostic Manual * Relational disorder (proposed DSM-5 new diagnosis) * Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health * * Structured Clinical Interview for DSM-IV ''(SCID)'' * Homosexuality in DSM
Further reading* *