The 4th edition of the Diagnostic and Statistical Manual, published by the American Psychiatric Association, is what health care professionals use to diagnose mental illnesses. The first edition was published in 1952, the second in 1968, the third in 1980, and the current version in 1994 (with a revision in 2000). Soon the 5th edition will be released.
The 5th addition brings about many changes to the structure of the DSM and as well as the included mental illnesses. Many of these changes build on our progress in understanding mental illness. Yet there remain questions of whether labels are appropriate and issues of over-diagnosis.
History of the DSM
The first official attempt to gather information about mental illness in the US was by the 1840 census, recording those prevalence of “idiocy/insanity.” The 1880 census included 7 categories of mental illness including mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
In 1917, the Census Bureau started using a plan by the American Medico-Psychological Association and the National Commission on Mental Hygiene to help gather statistics in mental hospitals. Like previous censuses, this wasn’t a system focused on classification for treatment purposes, rather the goal was to simply look at the prevalence of these illnesses.
Great changes came during World War II as the military developed treatments for soldiers. As veterans came home after witnessing horrific sights and some having experienced unspeakable torture, they experienced symptoms what we now know today is post-traumatic stress disorder (PTSD) including flash backs, feeling like they were reliving the events, avoiding things that reminded them of the war, trying to numb themselves emotionally (many with alcohol and drugs), problems with anger, or insomnia. I just read Unbroken: A World War II Story of Survival, Resilience and Redemption by Laura Hillenbrand which chronicle’s one man’s journey through these trials, wonderfully presents the issues with his, and other soldiers’, homecoming.
Then in 1952, the first DSM was published. Going through many revisions bringing us to the current DSM-IV and the soon to be DSM-V. For more on the history of the DSM visit the American Psychiatry Association website. For more information on the history of mental health and mental illness visit the second chapter of this Surgeon General’s report.
As these tools developed, the focus changed from prevalence to diagnosis and treatment. With these aids, health care professionals could more accurately and consistently diagnoses mental illness. With that in hand, they could help find treatments for these individuals.
How the DSM-IV currently works:
The DSM organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:
- Axis 1: Clinical disorders, including major mental disorders (such as depression, anxiety, bipolar, ADHD, autism spectrum disorders, eating disorders, schizophrenia), and learning disorders
- Axis 2: Personality disorders (paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, narcissistic personality disorder, histrionic personality disorder, obsessive-compulsive personality disorder, borderline personality disorder, and others) and intellectual disabilities
- Axis 3: Acute medical conditions and physical disorders (including brain injuries)
- Axis 4: Psychosocial and environmental factors contributing to the disorder
- Axis 5: Global Assessment of Functioning (a scale from 0 to 100 used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults)
Assessment on all of these axes should help a health care professional (doctor, therapist, psychiatrist) help diagnose mental health illness in order to find treatment so that they can live full and productive lives.
The New DSM-V:
In 1999, the National Institutes of Mental Health (NIMH) and the APA began discussion of the need to revise the DSM to expand the scientific basis for these diagnoses including their neurobiological roots. The new manual is expected in 2013.
The proposed changes will re-order the current 16 chapters which are based on underlying vulnerabilities as well as symptom characteristics. The current DSM-IV structure often results in many patients being diagnosed with multiple disorders within and across the axes and other disorders. The new DSM-V chapters will be arranged by general categories such as neurodevelopmental, emotional and physical, hopefully reflecting potential commonalities in causation within larger disorder groups.
Here are a few examples of changes:
- Obsessive-compulsive disorder (OCD) was thought to be an anxiety-driven disorder. But recent studies show that OCD and several related disorders involve distinct neurocircuits. Now they are listed separately.
- Research findings now link schizophrenia and schizotypal personality disorder into a schizophrenia spectrum. These disorders tend to aggregate within families.
- New categories for learning disorders are proposed along with a single diagnostic category for “autism spectrum disorders” incorporating the current diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified).
- Proposals also look to change the term “mental retardation” be changed to “intellectual disability.”
- Eliminating the current categories substance abuse and dependence, replacing them with the new category “addiction and related disorders.” This will include substance use disorders, with each drug identified in its own category. Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
- Proposed new suicide scales for adults and adolescents will help clinicians identify those individuals most at risk.
- New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa.
To find out more about the changes proposed and soon to be tested in the field go to www.dsm5.org.
I find many of these changes to be a great step forward – particularly in using our scientific understandings to help understand these ailments.
Criticism of DSM
To be sure, there are several criticisms that remain. The DSM forces labels and diagnoses on individuals with labels having both good and bad attributes. And as we know, we’ve gotten many of the labels wrong in the past. It also is an inexact science – there is no blood test for a mental health illness just yet. Then there are issues of cultural sensitivity and pharmaceutical involvement.
Labels help people find a sense of who they are or what is wrong with them and how to get help, but also come with stigma, brand someone with a name that may not reflect who they are, may be overused, and may be inaccurate. In the sense that we have names for things like depression, anxiety, schizophrenia, eating disorders, etc we can help people with common symptoms find solutions to issues that impede their ability to function mentally and physically in their every day lives. Understanding anorexia nervosa and finding treatments for the illness can mean life or death. Understanding schizophrenia means not shunning those who we think of as “crazy” or “insane” to the margins of society. No longer do we have to believe that people are possessed by demons or their issues are merely character flaws. There is real proof that these disorders exist and real ways to address them.
Yet, labels also come with stigma and discrimination. Being diagnosed with a personality disorder can be pretty damning. Misunderstandings of the disorders mean people act archaically as if these people are just insane and cannot be treated or get better. Once in your medical record, these diagnoses can follow you everywhere and even medical professionals will enter into discussions with their prior biases and judgments of what these disorders mean. This branding may not reflect who you are, but may be the best bet for the symptoms you are showing. Worse, you may only be seen as your diagnosis.
Being diagnosed with a mental illness can also come with ramifications for your future health. Though mental health parity laws which require insurance companies to cover mental health services to the same extent they do medical services, this isn’t really carried out in practice. Additionally, until pre-existing conditions are eliminated, getting health insurance when already diagnosed with a mental illness can be pretty hard if not impossible.
I would agree with many that these labels can be and often are used too much. I think that we do label children with diagnoses and put them on medicines that they don’t need. A lot of their behaviour is based on their age and it is our duty as adults to help them grow up healthy. Active children are a blessing. They don’t necessarily all have ADHD. I fear that parents are just not wanting to deal with the activity or annoyance kids may present and thus want to medicate them. To be fair, some children really do have mental health issues, just not as many as I think we diagnose. And the diagnoses we focus on like autism and ADHD leave out considering major mental health illnesses like post-traumatic stress disorder for children who experienced horrible events like abuse or even war (see my post on Orphans).
These diagnoses are also handed out quite easily. Prescribing medication is normal now. This goes hand in hand with pharmaceutical companies promoting their medications. Many of these are helpful and have proven effective for many with mental health illness. But they should not be the first option. Mental health illnesses should be treated with therapy first and perhaps medication in addition. Taking medication does not solve problems that may be underlying the illness or completely help you cope with the symptoms you have.
Finally, let us not forget that our labels can be wrong. The labels we have, as I said, are not completely accurate. Different clinicians can come up with different diagnoses using the DSM. Then what?
More so, we know that in the past we’ve “identified” many mental health illnesses that are in fact NOT illnesses. For instance, including homosexuality. Further, the diagnoses we’ve established don’t reflect cultural differences. And some are based on ancient notions. Hystrionic personality disorder is based on the idea of hysteria – a word literally meaning “wandering womb” with the Greeks applying it to excessive emotionality in women, thinking it was caused by a displaced uterus. The diagnosis is still gender biased.
The history of psychology and the DSM are fascinating and have huge impacts on our current health care and well-being. The DSM itself has many positive and negative attributes. Overall though, I think it is a good step in helping people with mental health illnesses get help. With the 5th edition of the DSM, hopefully we can make further progress in understanding mental health.
For further definitions of each mental health illness visit the NIMH website.