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Diagnostic and Statistical Manual of Mental Disorders☆
Diagnostic and Statistical Manual of Mental Disordersq V del Barrio, Universidad Nacional de Educación a Distancia, Madrid, Spain Ó 2017 Elsevier Inc. All rights reserved.
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Antecedents DSM-I (1952) DSM-II (1968) DSM-III Explicit Diagnostic Operational Criteria Inclusion of Five Diagnostic Axes DSM-III-R (1987) DSM-IV (1994) DSM-V Categorical Development of DSM Important Changes Critical Positions Further Reading
Glossary Axis A reference line in a coordinate system. Category Each division in a system of classification. Classification Grouping of elements according to classes. Code Number for disorders identification.
Mental disorder A clinically behavioral or psychological syndrome associated with stress or disability or with increased risk of suffering death, pain or an important loss of freedom. Syndrome A group of associated disease symptoms.
Antecedents Classification is both the process and the result of arranging individuals into groups formed on the basis of common characteristics. It is important in any science, but is usually a difficult task that raises a variety of problems (McGuire, 1973) for experts to deal with, including mixture (heterogeneity or homogeneity of a group), discrimination (between-group differences) and identification (assignment of an individual to a group). Historically, the first attempt to put the variety of psychological disorders into some kind of order was carried out by Greek physician Hippocrates (4th cent. BC); he coined the terms phrenesis, mania and melancholia, that were maintained by Galen in Rome (1st cent. AD). Much later, during the Renaissance, Barrough (1583) divided mental disorders into Mania, Melancholia and Dementia. The work was continued in Europe by German philosopher I. Kant in his Anthropologie, and Frenchman F. Pinel in his Nosologie Philosophique (1789), who divided mental disorders into maniadwith and without deliriumdmelancholia, dementia and idiocy. Sweden K. Linnaeus, better known for his classifications of plants and animals, also extended his work to the field of the human mind, employing such categories as: Ideales (delirium, amentia, mania, melancholia and vesania), Imaginnarii (hypochondria, phobia, somnambulism and vertigo) and Patheci (bulimia polydypsia, satyriasis and erotomania). At the end of the 19th century, German Emil Kraepelindoften considered the founder of modern scientific psychiatrydin his Lehrbuch der Psychiatrie [Handbook of Psychiatry] (1899), included a very influential classification. He aimed at identifying groups of patients through symptom clusters, that would define different syndromes. He attributed disorders to four organic roots: heredity, metabolic, endocrine, or due to brain disease. His categorization layed the basis for systems such as the first official APA classification, that included: Mental disorders by brain traumatism, Mental disorders by encephalopathy, Mental disorders by drugs, Mental disorders by infectious agents, Syphilis, Arteriosclerosis, Epilepsy, Schizophrenia, Manic-Depressive Psychosis, Psychopathy, Psychic reaction, Paranoia, Oligophrenia, and Other cases. Well in the 1960s, Neo-Kraepelinian psychiatrists wanted to improve the old classification, and men such as Spitzer, Endicott and Feighner began to prepare the building of a new American Psychiatric Classification.
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Change History: February 2016. V. del Barrio update the text, table and Further Reading section of this article.
Reference Module in Neuroscience and Biobehavioral Psychology
http://dx.doi.org/10.1016/B978-0-12-809324-5.05530-9
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While the roots of modern American classification are in Europe, it is true that the first official US classification was a census of mental disorders in 1840, with only two categories: idiocy and madness. Another important antecedent was the work of the Committee on Statistics of the American Psychiatric Association (1917), led by Dr. T. Salmon, which recorded mental disease statistics from the psychiatric services of hospitals. Its result was the Statistical Manual for the Use of Hospitals for Mental Disease (AMPA). A few years later, the New York Academy of Medicine organized a National Conference on Disease Nomenclature (1928), to unify the terminology and nosology used by practitioners; its Standard Classified Nomenclature of Diseases (1932; rev.ed., 1934), originally referred only to physical diseases, but a section on Diseases of the Psychobiological Unit was included later, and a 1951 edition was published for use in mental hospitals. All of these classifications were indebted with the Kraepelin’s system. The World War II brought so many diagnostic problems to military psychiatrists that they urged the construction of a Classification of Mental Problems. The psychological nomenclature was introduced in 1944 by the Navy Department, and by the Army Department in 1945. However, the existing Standard Nomenclature (1932) revealed itself inadequate to many situations, and the Armed Forces asked for a revision of the three systems in use. The result was the creation of the DSMs. In Europe, a parallel Movement of Mental Hygiene held its first meeting in Paris, in 1932. A European Classification would then unify psychiatric nomenclature, under the following categories: Congenital mental disorders, Endogenous Psychosis, Reaction Psychosis, Symptomatic Psychosis, Encephalopathies, Epilepsy and Toxicomany and Non-aliened. But the proposal was not well accepted by the mental health community. Today, there are two best known categorical classifications of mental disorders: the International Classification of Diseases (ICD), and the Diagnostic and Statistical Manual of Mental Disorders (DSM) from the USA. ICD, created in Europe, has been promoted by the World Health Organization (WHO) since 1900, but its original version included only physical diseases. DSM, published by the American Psychiatric Association since 1952, focuses on mental disorders. Both attempt to classify the same behaviors, and coincide to a large extent each other, but not without some important differences. The first ICD versions included only physical disorders (see Table 1); but ICD-6 (1948) finally incorporated mental diseases, so approaching to the 1952 DSM-I. This was also the case for 1967 ICD-8 and 1968 DSM-II, but the APA’s decision to develop the DSM-III generated new tensions solved through further communication.; the DSM-IV and ICD-10 re-established close relationship between WHO and the APA was recovered.
DSM-I (1952) The Diagnostic and Statistical Manual of Mental Disorders was first published (DSM-I) in 1952. Influenced by its European antecedents, and by the views of A. Meyer (a biologically oriented psychiatrist) and K. Menninger (a psychoanalytically oriented one), it took into account not only biological but also social and psychological elements, and offered a multidimensional consideration of disorders. The process of developing the manual involved the collaboration of the National Institute of Mental Health (NIMH) and Table 1
Year 1900 1910 1920 1929 1938 1948 1952 1955 1966 1967 1968 1975 1978 1980 1987 1992 1994 1996 1998 2000 2013
Relationship over time between the DSM and the ICD DSM diagnostic and statistical manual (APA) USA
ICD international classification of diseases (WHO) Europe ICD-1* ICD-2* ICD-3* ICD-4* ICD-5* ICD-6
DSM-I ICD-7 ICD-8 DSM-II ICD-9 ICD-9-CM DSM-III DSM-III-R ICD-10 DSM-IV ICD-10 children DSM-IV-R DSM-IV-TR DSM-V
Note: *ICD with only physical diseases.
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of different psychiatrists and military professionals. Mental disorders were here divided into disorders, (1) with psychotic reaction; (2) with neurotic reaction, and (3) with behavioral reaction. Its impact was quite limited. Smith and Fonda (1952), in a study using the DSM-I criteria found that inter-raters agreement was high for organic psychosis, melancholia and schizophrenia, but it was lower in many other categories. Other criticisms were presented by other studies. For instance, the omission of criteria was criticized by H.J. Eysenck (1952) and R.B. Cattell (1957); in their views, common nomenclature in itself would not improve clinical diagnosis, because clinicians would understand differently under the same labels. On the other hand, P.E. Meehl (1965) questioned the reliability of clinical judgment, and L. Cronbach and Meehl (1955) drew attention to the urgent need for accuracy in diagnostic identification. The appearance of the ICD-7 highlighted some differences between the WHO’s and APA’s classification. At the time, DSM-I categories were adopted for a computer program built for assessment tasks (Spitzer and Endicott’s DIAGNO, 1968), that generated some problems of application. The need to improve this system was evident. Endicott, Guze, Klein, Robins and Winokur assumed the task of reviewing and improving the manual.
DSM-II (1968) It was published as the American National Glossary to the ICD-8. An APA committee, with the help of some experts, carried out an in-depth revision of its first version. Meyer’s previous influence was drastically reduced, while larger room was given to psychoanalytical and Kraepelinian ideas, in order to improve its acceptance by clinicians. It was based on the medical illness model of different syndromes formed by clinical symptom clusters. Many unsuccessful attempts to coordinate the DSM and ICD systems took place, but in the end the differences increased both in diagnoses and in terminology. For instance, DSM-II appeared with 39 more diagnoses than ICD-8 10/3; concerning terminology, terms associated with a certain theoretical framework (such as “Schizophrenic reaction,” for Schizophrenia) were avoided, though others, such as “neuroses” or “psychophysiological disorders,” remained. DSM-II has been frequently referred to as “old wine in a new bottle,” since Meyer’ and Kraepelin’ influences were still present, but many of the new research perspectives were absent. One year after its publication, Jackson (1969) qualified it as a hotchpotch of different bases of classification. Also the studies on schizophrenia diagnosis in various countries (Cooper et al., 1972; Kennedy et al., 1974), greatly stimulated the revision tasks. Redoubled efforts were then applied to clarify basic diagnosis criteria, and then the way was free to face the construction of a new DSM-III.
DSM-III Criticism of the previous editions had remarked the lack of an organizing criterion and the mixture of categories (Spitzer and Wilson, 1975). Efforts to improve the instrument culminated in the publication of the DSM-III (1980). A Task Force, chaired by R. Spitzer, with international cooperation, and participation of N. Andreasen, J. Endicott, D.F. Klein, M. Kramer, Th. Millon, H. Pinsker, G. Saslow and R. Woodruff, prepared the work. New members were added subsequently. A large conference at St. Louis (1976) prepared a draft; many institutions were recruited, including the Academy of Psychiatry and the Law, the American Academy of Child Psychiatry, the American Academy of Psychoanalysis, the American Association of Chairmen of Departments of Psychiatry, the American College Health Association, the American Orthopsychiatry Association and the American Psychological Association. Some misunderstandings between the American Psychological Association and the American Psychoanalytical Association, were eventually solved. All of them tried: (1) to expand the classification to maximize its utility for the outpatient population, (2) to differentiate levels of severity and cause within syndromes, (3) to maintain compatibility with the ICD-9, (4) to establish diagnostic criteria on empirical bases, and (5) to evaluate concerns and criticisms submitted by professional and patient representatives (Millon, 1996). In the following time (1977–79), drafts were sent to experts and practitioners, for study and suggestions in order to determine the necessary modifications to be incorporated. The major characteristics of the DSM-III are (1) some operational or explicit criteria for assigning patients to diagnostic categories, and (2) the implementation of a multiaxial framework.
Explicit Diagnostic Operational Criteria Diagnostic criteria make explicit the signs and symptoms required for a certain diagnosis; they had been empirically validated. Criteria are not only descriptive, but also phenomenological and behavioral. They would permit greater effectiveness and reliability in diagnoses. It was also included for each disorder its description, the usual age at which it begins, mean duration, prognosis, rates by sex and risk factors. Criteria for Axes I and II are basically the same as the Feighner Criteria (Feighner et al., 1972), based only on disorder definitions, as in the DSM-I and DSM-II. Such criteria were used when creating the Research Diagnostic Criteria (Spitzer et al., 1975; Endicott and Spitzer, 1978), which included 23 disorders (schizophrenia, schizoaffective disorder-manic, schizoaffective disorder-depressed, depressive syndrome
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superimposed on residual schizophrenia, manic disorder, hypomanic disorder, bipolar with mania, bipolar with hypomania, major depressive disorder, minor depressive disorder, intermittent depressive disorder, panic disorder, generalized anxiety disorder, cyclothymic personality, labile personality, Briquet’s disorder, antisocial personality, alcoholism, drug-use disorder, obsessivecompulsive disorder, phobic disorder, unspecified functional psychosis, and other psychiatric disorders). An operative description of clinical disorders was included, employed in Axes I and II of the DSM-III to differentiate between syndromes. Unlike the biological classifications, DSM-III criteria are polythetic (patients do not need to have all the characteristics in order to be included in a category) and intensional (patient’s characteristics are listed).
Inclusion of Five Diagnostic Axes As a novelty, five diagnostic axes were added, in order to obtain greater sensitivity and accuracy in diagnoses and treatments, and room for considerations on the psychosocial aspects. The idea of such axes was introduced by Essen, Möller and Wohlfahrt (in Sweden, in 1947). They proposed to separate the syndromes from all etiological conceptions, creating two principal axes (“Phenomenological” and “Etiological”) plus three others (for “Temporality,” “Social functioning” and “Others.”). After two decades, Rutter et al. (1969), in the UK, also constructed another multiaxial classification system for children (with axes for: Clinical Syndromes, Delay of Development, Mental Retardation, Medical Condition and Psychosocial Situation); other multiaxial systems were proposed in the UK by Wing (1970); in Germany, by Helmchen (1975), and in USA by Strauss. This formula was first applied to the APA’s DSM-III (1980) and to the WHO’s ICD (1992). Axes were assigned as follows: Axis I, to clinical syndromes; Axis II, (with two sections), to child maturational problems and to adult personality disorders; Axis III considers physically-rooted problems; Axis IV relates to the intensity and severity of psychological stressors; and Axis V, to the patient’s level of adaptive functioning in the past year, objectively evaluated. Axes II, IV and V link the syndromes with environmental determinants, and reflect a shifting toward more psychological conceptions. In fact, DSM-III constitutes a true treatise on psychopathology (including differential diagnosis, etiology, treatment, prognosis and management). DSM-III, although atheoretical in principle, maintained a biologic interpretation of the field. While praised for its achievements, it was also criticized for including both essential and inessential characteristics of disorders, and for keeping a too high number of diagnostic categories (265); psychoanalysts also missed in it an axis that took into account defense mechanisms and ego functions. The replacement of the term “neuroses” by the term “anxiety disorders,” has also been viewed as placing psychoanalysis at a greater distance. DSM-III produced the greatest change in this evolution. It was both a quantitative one (395 syndromes, instead of 104; 500 pages, instead of 132) , and also a qualitative one: since 1980 on the corpus of categories remains practically constant, mostly after the axes system was adopted. DSM-III made some important progress, in relation to aspects such as reliability, intracategory coherence and differentiation, validity, and behavioral data (Haynes and O’Brien, 1988). It also favored the building of new assessment instruments, based on its criteria (e.g., self-rating questionnaires, semi-structured interviews, and so on). All these innovations and improvements did not prevent the need for further revisions, and brought with it the creation of a DSM-III-R.
DSM-III-R (1987) It appeared in 1987, as the final result of revisions carried out by a Work Group headed by Spitzer. Innovations here included the reorganization of categories, some improvements in Axes IV (on psychosocial stress) and V (inclusion of the Global Assessment of Relational Functioning (GARF) scale), and the incorporation of aspects related to drug abuse, homosexuality (now included in unspecified sexual disorders), hyperactivity and a reorganization of affective disorders. This version had a dramatic impact, spreading all over the worldþ and becoming more commonly used than the ICD even in Europe.
DSM-IV (1994) A Task Force, led by Allen Frances and collaborating many individuals and scientific groups from all over the world, prepared this new version. The common goal was to improve its cultural sensitivity and its ICD compatibility with the ICD (Widiger et al., 1994). Some traits of the new instrument are: (1) brevity of criteria set; (2) clarity of language; (3) explicit statements of its constructs; (3) an up-to-date collection of empirical data serving as its basis (Spitzer et al., 1994); (4) fair coordination with the ICD-10. The DSM-IV also presents a series of changes with respect to its predecessor. Categories like “organic mental disorders” disappeared, while others like “eating disorders,” “delirium,” “dementia” and “amnesic and other cognitive disorders,” and some severe developmental disorders (Rett’s Syndrome, Asperger’s Syndrome) were incorporated; finally, child and sexual disorders were rebuilt. In the multiaxial system, the changes occurred in Axis IV, which includes a larger number of stress-generating events, and Axis V, in which other scales are added for determining level of adaptation: the Social and Occupational Functioning Assessment Scale (SOFAS) and the Global Assessment of Relational Functioning (GARF) scale.
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It raised many criticism, rather coincidental, and in the end, a certain consensus was reached. A few years later, an APA team led by A. Frances, that integrated many psychologists, resolved all the doubts and produced a new modified version, the DSM-IV-TR (2000). In it, a new dimensional point of view was included, in which empirical research data would be considered in the task of producing diagnostic decisions.
DSM-V DSM V appeared in May 2013. Its realization, began in 2006, when the APA asked D.J. Kupper to create a Task Force for the revision of DSM IV, the result being, a team of 33 experts led by D.J. Kupper and D.A. Regier, also 17 researchers who provided empirical data, that founded the review. This process, lasted for 7 years. One of the novelties, was the renewal of the definition of “mental disorder.” “A mental disorder, is a syndrome characterized, by a clinical disturbance, significant cognition, emotional regulation or conduct, which reflects a dysfunction in the psychological, biological processes or development, underlying mental functioning” (APA, 2013, 20). In it, are taken into account the new knowledge gained in cognitive and psycho neurological research. There are other changes, of different types (Sandín et al., 2016). Some of them have joined together different disorders such as schizophrenia and other psychotic disorders; Asperger’s syndrome has also been joined with autism. Other changes, on the other hand, have consisted of separating previously united disorders, such us Anxiety and Obsessive Compulsive Disorders. Other minor changes, have introduce small variations in the syndrome names, as in the case of Sleep Disorders, now called Sleep-Wake Disorders, in a desire for accuracy. It also has added some new forms of disorders, like Adjustment and neurocognitive Disorders, and has eradicated others, like Factitious Disorders. One of the most important changes, was that the APA eliminated the long standing multiaxial system of mental disorders classification. The disappearance of the five diagnostic axes has been justified by pragmatic reasons; it has been accompanied by the introduction of a section DSM-II, where there is dimensional measuring of symptoms intensity (mild, moderate and severe); severity is based on social communication impairments, and restrictive, repetitive behavior patterns on three levels: (1) requiring support; (2) requiring substantial support, and (3) requiring very substantial support. Also some cultural criteria that helps the task of diagnosis have been included. A significant enhancement has been the renewal of the prevalence data of disorders on the grounds of recent research. After all, a great homogeneity with previous editions of the manual have been maintained here. Since its appearance, strong criticism has arisen between its advocates and detractors (Carpintero, 2015). Most of the critique has come from the former team of DSM-IV, and Allen Frances, its main editor, has made the following objections: (1) their ambition to achieve a “paradigm shift”; (2) the failure to provide clear methodological guidelines; (3) the lack of openness to critiques; (4) the inability to spot the dangers of their proposals. The scenario being, time pressure, will also lead, to an undeliverable rush of last minute decisions, overloading the system.
Categorical Development of DSM Important Changes Over time, DSM categories have undergone significant changes. While in 1952 there were 2 main categories, there were 17 in 2000; this is even more evident in the case of subcategories Table 2. Each diagnostic category is identified by a numerical code. The current DSM codes the different disorders with its own code and also with that of the ICD, making it possible to compare and contrast diagnoses made with these two different categorical systems, thus facilitating communication between them.
Critical Positions DSM classification system has raised various criticisms rooted in different theoretical points of view. Anti-psychiatry defendants have always been against the use of classifications in psychiatry (Szasz, 1966); they consider labeling a really dangerous procedure. Among psychologists, a famous case has been that of Eysenck, who spoke of the fundamental weakness of any scheme “based on democratic voting procedures rather than on scientific evidence” (Eysenck et al., 1983). Other critical positions refer to: (1) the cultural biases of all classification systems; (2) its extreme individualism: only individual diagnosis is taken into account; (3) the influence upon it of old fashioned medical classifications, despite modern developments in Psychology and Psychiatry; and (4) the “softness” of these categories, built through descriptions without explanation, despite the crucial importance of the later one. However, in spite of such criticisms, categorical classifications have made possible comparisons and inferences that pushed forward the clinical knowledge. Despite all their imperfections, they have made an enormous contribution in favor of diagnostic reliability and of common understanding among mental health professionals.
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Evolution of DSM categories
DSM-I 1952
DSM-II 1968
DSM-III 1980
DSM-III-R 1987
DSM-IV 1994
DSM-IV-TR 2000
DSM-V 2013
B Mental Deficiency (6)
I-Mental Retardation (6 diagnoses) Disorders usually first evident Disorders usually first Transient and situational I X- Behavioral Disorders of in infancy and adolescence diagnosed in infancy and personality disorders (6) childhood and adolescence (7) (45 diagnoses) adolescence (46) Delirium, Dementia (1)
A-Organogenic II A-Psychoses associated Disorders with organic brain 1-Acute brain disorders.(13 syndrome (40 d) diagnoses) II-B Non-psychotic organic 2-Chronic brain disorders brain syndrome (25)
C-1- Psychotic disorders (16)
C-3-Psychoneurotic Disorders (7)
Neurodevelopmental Disorders Disorders usually first Disorders usually first (26) diagnosed in infancy and diagnosed in infancy and adolescence(42) adolescence (46) Delirium, Dementia, and Delirium, Dementia, and Amnesic and other Cognitive Amnesic and other Cognitive Disorders (17) Disorders (33) Organic Mental Disorders (58 Mental Disorders due to Mental Disorders due to Mental Disorders due to diagnoses) a General Medical condition a General Medical condition a General Medical condition not elsewhere classified (61) not elsewhere classified (3) not elsewhere classified (3)
Substance use disorders (119) Substance-related disorders Substance-related disorders (22) (133) III-Psychoses not attributed to Schizophrenic Disorders (5 Schizophrenia Disorders (5) Schizophrenia and other physical conditions listed diagnoses) Psychotic Disorders (16) previously (24) Paranoid Disorders Other Psychotic Disorders (5) Other Psychotic Disorders (8)
IV-Neuroses (11)
C-2-Psychophysiologic VI-Psychophysio-logical Autonomic and visceral Disorders (10) Disorders (10)
Affective disorders (9)
Mood Disorders (9)
Anxiety Disorders (10)
Anxiety Disorders (9)
Psychological factors affecting physical condition (1) Somatoform Disorders (5) Somatoform Disorders (7)
Factitious disorders (3) Dissociative Disorders (5) Psychosexual Disorders (22)
Factitious disorders (3) Dissociative Disorders (5) Sexual Disorders (20)
Mood Disorders (16) Anxiety Disorders (12)
Substance-related disorders (120) Schizophrenia and other Psychotic Disorders (8)
Substance related and addictive disorders (71) Schizophrenia Spectrum and other Psychotic Disorders (14)
Mood Disorders (15)
Depressive Disorders. (20) Bipolar Disorders (23)
Anxiety Disorders (11)
Anxiety Disorders (10)
Somatoform Disorders (10)
Somatoform Disorders (7)
Factitious disorders (2) Dissociative Disorders (5) Sexual and Gender identity Disorders (31)
Factitious disorders (2) Dissociative Disorders (5) Sexual and Gender identity Disorders (29)
Obsessive and compulsive (8) Trauma and stressor related disorders (12) Somatic Symptom and Related Disorders (7)
Dissociative Disorders (7) Sexual Dysfunctions (9) Gender Dysphoria (4)
Diagnostic and Statistical Manual of Mental Disorders
Table 2
VII-Special symptoms (10)
Eating Disorders (3)
Eating Disorders(3)
Sleep Disorders (13) Disorders of Impulse-Control Impulse-Control Disorders (6) Impulse-Control Disorders not Impulse-Control Disorders(6) not elsewhere classified (6) elsewhere classified (6)
C-4-Personality Disorders (17)
VIII-Transient situational disturbances (5) V-Personality Disorders (33)
X-Condition without manifest Psychiatric disorders and non-specific conditions
Sleep Disorders (12)
Sleep Disorders (17)
Adjustment Disorders (8)
Adjustment Disorders (9)
Adjustment Disorders (6)
Adjustment Disorders (1)
Personality Disorders (12 diagnoses)
Personality Disorders (12)
Personality Disorders (11)
Personality Disorders (11)
V Codes for conditions not Other Other Other attributable to mental Conditions that may be focus in Conditions that may be focus in Conditions that may be disorders clinical attention (9) clinical attention (32) focus in clinical attention that are a focus of attention or (36) treatment
Feeding and Eating Disorders(8) Elimination Disorders (6) Sleep-Wake Disorders (31) Disruptive Impulse-Control Disorders(10) Neurocognitive Disorders (44)
Personality Disorders (13) Paraphilic Disorder (10) Other Mental Disorders (4) Other Conditions that may be focus in clinical attention (45) Medication Induced Movement Disorders and other adverse effects of Medication (16)
XI-Non diagnostic term for administrative use
146
Additional codes 216
Additional codes (5) 376
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No. of syndromes 90
Other Psychological Factors affecting physical condition (1) Additional codes Additional codes 242 368
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Each new edition of the classification system has tried to offer a new and more accurated instrument for evaluating and making diagnostic, according to more refined criteria, a fact that has not prevented the raising of new critiques, a necessary step in a process of continuous improvement. Recently, new ways of studying mental disorders have been introduced, that represent a critical position to DSM (Insel, 2013). Closely related to the trans-diagnostic point of view the US National Institute of Mental Health (NIMH, RMoC) with meetings from 2010 until 2012 starts the work. These meetings demonstrate the type of formative conversations that laid the foundation for each of the five domains that comprise: Negative and, Positive valence systems, Cognitions, Social processes, and Arousal and Regulation systems They practically cover the whole range of behavior types, when seen from a neuroscientific point of view. RDoC: has launched a project that tries to substitute diagnosis by a series of organized data in various matrices, that integrate a plurality of levels of information (genes, molecules, cells, circuits, physiology, behavior, self-report and paradigms) in order to get a better understanding of the basic functional dimensions that underlie the full range of both normal and abnormal human behavior. . From this perspective, mental disorders are analyzed along these dimensions or domains, and instead of looking for a “category” o label that could be applied to a certain individual, a cluster of analytical, data will represent its peculiar mental state. At least 137 units have been differentiated in behavior, and the sum of abnormalities that could be found in a single case would determine its final evaluation, and would indicate the lines along which the study might follow. The RDoC then, is not a substitute of DSM, but an instrument that offers an alternative interpretation of the studied disorder, and a guide for further research. Criticism is always needed to promote the creation of more homogeneous and accurate assessment instruments that will constitute the source of future progress in the field.
Further Reading American Psychiatric Association (APA), 1952. Diagnostic and Statistical Manual of Mental Disorders, first ed. APA, Washington, DC www.turcopsikiyatri.org/arsiv/dsm-1952.pdf. American Psychiatric Association (APA), 1968. Diagnostic and Statistical Manual of Mental Disorders, second ed. APA, Washington, DC www.terapiacognitiva.eu/dwl/dsm5/DSMII.pdf. American Psychiatric Association (APA), 1980. Diagnostic and Statistical Manual of Mental Disorders, third ed. APA, Washington, DC. American Psychiatric Association (APA), 1987. Diagnostic and Statistical Manual of Mental Disorders, third ed., revised. APA, Washington, DC. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, DSM-4 TM. American Psychiatric Association, Washington. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, DSM-5. American Psychiatric Association, Arlington, VA. Carpintero, H., 2015. Una nueva Mirada a la psicopatología. El DSM-V y su significación histórica. An. Real Acad. Ciencias Morales Políticas 92, 389–426. Cronbach, L.J., Meehl, P.E., 1955. Construct validity in psychological tests. Psychol. Bull. 529, 281–302. Eron, L.D., 1966. Classification of Behavior Disorders. Aldine- Atherton, Chicago. Feighner, J.P., Robins, E., Guze, S.B., Woodruff, R.A., Winokur, G., Muñoz, R., 1972. Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26, 57–63. Frances, A.J., Widiger, T., 2012. Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Ann. Rev. Clin. Psychol. 8, 109–130. Frances, A.J., May 11, 2012. Diagnosing the D.S.M. New York Times (opinion). Haynes, S.N., O’Brien, W.H., 1988. The Gordian knot of DSM-III use: interacting principles of behavioral classification and complex causal models. Behav. Assess. 10, 95–105. Insel, T., 2013. Transforming Diagnosis, en Director’s Blog, NIHM Web Page. Blog April 29, 2013. www.nimh.nih.gov/about/director/2013/transforming.diagnosis.shtml. Kraepelin, E., 1899. Lehrbuch. Berlin. Millon, Th, 1996. The DSM-III: some historical and substantive reflections. In: Millon, T.H. (Ed.), Personality Psychopathol. John Wiley & Sons, New York. Sandin, B., Chorot, P., Valiente, R., 2016. DSM, 5 Cambios en la clasificación de los trastornos mentales. UNED, Madrid. Schmith, H.O., Fonda, C., 1952. The reliability of psychiatry diagnosis. J. Abnorm. Soc. Psychol. 52, 262–267. Spitzer, R.L., Endicott, J., Robins, E., 1975. Research Diagnostic Criteria (RDC). N.Y. State Psychiatric Institute, New York. Spitzer, R.L., Willson, P.T., 1975. Nosology and the Official Psychiatry Nomenclature. In: Freeman, A.M., Kaplan, H.I., Sadock, B.J. (Eds.), Compressive Textbook of Psychiatry, vol. II. Williams and Wilkins, Baltimore. Spitzer, R.L., Gibbson, M., Skoldol, A.E., Williams, J., First, M.B., 1994. DSM-IV Casebook: A Learning Comparison to the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Press, Washington. Szasz, T., 1966. The psychiatry classification of behavior: a strategy of personal constraint. In: Eron, L.D. (Ed.), The Classification of Behavior Disorders. Aldine, Chicago, pp. 123–170. Widiger, T.A., Frances, A.J., Pincus, H.A., First, M.B., Ross, R., Davis, W., 1994. DSM-IV Sourcebook. APA, Washington, DC.
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Antecedents DSM-I (1952) DSM-II (1968) DSM-III Explicit Diagnostic Operational Criteria Inclusion of Five Diagnostic Axes DSM-III-R (1987) DSM-IV (1994) DSM-V Categorical Development of DSM Important Changes Critical Positions Further Reading
Glossary Axis A reference line in a coordinate system. Category Each division in a system of classification. Classification Grouping of elements according to classes. Code Number for disorders identification.
Mental disorder A clinically behavioral or psychological syndrome associated with stress or disability or with increased risk of suffering death, pain or an important loss of freedom. Syndrome A group of associated disease symptoms.
Antecedents Classification is both the process and the result of arranging individuals into groups formed on the basis of common characteristics. It is important in any science, but is usually a difficult task that raises a variety of problems (McGuire, 1973) for experts to deal with, including mixture (heterogeneity or homogeneity of a group), discrimination (between-group differences) and identification (assignment of an individual to a group). Historically, the first attempt to put the variety of psychological disorders into some kind of order was carried out by Greek physician Hippocrates (4th cent. BC); he coined the terms phrenesis, mania and melancholia, that were maintained by Galen in Rome (1st cent. AD). Much later, during the Renaissance, Barrough (1583) divided mental disorders into Mania, Melancholia and Dementia. The work was continued in Europe by German philosopher I. Kant in his Anthropologie, and Frenchman F. Pinel in his Nosologie Philosophique (1789), who divided mental disorders into maniadwith and without deliriumdmelancholia, dementia and idiocy. Sweden K. Linnaeus, better known for his classifications of plants and animals, also extended his work to the field of the human mind, employing such categories as: Ideales (delirium, amentia, mania, melancholia and vesania), Imaginnarii (hypochondria, phobia, somnambulism and vertigo) and Patheci (bulimia polydypsia, satyriasis and erotomania). At the end of the 19th century, German Emil Kraepelindoften considered the founder of modern scientific psychiatrydin his Lehrbuch der Psychiatrie [Handbook of Psychiatry] (1899), included a very influential classification. He aimed at identifying groups of patients through symptom clusters, that would define different syndromes. He attributed disorders to four organic roots: heredity, metabolic, endocrine, or due to brain disease. His categorization layed the basis for systems such as the first official APA classification, that included: Mental disorders by brain traumatism, Mental disorders by encephalopathy, Mental disorders by drugs, Mental disorders by infectious agents, Syphilis, Arteriosclerosis, Epilepsy, Schizophrenia, Manic-Depressive Psychosis, Psychopathy, Psychic reaction, Paranoia, Oligophrenia, and Other cases. Well in the 1960s, Neo-Kraepelinian psychiatrists wanted to improve the old classification, and men such as Spitzer, Endicott and Feighner began to prepare the building of a new American Psychiatric Classification.
q
Change History: February 2016. V. del Barrio update the text, table and Further Reading section of this article.
Reference Module in Neuroscience and Biobehavioral Psychology
http://dx.doi.org/10.1016/B978-0-12-809324-5.05530-9
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While the roots of modern American classification are in Europe, it is true that the first official US classification was a census of mental disorders in 1840, with only two categories: idiocy and madness. Another important antecedent was the work of the Committee on Statistics of the American Psychiatric Association (1917), led by Dr. T. Salmon, which recorded mental disease statistics from the psychiatric services of hospitals. Its result was the Statistical Manual for the Use of Hospitals for Mental Disease (AMPA). A few years later, the New York Academy of Medicine organized a National Conference on Disease Nomenclature (1928), to unify the terminology and nosology used by practitioners; its Standard Classified Nomenclature of Diseases (1932; rev.ed., 1934), originally referred only to physical diseases, but a section on Diseases of the Psychobiological Unit was included later, and a 1951 edition was published for use in mental hospitals. All of these classifications were indebted with the Kraepelin’s system. The World War II brought so many diagnostic problems to military psychiatrists that they urged the construction of a Classification of Mental Problems. The psychological nomenclature was introduced in 1944 by the Navy Department, and by the Army Department in 1945. However, the existing Standard Nomenclature (1932) revealed itself inadequate to many situations, and the Armed Forces asked for a revision of the three systems in use. The result was the creation of the DSMs. In Europe, a parallel Movement of Mental Hygiene held its first meeting in Paris, in 1932. A European Classification would then unify psychiatric nomenclature, under the following categories: Congenital mental disorders, Endogenous Psychosis, Reaction Psychosis, Symptomatic Psychosis, Encephalopathies, Epilepsy and Toxicomany and Non-aliened. But the proposal was not well accepted by the mental health community. Today, there are two best known categorical classifications of mental disorders: the International Classification of Diseases (ICD), and the Diagnostic and Statistical Manual of Mental Disorders (DSM) from the USA. ICD, created in Europe, has been promoted by the World Health Organization (WHO) since 1900, but its original version included only physical diseases. DSM, published by the American Psychiatric Association since 1952, focuses on mental disorders. Both attempt to classify the same behaviors, and coincide to a large extent each other, but not without some important differences. The first ICD versions included only physical disorders (see Table 1); but ICD-6 (1948) finally incorporated mental diseases, so approaching to the 1952 DSM-I. This was also the case for 1967 ICD-8 and 1968 DSM-II, but the APA’s decision to develop the DSM-III generated new tensions solved through further communication.; the DSM-IV and ICD-10 re-established close relationship between WHO and the APA was recovered.
DSM-I (1952) The Diagnostic and Statistical Manual of Mental Disorders was first published (DSM-I) in 1952. Influenced by its European antecedents, and by the views of A. Meyer (a biologically oriented psychiatrist) and K. Menninger (a psychoanalytically oriented one), it took into account not only biological but also social and psychological elements, and offered a multidimensional consideration of disorders. The process of developing the manual involved the collaboration of the National Institute of Mental Health (NIMH) and Table 1
Year 1900 1910 1920 1929 1938 1948 1952 1955 1966 1967 1968 1975 1978 1980 1987 1992 1994 1996 1998 2000 2013
Relationship over time between the DSM and the ICD DSM diagnostic and statistical manual (APA) USA
ICD international classification of diseases (WHO) Europe ICD-1* ICD-2* ICD-3* ICD-4* ICD-5* ICD-6
DSM-I ICD-7 ICD-8 DSM-II ICD-9 ICD-9-CM DSM-III DSM-III-R ICD-10 DSM-IV ICD-10 children DSM-IV-R DSM-IV-TR DSM-V
Note: *ICD with only physical diseases.
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of different psychiatrists and military professionals. Mental disorders were here divided into disorders, (1) with psychotic reaction; (2) with neurotic reaction, and (3) with behavioral reaction. Its impact was quite limited. Smith and Fonda (1952), in a study using the DSM-I criteria found that inter-raters agreement was high for organic psychosis, melancholia and schizophrenia, but it was lower in many other categories. Other criticisms were presented by other studies. For instance, the omission of criteria was criticized by H.J. Eysenck (1952) and R.B. Cattell (1957); in their views, common nomenclature in itself would not improve clinical diagnosis, because clinicians would understand differently under the same labels. On the other hand, P.E. Meehl (1965) questioned the reliability of clinical judgment, and L. Cronbach and Meehl (1955) drew attention to the urgent need for accuracy in diagnostic identification. The appearance of the ICD-7 highlighted some differences between the WHO’s and APA’s classification. At the time, DSM-I categories were adopted for a computer program built for assessment tasks (Spitzer and Endicott’s DIAGNO, 1968), that generated some problems of application. The need to improve this system was evident. Endicott, Guze, Klein, Robins and Winokur assumed the task of reviewing and improving the manual.
DSM-II (1968) It was published as the American National Glossary to the ICD-8. An APA committee, with the help of some experts, carried out an in-depth revision of its first version. Meyer’s previous influence was drastically reduced, while larger room was given to psychoanalytical and Kraepelinian ideas, in order to improve its acceptance by clinicians. It was based on the medical illness model of different syndromes formed by clinical symptom clusters. Many unsuccessful attempts to coordinate the DSM and ICD systems took place, but in the end the differences increased both in diagnoses and in terminology. For instance, DSM-II appeared with 39 more diagnoses than ICD-8 10/3; concerning terminology, terms associated with a certain theoretical framework (such as “Schizophrenic reaction,” for Schizophrenia) were avoided, though others, such as “neuroses” or “psychophysiological disorders,” remained. DSM-II has been frequently referred to as “old wine in a new bottle,” since Meyer’ and Kraepelin’ influences were still present, but many of the new research perspectives were absent. One year after its publication, Jackson (1969) qualified it as a hotchpotch of different bases of classification. Also the studies on schizophrenia diagnosis in various countries (Cooper et al., 1972; Kennedy et al., 1974), greatly stimulated the revision tasks. Redoubled efforts were then applied to clarify basic diagnosis criteria, and then the way was free to face the construction of a new DSM-III.
DSM-III Criticism of the previous editions had remarked the lack of an organizing criterion and the mixture of categories (Spitzer and Wilson, 1975). Efforts to improve the instrument culminated in the publication of the DSM-III (1980). A Task Force, chaired by R. Spitzer, with international cooperation, and participation of N. Andreasen, J. Endicott, D.F. Klein, M. Kramer, Th. Millon, H. Pinsker, G. Saslow and R. Woodruff, prepared the work. New members were added subsequently. A large conference at St. Louis (1976) prepared a draft; many institutions were recruited, including the Academy of Psychiatry and the Law, the American Academy of Child Psychiatry, the American Academy of Psychoanalysis, the American Association of Chairmen of Departments of Psychiatry, the American College Health Association, the American Orthopsychiatry Association and the American Psychological Association. Some misunderstandings between the American Psychological Association and the American Psychoanalytical Association, were eventually solved. All of them tried: (1) to expand the classification to maximize its utility for the outpatient population, (2) to differentiate levels of severity and cause within syndromes, (3) to maintain compatibility with the ICD-9, (4) to establish diagnostic criteria on empirical bases, and (5) to evaluate concerns and criticisms submitted by professional and patient representatives (Millon, 1996). In the following time (1977–79), drafts were sent to experts and practitioners, for study and suggestions in order to determine the necessary modifications to be incorporated. The major characteristics of the DSM-III are (1) some operational or explicit criteria for assigning patients to diagnostic categories, and (2) the implementation of a multiaxial framework.
Explicit Diagnostic Operational Criteria Diagnostic criteria make explicit the signs and symptoms required for a certain diagnosis; they had been empirically validated. Criteria are not only descriptive, but also phenomenological and behavioral. They would permit greater effectiveness and reliability in diagnoses. It was also included for each disorder its description, the usual age at which it begins, mean duration, prognosis, rates by sex and risk factors. Criteria for Axes I and II are basically the same as the Feighner Criteria (Feighner et al., 1972), based only on disorder definitions, as in the DSM-I and DSM-II. Such criteria were used when creating the Research Diagnostic Criteria (Spitzer et al., 1975; Endicott and Spitzer, 1978), which included 23 disorders (schizophrenia, schizoaffective disorder-manic, schizoaffective disorder-depressed, depressive syndrome
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superimposed on residual schizophrenia, manic disorder, hypomanic disorder, bipolar with mania, bipolar with hypomania, major depressive disorder, minor depressive disorder, intermittent depressive disorder, panic disorder, generalized anxiety disorder, cyclothymic personality, labile personality, Briquet’s disorder, antisocial personality, alcoholism, drug-use disorder, obsessivecompulsive disorder, phobic disorder, unspecified functional psychosis, and other psychiatric disorders). An operative description of clinical disorders was included, employed in Axes I and II of the DSM-III to differentiate between syndromes. Unlike the biological classifications, DSM-III criteria are polythetic (patients do not need to have all the characteristics in order to be included in a category) and intensional (patient’s characteristics are listed).
Inclusion of Five Diagnostic Axes As a novelty, five diagnostic axes were added, in order to obtain greater sensitivity and accuracy in diagnoses and treatments, and room for considerations on the psychosocial aspects. The idea of such axes was introduced by Essen, Möller and Wohlfahrt (in Sweden, in 1947). They proposed to separate the syndromes from all etiological conceptions, creating two principal axes (“Phenomenological” and “Etiological”) plus three others (for “Temporality,” “Social functioning” and “Others.”). After two decades, Rutter et al. (1969), in the UK, also constructed another multiaxial classification system for children (with axes for: Clinical Syndromes, Delay of Development, Mental Retardation, Medical Condition and Psychosocial Situation); other multiaxial systems were proposed in the UK by Wing (1970); in Germany, by Helmchen (1975), and in USA by Strauss. This formula was first applied to the APA’s DSM-III (1980) and to the WHO’s ICD (1992). Axes were assigned as follows: Axis I, to clinical syndromes; Axis II, (with two sections), to child maturational problems and to adult personality disorders; Axis III considers physically-rooted problems; Axis IV relates to the intensity and severity of psychological stressors; and Axis V, to the patient’s level of adaptive functioning in the past year, objectively evaluated. Axes II, IV and V link the syndromes with environmental determinants, and reflect a shifting toward more psychological conceptions. In fact, DSM-III constitutes a true treatise on psychopathology (including differential diagnosis, etiology, treatment, prognosis and management). DSM-III, although atheoretical in principle, maintained a biologic interpretation of the field. While praised for its achievements, it was also criticized for including both essential and inessential characteristics of disorders, and for keeping a too high number of diagnostic categories (265); psychoanalysts also missed in it an axis that took into account defense mechanisms and ego functions. The replacement of the term “neuroses” by the term “anxiety disorders,” has also been viewed as placing psychoanalysis at a greater distance. DSM-III produced the greatest change in this evolution. It was both a quantitative one (395 syndromes, instead of 104; 500 pages, instead of 132) , and also a qualitative one: since 1980 on the corpus of categories remains practically constant, mostly after the axes system was adopted. DSM-III made some important progress, in relation to aspects such as reliability, intracategory coherence and differentiation, validity, and behavioral data (Haynes and O’Brien, 1988). It also favored the building of new assessment instruments, based on its criteria (e.g., self-rating questionnaires, semi-structured interviews, and so on). All these innovations and improvements did not prevent the need for further revisions, and brought with it the creation of a DSM-III-R.
DSM-III-R (1987) It appeared in 1987, as the final result of revisions carried out by a Work Group headed by Spitzer. Innovations here included the reorganization of categories, some improvements in Axes IV (on psychosocial stress) and V (inclusion of the Global Assessment of Relational Functioning (GARF) scale), and the incorporation of aspects related to drug abuse, homosexuality (now included in unspecified sexual disorders), hyperactivity and a reorganization of affective disorders. This version had a dramatic impact, spreading all over the worldþ and becoming more commonly used than the ICD even in Europe.
DSM-IV (1994) A Task Force, led by Allen Frances and collaborating many individuals and scientific groups from all over the world, prepared this new version. The common goal was to improve its cultural sensitivity and its ICD compatibility with the ICD (Widiger et al., 1994). Some traits of the new instrument are: (1) brevity of criteria set; (2) clarity of language; (3) explicit statements of its constructs; (3) an up-to-date collection of empirical data serving as its basis (Spitzer et al., 1994); (4) fair coordination with the ICD-10. The DSM-IV also presents a series of changes with respect to its predecessor. Categories like “organic mental disorders” disappeared, while others like “eating disorders,” “delirium,” “dementia” and “amnesic and other cognitive disorders,” and some severe developmental disorders (Rett’s Syndrome, Asperger’s Syndrome) were incorporated; finally, child and sexual disorders were rebuilt. In the multiaxial system, the changes occurred in Axis IV, which includes a larger number of stress-generating events, and Axis V, in which other scales are added for determining level of adaptation: the Social and Occupational Functioning Assessment Scale (SOFAS) and the Global Assessment of Relational Functioning (GARF) scale.
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It raised many criticism, rather coincidental, and in the end, a certain consensus was reached. A few years later, an APA team led by A. Frances, that integrated many psychologists, resolved all the doubts and produced a new modified version, the DSM-IV-TR (2000). In it, a new dimensional point of view was included, in which empirical research data would be considered in the task of producing diagnostic decisions.
DSM-V DSM V appeared in May 2013. Its realization, began in 2006, when the APA asked D.J. Kupper to create a Task Force for the revision of DSM IV, the result being, a team of 33 experts led by D.J. Kupper and D.A. Regier, also 17 researchers who provided empirical data, that founded the review. This process, lasted for 7 years. One of the novelties, was the renewal of the definition of “mental disorder.” “A mental disorder, is a syndrome characterized, by a clinical disturbance, significant cognition, emotional regulation or conduct, which reflects a dysfunction in the psychological, biological processes or development, underlying mental functioning” (APA, 2013, 20). In it, are taken into account the new knowledge gained in cognitive and psycho neurological research. There are other changes, of different types (Sandín et al., 2016). Some of them have joined together different disorders such as schizophrenia and other psychotic disorders; Asperger’s syndrome has also been joined with autism. Other changes, on the other hand, have consisted of separating previously united disorders, such us Anxiety and Obsessive Compulsive Disorders. Other minor changes, have introduce small variations in the syndrome names, as in the case of Sleep Disorders, now called Sleep-Wake Disorders, in a desire for accuracy. It also has added some new forms of disorders, like Adjustment and neurocognitive Disorders, and has eradicated others, like Factitious Disorders. One of the most important changes, was that the APA eliminated the long standing multiaxial system of mental disorders classification. The disappearance of the five diagnostic axes has been justified by pragmatic reasons; it has been accompanied by the introduction of a section DSM-II, where there is dimensional measuring of symptoms intensity (mild, moderate and severe); severity is based on social communication impairments, and restrictive, repetitive behavior patterns on three levels: (1) requiring support; (2) requiring substantial support, and (3) requiring very substantial support. Also some cultural criteria that helps the task of diagnosis have been included. A significant enhancement has been the renewal of the prevalence data of disorders on the grounds of recent research. After all, a great homogeneity with previous editions of the manual have been maintained here. Since its appearance, strong criticism has arisen between its advocates and detractors (Carpintero, 2015). Most of the critique has come from the former team of DSM-IV, and Allen Frances, its main editor, has made the following objections: (1) their ambition to achieve a “paradigm shift”; (2) the failure to provide clear methodological guidelines; (3) the lack of openness to critiques; (4) the inability to spot the dangers of their proposals. The scenario being, time pressure, will also lead, to an undeliverable rush of last minute decisions, overloading the system.
Categorical Development of DSM Important Changes Over time, DSM categories have undergone significant changes. While in 1952 there were 2 main categories, there were 17 in 2000; this is even more evident in the case of subcategories Table 2. Each diagnostic category is identified by a numerical code. The current DSM codes the different disorders with its own code and also with that of the ICD, making it possible to compare and contrast diagnoses made with these two different categorical systems, thus facilitating communication between them.
Critical Positions DSM classification system has raised various criticisms rooted in different theoretical points of view. Anti-psychiatry defendants have always been against the use of classifications in psychiatry (Szasz, 1966); they consider labeling a really dangerous procedure. Among psychologists, a famous case has been that of Eysenck, who spoke of the fundamental weakness of any scheme “based on democratic voting procedures rather than on scientific evidence” (Eysenck et al., 1983). Other critical positions refer to: (1) the cultural biases of all classification systems; (2) its extreme individualism: only individual diagnosis is taken into account; (3) the influence upon it of old fashioned medical classifications, despite modern developments in Psychology and Psychiatry; and (4) the “softness” of these categories, built through descriptions without explanation, despite the crucial importance of the later one. However, in spite of such criticisms, categorical classifications have made possible comparisons and inferences that pushed forward the clinical knowledge. Despite all their imperfections, they have made an enormous contribution in favor of diagnostic reliability and of common understanding among mental health professionals.
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Evolution of DSM categories
DSM-I 1952
DSM-II 1968
DSM-III 1980
DSM-III-R 1987
DSM-IV 1994
DSM-IV-TR 2000
DSM-V 2013
B Mental Deficiency (6)
I-Mental Retardation (6 diagnoses) Disorders usually first evident Disorders usually first Transient and situational I X- Behavioral Disorders of in infancy and adolescence diagnosed in infancy and personality disorders (6) childhood and adolescence (7) (45 diagnoses) adolescence (46) Delirium, Dementia (1)
A-Organogenic II A-Psychoses associated Disorders with organic brain 1-Acute brain disorders.(13 syndrome (40 d) diagnoses) II-B Non-psychotic organic 2-Chronic brain disorders brain syndrome (25)
C-1- Psychotic disorders (16)
C-3-Psychoneurotic Disorders (7)
Neurodevelopmental Disorders Disorders usually first Disorders usually first (26) diagnosed in infancy and diagnosed in infancy and adolescence(42) adolescence (46) Delirium, Dementia, and Delirium, Dementia, and Amnesic and other Cognitive Amnesic and other Cognitive Disorders (17) Disorders (33) Organic Mental Disorders (58 Mental Disorders due to Mental Disorders due to Mental Disorders due to diagnoses) a General Medical condition a General Medical condition a General Medical condition not elsewhere classified (61) not elsewhere classified (3) not elsewhere classified (3)
Substance use disorders (119) Substance-related disorders Substance-related disorders (22) (133) III-Psychoses not attributed to Schizophrenic Disorders (5 Schizophrenia Disorders (5) Schizophrenia and other physical conditions listed diagnoses) Psychotic Disorders (16) previously (24) Paranoid Disorders Other Psychotic Disorders (5) Other Psychotic Disorders (8)
IV-Neuroses (11)
C-2-Psychophysiologic VI-Psychophysio-logical Autonomic and visceral Disorders (10) Disorders (10)
Affective disorders (9)
Mood Disorders (9)
Anxiety Disorders (10)
Anxiety Disorders (9)
Psychological factors affecting physical condition (1) Somatoform Disorders (5) Somatoform Disorders (7)
Factitious disorders (3) Dissociative Disorders (5) Psychosexual Disorders (22)
Factitious disorders (3) Dissociative Disorders (5) Sexual Disorders (20)
Mood Disorders (16) Anxiety Disorders (12)
Substance-related disorders (120) Schizophrenia and other Psychotic Disorders (8)
Substance related and addictive disorders (71) Schizophrenia Spectrum and other Psychotic Disorders (14)
Mood Disorders (15)
Depressive Disorders. (20) Bipolar Disorders (23)
Anxiety Disorders (11)
Anxiety Disorders (10)
Somatoform Disorders (10)
Somatoform Disorders (7)
Factitious disorders (2) Dissociative Disorders (5) Sexual and Gender identity Disorders (31)
Factitious disorders (2) Dissociative Disorders (5) Sexual and Gender identity Disorders (29)
Obsessive and compulsive (8) Trauma and stressor related disorders (12) Somatic Symptom and Related Disorders (7)
Dissociative Disorders (7) Sexual Dysfunctions (9) Gender Dysphoria (4)
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Table 2
VII-Special symptoms (10)
Eating Disorders (3)
Eating Disorders(3)
Sleep Disorders (13) Disorders of Impulse-Control Impulse-Control Disorders (6) Impulse-Control Disorders not Impulse-Control Disorders(6) not elsewhere classified (6) elsewhere classified (6)
C-4-Personality Disorders (17)
VIII-Transient situational disturbances (5) V-Personality Disorders (33)
X-Condition without manifest Psychiatric disorders and non-specific conditions
Sleep Disorders (12)
Sleep Disorders (17)
Adjustment Disorders (8)
Adjustment Disorders (9)
Adjustment Disorders (6)
Adjustment Disorders (1)
Personality Disorders (12 diagnoses)
Personality Disorders (12)
Personality Disorders (11)
Personality Disorders (11)
V Codes for conditions not Other Other Other attributable to mental Conditions that may be focus in Conditions that may be focus in Conditions that may be disorders clinical attention (9) clinical attention (32) focus in clinical attention that are a focus of attention or (36) treatment
Feeding and Eating Disorders(8) Elimination Disorders (6) Sleep-Wake Disorders (31) Disruptive Impulse-Control Disorders(10) Neurocognitive Disorders (44)
Personality Disorders (13) Paraphilic Disorder (10) Other Mental Disorders (4) Other Conditions that may be focus in clinical attention (45) Medication Induced Movement Disorders and other adverse effects of Medication (16)
XI-Non diagnostic term for administrative use
146
Additional codes 216
Additional codes (5) 376
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Diagnostic and Statistical Manual of Mental Disorders
No. of syndromes 90
Other Psychological Factors affecting physical condition (1) Additional codes Additional codes 242 368
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Each new edition of the classification system has tried to offer a new and more accurated instrument for evaluating and making diagnostic, according to more refined criteria, a fact that has not prevented the raising of new critiques, a necessary step in a process of continuous improvement. Recently, new ways of studying mental disorders have been introduced, that represent a critical position to DSM (Insel, 2013). Closely related to the trans-diagnostic point of view the US National Institute of Mental Health (NIMH, RMoC) with meetings from 2010 until 2012 starts the work. These meetings demonstrate the type of formative conversations that laid the foundation for each of the five domains that comprise: Negative and, Positive valence systems, Cognitions, Social processes, and Arousal and Regulation systems They practically cover the whole range of behavior types, when seen from a neuroscientific point of view. RDoC: has launched a project that tries to substitute diagnosis by a series of organized data in various matrices, that integrate a plurality of levels of information (genes, molecules, cells, circuits, physiology, behavior, self-report and paradigms) in order to get a better understanding of the basic functional dimensions that underlie the full range of both normal and abnormal human behavior. . From this perspective, mental disorders are analyzed along these dimensions or domains, and instead of looking for a “category” o label that could be applied to a certain individual, a cluster of analytical, data will represent its peculiar mental state. At least 137 units have been differentiated in behavior, and the sum of abnormalities that could be found in a single case would determine its final evaluation, and would indicate the lines along which the study might follow. The RDoC then, is not a substitute of DSM, but an instrument that offers an alternative interpretation of the studied disorder, and a guide for further research. Criticism is always needed to promote the creation of more homogeneous and accurate assessment instruments that will constitute the source of future progress in the field.
Further Reading American Psychiatric Association (APA), 1952. Diagnostic and Statistical Manual of Mental Disorders, first ed. APA, Washington, DC www.turcopsikiyatri.org/arsiv/dsm-1952.pdf. American Psychiatric Association (APA), 1968. Diagnostic and Statistical Manual of Mental Disorders, second ed. APA, Washington, DC www.terapiacognitiva.eu/dwl/dsm5/DSMII.pdf. American Psychiatric Association (APA), 1980. Diagnostic and Statistical Manual of Mental Disorders, third ed. APA, Washington, DC. American Psychiatric Association (APA), 1987. Diagnostic and Statistical Manual of Mental Disorders, third ed., revised. APA, Washington, DC. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, DSM-4 TM. American Psychiatric Association, Washington. American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, DSM-5. American Psychiatric Association, Arlington, VA. Carpintero, H., 2015. Una nueva Mirada a la psicopatología. El DSM-V y su significación histórica. An. Real Acad. Ciencias Morales Políticas 92, 389–426. Cronbach, L.J., Meehl, P.E., 1955. Construct validity in psychological tests. Psychol. Bull. 529, 281–302. Eron, L.D., 1966. Classification of Behavior Disorders. Aldine- Atherton, Chicago. Feighner, J.P., Robins, E., Guze, S.B., Woodruff, R.A., Winokur, G., Muñoz, R., 1972. Diagnostic criteria for use in psychiatric research. Arch. Gen. Psychiatry 26, 57–63. Frances, A.J., Widiger, T., 2012. Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Ann. Rev. Clin. Psychol. 8, 109–130. Frances, A.J., May 11, 2012. Diagnosing the D.S.M. New York Times (opinion). Haynes, S.N., O’Brien, W.H., 1988. The Gordian knot of DSM-III use: interacting principles of behavioral classification and complex causal models. Behav. Assess. 10, 95–105. Insel, T., 2013. Transforming Diagnosis, en Director’s Blog, NIHM Web Page. Blog April 29, 2013. www.nimh.nih.gov/about/director/2013/transforming.diagnosis.shtml. Kraepelin, E., 1899. Lehrbuch. Berlin. Millon, Th, 1996. The DSM-III: some historical and substantive reflections. In: Millon, T.H. (Ed.), Personality Psychopathol. John Wiley & Sons, New York. Sandin, B., Chorot, P., Valiente, R., 2016. DSM, 5 Cambios en la clasificación de los trastornos mentales. UNED, Madrid. Schmith, H.O., Fonda, C., 1952. The reliability of psychiatry diagnosis. J. Abnorm. Soc. Psychol. 52, 262–267. Spitzer, R.L., Endicott, J., Robins, E., 1975. Research Diagnostic Criteria (RDC). N.Y. State Psychiatric Institute, New York. Spitzer, R.L., Willson, P.T., 1975. Nosology and the Official Psychiatry Nomenclature. In: Freeman, A.M., Kaplan, H.I., Sadock, B.J. (Eds.), Compressive Textbook of Psychiatry, vol. II. Williams and Wilkins, Baltimore. Spitzer, R.L., Gibbson, M., Skoldol, A.E., Williams, J., First, M.B., 1994. DSM-IV Casebook: A Learning Comparison to the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Press, Washington. Szasz, T., 1966. The psychiatry classification of behavior: a strategy of personal constraint. In: Eron, L.D. (Ed.), The Classification of Behavior Disorders. Aldine, Chicago, pp. 123–170. Widiger, T.A., Frances, A.J., Pincus, H.A., First, M.B., Ross, R., Davis, W., 1994. DSM-IV Sourcebook. APA, Washington, DC.