A Brief History of the DSM
The first DSM appeared in 1952 and, since then, has garnered both accolades and criticisms. Once intended for today, guidelines for diagnoses are quite elaborate and, consequently, controversial. In particular are concerns about the increase in statistics for mental illnesses as a result of reclassifying what was once considered part of everyday living (“normal”) could potentially be reclassified pathological.
The DSM is a relatively young classification system of mental disorders, filling a need that has a long history in medicine and psychiatry. After two millennia of evolution, with varying emphases on pathological theories, etiology, and defining features, and, most notably the principle objectives for its use (clinical? research? statistics?).
In North America, the initial stimulus for a mental disorders classification system was to satisfy a need for statistics. In the mid 1800s world governments were recognizing the need to take responsibility for individuals with a mental illness and the volumes of the cost of new care facilities was daunting. Consequently, the first 1840 the first variant of a today’s classification of mental disorders was created. And a small manual it was—having one category. Quite simply “idocy/insanity.” By 1880, seven categories were distinguished: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. Apart from the need for census statistics, the manual was used to determine who could function in society and who would need new, as yet not created, mental illness services.
In 1917, the American Medico-Psychological Association, forerunner of the American Psychological Association, and the National Commission on Mental Hygiene called for a more detailed diagnostic system, still utilitarian in that it would gather uniform statistics across mental hospitals. It was still primarily utilitarian with 22 diagnoses (the Statistical Manual for the Use of Institutions for the Insane).
Chief concern in North America soon became how to treat the large number of returning soldiers suffering shell shock. The practical consideration now became paramount, considering the dependence of the armies upon medical assessment and fitness for duty determination. Consequently, a new diagnostic system and an expanded nomenclature (developed by the US Army) was published (1943) and adopted by the US armed forces. The Veterans Association participated in the development of the expanded nomenclature and adopted by the Association to better incorporate the outpatient presentations of WWII vets.
The next leap of development was urged by changes to the International Classification of Diseases which had, until 1948, focused exclusively on physical illness. Following the addition of a section on mental disorders the APA produced an adapted version of “Medical 203”, a precursor to the DSM and considered the original DSM. And this DSM was the first to include clinical utility among its objectives. However, the manual reflected psychiatric thought at the time, largely Freudian (which attributes mental disorders to an individual’s childhood experiences and unresolved issues from the past).
DSM-I listed 95 mental disorders. Two years later, that number great to 130 (DSM-II).
The subjectivity of diagnosis of both early versions of the DSM were quickly criticized and responded to with a wealth of research demonstrating wide variation in diagnostic rates of schizophrenia in different countries—the US having the highest reported prevalence. Most notably, psychological David Rosenhan studied the diagnostic outcomes of eight healthy, otherwise ‘normal’ individuals sent to gain admission to 12 different psychiatric hospitals, saying they ‘heard voices.’ Once admitted, they were to exhibit no symptoms and act naturally and normally. No hospital detected that these were fake attempts at mental disorder and all were diagnosed with a mental illness and prescribed medication accordingly. That medication, in turn, wildly varied across hospital despite the same initial symptom presentation across ‘patients.’
The DSM-III aimed to improve the uniformity and validity of psychiatric diagnosis and prevent overdiagnosis. New theories of mental pathology were adopted, Freud was abandoned, and symptoms were diagnosed based on presentation of symptoms alone, all of which were more clearly defined. New objectives were also satisfied…those focusing on explicit diagnostic criteria, a multiaxial system, and a descriptive approach that was neutral to theories of etiology.
Now reaching 188 diagnostic categories, and being as large as a typical phone book, the DSM was stretching itself further. A between-version revision, DSM-IIIR, add yet another 27 categories, bringing that total to 215. And more pages, of course.
New problems. The chair of the DSM committee, himself, criticized the manual citing medicalization of 20 to 30 percent of the population as chief among the problems.
The APA decided it was time for an even larger edition and in 1994 published the 283-diagnosis 886 page tome, DSM-IV. The most notable evolution was the requirement in diagnosis of determining “clinical significant distress or impairment in social, occupational, or other important areas of functioning.” Hmm. More subjectivity and confusion because each individual will express differing expressions of what is ‘distressing’ to them. And context is also largely a determinant of functionality and distress.
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