We all have those days when we think to ourselves - this is nuts. Or, that was crazy. Or, I feel insane today. Some of us do struggle with a clinical mental illness, treated or untreated. Many of us will go our entire lifetimes without a psychiatrist or psychologist labeling us with a diagnosis, and some of us that do receive a diagnosis may receive it in error, or for a disorder that has no basis in science. The diagnostic go-to manual for those in the mental health profession is the Diagnostic and Statistical Manual of Mental Disorders (or DSM for short). The DSM has been through many iterations, since before World War 2, and currently the DSM V is in the works. The DSM helps doctors diagnose and treat patients with psychiatric illness, by outlining the symptoms and diagnostic criteria for various diseases of mental health. It serves as a template for insurance company coverage of mental illness and affects research funding in these areas. Its importance and influence in the field of mental healthcare is unparalleled. Its history of controversy is also unparalleled.
The history of psychiatric classifications and the evolution of the DSM is an interesting one. The American Psychiatric Association provides a historical overview on their web page, including these excerpts:
What might be considered the first official attempt to gather information about mental illness in the United States was the recording of the frequency of "idiocy/insanity" in the 1840 census. By the 1880 census, seven categories of mental illnesses were distinguished: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.
The American Psychiatric Association Committee on Nomenclature and Statistics developed a variant of the ICD-6 (International Classification of Diseases) that was published in 1952 as the first edition of the Diagnostic and Statistical Manual: Mental Disorders (DSM-I). DSM-I contained a glossary of descriptions of the diagnostic categories and was the first official manual of mental disorders to focus on clinical utility. The use of the term “reaction” throughout DSM-I reflected the influence of Adolf Meyer's psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors.
DSM-II was similar to DSM-I but eliminated the term “reaction.” DSM-III introduced a number of important methodological innovations, including explicit diagnostic criteria, a multiaxial system, and a descriptive approach that attempted to be neutral with respect to theories of etiology. This effort was facilitated by extensive empirical work on the construction and validation of explicit diagnostic criteria and the development of semistructured interviews. Several years later, in 1994, the last major revision of the DSM, DSM-IV, was published. Numerous changes were made to the classification (e.g., disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text based on a careful consideration of the available research about the various mental disorders.
However, this overview is very politically correct. It does not attempt to address the many controversies that have surrounded the DSM over the years, or the so called ‘diseases’ contained within various DSM editions which were later removed when they were found to be without scientific basis. Currently, the DSM V is in the works, with drafts released earlier this year. AAAS/Science has done extensive coverage on the release of these drafts in February/March 2010. Rewrites to this fifth version of the psychiatric bible include the addition for the first time of behavioral addictions, when previously the only addictions given classification in the DSM were those for drugs, alcohol and gambling. Now, Internet Addiction may be added to this list, as it is poised to sit in the appendix of DSM-V. When or how one might diagnose this vague disorder is still a subject of controversy.
Other behavioral addictions are also addressed: binge-eating is no longer in the appendix and will appear in the eating disorders category, and sex-addiction was found to not be scientifically founded for inclusion in DSM-V (unlike gambling, which has a host of scientific findings to support its existence).
Other revisions for DSM-V include wording about OCD-spectrum disorders (in the Anxiety category), which will now include hoarding and Tourrette syndrome. The formerly 12 personality disorders will now be only 5 in number (narcissistic personality is out, borderline personality stays in). One of the controversial revisions for DSM-V is whether or not to include anxiety in the list of symptoms for depression. Overall, today’s goal for many in the mental health profession is to align the DSM with scientific data including a brain-based classification of diseases.
Some of the controversy surrounding the DSM throughout the years has centered around the diagnosis of personality disorders. Borderline personality used to sit somewhere between neurotic and psychotic (think the diagnosis of Winona Ryder’s character in Girl Interrupted). Today, a patient must display 5 of 9 possible symptoms including impulsiveness, self-mutilating behavior, or chronic feelings of emptiness. However, this disorder is still considered one of the most controversial to diagnose correctly (see this list from Live Science).
Another controversy has been the inclusion of homosexuality as a mental disorder in previous versions of the DSM. In 1973 the APA declared that homosexuality is not a disease, but it remained in the 1980 DSM-III, to be removed for good only relatively recently, in 1986.
Gender identity disorder is another DSM-V controversy, given that the criteria for diagnosis appear to reflect societal discomfort with a biological phenomena, instead of actual mental illness.
These and other controversial inclusions and removals for the DSM-V will continue to be discussed, with the final DSM-V expected to be released in 2013.
AAAS provides this DSM-V at a glance:
Old subtypes for schizophrenia will be discarded. Diagnosiswill be made based on common symptoms such as hallucinationsand thought disorder, as well as their duration and severity.
Newly proposed is "psychosis risk syndrome" for people showingwarning signs such as delusions, hallucinations, or disorganizedspeech and experiencing distress. Critics say this could stigmatizemany young people. Defenders say early identification couldhelp them.
DSM-IV lists nine symptoms on which to base diagnosis of depression.The proposed one emphasizes three basic dimensions: depressionwith anxiety, with substance abuse, and with suicidality. Anew diagnosis of "mixed anxiety depression" is proposed. Thethreshold for bipolar diagnosis is lowered slightly, to accommodatedepression with only one or two episodes of mania. This changerecognizes the fact that some antidepressants can trigger amanic episode in the vulnerable.
The main change is the expansion of obsessive-compulsive disorder(OCD) spectrum, which now pulls in disorders from far-flungparts of DSM-IV. These include Tourette syndrome, body dysmorphicdisorder (obsession with changing a normal body part), and trichotillomania(hair-pulling). "Hoarding disorder" has also been added to thespectrum. There is still debate over whether OCD should havea designation separate from anxiety disorders.
The old DSM laundry list of 12 personality disorders will betrimmed to five: borderline, schizotypal, avoidant, obsessive-compulsive,and antisocial/psychopathic. ("Psychopathic," eschewed in earlierDSMs, is now back.) The other diagnoses will be superceded bya "mix and match" menu of symptoms that reflect two types ofcore pathologies: disturbances related to self-concept, andthose related to interpersonal functioning such as cooperativenessand empathy.
Addiction and Related Disorders
Vocabulary is being overhauled. "Dependence" (which impliesphysical and not necessarily psychological dependence) is out."Abuse" is also out as unsupported scientifically. Instead,varying degrees of "use disorder," as in "alcohol use disorder,"are proposed.
"Gambling disorder" has achieved the status of addiction, basedon behavioral and biological similarities to substance addiction."Internet addiction" is under consideration but hasn't yet madethe grade.
New addition is "binge eating," which has been moved from theDSM Appendix to become a full-fledged disorder.
Sexual and Gender Identity Disorders
"Gender identity disorder" has been retained despite pressurefrom transsexual advocates. Several new diagnoses, including"sexual interest/arousal disorder in women," are proposed. Themost controversial is a proposal for "hypersexual disorder,"involving recurrent and distressing sexual "fantasies, urgesand behavior."
ADHD and Disruptive Behaviors
Changes to attention disorder diagnoses are still under consideration.The group proposes a new subtype of conduct disorder that includescallous, unemotional traits (such as lack of guilt or remorse),citing recent evidence that this subset of children and adolescentsmay be more prone to chronic violent behavior and require differenttypes of treatment.
Childhood and Adolescent Disorders
Additions include specific criteria for diagnosing post-traumaticstress disorder in preschool children and "temper dysregulationdisorder with dysphoria," characterized by severe temper outburstsalternating with negative mood states. Children with this problemare often diagnosed with juvenile bipolar disorder under DSM-IV.
This new category would subsume various DSM-IV diagnoses, dividingthem into major and minor disorders. Major neurocognitive disorders(such as various forms of dementia) involve a decline that interfereswith independent living. Minor disorders would include mildcognitive impairment (MCI), a suite of memory and other problemsconsidered a possible prelude to Alzheimer's. Elevating MCIto a formal diagnosis could facilitate clinical trials aimedat preventing Alzheimer's.
Several DSM-IV diagnoses would be consolidated into a single,broader diagnosis of "autism spectrum disorders." These includeAsperger's syndrome, a high-functioning form of autism. Thegroup says there is no scientific justification for the term,but the change has been strenuously resisted by Asperger's advocates.Also, the term "mental retardation" would be replaced with "intellectualdisabilities."
DSM-IV distinguishes "primary insomnia" from insomnia causedby other conditions. These would be merged into a single diagnosisin DSM-V, with clinicians asked to note accompanying dimensionssuch as depression or heart disease. "Restless leg syndrome"would be elevated to a formal diagnosis.
Somatic Distress Disorders
Several diagnoses that deal with bodily complaints would befolded into a new umbrella diagnosis of "complex somatic symptomdisorder" on the grounds that DSM-IV diagnoses such as somatizationdisorder and hypochondriasis have common features such as chronicphysical complaints and distorted perceptions of symptoms.