Janet B.W. Williams, PhDProfessor Emerita of Clinical Psychiatric Social Work,

Dept. Of Psychiatry, Columbia UniversitySenior VP of Global Science, MedAvante, Inc.

12/7/13

The Evolution of DSM

Why the DSM (1952)?

• Pre-1952: several different national systems in

• use, multiple state systems• Dissatisfaction with existing

classifications• APA develops its own • First glossary definitions of disorders• Of little or no interest to clinicians,

researchers

Diagnostic and Statistical Manual of Mental Disorders and International Classification of

Diseases

DSM ICD

1952 DSM

1968 DSM-II ICD-8

1980 DSM-III ICD-9-CM

1987 DSM-III-R

1994 DSM-IV ICD-10

2000 DSM-IV-TR

2013 DSM-V

DSM-I Classification

• Acute/chronic brain disorders• Mental deficiency• Psychotic disorders• Psychophysiologic disorders• Psychoneurotic disorders• Personality disorders • Transient situational personality

disorders

Significance of DSM-I (1952)

• First glossary of definitions of categories• APA in control of classification• Influence of Adolph Meyer

“Schizophrenic reaction” “Manic depressive reaction”

“Anxiety reaction”• Psychoanalytic concepts in neuroses and

psychophysiologic disorders• “...utilization of various defense

mechanisms...”

DSM-I Description of Manic Depressive Reaction, Manic Type (1952)

“This group is characterized by elation or irritability, with overtalkativeness, flight of ideas, and increased motor activity. Transitory, often momentary, episodes of depression may occur, but will not change the classification from the manic type of reaction.” (p. 25)

DSM-II Classification

• Mental retardation• Organic brain syndromes• Psychoses• Neuroses• Personality disorders and certain other

non-psychotic mental disorders• Psychophysiologic disorders• Special symptoms• Transient situational disturbances

Significance of DSM-II (1968)

• APA decides to use ICD-8 (slightly modified)

• British hegemony in ICD

• Eliminating “Reaction”

• Multiple diagnoses encouraged

DSM-II Description of Manic-depressive Illness, Manic Type (1968)

“This disorder consists exclusively of manic episodes. These episodes are characterized by excessive elation, irritability, talkativeness, flight of ideas, and accelerated speech and motor activity. Brief periods of depression sometimes occur, but they are never true depressive episodes.” (p. 36)

Eli Robins, MD

Robert L. Spitzer, MDChair, DSM-III and DSM-III-R

Text EditorDSM-III

Coordinator of DSM-III Field Trials

DSM-III-R Task Force

Janet B.W. Williams, DSW (now PhD)

Noah Spitzer-Williams, 1984

What Principles Guided DSM-III?• Inclusiveness

• Descriptive approach: usable across theoretical

orientations

• Diagnostic (“operational”) criteria

• Expanded descriptions

• Multiaxial system

• ICD compatibility a formality

Goals of DSM

• communication: precision in language, “short-hand”

• clinical: facilitate identification, treatment, and prevention of mental disorders

• research: further understanding of etiology• education: teach psychopathology• data collection: statistical registry

Types of Information in the Text• Essential features• Associated features• Age at onset• Course• Impairment• Complications• Predisposing factors• Prevalence• Sex ratio• Familial pattern• Differential diagnosis

DSM-III Controversies

• Task Force unrepresentative

• Definition of mental disorder

• Dysthymia (Neurotic depression) vs Neurotic depression (Dysthymia)

January 3, 2005

THE DICTIONARY OF DISORDER

by ALIX SPIEGEL

www.newyorker.com

Multiaxial System – Eliminated in DSM-5• Axis I: Clinical Conditions• Axis II: Personality Disorders and Mental

Retardation• Axis III: general medical conditions• Axis IV: psychosocial stressors and

environmental problems• Axis V: Global Assessment of Functioning Scale

Person-in-Environment System

Four factors:• Social roles in relationship to others• Mental health• Social environment• Physical health

DSM CasebooksDSM-IV SourcebooksStructured Clinical Interview for DSM (SCID)

- SCID-I (for Axis I)- SCID-RV (Research Version)- SCID-CV (Clinician Version)

- SCID-II (for Axis II)- SCID-CT (for Clinical Trials)

Additional Materials

1987: DSM-III-R

• originally intended to be just a “fine tuning”• corrected inconsistencies and incorporated

latest research• disadvantage: change too disruptive

Allen Frances, MDChair, DSM-IV

1994: DSM-IV

• revision process based on empirical review• elimination of the term “organic”• expansion of appendix categories• new and deleted categories

DSM-IV Process

• Decentralization of revision process• Literature reviews and data reanalysis• Field trials• ICD-10 compatibility• Avoid public controversy• “User-friendly”• High threshold for new diagnoses

2000 - DSM-IV Text Revision

• fills 12+ year gap between DSM-IV and

DSM-V• based on comprehensive lit review from

1992 to 1999• no changes to criteria sets allowed• most changes to Associated Features

and Disorders, Age, Culture and Gender Features, Prevalence, Course, and Familial Pattern

Michael First, MDDSM-IV Text Editor

David Kupfer, MD and Darrel Regier, MD Co-chairs, DSM-5

Michael B. First, MD• Professor of Clinical Psychiatry• Research Psychiatrist, NYSPI• schematherapy and psychopharmacology practice

in Manhattan• Forensic expert• Editor of Text and Criteria for DSM-IV and DSM-IV-TR• Editorial and Coding Consultant for DSM-5• Chief technical and editorial consultant on ICD-11