The Evolution of the Diagnostic & Statistical Manual of Mental Disorders (DSM)

Rebecca Rotondo, M. Ed.2013

DSM-11950-American Psychiatric Association produced the first draft

1952-DSM-I was published marking the beginning of modern mental

illness classification 106 diagnoses primarily characterized as

reactions to psychological, social, and biological factors

130 pages

DSM-IIpublished in 1968 listed 182 disorders134 pages longquite similar to the DSM-I

The term "reaction" was dropped, but the term “neurosis" was retained

Seventh printing of the DSM-II1974no longer listed homosexuality as

a category of disorder. The diagnosis was replaced with the category of "sexual orientation disturbance".

DSM-IIIPublished in1980The pychodynamic or physiological

view was abandoned, in favor of a regulatory or legislative model.

A new "multiaxial" system attempted to yield a picture more open to a statistical population census, rather than just a simple diagnosis

494 pageslisted 265 diagnostic categories

DSM-III-R In 1987 the DSM-III-R was published as a revision of

DSM-III Categories were renamed, reorganized, and

significant changes in criteria were made. Six categories were deleted while others were

added. Controversial diagnoses considered and discarded.

"Sexual orientation disturbance" was also removed and was largely included under "sexual disorder not otherwise specified" which can include "persistent and marked distress about one’s sexual orientation.“

292 diagnoses 567 pages long

DSM-IVPublished in 1984297 disorders 886 pagesmajor change from previous versions was

the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning“

Some personality disorder diagnoses were deleted or moved to the appendix

DSM-IV-TRPublished in 2000"text revision" of the DSM-IVdiagnostic categories and the

vast majority of the specific criteria for diagnosis were unchanged

text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes

CategorizationQualifiers are sometimes used, for

example mild, moderate or severe forms of a disorder

For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning

Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Multi-axial systempsychiatric diagnosis into five dimensions (axes) relating to

different aspects of disorder or disability:Axis I: All diagnostic categories except mental retardation and

personality disorderdepression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders,

anorexia nervosa, bulimia nervosa, and schizophreniaAxis II: Personality disorders and mental retardation (although

developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I)include personality disorders: paranoid personality disorder,

schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities.

Axis III: General medical condition; acute medical conditions and physical disordersbrain injuries and other medical/physical disorders which may aggravate existing

diseases or present symptoms similar to other disorders.Axis IV: Psychosocial and environmental factors contributing to the

disorderAxis V: Global Assessment of Functioning or

Children's Global Assessment Scale for children and teens under the age of 18

CriticismValidity and reliabilitySuperficial symptomsDividing lines

Some argue rather a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence

Cultural biasMedicalization and financial conflicts of interest

Political controversies“Labeling” individuals causing social stigmas or discrimination

DSM-V Timeline

1999-2007: Phase 1-Pre-Planning white papers (research on a number of topics)

2004-2007: Phase 2-Refining the Research Agenda2006-2008: DSM-5 Work Group Chairs and Members are appointed

and announced.2008-2010: Work Groups formulating their proposed draft criteria,

including conducting extensive literature reviews, performing secondary data analyses, and soliciting feedback from colleagues and professionals.

April, 2010-February, 2012: Field Trials and Data CollectionMarch 2012-November 2012: Final Drafts of TextsMarch-December 2012: Presentation of DSM-5 proposals to APA

Board of Trustees; Feedback and final revisions; Final Approval by APA Board of Trustees; Submission to American Psychiatric Publishing, Inc.

May 18-22, 2013: it will be released

Asperger’s Syndromeeliminated as a separate disorder,

and merged under autism spectrum disorders (ASD).

Clinicians now will rate the severity of clinical presentation of ASD as severe, moderate or mild

http://en.wikipedia.org/wiki/Diagnosis_of_Asperger_syndrome#Proposed_changes_to_DSM-5

Proposed changes to DSM-IV Diagnoses

Current Diagnoses (DSM-IV)Pervasive Developmental

Disorders include:Autistic DisorderAsperger’s DisorderPervasive Developmental Disorder,

NOSRett’s DisorderChildhood Disintegrative Disorder

PrevalenceApproximately 1 in 88 children will be

diagnosed with an ASD (CDC, 2008)Pervasive Developmental Disorders are

more common in males 3 – 4 times more common in malesPervasive Developmental Disorders are

the fastest growing developmental disabilities (CDC, 2007)

DSM–V WorkgroupSeverity Level for ASD

SocialCommunication

Restricted Interests and Repetitive Behaviors

Level 1 Requiring support

Without supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.

Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.

DSM–V WorkgroupSeverity Level for ASD

Social Communication

Restricted Interests and Repetitive Behaviors

Level 2 Requiring substantial support

Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.

Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.

DSM–V WorkgroupSeverity Level for ASD

Social Communication

Restricted Interests and Repetitive Behaviors

Level 3 Requiring very substantial support

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.

Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.

Proposed CriteriaA. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers)

Proposed CriteriaB. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change

3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment

Proposed CriteriaC. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning.

Several social/communication criteria were merged

Increases clarity and specificity of diagnosis Improves stability of ASD diagnosis over

time Encompasses various language levels Premise that deficits in communication and

social behaviors are inseparable and can be more accurately considered as a single set of symptoms

Key points in domain changes

Lord & Jones, 2012

Attention deficit hyperactivity disorderchange the diagnostic criteria from

symptoms being present before seven years of age to symptoms being present before twelve years of age.

Inattentive type and Hyperactive/Impulsive type, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current criteria of meeting a minimum of six symptoms for the would still apply for those 16 years of age or younger.

Bipolar disorderinclude further and more accurate sub-

typing for bipolar disorder. more stringent criteria for the diagnosis

of bipolar disorder in children with a new diagnosis temper dysregulation disorder with dysphoria proposed

Depressioncurrently grief is only considered a sign

of depression if two months have elapsed since the death of a loved one, the new version would allow for diagnosis within the first few weeks

Considerations

Research suggests that if implemented, up to 40% of those with autism as defined by the current criteria would be excluded from such a diagnosisStudy by McPartland et al. (2012)

Other researchers and experts in field disagree with findings

Cathy Lord (ADOS)

Oppositional defiant disorder the eight symptoms will be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior Vindictiveness. (four of these symptoms need to be present to meet diagnostic criteria. The

minimum four symptoms can come from all (or even just one or two) of the three categories)

children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months".

For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months.

Personality disorders revamped definition of personality disorder and a dimensional rather than a

categorical approach based on the severity of dysfunctional personality trait domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy). In addition, patients would be assessed on how much they match each of six prototypic personality disorder types: antisocial/psychopathic, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal with their criteria being derived directly from the dimensional personality trait domains.

Posttraumatic stress disorderVarious changeshttp://

en.wikipedia.org/wiki/Posttraumatic_stress_disorder#DSM-5_proposed_diagnostic_criteria_changes

Proposed new diagnoses Complex post-traumatic stress disorder Depressive personality disorder Compulsive hoarding Olfactory Reference Syndrome Negativistic (passive-aggressive)

personality disorder Relational disorder Skin Picking Disorder Sluggish cognitive tempo Binge Eating

Conditions proposed by outside sources Apathy Syndrome Body Integrity Identity Disorder Complicated Grief Disorder Developmental Trauma Disorder Disorders of Extreme Stress Not Otherwise Specified Fetal Alcohol Syndrome Internet Addiction Disorder Male-to-Eunuch Gender Identity Disorder Melancholia Parental Alienation Syndrome Seasonal Affective Disorder Sensory Processing Disorder

Additional References for DSM-Vhttp://www.goodtherapy.org/blog/

dsm-v-5-criteria-aspergers-autism-spectrum-1203128

http://www.dsm5.org/Pages/Default.aspx

50 Year Change

DSM-1 106 diagnoses

130 pages

DSM-II 182 diagnoses

134 pages

DSM-III 265 diagnoses

494 pages

DSM-III-R

292 diagnoses

567 pages

DSM-IV 297 diagnoses

886 pages

DSM-IV-TR

297 diagnoses

936 pages

Sources Dsm-5 development. In (2013). American Psychiatric

Association. Retrieved from http://www.dsm5.org/Pages/Default.aspx

(2011, November 1). Wikipedia. Retrieved fromhttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders