Latest update: July 12th, 2012
Mental health specialists tend to speak about their patients according to a classification referred to as the DSM, which stands for the Diagnostic and Statistical Manual of Mental Disorders. This classification system was first published in 1952 by the American Psychiatric Association as a method to classify mental disorders and develop a statistical baseline through which disorders can be understood, studied and treated. It is not the only classification system available: the International Classification of Diseases, published by the World Health Organization, contains mental health diagnoses that parallel those of the DSM, but the DSM is most widely used in the mental health field, especially in the United States.
All classification systems evolve over time, and we are about to receive the latest iteration of the DSM in 2013. To understand why changes are made, one need only look at the changes made in each of the DSM revisions in the past. In the first DSM, which was based primarily on soldiers’ reactions to the stresses of World War II, all of the 106 diseases listed were termed reactive, or caused by reactions to social or environmental factors. This limited classification to traumas and environmental stressors.
In the DSM II, which contained 182 illnesses, the word reactive was removed, allowing for a broader approach to understanding possible biological or genetic contributions and other non-stress induced disorders.
DSM III, published in 1980, formulated a system that included a description of 265 diagnostic categories without any suggestion as to cause, unless it was very well documented, and conformed to very specific diagnostic criteria.
In 1994, the DSM IV added and deleted a variety of categories based on the research available at the time. In that version, which was further revised in 2000, only symptoms that caused clinically significant distress or impairment in functioning were included. Definitions of Attention Deficit Hyperactivity disorders and Autistic Spectrum disorders were expanded, and all of the disorders had a checklist of specific diagnostic criteria that had to be met in order to apply a diagnosis. This gave both clinicians and researchers a measurable way to classify their patients, the goal of which was to help find empirically validated treatments.
Every revision of the DSM causes a reaction among professionals and the public. Changes are often attributed to political considerations rather than research that supports the suggested changes. For example, in 1973, the DSM declassified homosexuality as a disorder, and the diagnosis was replaced by the category of Sexual Orientation Disturbance (SOD) because research failed to identify a specific abnormality caused by this sexual preference. Over the years, SOD has been modified and expanded to include a wider variety of sexual disorders and paraphilias. Some individuals still believe that gay activists advocating for their own agenda brought about this change, although that is highly unlikely.
The task force working on the DSM-5 was initially sworn to secrecy. This caused an uproar in the scientific community, which rightfully demanded an open process. Once the revision process was publicized and the recommendations for change became available, critics of the DSM-5 voiced three primary concerns. These include lowering of diagnostic thresholds that would increase the number of individuals who fit a diagnosis, introducing new disorders that are currently considered normal behavioral patterns, and questions regarding the scientific validity of certain categories.
If the DSM-5 goes forward as proposed, it could include changes such as a significantly broader definition of Attention Deficit Hyperactivity disorder; an Attenuated Psychosis Syndrome which would allow the diagnosis of individuals without a psychotic disorder to be classified as having one; and the categorization of shyness as a pathology.
Another proposed change would be a complete overhaul of the category now referred to as personality disorders. Perhaps the greatest concern of the scientific community is the neuro-biological emphasis of the DSM-5, and what some are calling the “over-medicalization” of disorders that are clearly a combination of biological, psychological, and social stressors. This is of great concern because it would provide justification for wider use of psychotropic medications, many of which have questionable utility, in vulnerable people who might benefit more from psychotherapy or counseling.
The need for practical interventions that are proven effective should be the primary motivator, but financial considerations are a pragmatic driving force. In the end, there is a great fear that the new criteria proposed in the DSM-5 will favor medical interventions, which may be seen by insurance companies as cheaper than therapy.
Despite questions of reliability and validity, the DSM has always been useful for research purposes. It provides a basis for classification of disorders and allows for the monitoring of interventions over time. An empirical approach to diagnosis sets clear parameters by which patients’ diagnoses can be understood and treatment guidelines established. Because this is a scientific process, it will always proceed further. About 10 years after the DSM-5 is introduced, a DSM-6 will inevitably be proposed. But the most significant question for those who use the DSM to diagnose and treat individuals will be more about how to make it fit the needs of insurance paperwork more than about how a diagnosis precisely fits any individual patient.
Dr. Michael Salamon, a fellow of the American Psychological Association, is the founder and director of ADC Psychological Services in New York. He is the author of numerous articles, several psychological tests and books including “The Shidduch Crisis: Causes and Cures” (Urim Publications) and “Every Pot Has a Cover” (University Press of America). His newest book is called “Abuse in the Jewish Community: Religious and Communal Factors that Undermine the Apprehension of Offenders and the Treatment of Victims.”
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