History of the DSM

The DSM, or the Diagnostic and Statistical Manual of Mental Disorders has a long and storied history in the history of psychiatry. As the cornerstone of psychiatry and guide for millions of clinicians and healthcare providers, it has been the most significant advance in the diagnosis and treatment of mental disorders. However, in the midst of its success, criticisms of its role have also developed.

Even though the DSM II was published in 1968 (!) the following excerpt is sage advice even (and especially) today.

A Tip From the DSM-II...

The diagnostician, however, should not lose sight of the rule of parsimony and diagnose more conditions than are necessary to account for the clinical picture. The opportunity to make multiple diagnoses does not lessen the physician's responsibility to make a careful differential diagnosis.

The DSM-5 on Boundaries Between Disorders

Although some mental disorders may have well-defined boundaries around symptom clusters, scientific evidence now places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors, and possibly shared neural substrates (perhaps most strongly established for a subset of anxiety disorders by neuroimaging and animal models). In short, we have come to recognize that the boundaries between disorders are more porous than originally perceived.

– (DSM-5, Introduction, page 5)

The DSM-5 on Checklist Diagnoses

The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis.

– (DSM-5, Use of the Manual, page 19)
“A single diagnostic interview, regardless of how reliable, does not capture the essence of what is happening….Accurate diagnosis must be part of the ongoing clinical dialogue with the patient.”

Freedman, R., Lewis, D. A., Michels, R., Pine, D. S., Schultz, S. K., Tamminga, C. A., ... & Shrout, P. E. (2013). The initial field trials of DSM-5: new blooms and old thorns.

In non-North American circles (i.e. - outside of Canada and the United States), countries use the World Health Organization's International Statistical Classification of Diseases and Related Health Problems, also known as the ICD-10.

The diagnostic criteria for the ICD-10 varies from the DSM-5 for a variety of mental disorders. See Tyrer, P. (2014). A comparison of DSM and ICD classifications of mental disorder. Advances in psychiatric treatment, 20(4), 280-285.

RDoC is a research framework proposed by the National Institute for Mental Health (NIMH) for new ways of studying mental disorders. It integrates many levels of information (from genomics to self-report) to better understand basic dimensions of functioning underlying the full range of human behaviour from normal to abnormal.

‘Mental illness’ is terribly misleading because the ‘mental disorders’ we diagnose are no more than descriptions of what clinicians observe people do or say, not at all well established diseases.

— Allen Frances, DSM-IV Task Force Chairman, 2015

While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

— Thomas Insel, National Institute of Mental Health Director, 2013