MORE THAN YOU EVER WANTED TO KNOW... ABOUT THE D(iagnostic)&S(tatistical)M(anual) ... of Mental Disorders!!! yay! Referrences and resources included!!! :D
DSM-IV-TR: the current version
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries...” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers 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", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:
- Axis I: Clinical disorders, including major mental disorders, and learning disorders
- Axis 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)
- Axis III: Acute medical conditions and physical disorders
- Axis IV: Psychosocial and environmental factors contributing to the disorder
- Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18
Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, and schizophrenia.
Common Axis II disorders 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 mental retardation.
Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.
The DSM-IV-TR states, because it is produced for the completion of federal legislative mandates, its use by people without clinical training can lead to inappropriate application of its contents. Appropriate use of the diagnostic criteria is said to require extensive clinical training, and its contents “cannot simply be applied in a cookbook fashion”. The APA notes diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises laypersons should consult the DSM only to obtain information, not to make diagnoses, and people who may have a mental disorder should be referred to psychological counseling or treatment. Further, a shared diagnosis or label may have different causes or require different treatments; for this reason the DSM contains no information regarding treatment or cause. The range of the DSM represents an extensive scope of psychiatric and psychological issues or conditions, and it is not exclusive to what may be considered “illnesses”.
The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses and field trials. The Sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and hence the scientific credibility of contemporary psychiatric classification.
Validity and reliability
The most fundamental scientific criticism of the DSM concerns the validity and reliability of its diagnoses. This refers, roughly, to whether the disorders it defines are actually real conditions in people in the real world, that can be consistently identified by its criteria. These are long-standing criticisms of the DSM, originally highlighted by the Rosenhan experiment in the 1970s, and continuing despite some improved reliability since the introduction of more specific rule-based criteria for each condition.
Proponents argue that the inter-rater reliability of DSM diagnoses (via a specialised Structured Clinical Interview for DSM-IV (SCID) rather than usual psychiatric assessment) is reasonable, and that there is good evidence of distinct patterns of mental, behavioral or neurological dysfunction to which the DSM disorders correspond well. It is accepted, however, that there is an "enormous" range of reliability findings in studies, and that validity is unclear because, given the lack of diagnosticlaboratory or neuroimaging tests, standard clinical interviews are "inherently limited" and only a ("flawed") "best estimate diagnosis" is possible even with full assessment of all data over time.
Critics, such as psychiatrist Niall McLaren, argue that the DSM lacks validity because it has no relation to an agreed scientific model of mental disorder and therefore the decisions taken about its categories (or even the question of categories vs. dimensions) were not scientific ones; and that it lacks reliability partly because different diagnoses share many criteria, and what appear to be different criteria are often just rewordings of the same idea, meaning that the decision to allocate one diagnosis or another to a patient is to some extent a matter of personal prejudice.
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect them together based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. AsDSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology." However, the DSM is based on an underlying structure that assumes discrete medical disorders that can be separated from each other by symptom patterns. Its claim to be “atheoretical” is held to be unconvincing because it makes sense if and only if all mental disorder is categorical by nature, which only a biological model of mental disorder can satisfy. However, the Manual recognizes psychological causes of mental disorder, e.g. PTSD, so that it negates its only possible justification.
The DSM's focus on superficial symptoms is claimed to be largely a result of necessity (assuming such a manual is nevertheless produced), since there is no agreement on a more explanatory classification system. Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis.
Despite the lack of consensus on underlying causation, advocates for specific psychopathological paradigms have nonetheless faulted the current diagnostic scheme for not incorporating evidence-based models or findings from other areas of science. A recent example is evolutionary psychologists' criticism that the DSM does not differentiate between genuine cognitive malfunctions and those induced by psychological adaptations, a key distinction within evolutionary psychology, but one widely challenged within general psychology. Another example is a strong operationalist viewpoint, which contends that reliance on operational definitions, as purported by the DSM, necessitates that intuitive concepts such as depression be replaced by specific measurable concepts before they are scientifically meaningful. One critic states of psychologists that "Instead of replacing 'metaphysical' terms such as 'desire' and 'purpose', they used it to legitimize them by giving them operational definitions...the initial, quite radical operationalist ideas eventually came to serve as little more than a 'reassurance fetish' (Koch 1992) for mainstream methodological practice."
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.
Because an individual's degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who don't meet symptom counts may nevertheless experience comparable distress or disability in their life.
Despite doubts about arbitrary cut-offs, yes/no decisions often need to be made (e.g. whether a person will be provided a treatment) and the rest of medicine is committed to categories, so it is thought unlikely that any formal national or international classification will adopt a fully dimensional format.
Some psychiatrists also argue that current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that the cultural and ethnic diversity of individuals is often discounted by researchers and service providers. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that the Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Kleinman's negative view towards the culture-bound syndrome is largely shared by other cross-cultural critics, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented. Many mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of the DSM-III, has opined that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.
Drug companies and medicalization
It has also been alleged that the way the categories of the DSM are structured, as well as the substantial expansion of the number of categories, are representative of an increasing medicalization of human nature, which may be attributed to disease mongering by pharmaceutical companies and psychiatrists, whose influence has dramatically grown in recent decades. Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest. In 2005, then American Psychiatric Association President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".
However, although the number of identified diagnoses has increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argue it almost entirely represents greater specification of the forms of pathology, thereby allowing better grouping of more similar patients.
There is scientific and political controversy regarding the continued inclusion of sex-related diagnoses such as the paraphilias (sexual fetishes) and hypoactive sexual desire disorder (low sex drive).
Critics of these and other controversial diagnoses often cite the DSM's previous inclusion of homosexuality, and the APA's eventual decision to remove it, as a precedent for current disputes. That 1973 decision is still challenged by some, mainly conservative and religious, groups who maintain that its removal does not decide empirical issues relating to statistical infrequency, personal distress, maladaptiveness or deviation from social norms. However, the consensus from the American Psychiatric Association, American Psychological Association, and other institutions in other countries, is that the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality.
Leaders of the Hearing Voices Network such as psychiatrist Marius Romme have claimed that many people who hallucinate "are like homosexuals in the 1950s -- in need of liberation, not cure."
Disputes over inclusion or exclusion can underscore the fact that reevaluation of controversial disorders can be viewed as a political as well as scientific decision. Indeed, Robert Spitzer, a past editor and leading proponent of scientific impartiality in the DSM, conceded that a significant reason that certain diagnoses (the paraphilias) would not, in his opinion, be removed from the DSM is because "it would be a public relations disaster for psychiatry".
A similar line of criticism has appeared in non-specialist venues. In 1997, Harper's Magazine published an essay, ostensibly a book review of the DSM-IV, that criticized the lack of hard science and the proliferation of disorders. The language of the DSM was described as "simultaneously precise and vague" in order to provide an aura of scientific objectivity yet not limit psychiatrists in a semantic or financial sense, and the manual itself compared to "a militia's Web page, insofar as it constitutes an alternative reality under siege" by critics.
A Consumer is a person who has accessed psychiatric services and been given a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders. Some Consumers are relieved to find that they have a recognized condition to which they can give a name. Indeed, many people self-diagnose. Others, however, feel they have been given a "label" that invites social stigma and discrimination, or one that they simply do not feel is accurate. Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists find that this can worsen symptoms and inhibit the healing process. Some in the Consumer/Survivor/Ex-Patient Movement actively campaign against their diagnosis, or its assumed implications, and/or against the DSM system in general. It has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and that can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.
DSM-5: the next version
The next (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), DSM-5, is currently in consultation, planning and preparation. It is due for publication in May 2013. APA has a website about the development, including draft versions, of what it is now referring to as the DSM-5 (rather than the roman numeral). It includes several changes, including proposed deletion of several types of schizophrenia.
- Relational disorder (proposed DSM-5 new diagnosis)
- Classification of mental disorders
- Chinese Classification and Diagnostic Criteria of Mental Disorders
- DSM-IV Codes
- GAF Scale
- Psychodynamic Diagnostic Manual
- Structured Clinical Interview for DSM-IV (SCID)
- Diagnostic classification and rating scales used in psychiatry
- ^ a b DSM-5 Publication Date Moved to May 2013
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- ^ DSM FAQ
- ^ DSM-IV Sourcebook Volume 1
- ^ DSM-IV Sourcebook Volume 2
- ^ DSM-IV Sourcebook Volume 3
- ^ DSM-IV Sourcebook Volume 4
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- ^ What is the Reliability of the SCID-I?
- ^ What is the "validity" of the SCID-I?
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- ^ Dominic Murphy, PhD; Steven Stich, PhD (1998) Darwin in the Madhouse
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- ^ Maser, JD & Akiskal, HS. et al. (2002) Spectrum concepts in major mental disorders Psychiatric Clinics of North America, Vol. 25, Special issue 4
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- ^ Shankar Vedantam, Psychiatry's Missing Diagnosis: Patients' Diversity Is Often Discounted Washington Post: Mind and Culture, June 26
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- ^ Cosgrove, Lisa, Krimsky, Sheldon,Vijayaraghavan, Manisha, Schneider, Lisa, Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry
- ^ Sharfstein, SS. (2005) Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly Psychiatric News August 19, 2005 Volume 40 Number 16
- ^ Alexander, B. (2008) What's ‘normal’ sex? Shrinks seek definition Controversy erupts over creation of psychiatric rule book's new edition MSNBC Today, May.
- ^ Normality or Disorder: Answering the Question
- ^ American Psychological Association: Appropriate Therapeutic Responses to Sexual Orientation
- ^ Royal College of Psychiatrists: Submission to the Church of England’s Listening Exercise on Human Sexuality.
- ^ Voices Carry Boston Globe, 2007
- ^ Kleinplatz, P.J & Moser, C. (2005). Politics versus science: An addendum and response to Drs. Spitzer and Fink. Journal of Psychology and Human Sexuality, 17(3/4), 135-139.
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- ^ How Using the Dsm Causes Damage: A Client’s Report Journal of Humanistic Psychology, Vol. 41, No. 4, 36-56 (2001)
- ^ Michael T. Compton (2007) Recovery: Patients, Families, Communities Conference Report, Medscape Psychiatry & Mental Health, October 11–14, 2007
- ^ DSM-5 development
- ^ "Schizophrenia and Other Psychotic Disorders". American Psychiatric Association. Retrieved May 6, 2010.
- Official DSM-5 development website
- Topic Center from the Psychiatric Times: DSM-5
- DSM-IV-TR Official Site - American Psychiatric Association
- Diagnostic Criteria from DSM-IV-TR
- DSM-IV Made Easy Summary of diagnostic criteria by James Morrison
- Sections of the DSM-IV-TR on Google Books.
- Reproduction of Medical 203