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The Diagnostic and Statistical Manual of Mental Disorders ('''DSM''') is a handbook for Mental Health Professionals that lists different categories of Mental Disorder and the criteria for diagnosing them, according to the publishing organization the American Psychiatric Association . It is used worldwide by clinicians and researchers as well as insurance companies, pharmaceutical companies and policy makers. It has attracted controversy and criticism as well as praise. There are five revisions of the DSM since it was first published in 1952. The last major revision was the DSM-IV published in 1994, although a "text revision" was produced in 2000. The DSM-V is currently in consultation, planning and preparation, due for publication in approximately 2012. DSM-5 Timeline The mental disorders section of the International Statistical Classification Of Diseases And Related Health Problems (ICD) is another commonly-used guide, and the two classifications use the same Diagnostic Codes . HISTORY The Diagnostic and Statistical Manual of Mental Disorders was first published in and Psychosis (roughly, anxiety/depression broadly in touch with reality, or Hallucinations / Delusions appearing disconnected from reality). Sociological and biological knowledge was also incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.Wilson, M. (1993) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=8434655 DSM-III and the transformation of American psychiatry: a history.] ''Am J Psychiatry.'' 1993 Mar;150(3):399–410. In . The criteria and classification system of the DSM-III was based on a process of consultation and committee meetings. An attempt was made to base categorization on description rather than assumptions of Etiology , and the Psychodynamic view was abandoned, perhaps in favor of a Biomedical Model , with a clear distinction between normal and abnormal. The criteria adopted for many of the mental disorders were expanded from the (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, such that the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless “neurosis” was included in some capacity, a political compromise reinserted the term in parentheses after the word “disorder” in some cases. In 1980 , the DSM-III was published, at 494 pages long and listing 265 diagnostic categories. The DSM-III rapidly came into widespread international use by multiple stakeholders and has been termed a revolution or transformation in psychiatry. In 1987 the DSM-III-R was published as a revision of DSM-III, under the direction of Spitzer. Categories were renamed, reorganized, and significant changes in criteria were made. Six new categories were deleted while others were added. Controversial diagnoses such as pre-menstrual dysphoric disorder and Masochistic Personality Disorder were considered and discarded. Altogether, DSM-III-R contained 292 diagnoses and was 567 pages long. In 1994 , DSM-IV was published, listing 297 disorders in 886 pages. The task force was chaired by Allen Frances . A steering committee of 27 people was introduced, including four psychologists. The steering committee created 13 work groups of 5–16 members. Each work group had approximately 20 advisers. The work groups conducted a three step process. First, each group conducted an extensive literature review of their diagnoses. Then they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative. Finally, they conducted multicenter field trials relating diagnoses to clinical practice.Allen Frances, Avram H. Mack, Ruth Ross, and Michael B. First (2000) The DSM-IV Classification and Psychopharmacology .Schaffer, David (1996) A Participant's Observations: Preparing DSM-IV Can J Psychiatry 1996;41:325–329. A major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required that symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. A "Text Revision" of the DSM-IV, known as the DSM-IV-TR, was published in 2000 . The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged.APA Summary of Practice-Relevant Changes to the DSM-IV-TR . The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes in order to maintain consistency with the ICD. DSM AND POLITICS Following controversy and protests from gay activists at APA annual conferences from 1970 to 1973, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After talks led by the psychiatrist 2002 .) "81 Words" . In Ira Glass (producer), ''This American Life''. Chicago: Chicago Public Radio. A category of "sexual disorder not otherwise specified" continues in the DSM-IV, which may include "persistent and marked distress about one’s sexual orientation”. THE CURRENT DSM Categorization 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 that “there is no assumption that 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.Maser, JD. & Patterson, T. (2002) Spectrum and nosology: implications for DSM-V ''Psychiatric Clinics of North America'', Dec, 25(4)p855-885 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. Multi-axial system The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:
Common Axis I disorders include Depression , Anxiety Disorders , Bipolar Disorder , ADHD , and Schizophrenia . Common Axis II disorders include Borderline Personality Disorder , Schizotypal Personality Disorder , Antisocial Personality Disorder , Narcissistic Personality Disorder , and Mild Mental Retardation . Cautions The DSM-IV-TR states that, because it is produced for mental health specialists, 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”.http://www.psych.org/research/dor/dsm/dsm_faqs/faq81301.cfm The APA notes that diagnostic labels are primarily for use as a “convenient shorthand” among professionals. The DSM advises that laypersons should consult the DSM only to obtain information, not to make diagnoses, and that people who may have a mental disorder should be referred to psychiatric counseling or treatment. Further, people sharing the same diagnosis/label may not have the same Etiology (cause) or require the same treatment; the DSM contains no information regarding treatment or cause for this reason. The range of the DSM represents an extensive scope of psychiatric and psychological issues, and it is not exclusive to what one may consider “illnesses”. DSM-IV sourcebooks The DSM-IV doesn't 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. DSM-IV Sourcebook Volume 1 DSM-IV Sourcebook Volume 2 DSM-IV Sourcebook Volume 3 DSM-IV Sourcebook Volume 4 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.Poland, JS. (2001) Review of Volume 1 of DSM-IV sourcebook Poland, JS. (2001) Review of vol 2 of DSM-IV sourcebook DSM-V PLANNING The DSM-V is tentatively scheduled for publication in 2011. DSM-V Prelude Project website In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute Of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-IV,First, M. (2002) A Research Agenda for DSM-V: Summary of the DSM-V Preplanning White Papers Published in May 2002 and the resulting work and recommendations were reported in an APA monographKupfer, First & Regier (2002) A Research Agenda for DSM-V and peer-reviewed literature.Regier, DS., Narrow, WE., First, MB., Marshall, T. (2002) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=12145504 The APA classification of mental disorders: future perspectives.] ''Psychopathology.'' Mar-Jun;35(2-3):166-70. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. DSM-5 Research Planning The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.APA DSM-V Research Planning Activities On July 23rd 2007, the APA announced the task force that will oversee the development of DSM-V. The DSM-V Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. The APA has entrusted the revision of the DSM to world-renowned scientists who have vast experience in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. As a group, task force members have authored over 2,500 research reports, books, chapters, white papers and journal articles. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members'disclosures available during the announcement of the task force. Several otherwise highly qualified individuals were ruled ineligible for task force appointments due to their competing interests. Revision of the DSM will continue over the next five years. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions. CRITICISM There have been a number of persistent critical debates concerning the DSM.
Volume 40 Number 11, p17 Jerome C. Wakefield, PhD, DSW; Mark F. Schmitz, PhD; Michael B. First, MD; Allan V. Horwitz, PhD (2007) Extending the Bereavement Exclusion for Major Depression to Other Losses: Evidence From the National Comorbidity Survey ''Arch Gen Psychiatry.'' 2007;64:433-440. It is claimed that the use of distress and disability as additional criteria for many disorders has not solved this false-positives problem, because the level of impairment is often not correlated with symptom counts and can stem from various individual and social factors.Spitzer RL, Wakefield JC. (1999) DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? ''Am J Psychiatry.'' 1999 Dec;156(12):1856-64. PMID 10588397
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