The Diagnostic & Statistical Manual of Mental Disorders - Nature, Developments & Issues.

The Diagnostic & Statistical Manual of Mental Disorders, otherwise known as the DSM, can be considered the bible of all mental health professionals. It documents the various kinds of mental disorders that have been dealt with and scientifically researched upon by a mental health professionals.

History & Developments.

The first DSM, DSM-I, was published in 1952. It was collated simply based on the consensus of a group of clinicians regarding what should/should not be included in the manual based on their own clinical experiences. Hence, data included were far less objective.

DSM-II was published in 1968 where treatment of mental illnesses experienced a shift from reactions to medical conditions. It also geared towards standardisation with WHO (World Health Organisation) and ICD (Inernational Classification of Diseases).

In 1980, DSM-III was formulated with major changes from DSM-II. In this edition, diagnostic criteria was introduced by means of the multi-axial approach. The description of disorders were far more expanded, with additional categories and backed by more objective research data. It was also made a-theoretical, i.e. more neutral towards theory, making it more widely acceptable. 7 years later, DSM-III-R (revised) replaced the DSM-III, with more disorders added.

The DSM-IV in 1994 expanded on classification categories with much more emphasis on empirical data. Then, the DSM-IV-TR (text revision) took place of DSM-IV in 2000, enhanced with current and up-to-date information, to ensure greater accuracy in diagnostic criteria. It also serves to bridge the gap between IV and V, which is the upcoming edition. Currently, the DSM-IV-TR is used by all mental health professionals.

What is the DSM?

The DSM is a multi-axial system for classifying and diagnosing mental disorders, published by the American Psychiatric Association (APA). The multi-axial system involves an assessment of several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome.

There are 5 axes in the DSM-IV-TR classification:

Axis I -
Clinical Disorders: Grouped into 16 major diagnostic classes (e.g. Substance-related disorders, mood disorders, anxiety disorders).

Other conditions that may be a focus of clinical attention (e.g. Medication-induced movement disorder, malingering, acculturation problem).

Axis II -
Personality Disorders and/or Mental Retardation
These conditions are usually permanent, enduring and chronic than Axis I disorders. Not all chronic disorders are included nevertheless (e.g. Anorexia, Schizophrenia).

Axis III -
General Medical Conditions (e.g. Obesity, lung disease, heart attack, arthritis)
These conditions could help to rule out certain disorders.

Axis IV -
Psychosocial & Environmental Problems (e.g. Unemployment, lack of social support system, criminal record, legal difficulties, difficulty in accessing healthcare services, dysfunctional marriage)
With such knowledge, clinicians can then refer them to appropriate institutions and professionals to seek further help.

Axis V -
Global Assessment of Functioning
Assessed on a rating of 1-100 (0 being too little information)
1-30 indicates critical condition.

Axes III, IV and V are very important but often neglected. They set the context of illness and refer patients to appropriate agencies, as well as affect the kind of treatment method, goal and outcome.

The DSM-IV-TR also takes on a prototypical approach which is a system for categorizing disorders using essential, defining characteristics and a range of variation on other characteristics.

Issues of the DSM.

Benefits:

1) It is largely atheoretical and widely applicable in a variety of settings
- Atheoretical: neutral towards theory/etiology.
- Settings: inpatient, outpatient, consultation liaison, private practice, primary care etc.

2) Provides clear descriptions of diagnostic categories for clinical practice, facilitating the collection and communication of clinical information and aids in treatment planning.

3) Facilitates research and improves communication among clinicians and researchers.

4) Serves as an educational tool for teaching psychopathology.

Drawbacks:

1) It is a categorical classification system that divides mental disorders into types based on criteria sets with defining features and hance, does not fit well with the comorbid and heterogeneous nature of mental disorders.

- Greater blurring at the boundaries of categories and some symptoms apply to more than 1 disorder, making conclusion on course of disorder, treatment response and likelihood of associated problems confusing.

- E.g. Substance-related & mood/personality/anxiety disorder, Eating & mood disorder.

- Are personality disorders extreme versions of normal behaviour? variations? If so, a dimensional approach should be taken instead of a categorical one (like gender) since a categorical approach does not rate level of dependence (no in betweens, you have it or not).

- Hence a five-factor model was introduced as a supplement to describing personality: extraversion, agreeableness, conscientiousness, emotional stability, openness to experience.

2) Inadequate emphaiss on cultural factors that may contribute to mental health problems.

- Context of patient's cultural setting/reference group (as well as that of the clinician's).

-Cultural significance of certain disorders.

3) The DSM promotes an "orientation towards inadequacies" by attending to tragedies and failures rather than solution, resources and competence.

- Mental retardation diagnosis: mild, moderate, severe, profound. Highly stigmatising.

- AAMR categories: intermittent, limited, extensive, pervasive. Less stigmatising since it focuses on level of support and assistance required.

4) Persons are pathologised and stigmatised through psychiatric labelling.

- Individuals with the disorder may identify with the negative connotaions associated with the label which affects their self-esteem.

5) Emphasis on reliability at the expense of validity.

- "I am depressed" can be considered reliable. But most patients express that they are depressed when presenting their problems. Is "I am depressed" then, useful?

- If a clinician were to diagnose someone with a disorder using the DSM, different clinicians are likely to come up with the same diagnosis (highly reliable).

- However, the disorder might not manifest or present itself in the ways listed by the DSM (low validity).

- It traces back to research methods that had produced the categorization. The more controlled and "clean" the research method, the more reliable. Nevertheless, the world is not that "clean" hance results might not prove to be valid in actual fact.

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"The listing of Personality disorders and Mental Retardation on a separate axis (Axis II) ensures that consideration will be given to the possible presence of Personality disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid (elaborated) Axis I disorders." (The DSM-IV-TR)

Arbitrariness of the DSM?

Futher criticisms (Tomm, 1990, p.4):

1) DSM fails to include the diagnosis of the "DSM syndrome" - a spiritual psychosis characterized by a compulsive desire to objectify persons and to label them according to a predetermined psychiatric diagnosis.

2) These "victims" of modern psychiatric ideology give priority to knowledge about precise definitions - over knowledge about healing interactions - as manifest by obsessive preoccupation with preoccupation with pejorative adjectives, inclusion and exclusion criteria, etc.