Applied History of Psychology/DSM and Other Diagnostic Systems

Brief History of the DSM

The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was published in 1952, and listed about 60 different disorders. DSM-II was published in 1968. Both of these editions were strongly influenced by the psychodynamic approach. There was no sharp distinction made between normal and abnormal, and all disorders were considered reactions to environmental events.

The early editions of the DSM distinguished between a psychosis and a neurosis. A psychosis is a severe mental disorder characterized by a break with reality. Psychoses typically involve hallucinations, delusions, and illogical thinking. A neurosis is a milder mental disorder characterized by distortions of reality, but not a complete break with reality. Neuroses typically involve anxiety and depression.

In 1980, with DSM-III, the psychodynamic view was abandoned and the medical model became the primary approach, introducing a clear distinction between normal and abnormal. The DSM became "atheoretical", since it attempted to have no preferred etiology for mental disorders. In 1987 the DSM-III-R appeared as a revision of DSM-III.

In 1994, it evolved into DSM-IV. Edits were made a few years later, with the introduction of the 'Text Revision' of the DSM-IV, also known as the DSM-IV-TR, published in 2000. In 2013, the DSM-5 was published, making it the most recent version.

Introduction to the DSM-IV-TR

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) is the manual used to diagnose mental illnesses in North America right now (The International Statistical Classification of Diseases and Health Related Problems-10 [ICD-10] is used in the rest of the world). It is put out by the American Psychiatric Association. It comprises a list of clinical entities that have been constructed and defined by people with particular interests (psychiatrists, psychologists, medical doctors). These individuals met and agreed upon lists of criteria (signs and symptoms) that need to be present for a particular diagnosis to be assigned.

Utility of the DSM

The DSM can help clinicians choose the best treatment for any particular person. It also helps with classification for research purposes. In addition, having a DSM diagnosis can provide access to funding for treatment (i.e., through insurance companies).

The DSM provides professionals within the world of psychology a common language in which to talk about mental disorders. Clinicians are able to discuss cases and be more confident that their colleagues will understand what they are referring to when they state that a patient meets diagnostic criteria for say 'depression' or 'anxiety'.

Validity and reliability issues

The validity and reliability problems associated with diagnostic activities are well-documented, but not often widely recognized and discussed (Ericksen & Kress, 2005; Kutchings & Kirk, 1997). One of the problems with diagnosis is that there are different classification systems (e.g., DSM-IV-TR and ICD-10) using different labels and criteria. This creates some problems in clinical practice. For instance, psychologists trained in Canada generally use the DSM-IV-TR. If they are called to work in the Motor-Vehicle Accident industry, they have to use ICD codes in administrative procedures, but will often use DSM-IV-TR codes in their psychological reports.

Even within one classification system, validity and reliability problems are prevalent. In addition, co-morbidity in clinical practice is more the rule than the exception, which then raises doubt about the validity of these illnesses as distinct.

Another issue is that the DSM is revised every 10 or so years, which points to the lack of reliability and validity of the manual (i.e., how can we trust these sets of criteria if they are constantly changing—presumably the disorders are not actually changing).

Stigma or Damage of Labelling and other Critical Issues

There are many arguments for and against the use of DSM-IV-TR diagnoses. This section discusses the effects of diagnoses more broadly and pays particular attention to the actual lived experience of those who have experienced this process.

Giving someone a label can be stigmatizing in that people often have preconceived ideas about certain diagnoses. For instance, some clinicians prefer not to work with people diagnosed with Borderline Personality Disorder, as clients with that diagnosis are often considered "difficult to work with." In addition, a person who received such a diagnosis and looks it up on the internet might become discouraged and feel that he or she is hopeless.

Labels can also prevent the clinician from seeing factors that might be unique for clients with the same diagnosis in that it can make the clinician interpret everything the client does as consistent with the label. One controversial study by David Rosenhan (1973) demonstrated this point quite effectively. Rosenhan and seven of his colleagues were admitted to mental hospitals (and designated "mentally ill") after complaining that they were "hearing voices." Once admitted to the mental hospital, Rosenhan and the other patients no longer purposefully exhibited any further symptoms and they were completely honest when their life history interviews were conducted. In spite of this, the clinicians who worked with the "patients" often interpretted their seemingly normal behaviour as disordered (e.g. writing in a journal was interpretted as excessive notetaking)and were able to uncover the causes of their disorders by analyzing their quite normal life histories.

On the other hand, some feel that "diagnosis and "labeling" is often helpful to the individual. People with psychological difficulties often feel isolated, alone, and misunderstood; labeling tells the suffering person "you're understood, and there are others with similar experiences. You're not alone." Labeling (i.e., diagnosing) a psychological disorder provides a framework and language with which to communicate. It also can provide access to funding for treatment, which some individuals would otherwise not have access to.

A further argument in support of diagnosis involves treatment implications. Specifically, some suggest that providing a working diagnosis throughout therapy guides treatment efforts in order to best help clients.

Ronald Bassman (1999; 2001), a psychologist and self-identified psychiatric survivor, as well as other professionals with similar experiences have widely written about the damaging impact of diagnosis. Their difficulties in living and emotional distress was made worse in part because the label they received suggested poor prognosis (e.g., chronicity of schizophrenia) and in part because it guided treatment that they experienced as very damaging (e.g., ECT for a diagnosis of depression leading to permanent memory loss, forced neuroleptic drugging for diagnosis of schizophrenia leading to post-traumatic stress symptoms, forced insulin shock treatment for psychotic disorders NOS). They argue that individuals with psychological difficulties can best be supported and feel understood through community and empowerment processes (see also Burstow, 2004; 2005; 2006).

For more information see: http://www.concernedcounseling.com/Communities/Thought_Disorders/schizo/articles/psychtoday.asp

The use of psychiatric diagnoses cannot be detached from the history of psychiatry. Even if no biological tests exists to "diagnose" so-called mental disorders, the biomedical model of emotional distress continues to prevail. This is likely partly due to our being part of a capitalistic society, in that workers in mental health require a structure and guidelines in order to receive pay for service. Without diagnoses, it is difficult to quantify and document time and treatment provided to clients, and therefore, little justification or basis for fee-for-service.

Alternatives to the DSM-IV-TR

Other systems for diagnosis include the Diagnostic Classification of Mental Health And Development Disorders Of Infancy and Early Childhood: DC: 0-3R, a manual designed for diagnosing difficulties (including relational problems) in very young children by the Zero to Three organization (2005). As mentioned above ICD-10 is typically used outside of North America. Psychodynamically-oriented clinicians also recently created their own manual called the Psychodynamic Diagnostic Manual (PDM; 2006)