The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA). It is an official archive of all conditions that are formally recognized as mental health disorders.
The tool has two key features. It contains information critical for diagnosing mental disorders including:
- diagnostic criteria
The S in DSM-V stands for statistics, the second key feature. The DSM contains statistical information about each mental health condition including:
- typical age of onset
- population most affected
- effects of treatment
- most common treatment strategies
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The History of the DSM
The DSM was originally published in 1952. Since its inception, the DSM has undergone several revisions as the APA and general public’s understanding of mental pathology changes and evolves. DSM-5, first published in 2013, is the edition that followed DSM-IV (published in 1994). To date, the latest edition is the DSM-5-TR, published in 2022. This article will also explain the difference between the DSM-5 and the DSM-5-TR.
In order to categorize the mental disorders that is describes, the DSM adheres to a number of specific criteria. Ideally, it is through the DSM’s criteria that mental health professionals can stay on the same page in terms of addressing and treating various mental health conditions with a relatively consistent rate of success. Through the criteria, public health records of mental condition prevalence can be collected in a slightly more organized fashion.
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The DSM-IV-TR and the Multiaxial Diagnosis
The DSM-IV-TR, published in 2000, introduced the concept of a multiaxial or multidimensional approach to diagnostics. The specific process of diagnosis that the DSM uses for identifying mental disorders is referred to as a “multiaxial” assessment system. It was created to help clinicians evaluate different factors that impact a mental health condition including:
- psychological factors
- environmental factors
- biological factors
In the multiaxial model, different symptoms are collectively treated as potential puzzle pieces of a larger, all-inclusive picture that represents an overarching mental disorder.
Comprising the multiaxial system are five different pillars that are each sued to represent a different quality of mental disorders; these five mental disorder qualities are referred to as the “five axes”. The DSM’s axes are as follows:
- Axis I
- Axis II
- Axis III
- Axis IV
- Axis V
The first Axis, Axis I, is a measurement of all the different acute symptoms there are that necessitate immediate treatment. Within Axis I are the most widely known conditions, such as anxiety attacks and manic episodes.
Axis II refers to personality disorders and mental retardation. The term mental retardation has been replaced with intellectual disability, usually on a lifelong basis. Axis III refers to neurological or medical complications that stem from psychological conditions.
Axis IV concerns social sources of psychological stress, such as romantic fallout or loss or employment, and Axis V is a numerical rating (1-100) of a patient’s ability to function in general.
What is DSM 5? An Evolution and Important Changes
The DSM-5 emerged after some significant revisions. The most obvious is the omission of the Roman numeral system. Earlier editions were issued using roman numerals (DSM-IV or DSM V for example). The new system replaces Roman numerals with Arabic numbers. The DSM-V became the DSM-5.
Why the change starting with the DSMV? The change was made to create discontinuity from previous versions. The new system illustrates a major change in diagnostic criteria. Another advantage was the ability to create infinite revisions to the DSM as often as needed. Future versions could be ordered DSM-5.1, DSM-5.2, etc.
The DSM-5 eliminated the previous multiaxial system. This revision created categories of mental health disorders and different related disorders. Some examples of these categories include:
- depressive disorders
- anxiety disorders
- trauma and stressor related disorders
- feeding and eating disorders
- personality disorders
- elimination disorders
- paraphilic disorders
- Schizophrenia Spectrum and other psychotic disorders
- obsessive-compulsive and related disorders
- neurodevelopmental disorders
- bipolar and related disorders
Under each of these headings are specific conditions. For example, there are nine specific conditions that fall under the header of “anxiety disorders.” These include:
- separation anxiety disorder
- selective mutism
- specific phobia
- social anxiety disorder (social phobia)
- panic disorder
- generalized anxiety disorder
- substance/medication-induced anxiety disorder
- anxiety disorder due to another medical condition
Other key changes include:
- Asperger Syndrome is no longer a diagnosis. It is found under the category of autism spectrum disorder.
- Subtypes of schizophrenia were removed
- New diagnoses were added including binge eating disorder and hoarding disorder
How Providers use the DSM to Make a Diagnosis
The American Psychiatric Association created the DSM as a comprehensive resource for physicians and mental health professionals including:
- occupational and rehabilitation therapists
- forensic and legal specialists
- social workers
The DSM provides health professionals with a set of criteria to diagnose a mental health disorder. We will use the example of “Insomnia Disorder.” According to the DSM, an individual must have one or more of these symptoms:
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Early morning awakening with inability to return to sleep
The DSM goes on to specify that the sleep difficulty must be present for at least three months and occurs at least three nights per week. Additional diagnostic criteria:
- The sleep disturbance causes clinically significant impairment
- It occurs despite adequate opportunity to sleep
- It’s not better explained and does not occur only during the course of another sleep disorder
- It’s not caused by coexisting mental disorders or medical conditions
- It’s not caused by a substance or medication
DSM Implications Outside the Clinical Setting
An appropriate mental health diagnosis is just as important as a correct medical diagnosis. This is especially true when it comes to determining the right treatment (and getting it paid for!) Insurance companies often require a diagnosis when they are making payment for treatment. It’s important that clinicians and other mental health professionals make the correct diagnosis for billing purposes.
The Diagnostic and Statistical Manual of Mental Disorders issued another revision in 2022 with the DSM-5-TR. This update is the result of contributions made by over 200 professional experts. The DSM-5-TR includes:
- updated diagnostic criteria
- fully revised text and references
- updated ICD-10-CM codes
The DSM-5-TR provides a common language for clinicians to make assessments across a variety of clinical settings including:
- private practice
- primary care
Some significant changes were made with the DSM-5-TR including the use of more specific language. These include:
- The term “intellectual disability” was removed and replaced with “intellectual developmental disorder”
- The terms natal male and natal female were replaced with “individual assigned male at birth” and “individual assigned female at birth” respectively
- Terms like “Caucasian”, “minority”, and “non-white” are no longer used
- The term “race” was replaced with “racialized”
A new disorder was added, prolonged grief disorder. This new disorder is a longer lasting and more disruptive form of grief. The DSM-5-TR also adds symptom codes that allow practitioners to indicate if an individual has a history or presence of:
- suicidal behavior
- non-suicidal self-injury
- dangerous behavior that has the potential to lead to injury
These don’t qualify as a mental disorder in and of themselves but provide a way for practitioners to document symptoms.
In all, there are updated diagnostic criteria for over 70 different disorders.
Controversy And Criticisms
The DSM is recognized by many as an authoritative and reputable text on the classifications of mental disorders. There are some detractors who criticize it for leaving more objectively scientific metrics to be desired in is criteria.
The shades of doubt some have cast over the DSM have often been related the inherent subjectivity of some its claims, which could pose a challenge to any definitive claims of validity.
In addition to subjectivity in terms of defining pathological conditions, organizations such as the National Institutes of Health have also criticized the DSM for its arguable focus on superficial symptoms.
Is There a Conflict of Interest?
With the release of the DSM-5, the American Psychiatric Association instituted a financial conflict disclosure policy. Almost 70% of the DSM’s task force members reported having financial relationships with pharmaceutical companies. Only 57% of the DSM-IV task force members had pharmaceutical ties. This increase indicates that transparency doesn’t necessarily remove bias.
An article published by Lisa Cosgrove and Sheldon Krimsky in 2012 illustrates why this is concerning. When looking at mental health disorders where pharmacological treatment is the first-line intervention, an alarming number of work group members have ties to the pharmaceutical industry.
Mood Disorders- 67% of the panel
Psychotic Disorders- 83% of the panel
Sleep/Wake Disorders- 100% of the panel
They argue that the DSM task force members should be free of financial conflicts of interest. If this is not possible, at least remove these individuals from decision making roles regarding revisions or the addition of new disorders.
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Despite the controversy that it has generated, the DSM has continued to serve as a cornerstone of the psychological community. With the DSM’s criteria, distinct symptoms with ambiguous causes can potentially be treated and lessened with a smaller margin of error. On an annual basis, DSM publications have created over $100 million profit for the APA to date.