Anyone with any degree of experience in mental health and care for mentally ill people, from the most Google-happy layman to the most experienced MSN-PMHNP (Master of Science – Psychiatric Mental Health Nurse Practitioner) graduate knows about the Diagnostic and Statistical Manual of Mental Disorders, or DSM.
Currently in its fifth edition, the DSM has been the diagnostic standard for mental illnesses since 1952. Since then it has undergone numerous changes, revisions, and updates. Today we’re going to look at the history of the DSM, how its contents have changed over time, and the circumstances surrounding these changes.
The Beginning
The DSM traces its origins back to the 1800s, a time when treatment for the mentally ill or intellectually disabled was draconian and often abusive. However, it soon became apparent that the treatment methods at these “asylums” were not fixing anything, as more and more patients kept filling up the hospitals. This signaled the need for dramatic changes, and soon hospitals began to focus on what they termed “moral treatments.”
However these methods were still largely ineffective, and to properly treat mental illnesses and conditions, they had to be studied and classified.
Currently, the first recognized attempt comes from French psychiatrist Jean-Etienne-Dominique Esquirol, who published his work Des Maladies Mentales, Considérées sous les Rapports Médical, Hygiénique, et Médico-Légal (Mental illnesses, considered from medical, hygienic, and medico-legal perspectives) in 1839. More than 40 years later, a German psychiatrist named Emil Kraepelin developed his mental illness classification with Compendium der Psychaitrie (Compendium of Psychiatry) in 1883.
Expansion, Revision, Implementation
These early classification attempts provided a solid base for medical science to leap from. However, it was not without some difficulty. Records from mid-1800s America show significant confusion on the part of clinicians using these new classifications, and as a result, there was an excess of inaccurate, ineffective diagnoses and therefore treatment.
In 1917, the American Medico-Psychological Association (now called the American Psyhiatric Association or APA), along with the National Commission on Mental Hygiene pooled their efforts to develop what would become the primary resources at the time for mental illness diagnosis and treatment. The APMPA assigned their Committee on Statistics to analyze patients with mental illness, and the result was the Statistical Manual for the Use of Institutions for the Insane was created.
This publication was groundbreaking, but far from complete, and this early ancestor of today’s DSM would go through 10 major revisions until 1942. However, there are flaws within it that may not have been so apparent then. Namely, Freud. Although Freud is often credited as the father of psychotherapy and psychoanalysis, the issue with being the “first” of anything is that it is rarely the best.
Freud was a heavily biased therapist, prone to misdiagnosing women, prescribing (and imbibing) cocaine as a form of treatment, and dismissive of conditions and experiences that did not fit his research. This Statistical Manual for the Use of Institutions for the Insane was heavily based on Freudian psychology, and as a result, it was far from perfect. At the time, however, it was the most cutting-edge manual on mental illness diagnosis. Partially because it was the only one of its kind.
The Dawn of the DSM
The first edition of the DSM was the DSM-1 and was published in 1952 by the APA. The purpose of the new manual was to further reduce the confusion around mental illness diagnosis and to narrow the number of proposed treatment solutions for these conditions so that patients could receive good care.
These diagnostic criteria were extremely broad and still based on Freudian Psychodynamic principles. However, despite its shortcomings, this was the document that would set into motion our modern understanding of mental illness and its diagnostic criteria.
When the deficiencies of the DSM-1 were sufficiently evident, work on the revision and expansion of the manual came into full swing, and in 1968 the DSM-2 was published. Despite the Freudian principles evident in the work, these practices were losing popularity around this time, and the two major modifications present in the DSM-2 included an expansion of the “mental illness” definition, and increased categorization that allowed for more accurate diagnostic categories.
Despite its advances, the DSM-2 attracted heavy criticism in the 60s and 70s. Complaints included that the DSM did not seem to consider mental illnesses actual illnesses and that there was next to nothing in the way of differentiating “normal” behaviour from mentally ill symptoms.
The implementation of different research tools, as well as feedback from the medical community and mental health sector led to the next revision of the manual, the DSM-3 in 1980. This revised version included 265 diagnostic categories and replaced certain psychiatric terminology with biological terminology. In other words, mental illness was being treated as clinical illnesses for the first time. This edition was revised again and re-released as the DSM-3-R, expanding the diagnostic categories to 292, and reaching a whopping 567 pages of content.
In 1994, the next revision called the DSM-4 was published, providing information on 297 disorders over a huge 886 pages, and was the first edition to stress “clinical significance”, i.e., the difficulty that a mental illness presented to a patient. This edition was revised similarly to the DSM-3 in the year 2000, newly titled DSM-4-TR. This edition used a diagnostic system of 5 pats to assess several diagnostic dimensions concerning mental illness.
Where We Are Now
The DSM-5 is the most recent version of the diagnostic manual and was released in 2013. Major changes included the deletion of certain conditions, as further research and expanded understanding of numerous “illnesses” revealed themselves to be something else, or merely a “version” of another disorder. Additionally, the five schizophrenia subtypes had been deleted and conceptualized as a single disorder, while other disorders were given their category or completely changed. The DSM-4-TR’s diagnostic system was also abandoned.
Currently, the DSM-5 represents the best mental illness diagnostic tool we have. Although its origins can be traced back to the 1800s, the document is still very young, and as a diagnostic tool, many professional bodies find it distinctly lacking, not least due to the sheer length of time it takes for major revisions to the document to be made.
However, despite criticism, the DSM-5 is representative of a world trying to understand the people within it, and although there are areas of improvement that need to be made, the fact is that there are millions of people today living with mental illness, who are functioning better due to the research and diagnostic criteria outlined therein.
