Diagnostic and Statistical Manual of Mental Disorders (DSM)

The DSM (Diagnostic and Statistical Manual of Mental Disorders) is a book compiled by the American Psychiatric Association that describes all currently identified mental health problems that may receive a formal medical diagnosis in the United States. Its most recent revision, the DSM-5-TR, was published in 2022.

DATE: 1952 forward

TYPE OF PSYCHOLOGY: Psychopathology

Introduction

The (DSM) is the primary classification scheme used to describe mental disorders identified in psychiatric practice in the United States; it is revised periodically. The manual, compiled by the American Psychiatric Association, provides a standardized definition and a numerical code for each of the mental disorders described. These codes are currently designed so that the majority of the DSM is consistent with the International Classification of Diseases (ICD), which is published by the World Health Organization (WHO). Whereas the ICD is used internationally, the DSM is used primarily in the United States, representing an American perspective on the classification of mental illness.

The 2022 revision of the DSM (referred to as the DSM-5-TR) features descriptions of general classification areas of mental health problems. These areas are clustered under the categories neurodevelopmental disorders; schizophrenia and other psychotic disorders; bipolar disorders; depressive disorders; anxiety disorders; obsessive-compulsive disorders; trauma- and stressor-related disorders; dissociative disorders; somatic symptom disorders; feeding and eating disorders; elimination disorders; sleep-wake disorders; sexual dysfunctions; gender dysphoria; disruptive, impulsive control, and conduct disorders; neurocognitive disorders; personality disorders; paraphilic disorders; and other mental disorders.

With the exception of the last general area of other mental disorders, all other cluster areas mentioned are known mental disorders that manifest themselves with identifiable behavioral, biological, cognitive, emotional, intrapersonal, social, or other features. The last general category, however, refers to problems that exhibit symptoms of mental disorders and cause distress in one or more areas of life, such as employment or social interactions, but do not meet the full criteria for diagnosis of other mental disorders. The category also covers mental disorders that are caused by medical conditions such as brain injury or trauma.

Types and Symptoms

Within all other areas of disorders mentioned, many types of disorders are listed. Each of these types is discrete, meaning that it is unique relative to the other disorders in that area. In this way, each disorder may be thought of as a category, or grouping, into which the symptoms of concern either fit or do not fit. While there may be a continuum, or range, of symptom severity within any category, the severity is less important in rendering a diagnosis than in making sure that the type and number of necessary symptoms are present.

Each specific symptom helps to define each unique mental disorder. In some cases, the same symptom may be identified as part of several different disorders. For example, depressed mood is a symptom associated with several mood disorders. For a particular disorder to be identified, the symptoms must occur in particular groupings, particular numbers of groups, or with specific consequences. When such conditions are met, an individual’s symptoms will be described as meeting the diagnostic criteria for a particular disorder. Diagnostic criteria are standard elements that must be included in a group of symptoms to allow for a judgment of its presence or absence. Some disorders are composed of multiple types of symptoms, such as behaviors, thoughts, and feelings. An individual might be required to have particular types of disrupted behaviors, thoughts, and feelings to qualify for a given disorder. If only disrupted behavior and feelings are present, but not thoughts, the diagnostic criteria might not be met.

Some disorders also have specifiers or rating scales for severity of symptoms in order to take into account differing approaches to treatment based on the specifying symptoms and the level of their severity. For example, a diagnosis of autism spectrum disorder is given if there is significant impairment during the early developmental period with long lasting deficits in communication and social interaction and repetitive behaviors and interests. The diagnosis is made more specific by denoting whether these symptoms occur with or without intellectual impairment, with a known medical or genetic condition, or whether they are associated with another neurodevelopmental or behavioral disorder. Other disorders are denoted as having additional slight variations through the means of diagnostic specifiers, or distinctions of variation with a particular type of disorder for one or more symptoms. An example would be bulimia nervosa, an eating disorder that has a purging and a nonpurging type identified by a specifier.

In general, each disorder demonstrates clinical significance, meaning that the disorder is causing distress or impaired judged that is important enough to warrant treatment in the eyes of the professional evaluator. Individual mental disorders are known to have specific sets of symptoms and a specific course, or pattern of development, of the disorder over time. The course of a disorder provides a picture of how the symptoms might be expected to evolve. Each disorder also has a known prevalence, or incidence rate, and is formally distinguished from similar disorders through a process called differential diagnosis.

Finally, in the DSM system, similar disorders are grouped together into twenty categories with additional subsets that are divided further within a category. For example, mood disorders are divided into two separate sections: Depressive Disorders and Bipolar and Related Disorders. The section on obsessive-compulsive and related disorders also includes compulsive hair pulling and hoarding. Also, despite the fact that anxiety is a symptom of many different disorders, there is a separate section in the DSM-5-TR for anxiety disorders that has been further separated into sections on panic disorder and generalized anxiety disorder.

Importance

It is important to have standard diagnostic definitions for mental illnesses in order to provide effective communication between clients and practitioners and to foster effective treatment planning and outcomes. The diagnostic terminology of the DSM-5-TR allows professionals to communicate clearly with one another about their clients’ symptoms. It also allows clinicians and researchers to communicate in their efforts to develop new interventions or to investigate emerging symptoms. Similarly, the DSM-5-TR nomenclature allows professionals to communicate with insurance agencies and others interested in the financial management of mental health problems. Standard diagnoses also allow for good communication among professionals, their clients, and the families of those afflicted. More generally, standard diagnoses facilitate the matching of problems to treatments. This process is similar in other areas of medicine. For example, abdominal pain is a common symptom, but depending on the other symptoms present at the same time, it might be treated with a change in diet or bed rest (for indigestion or the flu) or surgery (for appendicitis). The difference depends on the diagnosis.

History

As long as there has been health care, there has been a need for some sort of classification system to describe different mental health conditions. The first attempt to describe mental health problems in the United States occurred in the 1840 census, when officials tried to track the presence or absence of problems characterized by mental deficiency, such as insanity or idiocy. Forty years later in another census, seven categories of problems were included. In the ensuing seventy years, as mental hospitals increased in number and psychiatric conditions related to war garnered attention, the beginnings of the DSM took shape.

The DSM has evolved in the years since its original edition, published in 1952. It was followed by a second edition, DSM-II, in 1968; a third edition, DSM-III, in 1980; a revised third edition, DSM-III-R, in 1987; a fourth edition, DSM-IV, in 1994; a text revision, DSM-IV-TR, in 2000; and the fifth edition, DSM-5 in 2013. The manual is an evolving document because knowledge and information about psychiatric disorders grows daily. Between the original version of the DSM and DSM-II, for example, recognition increased concerning the need for explicit definitions of the conditions described so as to promote diagnostic reliability. Between DSM-II and DSM-III, an effort was made to coordinate the DSM with the ICD (International Classification of Disease) system. With DSM-III-R, changes were made to incorporate findings from statistical research. Similarly, DSM-IV updated the manual with an even greater emphasis on statistical data, clinical usefulness, and test characteristics such as reliability and validity. With DSM-IV-TR, changes were made to bring the manual into even better alignment with the ICD, as well as to allow for updated information regarding prevalence and biological data relevant for diagnosis.

Published in 2013, the DSM-5 changes include a greater integration of neuroscience, genetics, and research on cognition. This edition also moved away from the multiaxial system of diagnosis that was present in the DSM-IV and DSM-IV-TR, which many clinicians were not using, and makes the DSM-5 more in line with WHO (World Health Organization) and ICD diagnosis methods. The DMS-5-TR, published in 2022, updated the DSM-5 by clarifying diagnostic criteria, adding new references, and updating the codes for suicidal behavior. It also includes a new disorder, prolonged grief disorder, and integrates considerations of the impact of racism and discrimination on mental health.

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