How the DSM Came to Power: A Closer Look at the Transition between the DSM-IV and the DSM-V

By: Erin Hilliard

Released in March of 2013, the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) has been a hotly debated topic in many communities. Many stated concerns surround the ramifications of the changes in diagnostic structures, particularly regarding Autism Spectrum Disorders and Schizophrenia. What was the thought process behind these changes? How will insurance benefits, current program,s and previously diagnosed individuals be affected? In order to even begin addressing these questions, it is important to understand how the DSM is used today and to evaluate the historical evolution of the DSM as a tool for mental health diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders, often referred to as the “DSM” for short, has widespread authority, affecting numerous people and countless decisions. All workers in the mental health field – psychiatrists, psychologists, counselors and social workers – use the DSM to diagnose their patients. Health insurance providers are reimbursed based on DSM diagnoses and codes. The manual is used widely throughout the judicial system by lawyers, judges, and prison officials. Special education services are offered by public schools to children who meet DSM criteria. Even the accommodations employers are required to offer disabled employees under the Americans with Disabilities Act are affected by the DSM. Translated into many languages, the DSM has an impact on nearly all aspects of society in the United States and internationally. Yet, this wasn’t the case even thirty years ago. The DSM-III, published in 1980, was the first version of the manual to gain significant traction nationally and abroad. It would both revive and transform psychiatry while introducing to society a comprehensive new tool of communication and categorization that would give rise to considerable achievements as well as unintended consequences in the years to follow.

In order to understand the evolution of the DSM as a classificatory tool, some background knowledge on its conception is helpful. The Statistical Manual for the Use of Institutions for the Insane was the first published classification system for mental disorders. Issued in 1918 by what is now known as the American Psychiatric Association (APA) and the National Committee on Mental Hygiene, this first psychiatric nosology was predominantly a guide used to gather uniform statistics across mental hospitals. The Statistical Manual was revised ten times between the years of 1918 and 1942.[1] However, the events of World War II transformed psychiatric thinking. The existing nomenclature could not adequately describe nor account for the range of psychopathology seen during wartime. Once preoccupied with the seriously mentally ill populating state hospitals, psychiatrists became increasingly concerned with the psychological problems facing the general population. Active Personnel and Veterans Affairs psychiatrists struggled to appropriately classify the patients they worked with and began to adopt their own classification schemes to better encompass existing mental disturbances. It was evident that the Statistical Manual required an overhaul, ultimately resulting in the construction of the DSM-I.

The Diagnostic and Statistical Manual, authored by the APA, has become the primary source of standardized criteria for the classification of mental disorders. In 1949 the World Health Organization published the sixth version of the International Classification of Diseases (ICD), incorporating for the first time a section on mental disorders structured similarly to the categories devised by the American Armed Forces.[2] The APA was tasked to develop a classification tool similar to that of the military and the World Health Organization, but for use specifically in the United States. The DSM-I was approved by the APA and published in 1952. In 1968 the ICD underwent its eighth revision and in order for the coding to remain consistent across the two publications, the APA released a second, revised version of the DSM that same year. The DSM-II maintained the same overall approach as the DSM-I with a few additions, but the critical difference between the two manuals was the removal of the word “reaction” from all disorder titles. The term had previously been used to illustrate the belief that life circumstances could cause mental illness but was removed to avoid advocating for any specific psychological theories over others.[3]

It was with the release of the DSM-III, the third version of the manual since its inception, that the DSM began gaining significance outside of psychiatric research, rapidly becoming a topic of discussion in many circles. The powerful influence that the DSM holds today, not only medically but socially, culturally, and economically, arguably began with the DSM-III. There have since been four more revisions of the DSM (III-R, IV, IV-TR and V) and with each revision the purpose and goals of the manual shift also; sometimes slightly and sometimes considerably.

A number of changes were made with the introduction of the DSM-V. Some changes alter word choice while others are more substantive, adjusting disorder identification processes and even adding completely new disorders. Two of the most discussed changes are in regards to Autism and Schizophrenia. The DSM IV organized autism into three sub-groups or Pervasive Developmental Disorders (PDDs): Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorders Not Otherwise Specified (PDD-NOS). A child’s diagnosis depended on how thoroughly they met the criteria for an Autistic Disorder outlined in the DSM. The criteria were broken down into three categories: impairment in social interaction, impairment in communication, and restricted behavioral patterns. To qualify as autistic, a child needed to meet six or more of the criteria, at least two from the social category and one from both the communication category and the behavioral category.[4] Children who did not meet the necessary criteria for autistic disorder but displayed at least two social impairments and at least one behavioral limitation were diagnosed with Asperger’s Disorder. Pervasive Developmental Disorder Not Otherwise Specified was deemed appropriate when either a child showed serious impairment in one particular category and not the others, or met all of the autism disorder criteria, but the behavior was mild or appeared late in the child’s life.[5]

The DSM-V restructured the autism diagnosis, doing away with the separate classifications of Autistic Disorder, Asperger’s Disorder and PDD-NOS. Instead, Autism is now presented as one wide and continuous spectrum. Individuals will be diagnosed by level of severity: requiring support, substantial support, or very substantial support.[6] Those who do not qualify as autistic under these requirements, but still exhibit serious communication difficulties resembling those of an individual with autism, will fall under the new category of Social Communication Disorder (SCD). According to the American Psychological Association, a single umbrella disorder will improve consistency across clinics and service centers and encourage earlier childhood diagnosis while still allowing clinicians to account for symptom variation among individuals.[7]

Schizophrenia diagnosis underwent changes as well. There is now an additional symptom required to meet Criteria A for schizophrenia diagnosis and the different subtypes (paranoid, disorganized etc.) have been eliminated. There were concerns that the subtypes lacked consistency and validity. Additionally, a new chapter on Obsessive Compulsive Disorders was added to the DSM-V. This chapter includes Hoarding Disorder and Substance and Medication-Induced Obsessive Compulsive Disorder.[8] Because the DSM-V is so new, it is too early to tell what the exact impact of these structural changes will be. While there may be discussions of personal identity and proper terminology in the aftermath of the release of the DSM-V, the medical transition period will be slow moving with those effects still yet to be seen.[9]

There are many criticisms of the DSM as a whole and concerns regarding how heavily it is relied on as a guiding tool for mental health diagnoses. The issue of specific DSM-V changes aside, the public having access to any form of excessive information on a topic can be both beneficial and detrimental to society. Access to information provides opportunities for individuals to learn, grow, and improve; it gives humans agency. Too much agency in the form of over-information, however, can be dangerous as it gives people a falsified sense of power and knowledge, increasingly the likelihood of misuse and misinterpretation of that information. There is a strong argument to be made that the continual expansion of the DSM to include more criteria and more illnesses has actually caused significant societal harm though over-diagnosis, over-treatment, misdiagnosis, labeling of individuals and manipulation of the medical system.

Over-diagnosis and over-treatment are two growing concerns in the United States. The Center for Disease Control released statistics estimating that 13–20% of all children have a mental illness.[10] Autism in children has increased twentyfold, Bipolar Disorder by fortyfold and Attention Deficient/Hyperactivity has tripled.[11] In the 1980s roughly 33% of Americans met the criteria of a mental disorder.[12] One study estimates that today by the age of 21, more than 80% of young adults qualify for a lifetime mental health disorder.[13] But are mental illnesses more prevalent and more easily and accurately identified in today’s society, or do we use them to explain and fix situations that may not actually require intervention?

Philosopher Ian Hacking argues that some mental illnesses are “transient diseases”; they come into existence at a certain place and time, induced by cultural and societal norms. Hacking uses the examples of eighteenth century French hysteria and anorexia, one of which no longer exists and the latter of which was only consistently documented starting in the twentieth century.[14] An argument that inundated the anti-psychiatry movement and is still embraced today is the theory that many or all mental disorders are socially constructed; they did not exist until society gave them a name and a space within which to operate. One could go into immense detail regarding how society may induce illnesses to form, and the significant societal stigmas and struggles that can ensue. This post does not allow for an in-depth discussion of social construction and the validity of current disorders, but it is true that increased knowledge of a subject can lead to hyperawareness of behaviors and feelings. Mental illness is still stigmatized in society, but increased research and publicity of individual disorders has led to widespread acceptance and validation of their existence. When a person is both hyperaware of a situation and feels the majority of society will support his or her plights, it is likely that current standards are more easily stretched and expanded to incorporate new concerns. The number of recognized disorders has increased with each version of the DSM, offering proof that while knowledge has increased, the legitimacy filter may also have loosened.

Self-diagnosis is another cause for concern. With online symptom checkers provided by WebMD and a variety of other health advice services, self-diagnosis is becoming extremely common. It can save some people a lot of time and money by helping them diagnose simple illnesses and self-medicate with over-the-counter drugs. Doctors and nurses also benefit, allowing them to dedicate more time to patients suffering from serious ailments. However, the downside to having a large amount of accessible health criteria is it allows people to learn about a variety of illnesses and internalize the belief that they are suffering from conditions that they really are not experiencing. The rise of hypochondriasis, the persistent belief that one is becoming seriously ill, illustrates this. Affecting an estimated one in every 20 Americans who visit doctors, these individuals may be responsible for 10–20% of the country’s annual health care costs.[15] The ability to self-diagnose can lead to excess visits to physician offices and emergency rooms, burdening the health care system with additional costs that might not be justified.

In addition to misdiagnosis, there exists an increased incentive and ability to manipulate the diagnostic system. The DSM has come to hold such power and authority in the mental health world that psychiatrists and patients alike are aware they need to meet certain criteria in order to receive certain services. Patients with drug addictions can display symptoms in order to receive prescription drugs. Psychiatrists, aware of what is reimbursable and the payment differences for different diagnoses, are in a situation where they can over-bill insurance companies. Once a rule based system is put in place, it is only a matter of time before people become opportunistic and begin to test the boundaries of those rules in order to reap the greatest personal rewards possible.

It seems for the time being that we have reached a point of information saturation in regards to mental illness knowledge. Recent scientific advances in molecular biology, neuroscience and brain imaging have taught researchers a lot about how a normal brain functions, opening the door to further studies comparing unaffected brains with those of individuals with mental disorders. These new tools and discoveries are still developing though, unqualified to directly impact treatment without further testing and review. Continuing the trend of illustrating improvement by expanding the DSM with each revision, the DSM-V reorganizes and refines criteria to incorporate as much new, quality scientific information as possible. The DSM-V introduces new disorders, two of which are Mixed Anxiety Depression and Binge Eating. Many critics warn that the DSM-V dances a dangerous line between normal and mentally ill, offering even more opportunities for individuals to qualify for a mental illness diagnosis.

The DSM, with its wealth of information, became a catalyst for significant social change. Mental illnesses were defined and categorized in a scientific manner, published in a comprehensive manual available to psychiatric professionals and laymen alike. The DSM gave validity to mental disorders by providing a methodology for organizing and interpreting all existing information on each disorder, and compiling it into one collective manual. However, with continuous revisions of the DSM throughout history, the struggle exists not in whether mental illnesses are legitimate, but in distinguishing where healthy extremes end and “illness” begins. The DSM, particularly the DSM-III, heightened awareness of mental illness, but with this awareness came the unintended but inevitable consequences of overuse and misuse of that information to the detriment of society. As society moves forward so do our rapidly evolving informational tools. In the height of the technological age, the DSM will remain a cornerstone of psychiatry and continue its transformational impact on how society views, interprets, and treats mental health disorders.

Erin Hilliard graduated from the College in spring 2014 with a BA in Public Policy Studies.

  1. Gerald Grob, Origins of DSM-I: A Study in Appearance and Reality”, 148 Am. J. Psychiatry 421 (1991).  ↩

  2. DSM: History of the Manual, Amer. Psych. Assoc., online at /practice/dsm/dsm-history-of-the-manual.  ↩

  3. Id.  ↩

  4. Jill Boucher, The Autistic Spectrum: Characteristics, Causes and Practical Issues (Sage 2008).  ↩

  5. Id.  ↩

  6. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Washington 5ed 2013).  ↩

  7. DSM–5 Autism Spectrum Disorder Fact Sheet, Amer. Psych. Assoc. (2013), online at  ↩

  8. Highlights of Changes from DSM-IV-TR to DSM–5, Amer. Psych. Assoc. (2013), online at  ↩

  9. This summary is by no means exhaustive. A detailed list of changes in the DSM-V can be found online at  ↩

  10. Children’s Mental Health – New Report, Ctr. Disease Control, online at http://www.cdc. gov /features/childrensmentalhealth/.  ↩

  11. Allen Frances, Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM–5, Big Pharma, and the Medicalization of Ordinary Life 104 (William Morrow 2013).  ↩

  12. Lee Robins, et al., Lifetime Prevalence of Specific Psychiatric Disorders in Three Sites, 41 Arch. Gen. Psych. 949 (1984).  ↩

  13. William Copeland, et al., Cumulative Prevalence of Psychiatric Disorders by Young Adulthood: A Prospective Cohort Analysis from the Great Smoky Mountains Study, 50 J. Am. Academy Child Adolescent Psych. 252 (2011).  ↩

  14. Ian Hacking, Social Construction of What? 100–01 (Harvard 1999).  ↩

  15. Mary Duenwald, A New Era in Treating Imaginary Ills, NY Times (Mar. 30, 2004), online at ewanted=all&src=pm.  ↩