REVIEW ARTICLE
A Review of American Psychiatry Through Its Diagnoses
The History and Development of the Diagnostic and Statistical
Manual of Mental Disorders
Bernard A. Fischer, MD
Abstract: The history of the Diagnostic and Statistical Manual of Mental Dis-
orders (DSM) reflects the larger history of American psychiatry. As the field
anticipates DSM-5, it is useful to take stock of this history and consider not
only how diagnosis impacts our understanding of mental illness but also how
contemporary thought influences diagnosis. Before the DSM, the field was dis-
jointed. The publication of the first American diagnostic manual, the precursor
of the DSM, mirrored society’s interest in organized record keeping and pre-
vention rather than treatment of mental illness. The first and second editions
of DSM brought a common language to diagnosis and were largely the work
of outpatient and academic psychiatrists rather than those based in large state
hospitals. The third edition of the DSM saw the shift in American psychiatry’s
leadership from the eminent clinician to the researcher, whereas the fourth edi-
tion reflected the rise of ‘‘evidence-based medicine.’’ DSM-5 will likewise rep-
resent the current status of the fieldVnot only with regard to science but also
reflecting the place of American psychiatry in medicine today.
Key Words: DSM, diagnosis, history of medicine, psychiatry.
(J Nerv Ment Dis 2012;200: 1022Y1030)
V irtually every mental health care worker in the world is familiar
with the Diagnostic and Statistical Manual of Mental Disorders
(DSM). This diagnostic system is how the field communicates, how
research is standardized, and even how mental health services are re-
imbursed. As we anticipate the release of the fifth edition of the DSM,
it is useful to reflect on the history behind this manual. By looking at
the development of the DSM and its subsequent editions, one can see
an evolution in the thinking about mental illness. However, the history
of diagnosis in the United States also reflects the history of American
psychiatry. An appreciation of this history will not only allow an ap-
preciation of the limits and future directions of diagnosis but also
shed light on American psychiatry’s place in the treatment of mental
illness now and as the field progresses.
Two notes on this review: the first is that this is a summary
spanning decades and, by necessity, cannot completely cover all of the
influences on diagnostic thinking that faced American psychiatry.
Issues such as sex, race, the antipsychiatry movement, and how mental
illness separates from healthy extremes are important but cannot be
covered in this review in the detail these merit. Interested readers
are directed to more comprehensive works by Gerald Grob and Herb
Kutchins and Stuart Kirk for further reading. Second, in discuss-
ing the history of mental illness, it is sometimes necessary to use the
Capital Healthcare Area (VISN 5) Mental Illness Research, Education, and Clinical
Center (MIRECC), Department of Veterans Affairs, Baltimore, MD; and
Maryland Psychiatric Research Center, University of Maryland School of
Medicine, Baltimore.
Send reprint requests to Bernard A. Fischer, MD, Maryland Psychiatric Research
Center, University of Maryland School of Medicine, P.O. Box 21247,
Baltimore, MD 21228. E-mail: bfischer@mprc.umaryland.edu.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0022-3018/12/20012Y1022
DOI: 10.1097/NMD.0b013e318275cf19
1022 www.jonmd.com The Journal of Nervous and Mental Disease
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
terminology of the time even though it may be viewed as objection-
able today. Thus, terms such as asylum and insane are used in their
historical context and not meant in the stigmatizing way these are
currently viewed.
BEFORE THE DSM
In 18th-century America, each asylum had its own diagnostic
taxonomy. These systems suited the needs of the administration more
than the asylum physicianVthe position of asylum doctor was part
time, and most had a general medical practice outside the institution
(Zwelling, 1985). During this period, patients were usually divided into
broad categories such as ‘‘mania’’ (those who had the occasion to be
violent) versus ‘‘melancholia’’ (those who were nonviolent). As asy-
lums grew in size, it eventually became feasible for physicians to earn a
livelihood specializing in mental illness. As these physicians focused a
career on mental illness, they began developing their own terminology.
In 1844, psychiatry was firmly established as a medical specialty
in the United States when the Association of Medical Superintendents
of American Institutions for the Insane was founded (the organization
changed its name to American Medico-Psychological Association
[AM-PA] in 1892 and to American Psychiatric Association [APA]
in 1921.) However, despite the formation of a medical specialty, psy-
chiatrists did not have a uniform diagnostic system. Medicine, at that
time, was advancing at an astronomical pace. Although von Leeu-
wenhoek had reported his discovery of microbes in the 1680s, it was
not until 1876 that Koch demonstrated that Bacillus anthracis caused
anthrax. Suddenly, medicine was defining disease by proven causation
based on biological knowledge rather than theories based on antiquated
assumptions of the body. Asylum physicians began reporting more
definitive, physical causes for the mental illness in their patients. These
understandably included cancers and brain injuries, but even causes
such as excessive use of tobacco were diagnosed (Zwelling, 1985).
This type of reporting led to a plethora of classification schemes all
attempting to imply some biological causation of mental illnesses.
In keeping with this spirit of the times, Emil Kraepelin believed
that all mental illnesses would prove to have a biological basis. Support
for his conviction came from the discovery by Alois Alzheimer, who,
working in Kraepelin’s laboratory, demonstrated neuropathological
findings in certain cases of dementia (Alzheimer, 1906). However, in
the absence of proven pathogenesis, Kraepelin began discriminating
mental illnesses by reference to general patterns exhibited by patients
(1985). In this way, he separated manic depression from dementia
praecox. Although Kraepelin’s organizational method would eventually
revolutionize diagnoses, his techniques were virtually ignored in
America at the time. Psychiatrists in the United States went on using
multiple classification schemes, usually organized around prototypical
case studies, in which diagnosis was determined by the treatment team’s
majority vote (Barahal, 1965). Although there was little agreement in
American psychiatry on taxonomy, it did not matter much; there were
still no effective treatments for most mental illnesses and thus nothing
to be gained in ‘‘accurate’’diagnosis. However, at the start of the 1900s,
a different profession began looking into the classification of mental
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The Journal of Nervous and Mental Disease & Volume 200, Number 12, December 2012
illness and it did have something to gain: the US Census Bureau wanted
precise statistics.
As a spirit of reform began taking hold in America, the federal
government became interested in the diagnosis of individuals in
institutionsVnot just in their number. This desire for more accurate
information was in response to the idea that mental illness could
be prevented by social policy aimed at establishing ‘‘good mental hy-
giene’’ (Grob, 1991). Accurate statistics were required for compari-
sons region to region and between programs so that important patterns
might be noted. Initially, psychiatrists, represented by the AM-PA,
brushed off the Census Bureau’s interest in a standardized classifica-
tion. Having been asked in 1908 for their input, it was not until 5 years
later that the Committee on Statistics was finally formed (AM-PA,
1917; Grob, 1991). However, once called together, the committee rec-
ognized the disarray of America’s multiple classification systems. With
the census of 1920 looming on the horizon, the committee realized that
if they did not develop a uniform diagnostic scheme, the Census Bu-
reau would do it without them. Therefore, in 1918, the first American
standardized diagnostic system was issued: Statistical Manual for the
Use of Institutions for the Insane (Grob, 1991).
Although it was a step toward uniformity in classification,
the manual was not accepted by many prominent psychiatrists of
the time (Orton, 1919; Southard, 1919). Cited among its failures was
that it was too ‘‘narrow’’ in scope, meaning, as the title suggests, that
the manual was chiefly concerned with the diagnosis of patients in
asylums. Another criticism was that the same symptoms spanned sev-
eral diagnoses; thus, the scheme was ‘‘illogical’’ and ‘‘inconsistent.’’ Of
21 possible diagnoses, 18 were psychoses with some agreed-upon eti-
ology, 1 was ‘‘undiagnosed psychosis’’ (in which the psychosis could
not be attributed to a physical cause), and only 2 referred to patients
without psychosis: neuroses and ‘‘not insane’’ (conditions such as ep-
ilepsy or alcoholism without a history of psychosis; AM-PA, 1917).
The notion of presumed causation for most psychoses, in particular,
bothered the eminent Adolf Meyer. Meyer, a former student of
Kraepelin and the chair of psychiatry at Johns Hopkins School of
Medicine, had been a member of the Committee on Statistics but re-
fused to be associated with its product (Grob, 1991). Unlike Kraepelin,
he believed that all mental illnesses were on a continuum, and an
individual’s biology coupled with his/her life history determined what
‘‘reaction’’ would take placeVand thus the presentation of the illness
(Meyer, 1950).
Irrespective of Meyer’s and other’s critiques, the main limitation
of the nomenclature was that it was designed for collecting numbers
(Southard, 1919). There was still no help for the patient, or information
of real clinical utility, that depended on these diagnoses. In fact, al-
though it went through 10 editions until 1942, most clinicians ignored
the manual.
WORLD WAR II AND THE FIRST REVOLUTION IN
AMERICAN PSYCHIATRY: THE DSM
Although the 1930s and the early 1940s saw the beginnings
of psychiatry’s expansion outside the walls of large state hospitals, it
was not until World War II that this shift began to noticeably impact
the profession at large. Physicians working for the military during
World War I had recognized a condition they called ‘‘shell shock.’’
There was considerable debate over whether this condition was a re-
sponse of ‘‘normal’’ men to war or whether there was some inherent
psychopathological predisposition in some soldiers that could be wee-
ded out at the recruiting station (Wanke, 1999). The US military was
also concerned that, during peacetime, from 1910 to 1930, a ‘‘large
majority’’ of enlisted men who were given certificates of discharge
for disability were released for ‘‘neuropsychiatric conditions’’ (Kubie,
1945). The enormous mobilization as America entered World War II
therefore required an equally enormous mobilization of psychiatrists.
Many physicians who had trained in other specialties were given a brief
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American Psychiatry and the DSM
course in psychiatry and were forced into the specialty by the military
(Grob, 1991; Wanke, 1999).
Military psychiatrists were not only responsible for diagnosis at
the recruiting station but were also placed in charge of the so-called
neuropsychiatric casualties from the front. Considerable excitement
was generated at the ability of psychiatrists to treat service members by
removing them from the stressful conditions of war for a span of time
(Wanke, 1999). Might this work at home, too? Was there some simi-
larly stressful condition in American society that could be removed to
cure mental illness?
These wartime psychiatrists returned to peacetime practice with
a very different view of the field than the psychiatrists who had trained
in the state hospital system. It was painfully obvious to these returning
psychiatrists that the current ‘‘official’’ diagnostic scheme was inade-
quate for their workVmostly with outpatients and very psychody-
namically oriented. This inadequacy drove the US Armed Forces to
develop their own diagnostic systems. The army and navy each devel-
oped a nomenclature independent of the other (Grob, 1991; Raines,
1952). The Department of Veterans Affairs then developed a third
system because it would be impractical to use both the army and navy
systems. Counting a separate scheme used by the American Prison
Association (Foxe, 1938) and the latest edition of Statistical Manual for
the Use of Institutions for the Insane, there were at least five ‘‘official’’
nosologies for mental illness in use in America. The APA decided it
was time to put an end to the confusion and issue one definitive diag-
nostic system for all American psychiatry.
The makeup of psychiatrists attempting to classify mental ill-
ness after World War II was quite unlike its previous incarnation. The
number of psychiatrists who practiced outside state hospitals now
greatly outnumbered their counterparts (Grob, 1991). In addition, the
psychodynamic emphasis on conflicts between drives and external/in-
ternal stresses now colored almost every aspect of American psychiatry.
Using the Veterans’ classification system as a model, the new Com-
mittee on Nomenclature and Statistics began circulating proposed
manuals to representative psychiatrists across the United States and
Canada (Raines, 1952). After taking into consideration the replies from
241 of the 520 psychiatrists solicited, a tentative result was submitted
to the Council of the APA in November 1950.
Published in 1952, the Diagnostic and Statistical Manual,
Mental Disorders (it was not until the second edition that the word
‘‘of’’ appeared in the title; APA, 1952) separated mental illness into
two broad categories: disorders associated with an organic brain dis-
turbance and those that were not (see Table 1). Mental illnesses with
no known organic brain disturbance were diagnosed by comparison to
a general description of the disorder. These ‘‘functional’’ illnesses
were further divided into psychotic disorders, psychoneurotic disor-
ders, and personality disorders.
Several of the diagnoses included what we would now consider
problematic terminology. For example, a patient with low mood and
‘‘much uneasiness and apprehension’’ had manic-depressive reaction,
depressed type (p. 25). However, if the patient had had any previous
manic episode, the diagnosis was manic-depressive reaction, manic
typeVeven if the current episode was low mood. On the other hand, a
depressed mood ‘‘precipitated by a current situation I often associated
with guilt’’ was called ‘‘depressive reaction’’ and was a neurotic af-
fective reaction (p. 33). Thus, manic depression, a psychotic affective
reaction, was not confined to those patients who had demonstrated a
manic episode and need not involve psychosis at all.
Several points about DSM-I give insight to the field at the time:
first, every illness was termed a reactionVowing to Meyer’s influence
in American psychiatry. This was in keeping with the thought that
functional mental illness was on a continuum. Individual patients
responded differently only because their life histories differed. Indeed,
even within the same individual, stress may produce, first, a ‘‘depres-
sive reaction,’’ then, later in life, a ‘‘schizophrenic reaction.’’ Second,
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 TABLE 1. DSM: Editions, Notes on Diagnoses, and Historical Context

1024
Fischer
Chair of the APA
Publication Committee on Nomenclature Page
DSM Edition Date and Statistics Count Diagnostic Notes Historical Context
Statistical Manual 1918 Albert M. Barrett 40 Included 22 diagnoses, 19 of which were Authored in conjunction with the US National
for the Use of some form of psychosis. Others were Committee for Mental Hygiene.
Institutions for the involutional melancholia, neuroses, and
Insane (predecessor ‘‘not insane.’’ Diagnosis by comparison

www.jonmd.com
of the DSM) to general description.
Designed chiefly for reporting statistics from
state hospitals; included instructions for
determining race, economic situation, marital
status, and others. In addition, it included
guidance for reporting types of hospital employees.
DSM 1952 George N. Raines 119 Major divisions were organic versus functional Based on a system devised by the Department
mental disorder. Functional disorders included of Veterans Affairs. Designed to be of use to
psychotic, psychoneurotic, and personality disorders. psychiatrists after World War II: working in
Illnesses were ‘‘reactions.’’ Restrictions on diagnosing outpatient setting, psychodynamically oriented.
comorbidities. Diagnosis by comparison to general
description.
DSM-II 1968 Ernest M. Gruenberg 132 Ten main divisions for diagnosis. Included mental Initially meant to make the DSM compatible
retardation and mental illnesses in children. Removed with the ICDVreflected international concerns in
the term reaction. Removed the prohibition against American Psychiatry.
diagnosing comorbidities. Diagnosis by comparison
to general description.
Movement away from pronounced psychodynamic
ideas (removing ‘‘reaction’’). End of the focus on
statistics (by allowing comorbidities).
DSM-III 1980 Robert L. Spitzer 500 First manual to define a mental disorder. Introduced Initially planned because of a revision to the ICD.
the five-axis system of diagnosis. Introduced Based on the RDC of the St. Louis School of
diagnosis by checklist of features. Relegated Diagnosis; that is, reliability was the most important
neurotic diagnostic term to parenthetical note. aspect of diagnosis. Shift in American psychiatry
The Journal of Nervous and Mental Disease

leadership from ‘‘eminent clinician’’ to researcher.

Purported to be ‘‘atheoretical,’’ removed much of the
psychodynamically charged language.
Remedicalization of the specialty.
DSM-III-R 1987 Robert L. Spitzera 594 Changed axis V to a modified Global Assessment Meant to reexamine the utility of DSM-III using more
Scale. Paranoid disorders renamed delusional clinical input. Further removal of the psychodynamic
disorders; affective disorders renamed mood neurotic diagnostic terms from the manual.
disorders. Included proposed disorders in need
of further study. Neurotic diagnostic terms removed
from the main body of the manual.
DSM-IV 1994 Allen Francesb 911 Included Source Books: extensive literature reviews, Initially planned because of a revision to the ICD.
data reanalysis, and field trials. Organic mental APA faced criticism for the frequency of DSM

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
disorders renamed cognitive disorders. Added revisions/new editions. Reflected the rise of
(e.g., Asperger’s disorder) and removed ‘‘evidence-based medicine’’ in America.
(e.g., cluttering) several disorders.
DSM-IV-TR 2000 Allen Frances** 978 Updated the text in the ‘‘associated features’’ section Little change in diagnostic-related information led to
of diagnoses. critique that revision was motivated by financial
reasons.
a
The title of this position was chair, Work Group to Revise DSM-III.
b
The title of this position was chairperson, Task Force on DSM-IV.
& Volume 200, Number 12, December 2012

* 2012 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease & Volume 200, Number 12, December 2012
implied psychodynamic etiology is ubiquitous in the manual. Many
diagnoses were defined on the basis of which defense mechanisms
were used; for example, psychotic disorders used ‘‘retreat from reality’’
and ‘‘projection’’ as primary defenses against stress. Lastly, there was a
hierarchy of diagnoses that prohibited certain combinations. For ex-
ample, a psychotic disorder and a psychoneurotic disorder could not
be diagnosed in the same individual at the same time nor could two
psychoneurotic disorders. There were some disorders, such as alco-
holism, which, when present along with another mental illness, could
not be diagnosed, owing to the belief that these were only manifesta-
tions of the primary disorder. This also made gathering and reporting
statistics easier.
THE DSM-II
In 1948, the United Nations established the World Health Or-
ganization (WHO). It immediately took responsibility for the Interna-
tional List of Causes of Death, which had been published by one
organization or another since 1893 (WHO, 2004). It was renamed the
International Classification of Diseases, keeping the well-known ab-
breviation ICD. The United States was obligated by international treaty
to report its health data using the codes present in this manual. How-
ever, the DSM-I was incompatible with the psychiatric section of the
ICD (Spitzer and Wilson, 1969; Wolpert, 1969). When the international
community organized itself to produce the eighth edition of the ICD,
the APA’s Committee on Nomenclature and Statistics was charged with
updating the DSM to make it ICD compatible (Gruenberg, 1969).
Politics had more to do with establishing psychiatric termi-
nology than would be suspected from reading the introduction of the
DSM-II (APA, 1968). At the WHO’s Revision Conference, repre-
sentatives from around the world negotiated the included terminology
for every illness (Gruenberg, 1969). Although significant concessions
were given to the representatives from the United States, the APA
had few options when it came to reconciling the ICD-8 with a new
DSM: a) accept the ICD term, b) use the same code but call it something
different, c) ignore the ICD diagnosis, or d) subdivide the ICD diag-
nosis (Gruenberg, 1969). There was no option for the DSM to include
a disorder recognized in America if it was not already included in
the ICD. To assure compliance with international treaty, the final ver-
sion of the DSM-II had to be approved by three ‘‘special consulting
psychiatrists,’’ appointed by the president of the APA, who were not
themselves members of the Committee on Nomenclature and Statistics
(Gruenberg, 1969).
Within the United States, there was also political maneuvering
with regard to diagnoses in the new DSM. Although most of the United
States had accepted terminology in DSM-I, a notable exception was the
New York State Department of Mental Hygiene (Gruenberg, 1969).
Considering how many practicing psychiatrists were in New York City
alone, some pundits postulated that the real reason for the update of the
DSM was to reconcile New York and the rest of the country. Whatever
the reason, the second edition of the DSM was published in 1968.
Whereas the original DSM had only 2 main divisions, organic
and functional illness, the DSM-II had 10 (see Table 1). The order of
the groups was very specific. It was designed so that, with any given
patient, the categories could be examined one after the other until the
patient was diagnosed. For the most part, these new categories repre-
sented a rearrangement meant to highlight certain previous diagnoses.
However, a significant new aspect of these groups was the separation
of specific categories that focused on mental deficiency, now called
mental retardation, and the mental illnesses of children.
DSM-II maintained diagnosis by comparison to prototypical
descriptions and also continued to rely on psychodynamic explana-
tions for many diagnoses. It kept manic depression listed as a psychotic
disorder that did not require a manic episode for diagnosis. However,
there were some major changes. The most drastic was the elimina-
tion of the term reaction from all adult disorders. This was heralded
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American Psychiatry and the DSM
by some psychiatrists as progressVgiven that the word implied an
understanding the field did not yet have (Jackson, 1970). However, it
was a regressive turn toward ‘‘Neo-Kraepelinism’’ for others who
worried that the focus would become the disorder rather than the in-
dividual patient (Spitzer and Wilson, 1969). Other changes were the
fusion of ‘‘personality patterns’’ and ‘‘personality traits’’ into simply
‘‘personality disorders,’’ whereas the term sociopathic personality was
eliminated and divided into ‘‘alcoholism,’’ ‘‘drug dependence,’’ and
‘‘sexual deviation.’’ In addition, the preclusion of certain diagnostic
combinations was liftedVleaving the psychiatrist free to diagnose
many comorbid conditions.
In examining the DSM-II, one can see how the field was
changing in the 1950s and the 1960s. There was much more concern
for international opinionVwhich reflected both a desire for commu-
nication between countries and a greater sense of legitimacy in trans-
cending international borders. By establishing a separate section for
childhood and adolescence, the field began to consider how children
have their own unique expressions of pathology. Although psychody-
namic ideas were still incorporated in the manual, removing the term
reaction was the first step in moving toward an ‘‘atheoretical’’ system.
Finally, lifting the prohibition against certain diagnostic combinations
signaled the final end to American psychiatry’s primary focus on sta-
tistics. Concern was shifted to clinical practice.
THE SECOND REVOLUTION IN AMERICAN
PSYCHIATRY: DEVELOPING THE DSM-III
The story of the third edition of the DSM begins, oddly enough,
before the publication of the first edition. In 1952, at Washington
University, a group of psychiatric researchers established the St. Louis
School of Diagnosis (Singerman, 1981). For the next 20 years, the
group developed structured interviews, examined prognosis, and
studied families. They refined certain diagnostic criteria that lead to
exceptional reliability in establishing the presence of mental illnesses.
Their results, published by Feighner et al. in 1972 as Diagnostic Cri-
teria for Use in Psychiatric Research, became the most widely cited
article in American psychiatry’s history (Singerman, 1981; Wilson,
1993).
Although the DSM-I and DSM-II had provided a conceptual
framework for clinicians, their descriptions of illnesses did little to
ensure an individual would receive the same diagnosis by two psy-
chiatrists. Coupled with the implied psychodynamic and social expla-
nations of disorders, researchers were finding it difficult to accept
DSM diagnoses for studies. Research funding was also reflecting this
difficulty; NIMH funds had shrunk by 35% between 1965 and the time
the Feighner criteria were published (Wilson, 1993). Both the Feighner
criteria and the subsequent release of a modified version, the Research
Diagnostic Criteria (RDC), were meant to address this complaint.
However, research was not the only area within psychiatry where
funding was in jeopardy.
Insurers had initially reimbursed psychiatrists just as they did
every other medical specialty, but they soon began cutting mental
health coverage to increase profits. Case in point, Aetna began allowing
only 20 outpatient visits and 40 inpatient days per year (Wilson, 1993).
All third-party payers soon adopted this pattern of restriction of ser-
vices and carve-outs. They justified this discrimination partly because
the reliability of psychiatric diagnosis was less than that of other me-
dical illnesses. Insurers were also frustrated by paying for years of ex-
pensive psychotherapy when they had no real idea of what services
were rendered or when a patient, if ever, would recover (Wilson, 1993).
As already described, the United States was bound by treaty to
report health information using the codes present in the ICD. When
the WHO began working on the ICD’s revision, the APA organized to
again revise the DSM. In 1974, Robert Spitzer was appointed to head
the APA’s Task Force on Nomenclature and Statistics (Wilson, 1993).
Spitzer had trained as an analyst, but he had become intimately involved
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Fischer The Journal of Nervous and Mental Disease
with the St. Louis School because of his work on the RDC. He had
also served as one of the three special consultants to the committee that
had designed the DSM-II. Considering his diverse background and ex-
perience with the DSM, Spitzer seemed a most appropriate choice.
However, in examining the members of his task force, one can see
where his sympathies were: fully half of the members had some con-
nection to Washington University, whereas only one member was a
practicing psychoanalyst (Wilson, 1993). That same year, Spitzer and
Fleiss (1974) published an article lamenting the lack of reliability in
making psychiatric diagnoses and advocating the use of structured
interviews and diagnostic checklists.
A paper read at the 1975 APA annual meeting, and later pub-
lished in the American Journal, discussed the view of Spitzer’s team
(Spitzer et al., 1975). They argued that one of the main problems with
psychiatric diagnosis was a large amount of variance because of the
lack of discrete boundaries between illnesses. As an example, they cited
the description of the DSM-II diagnosis of manic-depressive disorder,
depressed type, and contrasted it with its RDC equivalent of major
depressive disorder. Whereas the DSM-II diagnosis relied on a general
account of the illness, the RDC diagnosis went by fulfilling a specified
number of features seen in the disorder. It was stressed that the inter-
diagnostician reliability of the RDC criteria was considerably superior
to that of the DSM-II. Although the paper concludes by stating that
the DSM-III would include these checklists of features along with
the ‘‘narrative definitions’’ seen in the DSM and DSM-II, the hierarchy
of the APA became concerned. It realized that it was entrusting what
should have been a relatively routine assignment to what might be a
radical group (Wilson, 1993).
Shortly after this paper was published, the APA appointed
some of its more politically minded members to a liaison committee
(Wilson, 1993). This committee was charged with reporting on the
activities of Spitzer’s task forceVespecially those that could be divi-
sive. From the beginning, the liaison committee saw problems. For one,
the task force showed no interest in making the DSM-III compatible
with the forthcoming new edition of the ICD, ostensibly the reason
for the revision of the DSM in the first place. The liaison committee
also balked at Spitzer’s notion of requiring ‘‘proof’’ before etiology
was included in the diagnosis. Did this necessarily demand the exclu-
sion of psychodynamic explanations? After all, analysts had been
working for nearly a century to unravel what was considered, albeit un-
provable, the root cause of certain disorders. Did the new DSM really
mean to ignore this work?
Although Spitzer’s team did mean to exclude psychodynamic
theory from the new DSM, they could not ignore it. Analysts from
across the country objected to its elimination, and the task force was
approached with the idea that Spitzer’s version of the DSM-III be
used only for research (Wilson, 1993). To avoid this relegation, the task
force entertained several different compromises. One was the inclusion
of a separate axis for a psychodynamic formulation. Another was a
companion volume that would explain treatment strategies, prognosis,
and etiologic theory (Bayer and Spitzer, 1985; Wilson, 1993). Although
neither of these compromises came to fruition, these appeased
Spitzer’s critics long enough for the work on the DSM-III to go on, that
is, until the task force attempted to remove the word neurosis from di-
agnostic terminology.
From the point of view of the task force, the term neurosis had
no place in a diagnostic manual. It was universally understood that
neurosis implied intrapsychic conflict that led to symptomatic anxiety
and/or depression. To accept this language would be to give endorse-
ment to a particular and, according to Spitzer’s team, unfounded view
of etiology. Even though most analysts at the time were more interested
in neurotic character (i.e., personality disorders) rather than neurotic
symptoms, they objected at the removal of this nearly century-old word
from the manual. In the opinion of analysts, removing the term neurosis
was not an attempt to make the manual more reliable but an attempt
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& Volume 200, Number 12, December 2012
to purge the field of psychodynamic theory. An example of the depth
of this concern can be seen in comments made by practicing New York
psychiatrist Howard Berk that ‘‘psychiatric textbooks and literature on
a massive scale’’ would need to be cast aside (Bayer and Spitzer, 1985).
Otto Kernberg stated the manual was ‘‘a straitjacket’’ and worried that
‘‘guns are pointed at us’’ (Bayer and Spitzer, 1985).
Some analysts’ concern was for the rich history of their profes-
sion. Some analysts’ worry was economic self-interest. After all, with
insurance companies already dubious about therapy, what would hap-
pen if psychodynamics and the bread-and-butter diagnosis of neu-
rosis were completely expunged from American psychiatry’s official
nomenclature? This controversy came to a head in 1979 when the
BaltimoreYDistrict of Columbia Society for Psychoanalysis pushed
for retention of the term. It is understandable that the issue was of
paramount importance to the BaltimoreYWashington, DC, area given
that government employees at the time had ‘‘generous [health plan]
coverage for psychotherapeutic treatment’’ (Bayer and Spitzer, 1985).
Whatever the motivations of analysts, the plans of the task force
for a new diagnostic manual were in danger. The BaltimoreYDistrict of
Columbia Society had recruited support for retaining neurosis from the
APA’s Area Three delegates: Maryland, Washington, Delaware, Penn-
sylvania, and New Jersey. When word reached Spitzer in early March
1979 that the New York delegates would also support Area Three’s
stand on neurosis, he realized that there was a real danger of DSM-III
not being accepted at the annual meetingVwhich was only several
weeks away (Bayer and Spitzer, 1985). A negotiation was attempted
in which the DSM would state that ‘‘anxiety disorders of childhood
and adolescence; some affective disorders; somatoform and dissocia-
tive disorders; and some psychosexual dysfunctions’’ were neurotic
disorders (Bayer and Spitzer, 1985). This, however, did not go far
enough to settle the dispute.
Roger Peele, the representative to the APA from Washington,
DC, suggested that the disorders labeled ‘‘neurotic’’ in DSM-II keep
their proposed DSM-III names but have the flexibility to be coded as
a neurotic disorder if the clinician chose to do so (Bayer and Spitzer,
1985). The exception to this would be the proposed ‘‘chronic depres-
sive disorder,’’ which would keep the DSM-II name of ‘‘neurotic de-
pression.’’ Spitzer’s team countered with the offer of replacing the
diagnosis chronic depressive disorder with ‘‘dysthymia.’’ An acceptable
compromise was finally reached with the insight of Dr John Talbott,
who would later go on to become APA president and to chair the
University of Maryland Department of Psychiatry. The ‘‘Talbott Plan,’’
as it came to be known, involved using the task force’s term followed
by the older, neurotic term in parentheses (Bayer and Spitzer, 1985).
Although there was still some back-and-forth about whether dysthy-
mia or neurotic depression would be the parenthetical diagnosis,
eventually, this plan was accepted at the 1979 APA annual meeting.
Published in 1980, the DSM-III was massive compared with its
predecessors. Whereas DSM-I and DSM-II were 119 and 132 pages,
respectively, the DSM-III was almost 500. It considerably expanded
the section on childhood and adolescent disorders and added eating
disorders, attention deficit disorders, and pervasive developmental
disorders. Whereas substance use disorders had their own section, al-
cohol and drug-related intoxication or withdrawal were listed as ‘‘or-
ganic mental disorders.’’ ‘‘Schizophrenic disorders’’ were a section
unto themselvesVas were paranoid disorders and ‘‘psychotic disorders
not elsewhere classified’’ (including schizophreniform disorder, brief
reactive psychosis, and schizoaffective disorder). For the first time,
manic-depressive disorder, now rechristened ‘‘bipolar disorder,’’ was
listed under an affective disorders section rather than as a psychotic
disorder. It also now required the patient to have had at least one past
manic episode for the diagnosis; if the patient presented with low mood
and had no history of a manic episode, the diagnosis was then major
depression. The affective disorders also included cyclothymia and
dysthymia in addition to atypical presentations of bipolar and major
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The Journal of Nervous and Mental Disease & Volume 200, Number 12, December 2012
depressive disorders. Each illness listed had had a history of clinical
relevance to the US psychiatrist. Some were adapted from DSM-II di-
agnoses; some were added after consultation with experts. Finally,
the manual was field-tested several times during its development using
550 clinicians and 12,667 patients (Spitzer, 1980).
DSM-III included several revolutionary changes. Whereas
DSM-I and DSM-II had used comparisons to prototypical descriptions
for diagnosis, DSM-III used checklists of features, considerably en-
hancing diagnostic reliability. The manual was also the first to define
what a mental disorder isVwhich was tremendously important in le-
gitimizing the field as a medical specialty (Zimmerman and Spitzer,
2005). In addition, the DSM-III introduced the multiaxial system. This
system was specifically designed to bring the clinician’s attention to
different areas. Axis I included ‘‘clinical syndromes’’ and the V codes
(nonillness conditions that might be the focus of clinical attention).
Axis II included personality disorders and academic skills disorders.
This separation was to make sure that the disorders listed in axis II
were taken into account in forming a complete picture of the patient.
Axis III contained physical disorders. Axis IV represented the severity
of psychosocial stressors. These were not specified but were rated as
‘‘none, minimal, mild, moderate, severe, extreme, or catastrophic.’’
Axis V was the rating of the highest level of adaptive function, not
a number but ‘‘superior, very good, good, fair, poor, very poor, or
grossly impaired.’’
As far as reconciling the DSM-III with ICD-9, it turned out that
psychiatry was not the only medical specialty that saw problems with
the ICD-9. In fact, many organized medical specialties were so dissat-
isfied with the way the ICD was constructed that the decision was
made to modify it for better use in America (Spitzer, 1980). This clin-
ical modification, or ICD-9-CM, allowed the American ICD mental
health task force to make the ICD-9 more compatible with the new
DSM. This was ironic, considering that the original aim of revising
the DSM was to make it compatible with the ICD.
A REVISION: THE DSM-III-R
DSM-III, or its quick-reference companion, was translated into
Chinese, Danish, Dutch, Finnish, French, German, Greek, Italian,
Japanese, Norwegian, Portuguese, Spanish, and Swedish (Spitzer and
Williams, 1987). It sold several hundred thousand copies and was
on the best-seller list of nonfiction books just behind the famous
Fanny Farmer Cookbook (Wilson and Skodol, 1988). Even some
analysts began extolling its virtues as ‘‘complementary’’ to a psycho-
dynamic perspective (Frances and Cooper, 1981). However, in 1983,
only 3 years after the DSM-III was published, work was started on
its revision.
Again, Robert Spitzer was chair of the work group to revise
DSM-III, and, again, he chose his team. The point of this revision was
to reexamine the utility of the DSM-III from the point of view of the
clinician. When DSM-III was being constructed, the task force not
only relied on the diagnoses researched by Feighner but also took
suggestions from clinicians who could describe a construct that
seemed useful (Spitzer, 1991, 2001). Some made the cutVsuch as
borderline personality disorder; some did notVsuch as ‘‘the atypical
child.’’ Reaction to these ‘‘untested’’ suggested diagnoses, as well as
clinical experience with the research-established ones, necessitated
a reexamination of the manual.
The team examined many suggestions from clinicians and re-
searchers. Proposed modifications were compared with empirical data
and expert opinion as well as weighed for usefulness. These were also
evaluated for whether these would fit with the expressed atheoretical
nature of the DSM-III. If these passed muster, the suggestions were
considered for adoption.
In DSM-III-R, published in 1987, the multiaxial system was
modified (APA, 1897). The severity of axis I disorders could now be
noted as ‘‘mild, moderate, severe, in partial remission/residual state,
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American Psychiatry and the DSM
or in complete remission.’’ Axis II was expanded to include mental
retardation and pervasive developmental disorders; thus, all develop-
mental disorders were now grouped together. This was more in keeping
with the idea that axis II pathology should have an early onset and
should be enduring without periods of ‘‘remission or exacerbation’’
(p. 410). Axis IV, the rating of psychosocial stressors, now required
notation of whether stressors were acute (G6 months’ duration) or
chronic. Axis V, the level of adaptive functioning, was changed from
notations of ‘‘superior’’ or ‘‘grossly impaired’’ to a modified version of
the Global Assessment Scale. This new Global Assessment of Func-
tioning (GAF) ranged from 1 to 90, with 0 being ‘‘inadequate infor-
mation.’’ Each block of 10 numbers had a description from ‘‘absent
or minimal symptoms’’ to ‘‘persistent danger of severely hurting self
or others I or persistent inability to maintain minimal personal hy-
giene’’ (p. 12).
The most striking changes in diagnostic criteria were in psy-
chotic disorders, affective disorders, anxiety disorders, and substance
use disorders. In schizophrenia, a specification that the illness begins
before the age of 45 years was removed because it was unsubstantiated.
However, clinicians were encouraged to note ‘‘late onset’’ in cases
occurring after the age of 45 years. Paranoid disorders were renamed
‘‘delusional disorders’’ because the popular term paranoid was not
in keeping with some of the nonsuspicious delusions seen in these
patients. Instead, one was to record the subtype: erotomanic, grandiose,
jealous, persecutory, somatic, or unspecified. The affective disorders
were renamed ‘‘mood disorders,’’ and one was to specify a ‘‘seasonal
pattern’’ if observed. Anxiety disorders could now be diagnosed even
when co-occurring with more debilitating axis I disorders such as
schizophrenia. In addition, substance intoxication and withdrawal were
removed from the organic mental disorders section, and, now, all drug-
related mental conditions were under one section.
Another addition to the DSM-III-R was the section on proposed
diagnoses that needed further study. These were three diagnoses that
were supported by some clinical experience and data but in which
concerns were raised about their misuseVespecially in pathologizing
women or excusing violence toward them (Spitzer and Williams, 1987).
The three were ‘‘late luteal phase dysphoric disorder,’’ ‘‘sadistic per-
sonality disorder,’’ and ‘‘self-defeating personality disorder’’ (formerly
‘‘masochistic personality disorder’’).
Curiously, the term neurosis appeared nowhere in the main body
of the manual. It was only mentioned parenthetically in the chapter
headings for anxiety disorders and dissociative disorders.
AN EXAMPLE OF DIAGNOSTIC EVOLUTION:
THE CASE OF HOMOSEXUALITY
In all areas of medicine, diagnoses are changed and refined as
new information is learned. There are many examples of an evolution
in thinking about psychiatric diagnosis. However, a prime example of
diagnostic change that also reflects the history of American psychiatry
is the case of homosexuality.
In the first DSM, homosexuality was listed as an example of
‘‘sexual deviation’’ and was categorized as a ‘‘sociopathic personality
disturbance.’’ Other examples of sexual deviation put homosexuality
in the same company as pedophilia and rape. It was not much different
in DSM-II. When sexual deviations were established as a category
separate from personality, homosexuality was elevated from an exam-
ple of ‘‘deviation’’ to a specific diagnosis with its own code.
It should be emphasized that pathologizing homosexuality
was not simply meant to reinforce social mores but was based on a real
belief among psychiatrists at this time that homosexuality was symp-
tomatic of psychological illness. However, in the 1950s and the 1960s,
evidence was slowly mounting that happy, well-adjusted lives were
not dependent on sexual orientation. Despite this, many psychiatrists
still could not believe that gay and lesbian people were not the product
of some psychopathology. At the close of the 1960s and the early
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1970s, a movement in the homosexual community began to address
intolerance. The Stonewall Riots of 1969 illustrated how many gay
men were becoming more visible and vocal about their rights. It was
in this climate that the APA decided to reexamine the assumed patho-
logy of homosexuality.
In May 1973, at the APA annual meeting, a formal session was
organized to address the status of homosexuality. Some psychiatrists,
such as Irving Bieber, were adamant that homosexuality was derived
from a pathological family with an overbearing mother and an aloof
or absent father (Stoller et al., 1973). This group cited case reports of
distraught individuals who presented to psychiatrists to be ‘‘cured’’ of
this ‘‘affliction.’’ They argued that psychiatry had done homosexuality
a favor by removing the condition from the realm of sin and placing it
in the realm of medicine. To counter this, Robert Stoller and others
voiced their belief that sexuality was on a continuum. There was ‘‘no
such thing as homosexuality’’Vonly ‘‘homosexual behavior’’ (Stoller
et al., 1973, p. 1207). As such, there was no way of drawing a line
where ‘‘illness’’ would begin. In December of this same year, the APA
Board of Trustees compromised and removed homosexuality per se
from DSM-II. It was replaced by ‘‘sexual orientation disturbance’’ in
subsequent printings. This diagnosis was to be reserved for those
‘‘disturbed by, in conflict with, or [who] wish to change their sexual
orientation’’ (DSM-III; APA, 1980, p. 380).
In DSM-III, sexual orientation disturbance was replaced by the
diagnosis ‘‘ego dystonic homosexuality.’’ This was done, in part, to
emphasize that only individuals who were distressed by their orienta-
tionVnot just inconvenienced by itVshould receive the diagnosis.
However, it was also to emphasize that the label pertained only to
homosexualsVnot to heterosexuals distressed by being straight.
When DSM-III-R was published, the diagnosis of ego-dystonic
homosexuality was not included. This recognized that, at least, in the
United States, many homosexual people go through a period in which
their sexual orientation is ego-dystonic. This marked a step toward de-
pathologizing homosexuality. However, many psychoanalytic societies
maintained a prohibition against training homosexual analysts. It was
not until 1991, with the work of Richard Isay, that the American Psy-
choanalytic Association began allowing homosexual candidates.
ON TO THE DSM-IV!
In 1988, only 1 year after the publication of the DSM-III-R, the
APA appointed a task force to prepare the DSM-IV. The scheduled
publication of a new ICD manual in 1993, and the treaty obligations
of the United States to maintain consistency with ICD codes, was cited
as the reason for a new DSM (Frances et al., 1989). This synchronicity
had also been cited as the reason for releasing DSM-II and DSM-III.
Spitzer was attached as a ‘‘special advisor’’ to the task force, but
the chairmanship went to Allen Frances. Frances was an analyst from
New York who had worked on the personality disorders section of the
DSM-III. After its publication, Frances coauthored a very favorable
article about the manual from a psychodynamic perspective (Frances
and Cooper, 1981). When the DSM-III was revised, Frances moved up
to membership in the work group properVas well as having input on
personality, mood, and anxiety disorders.
There were mental health professionals who objected to the
planned publication of DSM-IV (Ellis and Mellsop, 1990; Taylor, 1989;
Zimmerman, 1988, 1989). Mark Zimmerman, now an academic psy-
chiatrist but a medical student at the time, was one of the most out-
spoken. It would be problematic, he protested, having three different
DSMs in 12 years. He argued that there had not been enough time for
the research that would lead to changes, that resources used to reconcile
the new diagnoses with the old ones would be siphoned away from
more worthwhile work, that there was inadequate time to become fluent
in one set of criteria before these were changed, and that patients would
become frustrated if their diagnosis changed only because the diag-
nostic criteria changed. Citing studies that showed that psychiatrists
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& Volume 200, Number 12, December 2012
generally use the criteria under which they have trained, Zimmerman
postulated that the multiple editions of DSM would only cause confusion.
He was also skeptical of the need to coordinate the DSM-IV
with the ICD-10 as a reason for a new edition. DSM-III and DSM-III-R
had used codes that were compatible with the ICD-9, but the actual
names and criteria of diagnoses sometimes differed. Zimmerman
questioned whether this state of affairs truly warranted a new DSM
when the ICD-10 was published. Could the codes not be similarly
matched between the current DSM-III-R and the upcoming ICD-10?
After all, if the DSM and the ICD are so different, why publish these
at the same timeVand if these are to be made more compatible,
why would there even be a need for the DSM (Zimmerman, 1989)?
Although the task force never adequately answered these ques-
tions, the work on the DSM-IV was begun. The claim to fame of
the DSM-IV was to be extensive documentation. Although DSM-III
and its revision had relied on data from the RDC and Feighner criteria
for some diagnoses, most of the diagnoses included had been the result
of expert opinion. The DSM-IV task force was to change that by ex-
amining as many dataVpublished or unpublishedVas they could ac-
cumulate to critically review DSM diagnoses (Frances et al., 1989;
Widiger et al., 1991). About 150 literature reviews were done, and,
when information was lacking, existing data sets were reanalyzed with
support from the John D. and Catherine T. MacArthur Foundation
(Widiger et al., 1991). There were also field trials consisting of sur-
veys, videotaped field trials for reliability, and 11 focused studies
sponsored by the NIMH that examined proposed alternative criteria
sets (Widiger et al., 1991).
The resulting DSM manual was supported by the publication of
DSM-IV Source Books. These five large volumes included three
volumes of the literature reviews conducted, a volume of the data re-
analysis, and a volume on the field trials conducted. DSM-IV itself
was a hefty 886 pages. Although almost every diagnosis was slightly
tweaked, there were only a few significant changes compared with
DSM-III-R.
The organic mental disorders such as dementia and delirium
were renamed ‘‘cognitive disorders’’ because to call these ‘‘organic’’
implied other disorders, such as depression or schizophrenia, did not
have an organic basis (APA, 1994). Other changes focused on duration:
such as specifying that a month of positive symptoms were required for
schizophrenia versus 1 week in DSM-III-R or that a manic episode had
to last at least 1 week. This timing change was to increase the reliability
of diagnoses. Some diagnoses were added (notably, Rett’s disorder,
Asperger’s disorder, bipolar II, acute stress disorder, and narcolepsy);
some were removed or included under other categories (notably, clut-
tering, identity disorder, transsexualism, idiosyncratic alcohol intoxi-
cation, and passive-aggressive personality disorder).
The multiaxial system was also modified in DSM-IV. Pervasive
developmental disorders and academic skills disorders, now called
learning disorders, were removed from axis II and were placed on
axis I. Now, once again, developmental disorders were divided be-
tween axis I and II. Axis IV was now no longer just a rating of
psychosocial stressors, but the problems themselves could be re-
ported. Axis V was the same GAF, but the scale now extended to
100 instead of ending at 90.
A REVISION OF DSM-IV?
In the mid-1990s, the WHO announced that it would no
longer update the ICD on a regular 10-year cycle (Cooper, 1995). This
removed the pressure (or perhaps the excuse) to revise the DSM as
frequently as it had been. Consequently, DSM-5 was scheduled for
publication in 2010 (now delayed by several years). There was to be
no modification of diagnostic criteria until then. However, the APA
made the decision to update the text associated with each diagnosis on
the basis of research conducted from 1992 to 1998. To avoid confusion
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The Journal of Nervous and Mental Disease & Volume 200, Number 12, December 2012
with DSM-IV, and to prevent it from being considered a DSM-IV-R, it
was called DSM-IV-TR for ‘‘Text Revision’’ (First and Pincus, 2002).
‘‘Most of the changes made in the DSM-IV text were in the
‘associated features’sections, which included subsections on associated
laboratory findings; culture, age, and gender features; prevalence;
course; and familial pattern’’ (First and Pincus, 2002, p. 289). There
were also minor corrections in the wording of the criteria related to
pervasive developmental disorders, tic disorders, and paraphilias (APA,
2000). DSM-IV-TR included a change in how complicated dementias
were recorded. For example, instead of diagnosing Alzheimer’s disease
with depressionVthere would be two diagnoses: Alzheimer’s disease
and depression caused by a general medical condition.
The question that arises is whether these modifications deman-
ded an issuance of a new DSM, whether these could have been released
as bulletins or just updated in subsequent printings of DSM-IV. Re-
member, DSM-III was a best seller, and, by the early 1980s, the APA
had shifted its organization so that most of its funds came from pub-
lications (Wortis, 1984). In addition, the DSM is not only in use do-
mestically. A 1991 survey showed that the DSM was more popular
internationally than the ICD (Maser et al., 1991). There is also a score
of support books published along with the DSM: the DSM primary care
text, DSM desk reference, DSM quick reference, DSM classification
sheets, DSM guide books, DSM handbooks for differential diagnosis,
DSM casebooks, DSM clinical interview books, DSM study guides, and
even an electronic DSM. It has not escaped notice that the APA makes
a substantial profit with each new DSM released. In fact, Zimmerman
(1989) has pointed out that the APA should sell the DSM at cost to
address this very real critique.
CONCLUSIONS
As the field prepares for DSM-5, it is useful to consider the
history of this manual and how it reflects the history and contemporary
status of American psychiatry. The Statistical Manual for the Use of
Institutions for the Insane had chiefly been concerned with numbers.
As therapy or chlorpromazine proved useful in various mental illnesses,
more effort was put into making general distinctions between psychotic
and nonpsychotic conditions. DSM-I, and DSM-II even more so,
represented this shift toward a more clinical mind-set. However,
DSM-III signaled another change in mind-set. In the late 1970s, the
leaders in the field were no longer eminent clinicians but were
researchers. Advancement of mental health was linked tightly with
ever-greater knowledge about disorders. This knowledge could only
be supplied by rigorous investigationVespecially because the art
of medicine was replaced by ‘‘evidence-based practice.’’ The im-
portance of a research base and reliability across diagnosticians
has continued in the subsequent DSM texts.
Another aspect of American psychiatry reflected in the devel-
opment of the DSM-III was regarding finances. Although DSM-III may
have succeeded in rescuing research funding in America, DSM-III did
little to prevent insurance discrimination. In fact, despite warnings in
the DSMs since DSM-III-R that criteria sets are not to be used by those
untrainedVand that clinical diagnosis does not have to be strictly met
by criteriaVmental health professionals often find themselves justify-
ing diagnoses to untrained insurance reviewers criterion by criterion.
This would certainly not be the case if diagnosis were made by Gestalt
impression as in DSM-I and DSM-II. However, without the tangible
criteria of DSM-III, insurance companies might have totally eliminated
mental illness coverage by now.
A final reflection of American psychiatry seen in the DSM-III
was its ‘‘remedicalization.’’ During the time of DSM-I and DSM-II,
analysts often distanced themselves from medicineVmany even re-
fusing to prescribe medications. As other mental health professionals
began offering therapy, psychiatrists found themselves working to
keep their relevance. The DSM-III offered a model of mental illness
much more akin to medical diagnosis. It was reliable and took into
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American Psychiatry and the DSM
consideration signs and symptoms. Psychiatrists again found a niche
with medications such as neuroleptics and tricyclicsVwhich required
some expertise to prescribe.
What aspect of American psychiatry will be reflected in DSM-5?
We are in an age where nonpsychiatrist physicians, nurse practitioners,
and physician assistants are comfortable prescribing medications such
as serotonin reuptake inhibitors and atypical antipsychotics. Indeed,
the approved indications for these medications are so broad that one
could argue whether little diagnostic acumen is even necessary for their
use. Another traditional role of psychiatrists, providing therapy, is
now frequently done by master’s level clinicians as patients become
‘‘clients.’’ So what is the role of the psychiatrist? The APA is unique
in that it is the only medical specialty organization that controls and
produces its own diagnostic manual. Perhaps, a new edition of the DSM
is a tangible way for American psychiatry to keep hold of its place in
mental health.
DISCLOSURES
The author has received research funding from the NIH, the
Department of Veterans Affairs, and the Brain and Behavior Research
Foundation.
The author declares no conflict of interest.
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