The History of Psychiatric Classification

1
The History of Psychiatric Classification
The DSM 50 Years of Change

• Gina LoCascio
• History Systems
• April 7, 2008

2
Before the DSM Classification in the Ancient
World
The first recorded depiction of mental illness.
3000 B.C

• Description of the syndrome senile dementia

Sumerian Egyptian reference
2600 B.C
mental illness in the Ebers Papyrus

• Melancholia Hysteria

The oldest known attempt to systematically
1400 B.C
classify presentations in mental illness.

• Ayur-Veda System of medicine in ancient India

• Disorders were grouped based on 7 kinds

of demonic possession
Sources First, Frances, Pincus, 2004
3
Before the DSM Classification in the Ancient
World
460-377 B.C.
HIPPOCRATES
First to place psychiatric conditions within the
secular and naturalistic domain of medicine.
He identified 6 conditions
(1) Phrenitis (2) Mania (3) Scythian disease
(4) Epilepsy (5) Hysteria (6) Melancholia
Provided what amounted to a 2nd diagnostic axis
He noted 4 temperaments
(1) Choleric (2) Melancholic
(3) Sanguine (4) Phlegmatic

• Similar to personality traits

Sources First et al., 2004
4
Before the DSM Classification Until the 15th
Century

• Over the next 10 centuries, Hippocrates list of
  6 conditions was extended further
  differentiated.

• Culminated in classification proposed by Paul of
  Aegina (624-700 AD)

Hippocratic observation and empiricism
- vs. -

• Two approaches

Platonic rationalistic search for universal causes

• 15th century Sydenham (father of modern
  medical thinking) rejected the notion that a
  single dysfunction was the root of all problems.

• Instead, he hypothesized that each disease had
  an individual existence with a uniform
  presentation in different individuals.

• He proposed that diseases should be observed
  classified in the same way that botany was
  beginning to classify plants (i.e. system
  proposed by Boissier de Sauvages in which he
  classified 2,400 species of diseases)

Sources First et al., 2004
5
Before the DSM Classification in the 18th 19th
Centuries

• Boissier de Sauvages nosology was seen as
  complex impractical

• 18th century Movement towards a more simplified
  system

• A less systematic, more clinical approach to
  classification emerged

• Practical rule of thumb lists focusing on
  relevant clinical types

• Key Individuals Philippe Pinel, Jean-Dominque
  Esquirol

• 18th 19th centuries Movement towards organic
  etiologies

• Key Individuals Benedict Morel, Paul Broca,
  William Griersinger

• 1840 - US Census Initial attempts at formal
  psychiatric classification

• Idiocy and Insanity- Label given to
  individuals who were considered by health
  professionals to have mental illnesses.

• Normals - Identified all other individuals

• 1880 - Gvt. Re-classified System 5 additional
  categories

Sources First et al., 2004 Gaines, 1992
Malik Beutler, 2002
6
Before the DSM Classification in the 18th 19th
Centuries
1856-1926
EMIL KRAEPELIN

• German clinical/experimental psychiatrist

• Studied with Wundt Conducted pharmacological
  experiments

• Synthesized classification approaches from late
  19th century

• Compiled disorders in Compendium der Psychiatrie
  (1883) 9 editions in 40 yrs.

• In his books, he argued that psychiatry was a
  branch of medical science should be
  investigated by observation/experimentation

• He believed that all mental illness had an
  organic cause

• The structure of his classification system
  formed the basis for current psychiatric
  nosologies such as the DSM

Sources Alic, 2001 First et al., 2004
Müller, Fletcher, Steinberg, 2006
7
Before the DSM Classification in the 18th 19th
Centuries
1866-1950
ADOLF MEYER

• Swiss neuropathologist, psychiatrist,
  professor

• 1892 - Emigrated to the United States

• Largely responsible for the introduction
  dissemination of Kraepelins classification in
  the US.

• Embraced Kraeplins emphasis on prognosis for
  its applicability to treatment however, he had
  scientific concerns regarding the

• Generalizability from large groups of cases to
  the individual.

• Establishment of disease entities in the absence
  of empirical support

• He eventually proposed his own classification
  system

• Based on the notion of reaction types
  Disorders viewed as pathological reactions of the
  individual to environmental stressors.

Sources First et al., 2004
8
Before the DSM Classification in the 18th 19th
Centuries

• Other influences on classification

• Bleuler Combined Kraepelin Meyerian approaches

• Freud Classified neurosis (anxiety, depressive,
  hysterical, obsessive-compulsive)

• Health Records Asylums began developing their
  own classification systems intended primarily for
  the purpose of keeping statistics on their
  patients.

• Late 19th century Committee on Statistics of
  the American Medico-Psychological (became the
  American Psychiatric Association APA in 1921)
  was founded by a group of medical doctors.

• Concern that the lack of a uniform
  classification system would inhibit science by
  preventing accurate comparisons among patient
  groups

Sources First et al., 2004 Houts, 2000 Malik
Beutler Mendelson, 2003
9
Before the DSM Classification in the 20th Century
APA develops a diagnostic system listing 59
mental disorders
1917
1934
APA makes revision to classification
By the 1940s and following WWII, military
clinicians found little practical use for the
APAs diagnostic system
1940s
In response, General William Menninger chaired
the committee for the writing of a new
classification system, Medical 203
1943
Did not receive widespread attention-Used by a
few clinicians
APA did not officially support the document
1948
6th edition of the International Classification
of Diseases (ICD-6)
Propelled the APA Committee on Nomenclature to
develop an alternative to the ICD-6 for use in
the US
Sources Gaines, 1992 Houts, 2000 Widiger,
2004 Wilson Skodol, 1994
10
The Creation Emergence of the DSM
APA Committee on Nomenclature produced 1st draft
of the Diagnostic Statistical Manual of Mental
Disorders (DSM)
1950
First edition of the DSM (DSM-I) was published
1952
106 diagnoses - Characterized primarily as
reactions to psychological, social, and
biological factors
Heavily reflected psychodynamic thought
Ironically, despite the lack of initial attention
paid to Medical 203, the DSM-I was heavily
influenced by the document
Many of the passages were virtually identical to
Medical 203
Sources Gaines, 1992 Houts, 2000, 2002
Kutchins Kirk, 1995 Malik Beutler, 2002
Mayes Horwitz, 2005 Rentoul, 1995 Widiger,
2004 Wilson Skodol, 1994
11
Beginning Revisions DSM-II
1968
The first official changes were made to DSM
Rationale for DSM-II To conform to the system
used in the ICD
Published Edition
Continued to reflect the influence of
psychoanalysis Medical 203
DSM and DSM-II were strikingly similar to one
another
Symptoms conceptualized as reflecting underlying,
internal conflicts
Changes
Number of diagnoses from 106 to 182
diagnoses
In response to critics removed
reaction/reactive
Influences
Views of dominant 20th century psychiatrists
psychoanalysts
Meyer Menninger significantly shaped the
creation of both editions
Sources Gaines, 1992 Houts, 2002 Kutchins
Kirk, 1995 Malik Beutler, 2002 Mayes
Horwitz, 2005
12
The Beginning of the DSM Controversies DSM-III
1980
The third edition of the DSM (DSM-III) is
published
Rationale for DSM-III To retain conformity
with the newest ICD
Published Edition
Reflected a shift from a theoretical paradigm to
a medical model
Changes
Number of diagnoses from 182 to 265
diagnoses
In response to critics attempts at a
data-driven DSM
Multiaxial system - Focused on
Influences
symptoms rather than causes
1970s Ongoing struggle for power within the
professional field
Psychiatrists wanted the profession to be more
scientifically-oriented
Increased power of neo-Kraeplinian,
research-oriented psychiatrists who felt the
psychodynamic orientation to be unscientific
Sources Gaines, 1992 Houts, 2000 Kutchins
Kirk, 1995 Mayes Horwitz, 2005 Rogler, 1997
Widiger, 2004
13
Professional Political Controversies DSM-III
ROBERT SPITZER Chair of DSM -III Task Force
Task Force Chose professionals primarily
committed to medically-oriented research - Mostly
white male senior psychiatrists
Neurosis Controversy
Intended to delete neurosis felt had no
empirical basis
Due to opposition from psychodynamic
psychiatrists, APA Board of Trustees threatened
not to publish DSM-III unless neurosis was
included
Task force reinserted neurosis back before
final draft was published
Homosexuality as a Mental Illness
After protests, homosexuality was removed by vote
(1974, 7th printing of DSM-II)
As chairman, Spitzer was influential in the
decision to retain a diagnosis for homosexuals
experiencing distress over their sexual
orientation
Thus, the diagnosis of ego-dystonic homosexuality
appeared in DSM-III
Sources Houts, 2000 Kutchins Kirk, 1995
Mayes Horwitz, 2005 Rogler, 1997
14
Political Economic Controversies DSM-III
Managed Healthcare
Late 1960s Standard practice of medical
insurance companies to request a DSM diagnosis
before reimbursement will be made
Landmark case (1980) U.S. Court of Appeals ruled
against Blue Shield for refusal to pay clinical
psychologists unless billed through a physician.
Blue Shield reps pleaded with Spitzer to
standardize DSM-III so insurers could separate
legitimate mental illnesses from
non-psychiatric problems
Managed Healthcare PTSD
Vietnam War Vets often denied psychological
services because insurers would not reimburse for
problems that did not have a DSM diagnosis
Only after a 10 yr. political campaign of vets
a few psychiatrists did war-related stress
reactions become recognized in the DSM-III.
Despite claims that DSM-III was data-driven,
empirical literature was not the primary point of
contention in deciding the fate of PTSD . . .
Sources Albee Joffee, 2004 Gaines, 1992
Houts, 2000 Mayes Horwitz, 2005 Rogler, 1997
Zur Nordmarker, 2006
15
More Revisons DSM-III-R
1983
Robert Spizter task force begin working on
revisions
1987
The third edition-revised of the DSM (DSM-III) is
published
Rationale for DSM-III-R To increase
reliability validity
Published Edition
While revisions were intended to be few, several
diagnostic categories were renamed/reorganized,
significant changes made to diagnostic criteria.
Changes
Number of diagnoses from 265 to 292
diagnoses
In response to critics renamed reorgainized
Influences
Robert Spitzer DSM task force
External pressure from various sources
Sources Gaines, 1995 Houts, 2002 Kutchins
Kirk, 1995 Malik Beutler, 2002 Rentoul, 1995
Widiger, 2004
16
More Controversies DSM-III-R
Lack of Empirical Data
27 new diagnoses Drastic increase in of
diagnoses b/t DSM III DSM-III-R was much larger
than could be explained by research literature
Sleep Disorders (listed in the appendix of
DSM-III ) Promoted to mental disorders in
DSM-III-R based on a vote not results from new
research
Despite forces insistence of a scientific basis,
they were placed in a new appendix, Proposed
Diagnostic Categories in Need of Further Study
Political Social Pressures
Confrontations with feminists Resulted in
removal of paraphilic rapism,self-defeating
personality d/o, premenstrual dysphoric d/o
Removal of ego-dystonic homosexuality Spitzer
admits that homosexuality was not included or
removed from DSM-III-R on empirical grounds, but
became an issue based on inherent heterosexual
biases
Sources Gaines, 1995 Houts, 2002 Kutchins
Kirk, 1995 Spitzer, 1981 as cited by Rogler, 1997
17
A Major Change DSM-IV
1988
Work on DSM-IV began a year after DSM-III-R
1994
The fourth edition of the DSM (DSM-IV) is
published
Rationale for DSM-IV To retain conformity with
ICD-10
Published Edition
Detailed system of diagnostic criteria, change to
Axis IV
Changes
Number of diagnoses from 292 to 365
diagnoses
In response to critics Significant changes to
the revision process itself
Appointed Allen Frances as the new chairman
Established a task force of several hundred
mental health professionals
Effort to include women, minorities,
psychologists social workers
Sought to adhere to a more rigid empirical
approach
Stated primary objective of the was to move
beyond expert consensus
Sources Frances Egger, 1997 Houts, 2002
Kutchins Kirk, 1995 Malik Beutler, 2002
Widiger, 2004
18
Influences Motivating Change DSM-IV DSM IV-TR
While APA stated that new diagnoses had to meet
rigorous scientific tests for inclusion in
DSM-IV, most were carried over from earlier
editions
APA admitted that most of them did not meet the
new standards
A few years after publication, announcement to
revise the text was made
Fourth edition-revised of the DSM (DSM-IV-TR) is
published
2000
Currently translated in 22 languages
Published Edition
The 50-page increase from the DSM-IV reflected an
effort to include the growth that occurred in
research knowledge
Changes
Number of diagnoses 365 diagnoses (no diagnoses
added)
In response to critics Added cultural, ethnic,
age group variations
and new lab and physical findings
Sources Houts, 2002 Kutchins Kirk, 1995
19
Understanding 50 Years of Change
In 50 years 800 increase in the number of
diagnoses
DSM-II 182 disorders
134 pages
494 pages
DSM-III 265 disorders
567 pages
DSM-III-R 265 disorders
886 pages
DSM-IV 365 disorders
DSM-IV-TR 365 disorders
943 pages
The large increase in diagnoses (particularly in
the last 30 years) and poor reliability
validity of DSM-based research has attracted much
criticism
Argued that the increase in scientific knowledge
cannot explain expansion
Sources Houts, 2000, 2002 Kutchins Kirk,
1995 Zur Nordmarker, 2006
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Criticisms of the DSM
The DSM More of a Political (and economic) Art
Than a Science
Pharmaceutical companies have played a big part
in maintaining a medical model classification
system
With profits to gain, pharmaceutical companies
have readily funded research
The writers of DSM have also benefited from the
DSMs medical model
Of 170 contributors (DSM-IV/DSM-IV-TR)
56 had 1 (or more) financial ties to the
pharmaceutical industry
42 received funding for research from the same
industry
Certain diagnoses have received more attention
than others throughout different eras - frequent
parallels to development of new medications
Sources Albee Joffee, 2004 Cosgrove et al.,
2006 Gaines, 1992 Mayes Horowitz, 2005 Zur
Nordmarker, 2006
21
More Criticisms of the DSM
The DSM Pathologizes Normal Behaviors
Feeling jumpy agitated from drinking too much
coffee can now be diagnosed as Caffeine Related
Disorder
Healthy grieving may be diagnosed as Complicated
Grief Reaction if it lasts longer than the time
frame allotted by DSM
Smoking too much may lead to a diagnosis of
Nicotine Dependency Disorder, a disorder now
afflicting about 12.8 of the US adult population
The DSM Pathologizes Certain Groups Over Others
Children, Ethnic Minorities, Geriatric
Population, Women, and Sexual Minorities are at
an increased risk for being unfairly diagnosed
with mental illness
Sources Albee Joffee, 2004 Gaines, 1992
Grant Stinson, 2004 Widiger, 2004 Zur
Nordmarker, 2006
22
Thoughts Regarding the DSM
Frances DSM-IV chair Egger DSM Research
Fellow on DSM-IV
The present diagnostic system based on a
descriptive approach was a great advance of
previous systems which had a very low
reliability. This improvement has facilitated
research and clinical communication (1999, p.
164)
A Comment from Michael First DSM-IV editor
chair of DSM-V
For some of these, there is an issue of
grandfathering...The onus is on the person who
wants to change it to prove that we should do so
(from Time magazines How we get labeled,
Cloud, 2003).
A Criticism From the Field
as a text, the DSM is a simple collection of
tales of suffering and complaint, a compilation
of information (by its own admission) often
transient and mutable quality (Amundson, 1998,
p. 3).
23
Video Clip DSM
DSM Inventing Mental Illness
DSM Video Clip
From Citizens Commission on Human Rights,
http//www.cchr.org/
video/psychiatry_pseudo-science/dsm_inventing_ment
al_illness.html
24
The Future of the DSM Towards DSM -V
DSM-V Timeline
1999-2005 Development of DSM-V Preplanning
White Papers 2002 Publication of A Research
Agenda for DSM-V 2004-5 Publication of
additional DSM-V Preplanning White Papers
2004-2007 Review data from 10
APA/NIH-sponsored conferences on The Future of
Psychiatric Diagnosis Refining the Research
Agenda 2007 Appointment of DSM-V
Workgroups 2011 Publication of DSM-V
These dates are tentative
although these events will not occur any earlier,
they could occur later
DSM-V Links
To make suggestions/comments
http//www.dsm5.org/suggestions.cfm
List of Research Planning Activities
http//www.dsm5.org/planning.cfm
To View Timeline
http//www.dsm5.org/timeline.cfm
25
References

• Albee, G. W. Joffee, J. M. (2004). Mental
  illness is NOT an illness like any other. The
  Journal of Primary Prevention, 24(4), 419-437.
• Amundson, J. (1997). Tales of Suffering and
  Complaint - Asking DSM-IV to do more than it was
  Intended For. Journal of Systemic Therapy, 16(4)
  1-11.
• Alic, M. (2001). Kraepelin, Emil (1856-1926).
  Gale Encyclopedia of Psychology (2nd ed.).
  Retrieved on March 17, 2008 from
  http//findarticles.com/p/articles/mi_g2699/is_000
  5/ai_2699000523.
• Cosgrove, Krimsky, Vijayaraghavan, Schneider
  (2006). Financial ties between DSM-IV panel
  members and the pharmaceutical industry.
  Psychotherapy Psychosomatics, 75, 154- 160.
• First, M. B., Frances, A., Pincus, H. A.
  (2004). Roots A brief history of psychiatric
  classification. In DSM-IV-TR Guidebook (pp.
  3-11). Washington, DC American Psychiatric
  Press.
• Gaines, A. (1992). From DSM-III to DSM III-R
  Voices of self, mastery and the other A
  cultural constructivist reading of U.S.
  psychiatric classification. Social Science
  Medicine, 35(1), 3-24.
• Grant, B. F. Stintson, F. S. (2004). Nicotine
  dependence and psychiatric disorders in the
  United States. Archives of General Psychiatry,
  61, 1107-1115

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References
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27
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