Emergence of the DSM

many other followed these medications so that now drug therapy is a huge part of mental illness treatment.

The twenty-first century brought many other commonly used drugs for mental health management, such as Prozac and other SSRI drugs, which are also called selective serotonin reuptake inhibitors. This has led to even fewer hospitalizations and commitments with a bigger emphasis on outpatient management of mental illness. This is helpful for many but not helpful for those who need to have inpatient stays or who cannot afford medications for their mental illness. Others use drugs for recreational purposes and there is always the potential for abuse or a black market for certain drugs.

EMERGENCE OF THE DSM

The DSM or Diagnostic and Statistical Manual of Mental Disorders came out of a need to classify the different mental illnesses. The 1840 census was the first to ask about insanity or idiocy in the population, providing a general way of understanding the epidemiology of mental illness. This was fraught with problems because there were parts of the country that labeled all African Americans as having insanity of some kind.

The American Psychiatric Association or APA existed under a different name as of 1844 but became what it is now called in 1921. Later censuses began describing people in terms of more specific mental illnesses, such as melancholia, mania, epilepsy, and paresis. The APA also adopted these categories. They developed a manual in 1917 to guide mental hospitals. It was called the Statistical Manual for the Use of Institutions for the Insane. There were just 22 diagnoses in it.

A brand new classification method was developed in 1943 known as Medical 203. This was a psychiatric manual less focused on institutions and more on mental illness in general. It was put out by a division of the US Office of the Surgeon General. It was adopted by the US Armed Forces in dealing with mentally ill soldiers and veterans.

In 1949, the WHO put out its International Statistical Classification of Diseases or ICD that first had a section about mental disorders. It was similar to the Medical 203 document using categories based on the 1943 document.

The APA became officially involved in classifying and standardizing mental illnesses by creating the DSM-1 out of information taken from prior sources already in use. It basically reviewed and revised the Medical 203 classification method and called It the DSM-1, first published in 1952. Much of it was identical to passages in the Medical 203 document with a total of 106 mental disorders listed. Things like homosexuality, neurosis, and personality disturbances were some of the categories.

The DSM-II was then modified from the DSM-I and reflected the many changes in psychiatry during that time period. There were advocates that opposed to the concept that homosexuality was a mental illness. This was published in 1968 and listed 182 separate diseases. It was just 134 pages in length. Both of these versions touched on the idea that psychiatric diseases had biological bases. One of the problems was that there were vague distinctions between what is normal and what wasn’t.

The opposition to homosexuality as a psychiatric diagnosis continued after the DSM-II came out. Homosexuals in general had a great deal of opposition to psychiatry in general, which only intensified during the 1970s. The sixth printing of the DSM-II in 1974 removed the diagnosis of homosexuality in its volume. It was, however, replaced with the diagnosis called “sexual orientation disorder”.

The year 1980 brought another big change in psychiatry with the publishing of the DSM-III. The idea at the time was to match the DSM information as much as possible with the ICD put out by the World Health Organization. There was also an effort to make the diagnosis of mental disorders roughly the same as it was in Europe. There was a new multiaxial system used to broaden psychiatric diagnoses. There were Axis I disorders that were a primary diagnosis, an Axis II disorder, which was a personality disorder or metal retardation. Axis III meant that there would be an underlying medical condition to consider.

There were several changes made in 1980. Any reference to homosexuality or sexual orientation was replaced with ego-dystonic homosexuality and neurosis was removed as a primary diagnosis because it was too vague. PTSD was added as a new diagnosis in the DSM-III. The volume expanded to almost five hundred pages and there were 265 different diagnoses.

The DSM-III was revised in 1987 and was called the DSM-III-R. There were some changes and reorganization that occurred in this volume with six categories removed. A few categories were added. Contributors looked at adding premenstrual dysphoric disorder and masochistic personality disorder but these were not added to the volume. The diagnosis of ego-dystonic homosexuality disorder was finally removed and instead there was a nonspecific sexual disorder diagnosis that could be made if a person had symptoms suggestive of this disorder. About 292 separate disorders were included in the volume, which stressed the description of the different disorders rather than efforts to explain things like etiology.

A few years later in 1994, the DSM-IV was produced and published. There were 410 diagnoses in this large volume. Research was included to support the different diagnoses so they could be more valid and based on research evidence. Trials were conducted to show that the diagnoses could be replicated in clinical practice. An addition to the diagnosis was that there needed to be the requirement of a significant impairment in functioning in areas like social, emotional, or occupation life. A few personality disorders were removed or added to the appendix for completeness.

The DSM-IV-TR was a revision of the DSM-IV. Most of the diagnoses and criteria were the same as the original volume but the diagnostic codes were set up to better match with the World Health Organization’s ICD manual. There was a five-part axial system that added axes to include medical, psychosocial, environmental, or childhood factors to explain the main diagnoses. The idea was that doctors and psychologists could look at the different criteria and match the patient’s symptoms to the different criteria. The distress was included as part of most diagnoses except for paraphilias and tic disorders because most of these are not ego-dystonic. Codes were given for insurance purposes.

The DSM-IV-TR multiaxial system can be explained in the five different axes. These are included as these axes:

• Axis I is the main diagnosis except for any mental retardation or personality disorder.

• Axis II involved the different personality disorders and mental retardation or intellectual disability.