The Evolution of DSM

1. The Evolution of DSM Janet B.W. Williams, PhD Professor Emerita of Clinical Psychiatric Social Work, Dept. Of Psychiatry, Columbia University Senior VP of Global Science, MedAvante, Inc. 12/7/13

2. Why the DSM (1952)? • Pre-1952: several different national systems in • use, multiple state systems • Dissatisfaction with existing classifications • APA develops its own • First glossary definitions of disorders • Of little or no interest to clinicians, researchers

3. Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases

4. DSM-I Classification • Acute/chronic brain disorders • Mental deficiency • Psychotic disorders • Psychophysiologic disorders • Psychoneurotic disorders • Personality disorders • Transient situational personality disorders

5. Significance of DSM-I (1952) • First glossary of definitions of categories • APA in control of classification • Influence of Adolph Meyer “Schizophrenic reaction” “Manic depressive reaction” “Anxiety reaction” • Psychoanalytic concepts in neuroses and psychophysiologic disorders • “...utilization of various defense mechanisms...”

6. DSM-I Description of Manic Depressive Reaction, Manic Type (1952) “This group is characterized by elation or irritability, with overtalkativeness, flight of ideas, and increased motor activity. Transitory, often momentary, episodes of depression may occur, but will not change the classification from the manic type of reaction.” (p. 25)

7. DSM-II Classification • Mental retardation • Organic brain syndromes • Psychoses • Neuroses • Personality disorders and certain other non-psychotic mental disorders • Psychophysiologic disorders • Special symptoms • Transient situational disturbances

8. Significance of DSM-II (1968) • APA decides to use ICD-8 (slightly modified) • British hegemony in ICD • Eliminating “Reaction” • Multiple diagnoses encouraged

9. DSM-II Description of Manic-depressive Illness, Manic Type (1968) “This disorder consists exclusively of manic episodes. These episodes are characterized by excessive elation, irritability, talkativeness, flight of ideas, and accelerated speech and motor activity. Brief periods of depression sometimes occur, but they are never true depressive episodes.” (p. 36)

10. Eli Robins, MD

12. Robert L. Spitzer, MDChair, DSM-III and DSM-III-R

13. Janet B.W. Williams, DSW (now PhD) Text EditorDSM-III Coordinator of DSM-III Field Trials DSM-III-R Task Force

14. Noah Spitzer-Williams, 1984

16. What Principles Guided DSM-III? • Inclusiveness • Descriptive approach: usable across theoretical • orientations • Diagnostic (“operational”) criteria • Expanded descriptions • Multiaxial system • ICD compatibility a formality

17. Goals of DSM • communication: precision in language, “short-hand” • clinical: facilitate identification, treatment, and prevention of mental disorders • research: further understanding of etiology • education: teach psychopathology • data collection: statistical registry

18. Types of Information in the Text • Essential features • Associated features • Age at onset • Course • Impairment • Complications • Predisposing factors • Prevalence • Sex ratio • Familial pattern • Differential diagnosis

19. DSM-III Controversies • Task Force unrepresentative • Definition of mental disorder • Dysthymia (Neurotic depression) vs Neurotic depression (Dysthymia)

20. January 3, 2005 THE DICTIONARY OF DISORDER by ALIX SPIEGEL www.newyorker.com

21. Multiaxial System – Eliminated in DSM-5 • Axis I: Clinical Conditions • Axis II: Personality Disorders and Mental Retardation • Axis III: general medical conditions • Axis IV: psychosocial stressors and environmental problems • Axis V: Global Assessment of Functioning Scale

22. Person-in-Environment System Four factors: • Social roles in relationship to others • Mental health • Social environment • Physical health

23. Additional Materials DSM CasebooksDSM-IV SourcebooksStructured Clinical Interview for DSM (SCID) - SCID-I (for Axis I) - SCID-RV (Research Version) - SCID-CV (Clinician Version)- SCID-II (for Axis II)- SCID-CT (for Clinical Trials)

25. 1987: DSM-III-R • originally intended to be just a “fine tuning” • corrected inconsistencies and incorporated latest research • disadvantage: change too disruptive

26. Allen Frances, MDChair, DSM-IV

27. 1994: DSM-IV • revision process based on empirical review • elimination of the term “organic” • expansion of appendix categories • new and deleted categories

28. DSM-IV Process • Decentralization of revision process • Literature reviews and data reanalysis • Field trials • ICD-10 compatibility • Avoid public controversy • “User-friendly” • High threshold for new diagnoses

29. 2000 - DSM-IV Text Revision • fills 12+ year gap between DSM-IV and DSM-V • based on comprehensive lit review from 1992 to 1999 • no changes to criteria sets allowed • most changes to Associated Features and Disorders, Age, Culture and Gender Features, Prevalence, Course, and Familial Pattern

30. Michael First, MDDSM-IV Text Editor

32. David Kupfer, MD and Darrel Regier, MD Co-chairs, DSM-5

33. Michael B. First, MD • Professor of Clinical Psychiatry • Research Psychiatrist, NYSPI • schematherapy and psychopharmacology practice in Manhattan • Forensic expert • Editor of Text and Criteria for DSM-IV and DSM-IV-TR • Editorial and Coding Consultant for DSM-5 • Chief technical and editorial consultant on ICD-11