The Diagnostic and Statistical Manual of Mental Disorders (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and is considered one of the principal guides of psychiatry, along with the ICD, CCMD, and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.
It is used – mainly in the United States – by researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policymakers. Some mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients with mental disorders. Health-care researchers use the DSM to categorize patients for research purposes.
The DSM evolved from systems for collecting census and psychiatric hospital statistics, as well as from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, while removing those no longer considered to be mental disorders.
Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound nosology (the branch of medical science that deals with the classification of diseases) used in DSM-III. However, it has also generated controversy and criticism, including ongoing questions concerning the reliability and validity of many diagnoses; the use of arbitrary dividing lines between mental illness and "normality"; possible cultural bias; and the medicalization of human distress. The APA itself has published that the inter-rater reliability is low for many disorders in the DSM-5, including major depressive disorder and generalized anxiety disorder.
Distinction from ICD
An alternate, widely used classification publication is the International Classification of Diseases (ICD) is produced by the World Health Organization (WHO). The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 5 of the ICD specifically covers mental and behavioral disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM. An international survey of psychiatrists in sixty-six countries compared the use of the ICD-10 and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research. This may be because the DSM tends to put more emphasis on clear diagnostic criteria, while the ICD tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated. That is, the ICD descriptions of psychiatric disorders tend to be more qualitative information, such as general descriptions of what various disorders tend to look like. The DSM focuses more on quantitative and operationalized criteria; e.g. to be diagnosed with X disorder, one must fulfill 5 of 9 criteria for at least 6 months.
The DSM-IV-TR (4th. ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated. Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other. For instance, the two manuals contain overlapping but substantially different lists of recognized culture-bound syndromes. The ICD also tends to focus more on primary-care and low and middle-income countries, as opposed to the DSM's focus on secondary psychiatric care in high-income countries.
Census Office, AMA and ISI (1840–1911)
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category: "idiocy/insanity". Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns African Americans were all marked as insane, and calling the statistics essentially useless.
The Association of Medical Superintendents of American Institutions for the Insane ("The Superintendents' Association") was formed in 1844.
In 1860, during the international statistical congress held in London, Florence Nightingale made a proposal that was to result in the development of the first international model of systematic collection of hospital data.
In 1888, the Census Office published Frederick H. Wines' 582-page volume called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880). Wines used seven categories of mental illness, which were also adopted by the Superintendents: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis.
In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute (ISI) in Chicago. (The ISI had commissioned him to create it in 1891). A number of countries adopted the ISI's system. In 1898, the American Public Health Association (APHA) recommended that United States registrars also adopt the system.
In 1900, an ISI conference in Paris reformed the Bertillion Classification, and created the International List of Causes of Death (ILCD). Another conference would be held every ten years, and a new edition of the ILCD would be released. Five were ultimately issued. Non-fatal conditions were not included.
In 1903, New York's Bellevue Hospital published "The Bellevue Hospital nomenclature of diseases and conditions," which included a section on "Diseases of the Mind". Revisions were released in 1909 and 1911. It was produced with the assistance of the AMA and Bureau of the Census.
APA Statistical Manual (1917) and AMA Standard (1933)
In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the American Medico-Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This guide included twenty-two diagnoses. It would be revised several times by the Association, and by the tenth edition in 1942, was titled Statistical Manual for the Use of Hospitals of Mental Diseases.
The first edition of the DSM notes in its foreword: "In the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution."
In 1933, the AMA's general medical guide the Standard Classified Nomenclature of Disease, (referred to as the Standard), was released. Along with the New York Academy of Medicine, the APA provided the psychiatric nomenclature subsection. It became well adopted in the US within two years. A major revision of the Statistical Manual was made in 1934, to bring it in line with the new Standard. A number of revisions of the Standard were produced, with the last in 1961.
Medical 203 (1945)
World War II saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. The U.S. armed forces initially used the Standard, but found it lacked appropriate categories for many common conditions that troubled troops. The United States Navy made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance."
Under the direction of James Forrestal, a committee headed by psychiatrist Brigadier General William C. Menninger, with the assistance of the Mental Hospital Service, developed a new classification scheme in 1944 and 1945.
Issued in War Department Technical Bulletin, Medical, 203 (TB MED 203); Nomenclature and Method of Recording Diagnoses was released shortly after the war in October 1945 under the auspices of the Office of the Surgeon General. It was reprinted in the Journal of Clinical Psychology for civilian use in July 1946 with the new title Nomenclature of Psychiatric Disorders and Reactions. This system came to be known as "Medical 203".
This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of the standard in 1947.
The further developed Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions was released in 1949.
In 1948, the newly formed World Health Organization took over the maintenance of the ILCD. They greatly expanded it, included non-fatal conditions for the first time, and renamed it the International Statistical Classification of Diseases (ICD). The foreword to the DSM-I states the ICD-6 "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature."
Early versions (20th century)
The APA Committee on Nomenclature and Statistics was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the Standard's nomenclature, and the VA system's modifications of the Standard to approximately 10% of APA members. 46% of members replied, with 93% approving the changes. After some further revisions, the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic).
The foreword to this edition describes itself as being a continuation of the Statistical Manual for the Use of Hospitals of Mental Diseases. Each item was given an ICD-6 equivalent code, where applicable.
The DSM-I centers around three classes of symptoms: psychotic, neurotic, and behavioral. Within each class of mental disorder, classifying information is provided to differentiate conditions with similar symptoms. Under each broad class of disorder (e.g. "Psychoneurotic Disorders" or "Personality Disorders"), all possible diagnoses are listed, generally from least to most severe. The 1952 DSM version also includes sections detailing how to record patients' disorders along with their demographic details. The form includes information like a patient's area of residence, admission status, discharge date/condition, and severity of disorder. See Figure 1. for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information.
Furthermore, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a heroine to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.
In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder. A study published in Science, the Rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.
The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.
An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".
Seventh printing of the DSM-II (1974)
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."
This gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists.
Taking into account data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder.[a] After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".
In 1974, the decision to revise the DSM was made, and psychiatrist Robert Spitzer was selected as chair of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the International Classification of Diseases (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States. The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process.
The criteria adopted for many of the mental disorders were taken from the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University School of Medicine and the New York State Psychiatric Institute. Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." Personality disorders were placed on axis II along with "mental retardation".
The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance". The gender identity disorder in children (GIDC) diagnosis was introduced in the DSM-III; prior to the DSM-III's publication in 1980, there was no diagnostic criteria for gender dysphoria.
Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry.
When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:
Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalizability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator ...
In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as Premenstrual Dysphoric Disorder and Masochistic Personality Disorder, were considered and discarded. (Premenstrual Dysphoric Disorder was later be reincorporated in the DSM-5, published in 2013). "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" [p. xxiii].
In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by Allen Frances and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multi-center field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix.
The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom". It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder."
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.
DSM-IV multi-axial system
The DSM-IV was organized into a five-part axial system. Axis I provided information about clinical disorders, or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM-V as "mental retardation". Those were both covered on Axis II. Axis III covered medical conditions that could impact a person's disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person. Axis V was the GAF, or global assessment of functioning, which was basically a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life.
The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials. The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification.
A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but 9 diagnoses. The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, and course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM .
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in 20 years. DSM-5, and the abbreviations for all previous editions, are registered trademarks owned by the American Psychiatric Association.
A significant change in the fifth edition is the deletion of the subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. The deletion of the subsets of autistic spectrum disorder – namely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified – was also implemented, with specifiers regarding intensity: mild, moderate, and severe.
Severity is based on social communication impairments and restricted, repetitive patterns of behavior, with three levels:
- requiring support
- requiring substantial support
- requiring very substantial support
During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.
Future revisions and updates
Beginning with the fifth edition, the APA communicated that they intend to add subsequent revisions more often, to keep up with research in the field. It is notable that DSM-5 uses Arabic rather than Roman numerals. Beginning with DSM-5, the APA will use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2)[b] and whole numbers for new editions (e.g., DSM-5, DSM-6), similar to the scheme used for software versioning.
The National Board of Medical Examiners (NBME) which is responsible for creating and publishing board exams for medical students around the United States conforms to the use of DSM-5 criteria
A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and ICD-10-CM codes. The diagnostic criteria for avoidant/restrictive food intake disorder was changed, along with adding entries for prolonged grief disorder, unspecified mood disorder and stimulant-induced mild neurocognitive disorder. Prolonged grief disorder, which had been present in the ICD-11, had criteria agreed upon by consensus in a one day in-person workshop sponsored by the APA. A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD-11 could be explained by the DSM-5-TR criteria requiring symptoms persist for 12 months, and the ICD-11 requiring only 6 months.
Three review groups for sex and gender, culture and suicide, along with an "ethnoracial equity and inclusion work group" were involved in the creation of the DSM-5-TR which led to additional sections for each mental disorder discussing sex and gender, racial and cultural variations, and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self-injury for mental disorders.
Other changed mental disorders included:
- Autism spectrum disorder
- Bipolar I disorder, Bipolar II disorder, and related bipolar disorders
- Obsessive-compulsive personality disorder in the alternative DSM-5 model for personality disorders
- Depressive episodes with short-duration hypomania
- Intellectual developmental disorder
- Delusional disorder
- Disruptive mood dysregulation disorder
- Brief psychotic disorder
The APA have supplemented the DSM with supporting works, collectively forming the "DSM Library." As of 2022, the other books in the library are "DSM-5 Handbook of Differential Diagnosis", "DSM-5 Clinical Cases", "DSM-5 Handbook on the Cultural Formulation Interview" and "Guía De Consulta De Los Criterios Diagnósticos Del DSM-5".
Many different criticisms that have been leveled against the DSM and its usefulness as a diagnostic manual.
Reliability and validity
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability – the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Neither the issue of reliability or validity was settled.
In 2013, shortly before the publication of DSM-5, the director of the National Institute of Mental Health (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response."
Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.
Diagnosis based on superficial symptoms
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect these disorders based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. Proponents argue this absence of explanatory classification is necessary, but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."
While there is generally a lack of consensus on underlying causation for most psychiatric disorders, some proponents of specific psychopathological paradigms have faulted the DSM for failing to incorporate evidence from other disciplines. For instance, evolutionary psychology distinguishes between genuine cognitive malfunctions and malfunctions due to psychological adaptations (that is learned behaviors may be adaptive in one context but maladaptive in another). However, this distinction is one that is challenged within general psychology.
There is also criticism of the strong operationalist viewpoint of the DSM. The DSM relies on operational definitions, which means that intuitive concepts like depression are defined by specific measurable criteria (observable behavior, specific timelines). Some have argued that instead of replacing metaphysical terms like "desire" or "purpose" the DSM chose to legitimize them by giving them operational definitions. However, this may have served only to provide a "reassurance fetish" for mainstream methodological practice, rather than representing a substantial and meaningful alteration of mainstream psychiatric practice.
A central problem with the use of superficial symptoms is that psychiatry deals with the phenomena of consciousness, which adds much more complexity than the somatic symptoms and signs used by most of medicine. A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience gives the example of the problem of superficial characterization of psychiatric signs and symptoms . If a patient says they "feel depressed, sad, or down" there are actually a wide variety of underlying experiences they could be referencing: "not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth." This criticism is especially pertinent to the structured interview, as simple "yes or no" questions may not be specific enough to truly confirm or deny the diagnostic criterion at issue. That is, whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience. There is thus danger in being overconfident in the face value of the answers. The authors of the 2013 review give an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the experience did not "fully articulate itself" until the patient started talking about his experiences.
Obscuring the Root Causes of Psychological Distress
The role of the DSM-5 in protecting the interests of wealthy and politically powerful owners of the means of production in the United States has been criticized as well. Placing the blame for predictable and common psychological distress caused by the deleterious effects of economic inequality in the United States on individuals by attributing it to mental pathology has been criticized as hindering change of the root causes of the distress. The DSM-5's expansive criteria that attribute mental pathology to people with distress or impairment from a wide-ranging constellation of experiences has been criticized for pathologizing an unhelpful number of people for whom a psychiatric diagnosis is not helpful.
Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]." Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and autism spectrum disorder. Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics.
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.
In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.
Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.
Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.[page needed]
Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM in treating patients of the African diaspora.
Medicalization and financial conflicts of interest
There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing medicalization of human nature, very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model". It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.
William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million.
However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients.
Potential harm of labels
A core function of the DSM is the categorization of people's experiences into diagnoses based on symptoms. However, there is disagreement about the use of diagnoses as labels. Some individuals are relieved to find they have a recognized condition that they can apply a name to, and this has led to many people self-diagnosing. Others, however, question the accuracy of diagnosis, or feel they have been given a label that invites social stigma and discrimination (the terms "mentalism" and "sanism" have been used to describe such discriminatory treatment).
Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.
Critiques of DSM-5
Psychiatrist Allen Frances has been critical of proposed revisions to the DSM–5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription."
- Disruptive Mood Dysregulation Disorder, for temper tantrums
- Major Depressive Disorder, includes normal grief
- Minor Neurocognitive Disorder, for normal forgetfulness in old age
- Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
- Binge Eating Disorder, for excessive eating
- Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
- First-time drug users will be lumped in with addicts
- Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
- Generalized Anxiety Disorder, includes everyday worries
- Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."
- Are they more like theoretical constructs or more like diseases?
- How to reach an agreed definition?
- Should the DSM-5 take a cautious or conservative approach?
- What is the role of practical rather than scientific considerations?
- How should it be used by clinicians or researchers?
- Is an entirely different diagnostic system required?
In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other APA divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.
- Chinese Classification and Diagnostic Criteria of Mental Disorders
- Classification of mental disorders
- Diagnostic classification and rating scales used in psychiatry
- DSM-IV Codes
- Global Assessment of Functioning (GAF) Scale
- International Statistical Classification of Diseases and Related Health Problems (ICD)
- Kraepelinian dichotomy
- Psychodynamic Diagnostic Manual
- Relational disorder (proposed DSM-5 new diagnosis)
- Research Domain Criteria (RDoC), a framework being developed by the National Institute of Mental Health
- Rosenhan experiment
- Structured Clinical Interview for DSM-IV (SCID)
- Homosexuality in DSM
- Determining the correct DSM-II printing where the change occurred can be confusing because the American Psychiatric Association publication that announced the change is titled, in part, "Proposed change in DSM-II, 6th printing, page 44". However, a notice in that publication indicates that "the change appears on page 44 of this, the seventh printing."
- However, this planned change was not adopted for the initial revision of the DSM-5, which is named DSM-5-TR, in accordance with past convention.
- "DSM-5 Full Text Online" (PDF). Archive.Today. Retrieved 10 January 2022.
- First M, Rebello T, Keeley J, Bhargava R, Dai Y, Kulygina M, Matsumoto C, Robles R, Stona A, Reed G (June 2018). "Do mental health professionals use diagnostic classifications the way we think they do? A global survey". World Psychiatry. 17 (2): 187–195. doi:10.1002/wps.20525. PMC 5980454. PMID 29856559.
- Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner EH, Higgins JP, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JP, Geddes JR (7 April 2018). "Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis". Lancet. 391 (10128): 1357–1366. doi:10.1016/S0140-6736(17)32802-7. PMC 5889788. PMID 29477251.
- Bandelow B, Reitt M, Röver C, Michaelis S, Görlich Y, Wedekind D (July 2015). "Efficacy of treatments for anxiety disorders: a meta-analysis". International Clinical Psychopharmacology. 30 (4): 183–192. doi:10.1097/YIC.0000000000000078. ISSN 0268-1315. PMID 25932596. S2CID 24088074.
- Schneider-Thoma J, Chalkou K, Dörries C, Bighelli I, Ceraso A, Huhn M, Siafis S, Davis JM, Cipriani A, Furukawa TA, Salanti G, Leucht S (26 February 2022). "Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis". Lancet. 399 (10327): 824–836. doi:10.1016/S0140-6736(21)01997-8. ISSN 0140-6736. PMID 35219395. S2CID 247087411. Retrieved 1 May 2023.
- Gartlehner G, Crotty K, Kennedy S, Edlund MJ, Ali R, Siddiqui M, Fortman R, Wines R, Persad E, Viswanathan M (October 2021). "Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis". CNS Drugs. 35 (10): 1053–1067. doi:10.1007/s40263-021-00855-4. ISSN 1172-7047. PMC 8478737. PMID 34495494.
- Frances A (17 May 2013). "The New Crisis in Confidence in Psychiatric Diagnosis". Annals of Internal Medicine.
- Dalal PK, Sivakumar T (2009). "Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification". Indian Journal of Psychiatry. 51 (4): 310–319. doi:10.4103/0019-5545.58302. PMC 2802383. PMID 20048461.
- Kendell R, Jablensky A (January 2003). "Distinguishing between the validity and utility of psychiatric diagnoses". The American Journal of Psychiatry. 160 (1): 4–12. doi:10.1176/appi.ajp.160.1.4. PMID 12505793. S2CID 16151623.
- Baca-Garcia E, Perez-Rodriguez MM, Basurte-Villamor I, Fernandez del Moral AL, Jimenez-Arriero MA, Gonzalez de Rivera JL, et al. (March 2007). "Diagnostic stability of psychiatric disorders in clinical practice". The British Journal of Psychiatry. 190 (3): 210–216. doi:10.1192/bjp.bp.106.024026. PMID 17329740. S2CID 4888348.
- Pincus HA, Zarin DA, First M (December 1998). "'Clinical significance' and DSM-IV". Archives of General Psychiatry. 55 (12): 1145, author reply 1147–1145, author reply 1148. doi:10.1001/archpsyc.55.12.1145. PMID 9862559. Archived from the original on 2007-09-29.
- Regier D, Narrow W, Clarke D, Kraemer H, Kuramoto S, Kuhl E, Kupfer D (2013). "DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses". American Journal of Psychiatry. 170 (1): 59–70. doi:10.1176/appi.ajp.2012.12070999. PMID 23111466.
- ICD-10 Classification of Mental and Behavioural Disorders: "Clinical descriptions and diagnostic guidelines" (aka the "Blue Book"); and "Diagnostic criteria for research" (aka the "Green Book").
- Mezzich JE (2002). "International surveys on the use of ICD-10 and related diagnostic systems". Psychopathology. 35 (2–3): 72–75. doi:10.1159/000065122. PMID 12145487. S2CID 35857872.
- Tyrer, Peter (2014). "A comparison of DSM and ICD classifications of mental disorder". Advances in Psychiatric Treatment. 20 (4): 280–285. doi:10.1192/apt.bp.113.011296. ISSN 1355-5146.
- In Appendix G: "ICD-9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders"
- American Psychological Association (2009). "ICD VS. DSM". Monitor on Psychology. 40 (9): 63.
- Diagnostic criteria for research, p. 213–225 (WHO 1993)
- Gorwitz K (March–April 1974). "Census enumeration of the mentally ill and the mentally retarded in the nineteenth century". Health Services Reports. 89 (2): 180–187. doi:10.2307/4595007. JSTOR 4595007. PMC 1616226. PMID 4274650.
- "The original thirteen". Hospital & Community Psychiatry. 27 (7): 464–467. 1976. ISSN 0022-1597. PMID 776775.
- "A nomenclature of diseases: with the reports of the majority and of the minority of the committee thereon: presented to the American Medical Association at the meeting held in Philadelphia, May 1872 – Digital Collections – National Library of Medicine". collections.nlm.nih.gov. p. 53. Retrieved 2022-11-06.
- History of the Statistical Classification of Diseases and Causes of Death (PDF). National Centre for Health Statistics. 2011. Archived (PDF) from the original on 2011-05-05.
- Grob GN (1976). "Edward Jarvis and the Federal Census: A Chapter in the History of Nineteenth-Century American Medicine". Bulletin of the History of Medicine. The Johns Hopkins University Press. 50 (1): 4–27. JSTOR 44450311. PMID 769874.
- History of the DSM Archived 2013-09-11 at the Wayback Machine Nathaniel Deyoung, Purdue University. Retrieved 9 Sept 2013
- Barton WE (1987). The history and influence of the American Psychiatric Association. American Psychiatric Association. Washington, D.C.: American Psychiatric Press. p. 89. ISBN 0-88048-231-1. OCLC 13945621.
- Works of Jacques Bertillon, Internet Archive.
- "History of the development of the ICD" (PDF). Who.int. Retrieved 11 December 2017.
- The Bellevue Hospital nomenclature of diseases and conditions (3rd ed.). New York: Bellvue and Allied Hospitals. 1911.
- Statistical manual for the use of institutions for the insane (1918) University of Michigan via Internet Archive
- Clark LA, Cuthbert B, Lewis-Fernández R, Narrow WE, Reed GM (September 2017). "Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health's Research Domain Criteria (RDoC)". Psychological Science in the Public Interest. 18 (2): 72–145. doi:10.1177/1529100617727266. PMID 29211974. S2CID 206743519.
- Barton WE (1987). The history and influence of the American Psychiatric Association. American Psychiatric Association. Washington, D.C.: American Psychiatric Press. p. 168. ISBN 0-88048-231-1. OCLC 13945621.
- "DSM-1 Full PDF". 1952.
- Logie, H. B. (December 1933). "A Standard Classified Nomenclature of Disease". The Journal of Nervous and Mental Disease. 78 (6): 679. doi:10.1097/00005053-193312000-00075. ISSN 0022-3018.
- Greenberg SA, Shuman DW, Meyer RG (2004). "Unmasking forensic diagnosis". International Journal of Law and Psychiatry. 27 (1): 1–15. doi:10.1016/j.ijlp.2004.01.001. PMID 15019764.
- Thompson, ET; Hayden, AC, eds. (1961). Standard nomenclature of diseases and operations (5th ed.). New York: McGraw Hill.
- The Medical Department of the United States Army in World War II. Office of the Surgeon General, Department of the Army. 1966. p. 756.
- Sandison RA, Spencer AM (1953). "Mental Hospital Service". British Medical Journal. 1 (4809): 560. doi:10.1136/bmj.1.4809.560. PMC 2015553.
- Houts AC (July 2000). "Fifty years of psychiatric nomenclature: reflections on the 1943 War Department Technical Bulletin, Medical 203". Journal of Clinical Psychology. 56 (7): 935–967. doi:10.1002/1097-4679(200007)56:7<935::AID-JCLP11>3.0.CO;2-8. PMID 10902952. Archived from the original on 2013-01-05.
- "Nomenclature of psychiatric disorders and reactions". Journal of Clinical Psychology. 2 (3): 289–296. July 1946. doi:10.1002/1097-4679(194607)2:3<289::AID-JCLP2270020316>3.0.CO;2-O. PMID 20992064.
- U.S. Army. U.S. Navy. U.S. Air Force (1949). Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions.
- Grob GN (April 1991). "Origins of DSM-I: a study in appearance and reality". The American Journal of Psychiatry. 148 (4): 421–431. doi:10.1176/ajp.148.4.421. PMID 2006685.
- Oldham JM (2005). "Personality Disorders". FOCUS. 3: 372–382. Archived from the original on 2012-07-20.
- "Diagnostic and Statistical Manual" (PDF). American Psychiatric Association. The Committee on Nomenclature and Statistics. 1952. Retrieved April 25, 2023.
- Edsall NC (2003). Toward Stonewall: Homosexuality and Society in the Modern Western World. University of Virginia Press.
- Marcus E (2009). Making Gay History. Print: Harper Collins. pp. 58–59.
- Mayes R, Bagwell C, Erkulwater JL (2009). "The Transformation of Mental Disorders in the 1980s: The DSM-III, Managed Care, and "Cosmetic Psychopharmacology"". Medicating Children: ADHD and Pediatric Mental Health. Harvard University Press. p. 76. ISBN 978-0-674-03163-0. Retrieved 2013-12-03.
- Kirk SA, Kutchins H (1994). "The Myth of the Reliability of DSM". Journal of Mind and Behavior, 15 (1&2). Archived from the original on 2008-03-07.
- Mayes R, Horwitz AV (2005). "DSM-III and the revolution in the classification of mental illness". Journal of the History of the Behavioral Sciences. 41 (3): 249–267. doi:10.1002/jhbs.20103. PMID 15981242.
- Wilson M (March 1993). "DSM-III and the transformation of American psychiatry: a history". The American Journal of Psychiatry. 150 (3): 399–410. doi:10.1176/ajp.150.3.399. PMID 8434655.
- Spitzer RL, Fleiss JL (October 1974). "A re-analysis of the reliability of psychiatric diagnosis". The British Journal of Psychiatry. 125 (587): 341–347. doi:10.1192/bjp.125.4.341. PMID 4425771. S2CID 37782257.
- Kirk SA, Kutchins H (1994). "The Myth of the Reliability of DSM". Journal of Mind and Behavior. 15 (1&2): 71–86. Archived from the original on 2008-03-07. Retrieved 2008-03-04.
- Bayer, Ronald (1981). Homosexuality and American Psychiatry: The Politics of Diagnosis Princeton University Press p. 105.
- McCommon B (December 2006). "Antipsychiatry and the gay rights movement". Psychiatric Services. 57 (12): 1809, author reply 1809–1809, author reply 1810. doi:10.1176/appi.ps.57.12.1809. PMID 17158503. S2CID 37419476. Archived from the original on 2007-08-10.
- Rissmiller DJ, Rissmiller J (2006). "Letter in reply". Psychiatr Serv. 57 (12): 1809–1810. doi:10.1176/appi.ps.57.12.1809-a. Archived from the original on 2007-06-30.
- Spitzer RL (February 1981). "The diagnostic status of homosexuality in DSM-III: a reformulation of the issues". The American Journal of Psychiatry. 138 (2): 210–215. doi:10.1176/ajp.138.2.210. PMID 7457641.
- Homosexuality and sexuality orientation disturbance: Proposed change in DSM-II, 6th printing, page 44. Position Statement (Retired). APA Document Reference No. 730008. Arlington, VA: American Psychiatric Association, 1973. ("Since the last printing of this Manual, the trustees of the American Psychiatric Association, in December 1973, voted to eliminate Homosexuality per se as a mental disorder and to substitute therefor a new category titled Sexual Orientation Disturbance. The change appears on page 44 of this, the seventh printing.").
- Spiegel A (3 January 2005). "The Dictionary of Disorder: How one man revolutionized psychiatry". The New Yorker. Archived from the original on 12 December 2006.
- Cooper JE, Kendell RE, Gurland BJ, Sartorius N, Farkas T (April 1969). "Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation". The American Journal of Psychiatry. 10 Suppl (10 Suppl): 21–29. doi:10.1176/ajp.125.10s.21. PMID 5774702. Archived from the original on 2010-08-24.
- Lane C (2007). Shyness: How Normal Behavior Became a Sickness. Yale University Press. p. 263. ISBN 978-0-300-12446-0.
- Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association. 1980.
- Butler, Catherine; Hutchinson, Anna (2020). "Debate: The pressing need for research and services for gender desisters/Detransitioners" (PDF). Child and Adolescent Mental Health. 25 (1): 45–47. doi:10.1111/camh.12361. PMID 32285632. S2CID 210484832. Archived (PDF) from the original on 2022-11-28.
- American Psychological Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5 [Fact sheet]. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf
- Spiegel A, Glass I (18 January 2002). "81 Words". This American Life. Chicago: WBEZ Chicago Public Radio.
- Frances A, Mack AH, Ross R, First MB (2000) . "The DSM-IV Classification and Psychopharmacology". In Bloom FE, Kupfer DJ (eds.). Psychopharmacology: The Fourth Generation of Progress. American College of Neuropsychopharmacology. Archived from the original on 2007-03-23. Retrieved 2007-02-28.
- Shaffer D (August 1996). "A participant's observations: preparing DSM-IV". Canadian Journal of Psychiatry. 41 (6): 325–329. doi:10.1177/070674379604100602. PMID 8862851. S2CID 28547523.
- Maisel ER (23 July 2013). "The New Definition of a Mental Disorder". Psychology Today.
- Stein DJ, Phillips KA, Bolton D, Fulford KW, Sadler JZ, Kendler KS (November 2010). "What is a mental/psychiatric disorder? From DSM-IV to DSM-V". Psychological Medicine. 40 (11): 1759–1765. doi:10.1017/S0033291709992261. PMC 3101504. PMID 20624327.
- Maser JD, Patterson T (December 2002). "Spectrum and nosology: implications for DSM-V". The Psychiatric Clinics of North America. 25 (4): 855–885. doi:10.1016/s0193-953x(02)00022-9. PMID 12462864.
- DSM-IV to DSM-5 Changes: Overview. Internet: Substance Abuse and Mental Health Services Administration. 2016. pp. DSM-5 Changes: Implications for Child Serious Emotional Disturbance.
- DSM-IV Sourcebook. Vol. 1. Washington, DC: American Psychiatric Association. 1994. ISBN 978-0-89042-065-2.
- DSM-IV Sourcebook. Vol. 2. Washington, DC: American Psychiatric Association. 1996. ISBN 978-0-89042-069-0.
- DSM-IV Sourcebook. Vol. 3. Washington, DC: American Psychiatric Association. 1997. ISBN 978-0-89042-073-7.
- Sadock BJ (October 1999). "DSM-IV Sourcebook, vol. 4 (Book Forum: Assessment and Diagnosis)". American Journal of Psychiatry. 156 (10): 1655. doi:10.1176/ajp.156.10.1655. Archived from the original on 2013-12-06. Retrieved 2013-12-03.
- Poland JS (2001). Review of Volume 1 of DSM-IV sourcebook. Archived from the original on May 1, 2005.
- Poland JS (2001). Review of vol 2 of DSM-IV sourcebook. Archived from the original on September 27, 2007.
- "DSM-IV replaced by DSM-IV-TR: changes in diagnostic criteria". Behavenet.
- First MB, Pincus HA (March 2002). "The DSM-IV Text Revision: rationale and potential impact on clinical practice". Psychiatric Services. 53 (3): 288–292. doi:10.1176/appi.ps.53.3.288. PMID 11875221.
- Cassels C (2 December 2012). "DSM-5 Gets APA's Official Stamp of Approval". Medscape. WebMD, LLC. Retrieved 2012-12-05.
- Kinderman P (20 May 2013). "Explainer: what is the DSM?". The Conversation Australia. The Conversation Media Group. Retrieved 2013-05-21.
- Jayson S (12 May 2013). "Books blast new version of psychiatry's bible, the DSM". USA Today. Retrieved 2013-05-21.
- Pearson C (20 May 2013). "DSM-5 Changes: What Parents Need To Know About The First Major Revision In Nearly 20 Years". The Huffington Post. Retrieved 2013-05-21.
- "Trademark Electronic Search System (TESS)". Retrieved 2010-02-03.
- "Highlights of Changes from DSM-IV-TR to DSM-5" (PDF). American Psychiatric Association. 17 May 2013. Archived from the original (PDF) on 2015-02-26. Retrieved 2015-01-04.
- "DSM-5". psychiatry.org. Retrieved 2019-08-29.
- "DSM-5 FAQ". psychiatry.org. Retrieved 2019-08-29.
- Harold E, Valora J (9 March 2010). "APA Modifies DSM Naming Convention to Reflect Publication Changes" (Press release). Arlington, VA: American Psychiatric Association. Archived from the original (PDF) on 13 June 2010.
Beginning with the upcoming fifth edition, new versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be identified with Arabic rather than Roman numerals, marking a change in how future updates will be created, ... Incremental updates will be identified with decimals, i.e. DSM-5.1, DSM-5.2, etc., until a new edition is required.
- "Update: Exams to Transition to DSM-5", Psychiatric News, 49 (22): 1, 2014, doi:10.1176/appi.pn.2014.10a19
- "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR™)". American Psychiatric Association. Retrieved April 18, 2022.
- Appelbaum, Paul S.; Leibenluft, Ellen; Kendler, Kenneth S. (2021-11-01). "Iterative Revision of the DSM: An Interim Report From the DSM-5 Steering Committee". Psychiatric Services. 72 (11): 1348–1349. doi:10.1176/appi.ps.202100013. ISSN 1075-2730. PMID 33882702. S2CID 233349377.
- First, Michael B.; Yousif, Lamyaa H.; Clarke, Diana E.; Wang, Philip S.; Gogtay, Nitin; Appelbaum, Paul S. (2022-05-07). "DSM‐5‐TR: overview of what's new and what's changed". World Psychiatry. 21 (2): 218–219. doi:10.1002/wps.20989. ISSN 1723-8617. PMC 9077590. PMID 35524596.
- "Prolonged grief disorder recognized as official diagnosis. Here's what to know about chronic mourning". The Washington Post. 2022-09-08. ISSN 0190-8286. Retrieved 2023-05-23.
- "Supplemental Material for Same Name, Same Content? Evaluation of DSM-5-TR and ICD-11 Prolonged Grief Criteria". Journal of Consulting and Clinical Psychology. 2022. doi:10.1037/ccp0000720.supp. ISSN 0022-006X. S2CID 248338204.
- "Updates to DSM-5 Criteria & Text". American Psychiatric Association. Retrieved April 18, 2022.
- "Psychiatry Online". DSM Library. Retrieved 2022-11-07.
- Ghaemi SN, Knoll IV JL, Pearlman T (14 October 2013). "Why DSM-III, IV, and 5 are Unscientific". Psychiatric Times: Couch in Crisis Blog.
- Khoury B, Langer EJ, Pagnini F (2014). "The DSM: mindful science or mindless power? A critical review". Frontiers in Psychology. 5: 602. doi:10.3389/fpsyg.2014.00602. PMC 4060802. PMID 24987385.
- Insel T (29 April 2013). "Transforming Diagnosis". Director's Blog. National Institute of Mental Health. Archived from the original on 2013-05-29. Retrieved 2013-09-02.
- "NIMH » Transforming Diagnosis". nimh.nih.gov. Archived from the original on 2019-02-23. Retrieved 2019-02-25.
- Lane C. "The NIMH Withdraws Support for DSM-5". Psychology Today.
- Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, et al. (January 2013). "The initial field trials of DSM-5: new blooms and old thorns". The American Journal of Psychiatry. 170 (1): 1–5. doi:10.1176/appi.ajp.2012.12091189. PMID 23288382. Archived from the original on 2013-01-15.
- McHugh PR (May 2005). "Striving for coherence: psychiatry's efforts over classification". JAMA. 293 (20): 2526–2528. doi:10.1001/jama.293.20.2526. PMID 15914753.
- Fadul. J. A. (2014) Diagnostic and Statistical Manual of Mental Disorders. In Encyclopedia of Theory & Practice in Psychopathology & Counseling. (p. 143). Raleigh, NC: Lulu Press.
- Davis JB (April 1980). "Classification of psychiatric disorders". Canadian Medical Association Journal. 122 (7): 750. PMC 1801862. PMID 20313414.
- Murphy D, Stich S (16 December 1998). "Darwin in the Madhouse: Evolutionary Psychology and the Classification of Mental Disorders". Archived from the original on 5 December 2013. Retrieved 2013-12-03.
- Cosmides L, Tooby J (August 1999). "Toward an evolutionary taxonomy of treatable conditions". Journal of Abnormal Psychology. 108 (3): 453–464. doi:10.1037/0021-843x.108.3.453. PMID 10466269.
- McNally RJ (March 2001). "On Wakefield's harmful dysfunction analysis of mental disorder". Behaviour Research and Therapy. 39 (3): 309–314. doi:10.1016/S0005-7967(00)00068-1. PMID 11227812.
- Hands DW (December 2004). "On Operationalisms and Economics". Journal of Economic Issues. 38 (4): 953–968. doi:10.1080/00213624.2004.11506751. S2CID 141997867.
- Nordgaard J, Sass LA, Parnas J (June 2013). "The psychiatric interview: validity, structure, and subjectivity". European Archives of Psychiatry and Clinical Neuroscience. 263 (4): 353–364. doi:10.1007/s00406-012-0366-z. PMC 3668119. PMID 23001456.
- Zeira A (February 2022). "Mental Health Challenges Related to Neoliberal Capitalism in the United States". Community Mental Health Journal. 58 (2): 205–212. doi:10.1007/s10597-021-00840-7. ISSN 0010-3853. PMC 8145185. PMID 34032963.
- Horwitz AV (17 August 2021). DSM: A History of Psychiatry's Bible. JHU Press. ISBN 978-1-4214-4069-9.
- "Overdiagnosis, Mental Disorders and the DSM-5". World of Psychology. 2010-07-26. Retrieved 2018-09-18.
- "Psychiatric Fads and Overdiagnosis". Psychology Today. Retrieved 2018-09-18.
- Thomas R, Mitchell GK, Batstra L (November 2013). "Attention-deficit/hyperactivity disorder: are we helping or harming?". BMJ. 347 (nov05 1): f6172. doi:10.1136/bmj.f6172. PMID 24192646. S2CID 32080132.
- Bruchmüller K, Margraf J, Schneider S (February 2012). "Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis". Journal of Consulting and Clinical Psychology. 80 (1): 128–138. doi:10.1037/a0026582. PMID 22201328. S2CID 6436414.
- Vande Voort JL, He JP, Jameson ND, Merikangas KR (July 2014). "Impact of the DSM-5 attention-deficit/hyperactivity disorder age-of-onset criterion in the US adolescent population". Journal of the American Academy of Child and Adolescent Psychiatry. 53 (7): 736–744. doi:10.1016/j.jaac.2014.03.005. PMID 24954823.
- Wing L, Potter D (2002). "The epidemiology of autistic spectrum disorders: is the prevalence rising?". Mental Retardation and Developmental Disabilities Research Reviews. 8 (3): 151–161. doi:10.1002/mrdd.10029. PMID 12216059.
- Spitzer RL, Williams JB, First MB, Gibbon M. "Biometric Research". Psychiatric Institute 2001-2002. New York State Psychiatric Institute. Archived from the original on 7 March 2003.
- Maser JD, Akiskal HS (December 2002). "Spectrum concepts in major mental disorders". The Psychiatric Clinics of North America. 25 (4): xi–xiii. doi:10.1016/S0193-953X(02)00034-5. PMID 12462854.
- Krueger RF, Watson D, Barlow DH (November 2005). "Introduction to the special section: toward a dimensionally based taxonomy of psychopathology". Journal of Abnormal Psychology. 114 (4): 491–493. doi:10.1037/0021-843X.114.4.491. PMC 2242426. PMID 16351372.
- Wakefield JC, Schmitz MF, First MB, Horwitz AV (April 2007). "Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey". Archives of General Psychiatry. 64 (4): 433–440. doi:10.1001/archpsyc.64.4.433. PMID 17404120.
- Spitzer RL, Wakefield JC (December 1999). "DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem?". The American Journal of Psychiatry. 156 (12): 1856–1864. doi:10.1176/ajp.156.12.1856. PMID 10588397. S2CID 25642814.
- Widiger TA, Sankis LM (2000). "Adult psychopathology: issues and controversies". Annual Review of Psychology. 51 (1): 377–404. doi:10.1146/annurev.psych.51.1.377. PMID 10751976.
- Vedantam S (June 26, 2005). "Psychiatry's Missing Diagnosis: Patients' Diversity Is Often Discounted". The Washington Post.
- Sashidharan SP, Francis E (July 1999). "Racism in psychiatry necessitates reappraisal of general procedures and Eurocentric theories". BMJ. 319 (7204): 254. doi:10.1136/bmj.319.7204.254. PMC 1116337. PMID 10417096.
- Kleinman A (1997). "Triumph or pyrrhic victory? The inclusion of culture in DSM-IV". Harvard Review of Psychiatry. 4 (6): 343–344. doi:10.3109/10673229709030563. PMID 9385013. S2CID 43256486.
- Bhugra, D. & Munro, A. (1997) Troublesome Disguises: Underdiagnosed Psychiatric Syndromes Blackwell Science Ltd[ISBN missing]
- Irene A, Azibo DA (1991). "Diagnosing personality disorder in Africans (Blacks) using the Azibo nosology: Two case studies". Journal of Black Psychology. 17 (2): 1–22. doi:10.1177/00957984910172002. S2CID 144458287.
- ya Azibo DA (November 2014). "The Azibo Nosology II: Epexegesis and 25th Anniversary Update: 55 Culture-focused Mental Disorders Suffered by African Descent People" (PDF). Journal of Pan African Studies. 7 (5): 32–176. Archived (PDF) from the original on 2015-11-21.
- Zulu IM. "The Azibo Nosology: An Interview with Daudi Ajani ya Azibo" (PDF). Journal of Pan African Studies. 7 (5): 209–214. Archived (PDF) from the original on 2016-08-20.
Chandler E (September 2012). "Religious and spiritual issues in DSM-5: matters of the mind and searching of the soul". Issues in Mental Health Nursing. 33 (9): 577–582. doi:10.3109/01612840.2012.704130. PMID 22957950. S2CID 3453154.
Given the important role that spirituality and religion play for many people in the experiences of coping with health and illness, it seems odd that such important elements are in the margins of the powerful and commanding nosology of the DSM. Explanations for understanding the glaring absence are complex and impacted by some very powerful political and sociological forces, including contributory elements from within the mental health disciplines. This article invites the reader to explore salient issues in the emergence of a broader recognition of religion, spirituality and psychiatric diagnosis in the DSM-5.
- Healy D (2006) The Latest Mania: Selling Bipolar Disorder Archived 2009-02-12 at the Wayback Machine PLoS Med 3(4): e185.
- Cosgrove L, Krimsky S, Vijayaraghavan M, Schneider L (2006). "Financial ties between DSM-IV panel members and the pharmaceutical industry". Psychotherapy and Psychosomatics. 75 (3): 154–160. doi:10.1159/000091772. PMID 16636630. S2CID 11909535.
- "(Susan Bowman, 2006)". The National Psychologist. 2006-11-01. Archived from the original on 2017-06-26. Retrieved 2013-12-03.
- Greenberg G (January 29, 2012). "The D.S.M.'s Troubled Revision". The New York Times. The article's closing words: "it [the APA] will be laughing all the way to the bank."
- Giles DC, Newbold J (March 2011). "Self- and Other-Diagnosis in User-Led Mental Health Online Communities". Qualitative Health Research. 21 (3): 419–428. doi:10.1177/1049732310381388. ISSN 1049-7323. PMID 20739589. S2CID 1853974.
- Sanism in Theory and Practice Archived 2014-03-17 at the Wayback Machine May 9/10, 2011. Richard Ingram, Centre for the Study of Gender, Social Inequities and Mental Health. Simon Fraser University, Canada
- "How Using the Dsm Causes Damage: A Client's Report" Journal of Humanistic Psychology, Vol. 41, No. 4, 36–56 (2001)
- Cape Town Mad Pride (2013-06-08). "Known as the 'psychiatric bible', the Diagnostic and Statistical Manual of Mental Disorders appears in a fifth edition". Retrieved 28 Feb 2019.
- Michael T. Compton (2007) Recovery: Patients, Families, Communities Conference Report, Medscape Psychiatry & Mental Health, October 11–14, 2007
- Frances A (11 May 2012). "Diagnosing the D.S.M." New York Times (New York ed.). p. A19.
- Frances AJ (December 2, 2012). "DSM 5 Is Guide Not Bible – Ignore Its Ten Worst Changes: APA approval of DSM-5 is a sad day for psychiatry". Psychology Today. Retrieved 2013-03-09.
- Phillips J, Frances A, Cerullo MA, Chardavoyne J, Decker HS, First MB, et al. (January 2012). "The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis". Philosophy, Ethics, and Humanities in Medicine. 7 (1): 3. doi:10.1186/1747-5341-7-3. PMC 3305603. PMID 22243994.
- "Professor co-authors letter about America's mental health manual". Point Park University. December 12, 2011. Archived from the original on 2012-03-29. Retrieved 2012-04-04.
- Allday E (November 26, 2011). "Revision of psychiatric manual under fire". San Francisco Chronicle.
- American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR®. American Psychiatric Pub. ISBN 978-0-89042-025-6.
- Spitzer RL (2002). Dsm-Iv-Tr Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Pub. ISBN 978-1-58562-059-3.