Library of Congress Cataloging-in-Publication Data. Diagnostic and statistical manual of mental disorders: DSM-IV. — 4th ed. p. cm. Prepared by the Task Force. and Statistical. Manual of Mental Disorders, of disorders for the DSM-IV and DSM-IV-TR. . Identifying diagnostic and statistical codes established by WHO. DSM, DSM-IV, and DSM-IV-TR are trademarks of the American Psychiatric Association. Use Diagnostic and statistical manual of mental disorders: DSM- IV.
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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition writing by the American Psychiatric Association (APA), no part of this. PDF | The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Juuu 6 Attach a summary of the document incorporated by.
With all these experts involved, DSM-5 is in many ways a committee document, which may explain the inconsistencies in understandings and definitions that this article has in its searchlight.
However, while the manual is co-authored, it is still read as representing one voice and not just any voice but one of the most authorized understandings of mental illness. Between the two manuals, I have analysed DSM-5 in more depth. The article focuses on the abovementioned claim of having made DSM-5 more sensitive to cultural issues. The article also explores the reviews and statements made by the cultural expertise, focusing on both their critique and suggested revisions, and on their own conceptualizations of culture.
The analysis tackles three cases in point. First, I look at the conceptualization of culture. Here I compare and point to discrepancies between how culture is defined and how it is then subsequently used.
Secondly, I analyse the way psychiatric distress is, or is not, culturally contextualized. Here, I take criteria for Panic Anxiety as an illustrative example of how the manual continues to construct some symptoms of psychiatric distress as universal, whereas others are construed of as linked only to particular groups of people. In the third part of my analysis, I address the issue of context and its relation to symptoms in the manual more generally by discussing the Cultural Formulation Interview, which is a DSM-5 interview guide designed to be used in clinical practice.
I conclude the article by considering how my analytical points relate to current trends in bio psyhicatry and mental health diagnosing. Before pursuing my analysis, however, I will first situate DSM in a larger context and present the cultural perspectives of the manuals in more detail.
DSM and the hegemony of biological psychiatry At first glance, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides a neat impression where disorders are listed chapter by chapter in a menu-like format that contributes to a sense of overview.
To keep track of what becomes endless choices of paths, clinicians might turn to the vast number of references that accompany the manual: books presenting clinical cases Barnhill ; trees of diagnostic differences delineating disorders with similar symptoms from each other First ; diagnostic examination tools Nussbaum ; and in-depth knowledge on special disorders or phenomena of interest.
Add to this the numerous experts who have been appointed in the revision process, and it is easy to see that the DSM is an industry in and of itself Cosgrove and Wheeler Critics have also pointed to ties between some DSM panel members and the pharmaceutical industry that may have compromised the otherwise relatively open and transparent revision process Cosgrove and Wheeler ; Angell The manual is meant to serve both as a guide for clinical assessment and a classificatory system of different mental disorders.
It makes use of a phenomenological or categorical approach where criteria for a disorder consist of a number of symptoms that need to be met in order to acquire a diagnosis. The categorical approach thus implies that symptoms are described and ordered but not linked to any particular etiology. It represented a break with previous diagnostic systems that were based on Freudian psychoanalytic understandings and categorizations Horwitz and Wakefield The aim was to avoid hypothetical theories of etiology Kupfer et al.
However, even if DSM-III is presented as nonaligned to any particular philosophy, it has yet been looked upon as a benchmark in the history of biological psychiatry. As several critics have argued, a key reason for installing the categorical approach was to reinstate more credibility to psychiatry in response to the anti-psychiatric movements that flourished at the time Shorter That Feighner et al.
Biocapital plays a central role in biomedicalization, as do dominant discourses of consumerism and individualization, and the technoscientific development. Using standardized diagnostic criteria enabled comparisons of disorder prevalence and incidence i. With DSM-5, the advantage of bio-psychiatry is no longer a hidden endeavour. DSM-5 had an explicit aim to break this trend.
From the very beginning of the revision process, the DSM-5 Task Force emphasised how the developments in cognitive neuroscience, brain imagining, epidemiology, and genetics bring new light to psychiatry and that such knowledge should impact the revised manual. The goal was to increase validity of psychiatric diagnoses and break with the categorical system of previous editions Whooley ; A dimensional model, they argue, is more in line with the rest of medicine Kupfer et al.
To follow this through, all work groups assigned to suggest revisions of different disorders by the DSM-5 Task Force were initially instructed to look for biomedical evidence and, if possible, revise the manual in line with such thinking Kupfer et al. However, the field trials showed that while the psychometrics of a dimensional model may be valuable for research, it does not carry the same weight in clinical practice.
Also, as Owen Whooley has shown by interviewing leading experts of the revision, the process was circumscribed by the way the Task Force gave the different subcommittees to much freedom in designing severity scales , Adjusting the manual to a neuroscientific framework thus turned out to be easier said than done cf. Pickersgill ; Cooper In , when the manual was published, there was still a lack of strong evidence to justify a complete make-over. Save for some exceptions such as organizing the manual according to developmental and lifespan considerations, and limited changes towards a dimensional model for some disorders, the new manual largely remains symptom-based and descriptive in its approach.
Put in the light of biomedicalization theories however, it is clear that DSM-5 expresses the blurry line between normality and pathology that characterizes a biomedicalized society Clarke et al.
Since the categorical model was introduced with DSM-III, critics have cautioned against the pathologization of normal experience Horwitz and Wakefield DSM-5 was no exception.
During the revision process, critical commentators including many prominent psychiatric experts objected to the expansion of new diagnoses, in particular those that affect already vulnerable groups such as children and elderly Frances Arguments was also raised against the medical model that, critics said, decontextualizes human suffering and does not pay enough attention to social aspects, among others, issues of culture, race and ethnicity e.
British Psychological Society It is to these issues I will turn next. Cultural differences and the DSM Alongside searching for scientific evidence of underlying biological mechanisms, attending to cross-cultural matters was also set as a priority for the revision and cross-cultural expertise was appointed to all work groups as well as gathered to form a specific study group Kupfer et al.
The world-wide use of DSM lay behind the rationale of increasing the cultural sensitivity of the manual, and the tasks for the cultural expertise was to address cultural aspects of each disorder, as well as to draw more comprehensive conclusions across all relevant research areas Kupfer et al. The need to include cultural perspectives had been acknowledged already in DSM-IV , which pointed to how the manual is used in culturally diverse populations in the United States and internationally.
Research in this field poses a real challenge to psychiatric diagnosing as it shows that not only do symptoms vary across cultures but that culture also affects how disorders are understood, explained and coped with Kirmayer and Minas Categorizing the research field of cultural psychiatry, Alarcon et al. The third strand includes a more comprehensive investigation of nosology and diagnostic procedures. This strand acknowledges that also psychiatric knowledge and practice are, in themselves, outcomes of specific socio-political, economic and cultural contexts see also Kirmayer and Minas DSM-IV specify that culture is addressed in the manual in three different ways: 1 a discussion in the text of cultural variations in the clinical presentations of those disorders that have been included in the DSM-IV Classification a description of culture-bound syndromes that have not been included in the DSM-IV Classification 3 an outline for cultural formulation designed to assist the clinician in systematically evaluating and reporting the impact of the individual's cultural context.
There was also a need to standardize diagnostic practices within the US and with other countries after research showed psychiatric diagnoses differed between Europe and the US. 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 in St.
Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language which would be easier to use by federal administrative offices , rather than assumptions of cause, although its categorical approach 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 the DSM statement: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome. It introduced many new categories of disorder, while deleting or changing others.
A number of the unpublished documents discussing and justifying the changes have recently come to light. 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, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some capacity; 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".
It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry. However, according to a 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 generalisability 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 Categories were renamed and reorganized, and significant changes in criteria were made.
Six categories were deleted while others were added.
Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder , were considered and discarded. 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.
The task force was chaired by Allen Frances. A steering committee of twenty-seven people was introduced, including four psychologists.
The steering committee created thirteen work groups of five to sixteen members. Each work group had about twenty advisers. 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 multicenter field trials relating diagnoses to clinical practice.
Some personality disorder diagnoses were deleted or moved to the appendix. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged. The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.
The DSM-IV-TR characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress It states "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder" APA, and 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.
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. Typical psychosocial influences that are usually listed as having negative impact on life, mentality and health include, but are not limited to: Environmental factors of dysfunction such as those experienced within home, school and work; Social factors such as issues with drug use not diagnosed , enabling friends and conflicts with coworkers; Family complications such as divorce, social service involvement and court ordered placements; Various stressors such as recent accident, natural disaster and other traumatic occurrences i.
Sourcebooks[ edit ] 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.
Severity is based on social communication impairments and restricted, repetitive patterns of behaviour, with three levels: 1 requiring support , 2 requiring substantial support and 3 requiring very substantial support. During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion. Criticism[ edit ] Reliability and validity concerns[ edit ] 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.
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.
Insel , declared that the agency would no longer fund research projects that rely exclusively on DSM diagnostic criteria due to its lack of validity.
For example, major depressive disorder , a common mental illness, had a poor reliability kappa statistic of 0. The most reliable diagnosis was major neurocognitive disorder with a kappa of 0. It claims to collect them together 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. 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.
Reviewers note, however, that this approach is undermining research, including in genetics, because it results in the grouping of individuals who have very little in common except superficial criteria as per DSM or ICD diagnosis Fadul, , p.