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

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

Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases DSMICD 1952DSM 1968DSM-IIICD DSM-IIIICD-9-CM 1987DSM-III-R 1994DSM-IVICD DSM-IV-TR 2013DSM-V

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

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

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

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

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

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

Eli Robins, MD

Robert L. Spitzer, MD Chair, DSM-III and DSM-III-R

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

Noah Spitzer-Williams, 1984

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

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

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

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

January 3, 2005 THE DICTIONARY OF DISORDER by ALIX SPIEGEL

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

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

DSM Casebooks DSM-IV Sourcebooks Structured Clinical Interview for DSM (SCID) - SCID-I (for Axis I) - SCID-RV (Research Version) - SCID-CV (Clinician Version) - SCID-II (for Axis II) - SCID-CT (for Clinical Trials) Additional Materials

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

Allen Frances, MD Chair, DSM-IV

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

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

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

Michael First, MD DSM-IV Text Editor

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

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