Diagnostic and Statistical Manual of Mental Disorders

History

The need for statistical information was the initial impetus in the United States to develop a classification system of mental disorders. The first official attempt was the recording of the frequency of one category labeled ‘idiocy/insanity’ in the 1840 census. By the 1880 census, seven categories of mental illness were distinguished—dementia, dipsomania, epilepsy, mania, melancholia, monomania, and paresis. In 1952, the American Psychiatric Association Committee on Nomenclature and Statistics published the first edition of the DSM. This edition and the one that followed were based on a psychodynamic interpretation of each diagnosis. Beginning with the third edition, the DSM has used an atheoretical approach to diagnosis, which has increased the reliability between raters for establishing diagnoses.

Use of the DSM

The DSM consists of a multiaxial classification system used by clinicians to diagnose individuals, plan treatment interventions, and predict probable outcomes. Diagnoses are established along the following five axes:

• Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention
• Axis II: Personality Disorders and Mental Retardation
• Axis III: General Medical Conditions
• Axis IV: Psychosocial and Environmental Problems (rated with descriptive categories)
• Axis V: Global Assessment of Functioning (rated from 1 [persistent danger to self or others] to 100 [superior functioning to a wide range of activities])

All mental disorders/conditions listed in the DSM fall under Axis I with the exception of Personality Disorders and Mental Retardation (listed under Axis II). Mental disorders or conditions that are the main focus of clinical attention are usually listed on Axis I. This axis is composed of the following categories: schizophrenia and other psychotic disorders, mood disorders, [Page 239]anxiety disorders, somatoform disorders, disorders usually first diagnosed in childhood (e.g., autistic disorder), eating disorders, delirium, dementia, amnestic and other cognitive disorders, sleep disorders, impulse control disorders, and adjustment disorders.

Axis II is used for reporting personality disorders as well as mental retardation. Listing these conditions on a separate axis emphasizes the chronic and inflexible nature of this class of disorders. The personality disorders are classified into three broad clusters, as follows: cluster A, odd and eccentric (paranoid, schizoid, and schizotypal); cluster B, expressive/labile (antisocial, borderline, histrionic, and narcissistic); and cluster C, anxious (avoidant, dependent, and obsessive-compulsive).

General medical conditions that may be pertinent to the understanding and/or treatment of an individual's mental condition are reported on Axis III. For example, persons with severe forms of arthritis are more likely to be depressed due to the pain and physical limitations associated with their medical condition.

Axis IV accounts for environmental or psychosocial factors that may potentially limit the effectiveness of the treatment for disorders on the first three axes. For example, the loss of job and the financial issues associated with that loss would complicate treatment of depression. There is a broad range of possibilities that could be listed under this category. The clinician should list the category as well as specifics about the problem. The main categories with some examples are as follows: problems with primary support group (e.g., divorce, neglect of child, health problems among family members); problems related to the social environment (e.g., death of a friend, discrimination, adjustment to retirement); educational problems (illiteracy, academic problems); occupational problems (unemployment, stressful work environment, discord with a co-worker or boss); housing problems (homelessness, unsafe neighborhood); economic problems (poverty, inadequate finances); problems with access to health care (lack of transportation to health care services, inadequate or lack of health insurance); problems related to interaction with the legal system/crime (incarceration, litigation, victim of crime); other psychosocial and environmental problems (exposure to disaster, discord with nonfamily caregivers such as counselor, social worker, or physician).

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