Dsm-IV

Theoretical Influences

The first two versions of the manual–the DSM and DSM-II– were heavily influenced by the psychoanalytic model. Mental disease terms, such as neurosis and psychosis, derived from Freud's view that psychopathology resides within the person and can be traced to unconscious conflicts. From this standpoint, symptom profiles are comparatively worthless in understanding the etiology of a patient's intrapsychic conflicts and designing an effective treatment.

In contrast, the DSM-III was compiled by research-oriented psychiatrists who were intent on devising a scientifically supportable system that could be widely used by clinicians, regardless of their theoretical orientation. Unfortunately, adequate research was still lacking at the time the DSM-III was developed. In the absence of reliable data, it was not unusual for the editor of the DSM-III, psychiatrist Robert Spitzer, to formulate new diagnoses with the help of only a few committee members.

Carefully navigating a course away from psychoanalytic assumptions and terminology, Spitzer and his colleagues retained, in a few instances, the traditional psychoanalytic language while shifting to a method of diagnosis contingent on explicit symptoms. For the first time, each disorder was based on a list of operationally worded criteria, on which a final diagnosis could be determined. If a patient exhibited a certain number of symptoms out of the total list, the diagnostic threshold was crossed and the diagnosis was thus applied.

Critics have alleged that political and economic agendas, not science, account for the changes in the DSM's emphasis over the last 50 years. When insurance companies began to reimburse patients for mental health treatment during the 1960s, they pressed for a comprehensive list of specific and treatable disorders. In response, the DSM's formulators expanded the diagnostic categories in the DSM-III to more than 300 disorders. Such compliance was amply rewarded. Shortly after its publication, the DSM-III leapt into prominence as insurers began to require DSM-III codes as a prerequisite for reimbursement. Alongside the proliferation of disorders, the influence of pharmaceutical companies may account, at least in part, for the DSM's growing emphasis on the biological basis of mental disorders. By the time the DSM-IV was published in 1994, mental disorders had been largely recast as biologically based disorders that could be treated with medication. It was a convenient transformation, considering the rising influence of managed care and diminishing support for traditional long-term psychodynamic therapy.

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