Related Terms

• American Psychiatric Association, American Psychological Association, DSM-IV, DSM-IV-TR, Global Assessment of Functioning.

Background

• The Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM-IV, is a 943 page book that is most frequently used for diagnosing psychological problems, learning disabilities and mental retardation in the United States. The book lists criteria for various behaviors, which are considered abnormal and/or unhealthy, but does not suggest treatment options. In order to be diagnosed according to the DSM, an individual must fulfill a variety of diagnostic criteria. The most recently released version of the DSM is the DSM-IV-TR.

• The American Psychiatric Association publishes the DSM-IV. A diagnosis may be added or deleted over time. The criteria for a diagnosis may also change. The DSM is not intended to offer a complete clinical picture of an individual or their life experience.

• The DSM-I was first published in 1950. The book has gone through 5 revisions since the first edition. These revisions were II, III, III-R, IV and IV-TR. The most recent edition of the DSM was published in 2000. This version was the DSM-IV-TR. The diagnostic criteria remained the same from the DSM-IV, which was published in 1994, but the text between diagnostic criteria was changed.

• Although the DSM was originally written in order to provide a common set of terms under which to conduct research, its use is now much wider. For example, insurance companies may use the DSM-IV-TR for the purpose of reimbursement for health services. Mental health professionals may use the DSM IV-TR as shorthand for discussing cases.

• The diagnostic categories of the DSM are not necessarily permanent. Diagnoses are frequently created, changed, refined or omitted from one edition to the next. Changes in mainstream culture about what constitutes acceptable behavior and dialogues about the usefulness of diagnoses play a role in the categorization of emotional health.

• The DSM-V is expected to be released in 2011. The psychological community has been in vigorous debate about the merits and shortcomings of the DSM-IV-TR since it was released in 2000. The American Psychiatric Association will begin to assemble congresses to create, refine, alter and omit diagnoses in 2007.

Dsm Outline

• A statement released by the American Psychological Association states that an individual requires specialized training to use the DSM.

• The American Psychiatric Association has added and omitted diagnoses over time. For instance, homosexuality was once listed as a diagnosis but was omitted in 1973; attention deficit disorder (ADD) was added to the DSM-III in 1983.

• A considerable amount of dialogue occurs before a diagnosis is created, modified, or removed. Many articles are published in scientific and psychological publications. The American Psychiatric Association also establishes what is known as a congress to debate the diagnostic categories before a new edition of the DSM is released. In congresses, mental health professionals and experts in the field of psychology discuss the categorization of a disorder. Members may also create, modify or remove a diagnosis from the DSM. Sometimes, social activists play a role in diagnoses. For instance, public protests and activism on the part of homosexual groups created enough pressure for the 1980 version of the DSM to drop "homosexuality" as a diagnosis.

• For each diagnosis, the DSM includes a list of behaviors that commonly accompany the disorder. In order for an individual to be diagnosed, they must acknowledge experiencing, and the therapist must observe, at least a majority of those behaviors. For instance, for an individual to be diagnosed with a major depressive episode an individual must self-report, and a mental health professional must observe, at least 5 of the 9 listed behaviors.

• A person may be diagnosed with multiple disorders at the same time. Some of the criteria for diagnosis in the DSM are open to interpretation; different clinicians may diagnose the same patient differently.

• The DSM-IV-TR specifies that reports of an individual's mental illness are organized on 5 axes. Each axis provides specific information about an individual's life experience, stress level, and cognitive functioning. The axes were developed as a diagnostic tool because the American Psychiatric Association believes that life circumstances influence emotional functioning. The DSM-IV-TR is not organized on the basis of these axes.

• Axis I: Clinical disorders. These include major mental disorders, developmental disorders and learning disabilities. Common disorders on this axis may include: depression, anxiety disorders, bipolar disorder, ADD, and schizophrenia.

• Axis II: Personality disorders and mental retardation. These may include borderline personality disorder, schizotypal personality disorder, antisocial personality disorder, mild mental retardation, and substance abuse.

• Axis III: General medical condition. This axis includes any non-psychiatric medical condition. These conditions are also known as somatic conditions. Axis III acknowledges that a handicap or illness influences an individual's emotional wellbeing. Examples of these may include diabetes, HIV/AIDS or paraplegia.

• Axis IV: Psychosocial and environmental factors. This axis discusses social functioning and the impact that symptoms of emotional illness may have on an individual's day-to-day life. This axis acknowledges that one's social environment and life circumstances have an impact on an individuals' mental health. Recent bankruptcy, childhood trauma, and a death of a close relative are examples of factors that may be included on this axis.

• Axis V: Uses the Global Assessment of Functioning (GAF), which is a scale of 100 - 0. This scale was created by the American Psychiatric Association and is intended to give a numeric "snapshot" of a person's social, occupational and psychological functioning. This scale is only used for adults. For children, the Children's Global Assessment Scale is used. Individuals receiving psychological treatment should show improvement in their Global Assessment of Functioning over time. The ranking is as follows:

  • 91-100: Superior functioning in a wide range of activities; life's problems never seem to get out of hand; is sought out by others because of his or her many qualities. No symptoms.

  • 90-81: Absent or minimal symptoms; good functioning in all areas; interested and involved in a wide range of activities; socially effective; generally satisfied with life; no more than everyday problems or concerns.

  • 80-71: If symptoms are present, they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning.

  • 70-61: Some mild symptoms OR some difficulty in social, occupational, or school functioning, but generally functioning pretty well; has some meaningful interpersonal relationships.

  • 60-51: Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.

  • 50-41 Serious symptoms OR any serious impairment in social, occupational, or school functioning.

  • 40-31: Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

  • 30-21: Behavior is considered influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.

  • 20-11: Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.

  • 10-1: Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.

  • 0: Not enough information available to provide GAF.

Theory/Evidence

• An individual's diagnosis according to the DSM may influence their level of qualification for certain mental health services, type of medication prescribed, and even legal status. For this reason, the American Psychiatric Association recommends that clinicians carefully evaluate a patient before making a diagnosis according to the DSM-IV-TR.

• There is currently debate about what the DSM-IV-TR classifies as "subclinical behavior," namely thoughts and attitudes that do and do not currently warrant a diagnosis and whether these account for problem behaviors. At times, the threshold for diagnosis may be considered too high, and at other times, it may be considered too low. For instance, the DSM-IV-TR considers individuals who frequently make plans to molest children, but who do not follow through with those plans, subclinical. On the other hand, many individuals diagnosed with Asperger disorder, a mild form of autism, lead fairly normal lives and enjoy many satisfying social relationships.

• Many of the individuals who participate in congresses for the DSM have ties to pharmaceutical companies. Critics hold that these individuals have an inherent interest in creating as many diagnoses as possible, because pharmaceutical research to treat a condition occurs as soon as a diagnosis is made.

• Because a majority of the mental health professionals who write and revise the DSM are white, middle-upper and upper class individuals, many patients who come from socio-cultural backgrounds other than those of a majority of the book's authors, may be misdiagnosed. What is considered psychologically normal varies according to culture. For example, seeing ghosts after the death of a loved one may or may not be acceptable in a particular culture. For individuals native to the white upper-middle and upper class of the United States, this behavior might warrant psychological evaluation and treatment. Some other communities in the country, however, may consider it completely normal and even healthy.

Safety

• Mental illness is a serious condition, and should be treated as such. Individuals who think they may suffer from mental illness should consult with a qualified medical practitioner.

• Individuals who have suicidal or homicidal plans, and who intend to carry out those plans in the near future should immediately call a trusted friend / family member, a mental health hotline, or the local medical emergency number. Such individuals should also immediately consult with their doctor.

• A statement released by the American Psychological Association states that an individual requires specialized training to use the DSM.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American Psychiatric Association. 20 June 2006. www.psych.org

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision). Arlington, VA: American Psychiatric Publishing: 2000.

3. American Psychological Association. 20 June 20, 2006. www.apa.org

4. Barron, James W. Making Diagnosis Meaningful: Enhancing Evaluation and Treatment of Psychological Disorders. Washington, D.C.: American Psychological Association Press. 1998.

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6. DSM-IV-TR. 20 June 2006. www.dsm5.org/

7. DSM-V Prelude Project: Research and Outreach. 20 June 2006. www.dsm5.org

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