The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was published for the first time in May of 1994. It will become the contemporary nosological text in January of 1995 after the International Classification of Diseases-9-Clinical Modification (ICD-9-CM) has been updated in October of 1994 and subsequently published by the US Department of Health and Human Services. The ICD-9-Manual is a product of the World Health Organization (W.H.O.). The Clinical Modification variation is a product of the U.S. Government. DSM-IV had been planned for release in tandem with ICD-10 which was published by the W.H.O. in 1993. However, for a variety of reasons involving many organizations, including many data collection/keeping entities which must change coding and gear up for automated processing with new codes, it is unlikely that ICD-10 will be used in the United States before the end of this decade.

There has always been a need to organize medical classifications into a diagnostic scheme so that individuals with mental and physical ids-orders can be identified and treated. The first time the W.H.O. presented a Classification of Mental Disorders was in the volume International Classification of Diseases-6 (ICD-6) which was published in 1948. The first time the American Psychiatric Association published a Diagnostic and Statistical Manual of Mental Disorders (DSM-I) was in 1952 and at that time 106 diagnostic categories were identified. ICD-8 was published in 1968 as was DSM-II and at that time there were 182 different diagnostic categories described in this latter American Psychiatric Association publication.

In 1980 ICD-9 and DSM-III were published simultaneously and in a fashion that permitted a "crosswalk" between each of these diagnostic manuals. DSM-III included 265 diagnostic categories and represented a radical shift in how psychiatric diagnoses were conceptualized. The paradigm shift included an emphasis on diagnostic criteria that were meant to be neutral with regard to etiology and usable across the many different theoretical orientations in American psychiatry. The outcome of these explicit diagnostic criteria and the multiaxial diagnostic system introduced at that time improved on the record of poor diagnostic reliability of the previous DSM systems and helped clinical communication and research. The result was that studies were able to show that different psychiatrists using the new DSM classification system in evaluating the same patient agreed on the diagnosis 80% of the time. This is a high level of diagnostic reliability and comparable to that for many other medical illnesses.

DSM-III-R was published by the American Psychiatric Association in 1987. This volume was meant to correct inconsistencies found in the DSM-III and to include new evidence for diagnostic criteria. DSM-III-R expanded the number of different diagnostic categories to 296. DSM-III-R defined diagnoses even more clearly but involved few exclusionary hierarchies - in other words, it was more difficult to render differential diagnoses and to describe an individual with only one or two psychiatric diagnoses. Multiple diagnoses were encouraged for the same individual and the concepts of comorbidity and dual diagnoses were embraced. The trend towards inclusion of less severely ill patients into the diagnostic schema had become manifest and the diagnostic criteria had become more inclusive rather than exclusive.

An American Psychiatric Association Task Force for DSM-IV was appointed in May of 1988 after it had become clear from the early drafts of the W.H.O. ICD-10 scheduled for publication in 1993 that there were real differences from DSM-III-R and the ICD-9 Section on Mental Disorders. Since the United States is bound by a treaty obligation to make it's diagnostic coding and descriptions for the various and many medical disorders coincide with those used in the W.H.O. International Classification of Diseases Manual, something had to be done in terms of the dissonance. The solution was DSM-IV.

A 27 member Task Force worked five years to develop the DSM-IV manual in a process that involved more than 1,000 psychiatrists and other mental health professionals. The Task Force on DSM-IV was divided into 13 different work groups involving 5 or 6 members who drew on the expertise of between 50-100 advisors. The development of DSM-IV involved 3 empirical steps:

The 13 topical Work Groups of the DSM-IV Task Force included the subjects of:

A five volume DSM-IV Source Book is being assembled which will elaborate on the research background for the DSM-IV manual along with commentary by the Work Groups that produced it. This effort will become an archival reference. The research findings specified prevalence, age of onset, and course of illness in far greater detail than earlier efforts. This book will provide a comprehensive resource for recommendations about needed future research.

The terminology "Organic" has been redacted from DSM-IV in an attempt to minimize the usage of an anachronistic concept of a mind-body dichotomy. This term has been eliminated because it incorrectly implied that other psychiatric disorders (not described as organic) did not have biological links.

The criteria for Post Traumatic Stress Disorder have been changed. The new Criterion A requires that an individual "has experienced, witnessed or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others and that the person's response to the stressor must involve intense fear, helplessness, or horror." A new criterion requiring that the symptoms cause clinically significant distress or impairment has been added. The previous criterion A that described the stressor as "outside the range of normal human experience" has been deleted because experience with clinical application proved to be unreliable and inaccurate.

Conservatism was the guiding principal. Many diagnostic categories were simplified while a quest for precision added distinctions and sub-types to many disorders. Separate sections for "Delirium, Dementia, and other Cognitive Disorders," "Substance-Related Disorders," and "Mental Disorders due to a General Medical Condition" have been created. There was an expansion of the Dementia section which added specific types including "Dementia due to HIV Disease." Attention to cultural factors has been emphasized in order to diminish misdiagnoses based on cultural misunderstandings. There is an Appendix on Culture-Specific Syndromes and most individual diagnoses have sections on specific cultures, age, and gender features. Recognition is also given to the finding that mental illness has changing patterns across the life span.

The authors have stressed that rather than being on the cutting edge of research, it was the intention that DSM-IV to be on the trailing edge. In other words, DSM-IV is following research and not initiating it.

Small changes in criteria, nomenclature ("Multiple Personality Disorder" becomes "Dissociative Identity Disorder," for ex-ample), sub-types, and organization were many. Examples and explanations are listed in the 20 page Appendix D - the new "cross-walk" between DSM-III-R and DSM-IV. The most marked expansion was in the treatment of differential diagnoses. Criteria sets were abbreviated and simplified - notably for Somatization Disorder, Generalized Anxiety Disorder, Antisocial Personality Disorder and Schizophrenia (in ways that do not materially influence the number of patients so diagnosed).

Although the boundaries between the psychiatric disorders were left largely unaltered, particular attention was paid to "the boundary with normality." Therefore, descriptions of significant impairment or distress were made more explicit in the criteria sets. The defining presence of a mental disorder requires first of all, the criterion that the disorder cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning." DSM-IV was written for all mental health workers and it does not pontificate about which diagnoses are biomedically based and which are psychosocially based disorders. It is value neutral and descriptive.

The concept of mental disorder, like many other concepts in medical science, lacks a consistent operational definition which covers all situations. In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, (e.g., a painful symptom) or disability (i.e., impairment of one or more areas of functioning) or with a significant increased rate of suffering, death, pain, impairment or an important loss of freedom. In addition, the syndrome or pattern must not be readily anticipated or culturally sanctioned in response to a certain event, e.g., the death of a loved one. Whatever the original stressor, the disorder must currently be considered a manifestation of behavioral, psychological, or biological dysfunction in the individual.

One important change involves the category of Somatoform Disorders. The common feature of the Somatoform Disorders is the presence of physical symptoms which suggest a general medical condition but which are not fully explained by the general medical condition alone, by the direct effects of a substance, or by another mental disorder. The subcategory Psychogenic Pain Disorder has been replaced by the term Pain Disorder. The essential feature of Pain Disorder is characterized by pain as the predominant focus of clinical attention (Criterion A). In addition, psychological facts are judged to have an important role in the onset, severity, exacerbation or maintenance of pain. A specific set of criteria for subtypes and specifiers are described. The three separate subtypes include 1) Pain associated with Psychological Factors; 2) Pain associated with both Psychological Factors and General Medical Condition; 3) and Pain Disorder associated with a General Medical Condition. The latter condition is not considered a mental disorder but is included for discussion in the spirit of completeness.

This attempt to deal in a straight-forward way with pain coincides with the decision by the American Medical Association (A.M.A.) to develop a specific chapter (Chapter 15) in the 1993 A.M.A. Guides To The Evaluation of Permanent Impairment, (Fourth Edition). In the A.M.A. text it is stated that the Secretary of the US Department of Health and Human Services in 1985 formed a Commission on the Evaluation of Pain which concluded that chronic pain is not a psychiatric disorder. Despite that caveat, basic assumptions are elaborated and clinicians are subsequently encouraged to evaluate pain impairment although it is acknowledged in the text to be a difficult task.

Now with the sanction of the American Medical Association as portrayed in the 1993 A.M.A. Guides and with the blessing of the American Psychiatric Association (A.P.A.) through the 1994 DSM-IV, psychiatric clinicians will venture forth into what this writer considers a most uncertain area, pain assessment for purposes of determining degree of impairment. This writer anticipates that this subject will require the accumulation of experience and skill on the part of evaluators which will come only with time as both the 1993 A.M.A. Guides and the 1994 APA DSM-IV descriptions are applied to this topic. The concepts of reliability and validity will be sorely tested.

A common misconception is that a classification of mental disorders classifies people; whereas, what are actually being classified are disorders that people experience. Over one million copies of DSM-III and DSM-III-R were published. These two texts have been made available in 17 different languages. Now DSM-IV will provide the new clinical reference map with many coordinates that a careful reader will find illuminating, useful, and practical.

Additional Reading:

Dr. Weitzel is in private practice in Lexington, Kentucky. He became a Diplomate of the American Board of Psychiatry and Neurology in 1975 and of the American Board of Forensic Psychiatry in 1984.

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