Diagnostic and Statistical Manual of Mental Disorders

from Wikipedia, the free encyclopedia

The Diagnostic and Statistical Manual of Mental Disorders ( DSM ; English for "Diagnostic and Statistical Guide to Mental Disorders") is a classification system in psychiatry . It plays a central role in the definition and diagnosis of mental illness .

The DSM has been published by the American Psychiatric Society (APA) in the USA since 1952 . Today the DSM is used internationally in research and in many clinics and institutes. The currently valid fifth edition ( DSM-5 ) was published in 2013 and translated into German a year later. In the USA too, however, the ICD is the official psychiatric classification system that is used for billing with health insurance companies.

The DSM classification is developed by experts in order to make psychiatric diagnoses reproducible and statistically usable. It thus provides a clear vocabulary and a uniform language for all researchers and practitioners . This enables z. B. Representatives of a psychoanalytic , biological and behavioral therapy orientation to agree on a common description of the various forms of mental illness. This connecting technical language is seen as a great advantage and progress compared to earlier times and has generally contributed to more reliable diagnoses.

Basics

The Diagnostic and Statistical Manual of Mental Disorders is a diagnostic system based on the following basic principles. It is

  • categorical
  • operationalized
  • purely descriptive
  • and atheoretical

Mental illnesses are therefore understood as categories and not as a continuum with flowing transitions - for better handling. Operationalization means that there are precise, concrete criteria that must be met in order to diagnose any disorder. Purely descriptive means that the DSM limits itself to describing the symptoms as neutrally as possible. It is also largely atheoretical in that it does not include speculation on the causes or treatment recommendations.

According to DSM-5 , a mental disorder is “defined as a syndrome that is characterized by clinically significant disorders in a person's cognition, emotion regulation and behavior. Mental disorders are typically associated with significant ailments or disabilities in relation to social or professional / educational and other important activities. ”It should be noted, however, that normal grief and socially deviant behavior (in a political, sexual, or religious sense) is not a mental disorder.

A diagnosis should be as useful as possible for practical clinical work by enabling a prognosis and specifying the type of treatment. However, it should be emphasized that a diagnosis does not always mean the need for treatment. Whether this is also dependent on the suffering of the scope of the symptoms and effects or side effects of the patient from the treatment.

The DSM is often referred to as the “Bible of Psychiatry”, but it is much more of a dictionary. Because ultimately it is only a collection of symptom patterns, for each of which a name label and a definition have been established. The great strength of the DSM lies in its high reliability , i.e. In other words, it uses explicit criteria to ensure that the same patient receives the same diagnosis as everywhere as possible. However, its weakness lies in its low validity , since the syndromes present in the DSM up to now only very inadequately represent the actual clinical reality. The symptom complexes described (e.g. in the case of depression) are only provisional, helpful constructs for clinical practice, but are not yet delimitations in the sense of real medical diseases ( “nosological entities” as ideal). The purely symptom-based diagnosis, which does not include any objective biomarkers or laboratory tests, is also problematic . The individual life situation or the social context of the symptoms are also given little consideration.

Relation to ICD-10

The DSM competes with Chapter V - Mental and Behavioral Disorders of the ICD-10 (International Classification of Diseases) . However, the ICD is issued by the WHO and is widely used internationally. The DSM, on the other hand, is a classification system for the USA . It therefore does not have to take into account the numerous compromises and additions to the ICD-10 and sometimes contains more precise diagnostic criteria. This makes it particularly interesting for research. The ICD-10, on the other hand, focuses on an intercultural perspective and applicability in the countries of the global south . It also includes all medical diseases, so it is not limited to mental disorders like the DSM.

In contrast to the ICD-10, the DSM-5 takes gender-specific differences into account. It does not assign its own classification key, but rather a subset of the numbers selected by the APA that were provided for in the ICD-9, valid from 1979–1997, for the classification of psychiatric diseases. The ICD-10 has different classification keys, which makes comparison difficult; however, it is often possible to recode the diagnoses.

history

In 1840 in the United States at a census category "idiocy / insanity" (idiocy / insanity) levied. Forty years later it was expanded to include seven categories in a census. When many veterans had to be treated for mental disorders after the Second World War , the army and veterans' associations developed a much more comprehensive classification . This was followed by the World Health Organization (WHO) in its ICD-6 (see also Development of the Psychiatric Classification ).

In 1952, the American Psychiatric Association developed the classification and published the first edition. In the DSM-I , the classification keys deviated significantly from the ICD-6 and later also from the ICD-7.

The second edition appeared in 1968 with the DSM-II . It still had little influence on psychiatric teaching, research and clinical practice. When the well-known psychoanalyst Irving Bieber was asked, “Did you hear the terrible news? They take homosexuality out of the future prints of DSM-II. ", He replied," What is DSM-II? "

It was not until 1980 that the precise definitions of mental disorders required by the WHO were taken into account in DSM-III . The third edition represented a revolution in the previous classification, precisely because of these specific, explicit criteria. Further innovations were the multiaxial classification (see below) and the most extensive detachment from cause - and theory - related terminology. The DSM-III was therefore seen as a “ paradigm shift ”. The version produced under the direction of Robert L. Spitzer became the first widely adopted. The DSM-III later appeared in other languages; In 1984 a German-language edition came out for the first time.

A revision of the content of this edition ( DSM-III-R ) appeared as early as 1987 and the DSM-IV followed in 1994 under the direction of Allen Frances . The text revision of the fourth edition ( DSM-IV-TR ) was published in 2000. The German translation of this came out in 2003 and dominated scientific diagnostics in German-speaking countries for over ten years.

In May 2013 the DSM-5 , which had been worked on since 1999, finally appeared . From 2000, Darrel A. Regier was responsible for coordinating the preparatory work as research director of the APA, and since 2004 there has been a website of its own. Since 2006 there was a task force headed by David J. Kupfer , Darrel A. Regier acted as deputy. Since 2007, working groups have met regularly on the various diagnostic categories. In addition, the research results of numerous conferences and congresses were incorporated.

version Start of work English
(USA)		 pages Diagnoses German French
US census 1840 1 - -
US census 1880 7th - -
APA Committee on Statistics 1917 59 - -
DSM-I 1952 130 106 - -
DSM-II 1968 134 182 - -
DSM-III 1974 1980 494 265 1984 1983
DSM-IIIR ( revision ) 1987 567 292 1989 1989
DSM-IV 1988 1994 886 297 1996 1997
DSM-IVTR ( TextRevision ) 2000 943 297 2003 2003
DSM-5 1999 2013 947 374 2014 2015

Multiaxial division

In the DSM-III and DSM-IV (from 1980 to 2013), psychiatric diagnoses were previously divided into five so-called axes. The aim of this was the comprehensive assessment of the patient in terms of the biopsychosocial model . At that time, a complete diagnosis included specifying the condition on each of these five axes:

  • Axis I: Clinical disorders and other clinically relevant problems (all mental disorders, states and other problems; examples: schizophrenia , impulse control disorders, etc.).
  • Axis II: personality disorders (example: borderline personality disorder ) and intellectual disabilities .
  • Axis III: Medical disease factors (physical problems relevant to the mental disorder).
  • Axis IV: Psychosocial and environmental problems (examples: housing problems, professional problems, problems in the social environment)
  • Axis V: Global assessment of the functional level using the GAF scale .

On some of these axes, the specification could also be "none" or multiple. In the current DSM-5 , however, no more axes are used.

criticism

It is criticized that the DSM shows symptom-oriented , reductionist errors . It is also criticized that the authors of the DSM are not independent because they are financially supported by the pharmaceutical industry . In 2008 it turned out that more than half of the authors received additional income from the pharmaceutical industry, e.g. B. Remuneration for lectures or effectiveness studies. This may have clouded the objectivity of scientists in defining psychiatric illnesses. For this reason, the authors of DSM-5, published in 2013, were required to disclose additional income from the pharmaceutical industry. This allowed during the creation of the new DSM-5 is not more than 10,000  US dollars amount per year.

Another point of criticism is that the decision-making body of the American Psychiatric Association consists of a group of 160 people who are only legitimized by their promotion to the bodies of the association. There was a lack of transparency, scientific control and criticism.

Various other points of criticism are:

  • Reliability of the diagnosis: According to Henrik Walter , research into mental illnesses can only make progress if the diagnoses of these illnesses are also reliable. Thomas R. Insel , then head of the National Institute of Mental Health , stated in 2013 that the NIMH would no longer support research if they were solely to apply the criteria of the DSM. According to him, the definitions of the DSM are grouped around clinical symptoms and neglect other data sources useful for diagnosis, such as genetic makeup , imaging procedures , physiological circumstances and cognitive performance. Experiments showed that a common disease - unipolar depression (major depressive disorder, MDD) - was only diagnosed with an agreement of kappa = 0.28. The most reliably diagnosed disease was major neurocognitive disorder ( dementia ), with a kappa value of 0.78.
  • Failure to consider the causes: The DSM focuses on the symptoms of mental illness and not on the underlying causes. So it almost exclusively arranges the diseases according to clinical patterns. The DSM was compared with a bird identification book , which is appropriate for its purpose, but also does not claim to organize the bird world according to ecological criteria. However, this fact makes it difficult to research the causes of mental illness, especially when it comes to hereditary factors. From the evolutionary psychological point of view it is criticized that the DSM does not distinguish between real cognitive failures and the consequences of psychological adaptations.
  • Arbitrary delimitations: The DSM is accused of arbitrarily setting the boundaries between diagnoses or a diagnosis and the normal psychological state. For example, a patient has to meet a certain number of criteria, regardless of the actual extent of the suffering. The manual also takes little account of whether a complaint is about a pathological mental process or a normal psychological reaction to unfavorable external circumstances (e.g. grief). Likewise, the number of symptoms shown by the patient can be influenced by several social and individual factors, which leads to false-negative as well as false-positive diagnoses.
  • Incorrect consideration of cultural circumstances: Critics such as Carl Bell state that the DSM does not sufficiently respect the cultural and ethnic diversity of people. With the introduction of the 4th edition, culturally determined factors were taken into account, but as the anthropologist and psychiatrist Arthur Kleinman states, however, only in the case of mental disorders or concepts that are associated with non-American or non-European cultures. To what extent the European-American culture affects the diagnosis of mental illnesses is ignored by the manual. Robert Spitzer criticizes that the inclusion of cultural factors was exclusively politically and not scientifically motivated, and that psychiatric diagnoses must be equally valid in every cultural area. The majority of psychiatrists assume that cultural factors are either irrelevant or that the patient's culture only influences specific symptom presentations.

See also

literature

German editions of the DSM (sorted in descending order):

  • Peter Falkai, Hans-Ulrich Wittchen (ed.): Diagnostic and statistical manual of mental disorders . DSM-5. Hogrefe, 2015, ISBN 978-3-8017-2599-0 .
  • Henning Saß u. a. (Ed.): Diagnostic and statistical manual of mental disorders . Text revision - DSM-IV-TR. Hogrefe Verlag, 2003, ISBN 978-3-8017-1660-8 .
  • Henning Saß , Isabel Houben (Ed.): Diagnostic and statistical manual of mental disorders . DSM-IV. Hogrefe Verlag, Göttingen 1996, ISBN 978-3-8017-0810-8 .
  • Hans-Ulrich Wittchen (Ed.): Diagnostic and statistical manual of mental disorders . DSM III-R. Beltz Verlag, Weinheim 1989, ISBN 978-3-407-86108-5 .
  • Karl Koehler, Henning Saß (Ed.): Diagnostic and statistical manual of mental disorders . DSM III. Beltz Verlag, Weinheim 1984, ISBN 978-3-407-86104-7 .

Case presentations:

Web links

Individual evidence

  1. ↑ a b DSM: History of the Manual. American Psychiatric Association, 2014, accessed November 3, 2014 .
  2. ↑ a b Thomas Insel: Director's Blog: Transforming Diagnosis. National Institute of Mental Health , April 29, 2013, accessed March 2017 : “The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been "reliability" - each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. "
  3. ↑ Chapter 9: Classification of Mental Disorders . In: Jürgen Margraf , S. Schneider: Textbook of behavior therapy . Volume 1. Springer 2018. ISBN 978-3-662-54911-7 .
  4. ↑ Markus Jäger: Current psychiatric diagnostics: a guide for daily work with ICD and DSM . Thieme, 2015, ISBN 978-3-13-200531-0 , chapter 2.5, p. 48 f . ( limited preview in Google Book search).
  5. ↑ Peter Falkai, Hans-Ulrich Wittchen (ed.): Diagnostic and statistical manual of mental disorders DSM-5 . Hogrefe, 2015, ISBN 978-3-8017-2599-0 , pp. 26-27 .
  6. ↑ Eva Asselmann: DSM-5 - Major Innovations and Implications for ICD-11 . (Slide 5–6) Hamburg Chamber of Psychotherapists, 2014.
  7. ^ Robert L. Spitzer : Values ​​and Assumptions in the Development of DSM-III and DSM-III-R: An Insider's Perspective and a Belated Response to Sadler, Hulgus, and Agich's “On Values ​​in Recent American Psychiatric Classification” . (PDF; 72 kB) In: The Journal of Nervous and Mental Disease , Vol. 189, No. 6, 2001, p. 351
  8. ↑ Diagnostic and Statistical Manual of Mental Disorders (DSM – 5)
  9. ^ A b Brutus: The Diagnostic and Statistical Manual of Mental Disorders (DSM) By the Numbers. (PDF) In: The Carlat Report Psychiatry. March 29, 2011, accessed March 7, 2017 .
  10. ↑ James Davies: Cracked: Why Psychiatry is Doing More Harm Than Good . Icon Books, London 2013.
  11. ↑ The multiaxial system of the DSM IV . In: Hans-Ulrich Wittchen u. a. (Ed.): Clinical Psychology & Psychotherapy . Springer, 2011, ISBN 978-3-642-13017-5 , chapter 2.5.1, p. 44 ( limited preview in Google Book search).
  12. ^ Psychiatry: Frequent Conflicts of Interest of the DSM-V authors . ( Memento of the original from April 7, 2009 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: aerzteblatt.de , May 7, 2008. Accessed February 4, 2016. @1@ 2Template: Webachiv / IABot / www.aerzteblatt.de
  13. ↑ Jörg Blech : The Psychofalle. How the soul industry makes us patients. Fischer 2014, p. 21.
  14. ↑ Christopher Lane: The NIMH Withdraws Support for DSM-5. In: Psychology Today. May 4, 2013, accessed December 22, 2019 .
  15. ^ Freedman, Lewis et al .: The Initial Field Trials of DSM-5: New Blooms and Old Thorns. In: American Journal of Psychiatry. January 1, 2013, accessed December 22, 2019 .
  16. ^ Paul R. McHugh: Striving for Coherence: Psychiatry's Efforts Over Classification. In: JAMA. May 25, 2005, accessed December 22, 2019 .
  17. ^ Wakefield, Schmitz et al .: Extending the Bereavment Exclusion for Major Depression to Other Losses. In: Archives of General Psychiatry. April 2007, accessed December 22, 2019 .
  18. ↑ Arthur Kleinman: Triumph or Pyrrhic Victory? The Inclusion of Culture in DSM-IV. In: Harvard Review of Psychiatry. July 3, 2009, accessed December 22, 2019 .
  19. ↑ Widiger & Sankis: Adult Psychopathology: Issues and Controversies. In: Annual Review of Psychology. February 2000, accessed December 22, 2019 .