of psychopathology—The focus in this case is to use classification to understand the disorder.
classification: in psychopathology, a way to name, organize, and categorize the collections of symptoms seen in mental disorders
Over the past 200 years, numerous systems have been developed concerning the diagnosis and classification of mental disorders. In the past 50 years, the emphasis has been on reliability of diagnosis such that mental health professionals in one location would diagnose the same individual in the same manner as professionals in another location. As part of this emphasis, there has been a push for observable characteristics that would define a specific disorder. These types of criteria make up the structure of the DSM and the ICD. In general, the criteria used in the DSM and ICD are signs and symptoms that are delineated through observation of, and conversation with, the individual. Since ICD codes are used by many health facilities in the United States, I will note the similarities and differences in ICD and DSM criteria of mental disorders throughout this book.
International Statistical Classification of Diseases and Related Health Problems
The ICD, currently used in over 100 countries worldwide to classify disorders, has an interesting history. It began with the intent of identifying causes of death.
One of the factors that helped create the initial DSM was the search for consistency in diagnosis across clinicians throughout the country. Here, in the 1940s, an asylum committee assesses a patient’s mental health.
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Based on earlier attempts, a system for recording the cause of death was developed by the French statistician Jacques Bertillon in the late 1800s. This came to be known as the International List of Causes of Death. In 1898, the American Public Health Association suggested that the United States, Canada, and Mexico use this system and support its revision every 10 years. In 1948, the World Health Organization took over the ICD. The WHO collected health-related data worldwide. The sixth edition of the ICD published in 1949 included a section related to mental disorders. Currently, the ICD includes two sections, one for medical disorders and the other for mental and behavioral disorders. Because of the ICD inclusion of medical disorders, it is used for Health Insurance Portability and Accountability Act (HIPAA) purposes such as insurance in the United States.
ICD-10 is currently in use but is being updated for the eleventh edition in 2018. Mental disorders in the ICD-10 are more of a short narrative describing the condition, rather than specific criteria as seen in the DSM–5.
Diagnostic and Statistical Manual of Mental Disorders
The DSM was created by a group of psychiatrists in the 1940s who had been involved in directing mental hospitals and directing the mental health services for the U.S. Army and Navy during World War II, and others who were part of the American Psychiatric Association. The first version of the DSM (DSM–I) was published in 1952 (see Grob, 1991).
Origins of the DSM
A number of factors helped to create the initial DSM. One was the search for consistency in diagnosis across clinicians throughout the country. In this sense, DSM–I sought to bring together and standardize the classifications used in state and private mental hospitals, those classifications developed during World War II, and those used by professionals in private practice. Another factor that gained emphasis during World War II was the realization that environmental stress associated with combat was related to the expression of mental disorders. A related understanding was that these disorders could be treated without prolonged institutionalization. In addition, treatment worked best if begun early in the course of the disorder. This required that professionals be able to differentiate those who could be treated and sent back to battle and those who needed long-term care.
Early Versions of the DSM and the Eventual Focus on Diagnostic Criteria
The classification system used by DSM–I divided disorders into two broad categories. The first category was those disorders such as Huntington’s chorea or neurocognitive disorders (then called dementias) resulting from brain pathophysiologies. These were disorders that resulted from hereditary origins, infections, long-term drug addictions, tumors of the brain, and other such factors. The second category was those disorders that included an environmental component in which the individual found it difficult to cope with his or her world. This second category was further divided into three different types of disorders. The first was psychosis, including schizophrenia and other psychotic disorders. The second was neurosis, such as anxiety disorders. The third was referred to as character disorders such as psychopathy, which were involved in forensic decisions. As you will see later, those individuals who demonstrate psychopathic tendencies often find themselves accused of crimes such as cheating others. In general, it was assumed that the neurotic disorders would be more amenable to psychological treatment.
During World War II, mental health professionals realized that environmental stress associated with combat was related to the expression of mental disorders.
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DSM–II was released in 1968. Although it did not differ greatly from DSM–I, it did offer an opportunity for the mental disorder categories of ICD-8 and DSM–II to be almost identical. This allowed for a worldwide classification system, which increased the ability to collect statistics on particular mental disorders. One difference that did exist was that the ICD manual just listed the disorders, whereas the DSM included brief definitions.
During the 1970s, there were a variety of changes in issues of importance to both the scientific and larger lay community that influenced the next version of the DSM. In the scientific study of psychopathology, there was an increased emphasis on greater precision in describing the signs and symptoms associated with a particular psychopathology. In addition, there was an emphasis on differentiating one disorder from another as well as on using experimental research to inform these definitions. There was also an understanding that some individuals manifest a particular disorder in different ways. For example, as noted earlier in this chapter, some individuals with schizophrenia will hear voices, while others will have visual hallucinations.
When DSM–III was released in 1980, it included a number of major changes from DSM–I and DSM–II (see Blashfield et al., 2010). One major change was that it sought to rely on observable evidence to create a scientific system rather than just focus on the interpretations of experts in the field. Another change was that DSM–III described disorders in terms of specific criteria rather than the more general descriptions of a disorder seen in DSM–I and DSM–II. DSM–III also introduced a five-level system or axes to give a more complete picture of the person. Axis I described the individual’s psychopathological symptoms. Axis II described the person’s personality or mental retardation. Axis III described any medical disorders that the person had. Axis IV described significant environmental factors in the person’s life. Lastly, Axis V described the person’s level of functioning and any significant role impairment. Overall, DSM–III sought to be theory neutral and only use observable terms. DSM–III was adopted in a number of countries and translated into 16 languages. In 1987, DSM–III was revised in terms of diagnostic
