to medicalise trauma resulting from war?
3 DSM-III and DSM-III-R: Spitzer’s revolution
Robert Spitzer appointed a dozen committees which made recommendations about different categories. A key principle was that ‘DSM-III reflects an increased commitment in our field to reliance on data as the basis for understanding mental disorders’ (APA, 1980, p. 1). For Spitzer, detailed descriptive diagnoses were the foundation on which a scientific psychiatry could begin to test out theories of aetiology.
Aetiology A medical term that refers to theories about the causes of disorder or disease.
DSM-III, published in 1980 by the APA (APA, 1980), introduced a number of major changes designed to address problems of reliability:
Category boundaries: DSM-III drew clear boundaries around categories, advising clinicians to make multiple diagnoses if necessary, even within the same category.
Specific diagnostic criteria: For 163 of the 228 categories, specific criteria were included which needed to be satisfied before a diagnosis could be given.
An atheoretical approach: Since the aetiology of many conditions was considered unclear, DSM-III proposed defining categories in descriptive terms that did not imply a particular causal explanation. The term ‘disorder’ was much more frequently used; thus, DSM-II’s ‘neuroses’ were now labelled as ‘affective disorders’ (including depression) and ‘anxiety disorders’.
A multi-axial system: In order to provide a full, detailed assessment, different kinds of information needed to be gathered, and these were conceptualised along five different axes.
Field trials: A series of field trials were conducted to provide feedback on the new criteria and to assess whether they led to increased reliability.
The multi-axial system was a marked diversion from DSM-II. Diagnoses of mental disorders were made using the first two axes: Axis II included ‘personality disorders’ and ‘specific developmental disorders’ (e.g. ‘developmental reading disorder’), while Axis I included all other disorders. This meant that a person could be given a diagnosis on both Axes I and II. Since psychiatric service users could also have ‘physical disorders and conditions’, these were identified on Axis III. The last two axes were intended primarily for researchers: Axis IV enabled the identification of relevant psychosocial stressors, while Axis V provided a rating system to assess the extent to which a person’s problems affected their everyday adaptive functioning.
There has been debate about whether DSM-III was really atheoretical. For example, including PTSD, a category clearly based on a causal theory (i.e. that distress is the result of traumatic events), seems contrary to this aim. Moreover, the kinds of symptoms included in DSM-III tended to be those more consistent with biological models (Frances, 2013). Indeed, some categories were labelled as ‘organic’, implying a biological cause. The group of psychiatrists supporting Spitzer’s approach certainly advocated a medical model, although they did not seem to think this was a theoretical approach or that it involved presuppositions: ‘the medical model is without a priori theory but does consider brain mechanisms to be a priority’ (Compton and Guze, 1995, p. 200). It seemed that it was only non-biological models, especially psychodynamic approaches, from which DSM-III had distanced itself. Despite this, traces of US psychiatry’s psychodynamic legacy could still be seen in the DSM; for example, in subcategories such as ‘narcissistic’ and ‘borderline’ personality disorders.
DSM-III prompted a series of research studies which identified problems with some of the new categories and criteria. This prompted Spitzer to revise the manual, leading to the publication of DSM-III-R in 1987. By this time, administering structured interviews to service users was generally considered to increase the reliability of diagnosis, therefore Spitzer, together with some colleagues, developed one for DSM-III-R. There has been a structured clinical interview for each subsequent edition of the DSM.
Ultimately, DSM-III marked a radical diversion from previous DSMs, with its increased concern about the reliability of diagnosis and its move away from psychodynamic concepts. The claim that it was atheoretical was somewhat undermined by the introduction of the PTSD category and of symptoms more consistent with the medical model, as well as its retention of personality disorder subcategories with a psychodynamic heritage.
4 DSM-IV to DSM-5: the end of an era?
DSM-IV was much less radical in scope than DSM-III, but DSM-5 rejected many of the principles enshrined by Spitzer in DSM-III.
4.1 DSM-IV and DSM-IV-TR
DSM-IV was published in 1994 (APA, 1994). Its goals, as described by its chair, psychiatrist Allen Frances, were modest: they were ‘to introduce rigour, objectivity, and transparency in how decisions were made’ (Frances, 2013, p. 70). Conceptually and structurally, DSM-IV largely followed DSM-III, though it attempted to address the issue of cultural variation in mental health problems. Although the DSM is a US system, it is used in many countries and, of course, the US population itself is culturally varied. Culture researchers therefore argued that the manual needed to acknowledge that its construction of mental health was culturally shaped, but DSM-IV took a more minimalist approach. It included an appendix with an outline of a cultural formulation and a glossary of so-called ‘culture-bound syndromes’. These could refer to the way in which a DSM disorder was expressed differently in different cultures, or to an indigenous ‘folk’ category of distress. An example given by DSM-IV was ‘amok’, which referred to ‘a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at people and objects’ (APA, 1994, p. 845). This had apparently been reported primarily (although not exclusively) in Southeast Asia.
A further edition (DSM-IV-TR) was published six years later, in 2000, though the revisions were primarily textual rather than conceptual.
4.2 DSM-5: the end of Spitzer’s revolution?
Those involved in planning DSM-5 challenged key tenets of Spitzer’s approach. They identified a number of problems stemming from the changes implemented in DSM-III. These problems included the narrow and overly rigid categories introduced in DSM-III. As noted in the introduction to DSM-5: ‘the once plausible goal of identifying homogenous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders’ (APA, 2013, p. 12). DSM-5 argued that apparently high rates of comorbidity were a result of overly narrow categories that required clinicians to make more than one diagnosis, something that could be circumvented by using broader categories.
However, during the DSM-5 planning process, the government-funded National Institute for Mental Health (NIMH) had proposed an entirely different way forward: the Research Domain Criteria (RDoC) project. Thomas Insel (the NIMH director), and his colleagues, proposed that the answer lay not in the conceptualisation of clinical categories but in the identification of problems in the brain itself, in ‘neural circuitry’ (Insel et al., 2010). However, the team acknowledged this was a high risk, long-term option with no guarantee of a successful outcome. The competing approaches of the DSM-5 planners and the RDoC project suggested that there was a growing divide between practitioners and biomedically oriented psychiatric researchers.
DSM-5 was published in 2013 (APA, 2013) and led to widespread debate among academics, professionals, service users and in the media. DSM-5’s feedback website received over 13,000 comments
