DSM-I AND DSM-II
It was only in 1946 that representatives of the Veterans Administration, the War Department, and the civilian mental health community led by the American Psychiatric Association (APA) began to consider how to create a nomenclature that would meet their diverse needs. Their efforts led to the publication, in 1952, of the first edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-I). The DSM-I (APA, 1952) was the first comprehensive syndromal system developed. As such, it was designed to offer mental health professionals a common diagnostic language through which to communicate about their patients and their research findings. Its appearance sparked a similar effort in Europe that ultimately caused theWorld Health Organization (WHO) to add a mental disorders section to the eighth edition of the International Classification of Diseases (ICD-8; WHO, 1967). Despite its promise, DSM-I (and DSM-II [APA, 1968], which closely resembled it) shared serious problems that markedly compromised their diagnostic reliability, validity, and utility. Most obviously, the manuals contained relatively little textual material: The DSM-I contained 130 pages and fewer than 35,000 words; DSM-II was a mere four pages longer. As a consequence, these early efforts provided only brief descriptions of each syndrome, insufficient for reliable diagnoses. Moreover, the signs and symptoms of each syndrome were not empirically based. Instead, they represented the accumulated clinical wisdom of the small number of senior academic psychiatrists who staffed the DSM task forces. As a result, the diagnostic signs and symptoms that interested task force members were imperfectly related to the clinical experiences of mental health professionals working in public mental hospitals, mental health centers, and the like. Consequently, clinicians very often failed to agree with one another when assigning diagnoses based on DSM-I and DSM-II, whether they were presented with the same diagnostic information (interclinician agreement; Beck, Ward, Mendelson, Mock, & Erbaugh, 1962; Nathan, Andberg, Behan, & Patch, 1969) or they reevaluated the same patient after a period of time had passed (diagnostic consistency; Zubin, 1967). Not surprisingly, the low reliability of DSM-I and DSMII diagnoses affected both their validity and clinical utility. If clinicians could not agree on a diagnosis, they were unlikely to be able to validate it against other measures (Black, 1971), to have confidence in predictions of the future course of diagnosed disorders (Nathan, 1967), or to create the diagnostically homogeneous groups of patients necessary to spur substantive advances in etiological or treatment research (Nathan & Harris, 1980). Just as predictably, the low reliability and validity of DSMI and DSM-II diagnoses raised ethical concerns among practitioners and scholars. Psychiatrist Thomas Szasz (1960) created a national furor over what he considered the dehumanizing, stigmatizing consequences of psychiatric “labeling,” ultimately concluding that the modern categories of psychiatric illness were mere “myths.” Szasz’s ideas gained empirical substance in 1973 when psychologist David Rosenhan published, in the world’s most prestigious journal, Science, one of the most widely cited studies in psychiatry, “On Being Sane in Insane Places.” At Rosenhan’s behest, eight peers, friends, and graduate students presented for treatment to various psychiatric hospitals in northern California, complaining of “hearing voices.” Auditory hallucinations are, of course, a “first-rank” symptom of schizophrenia (Schneider, 1959), and all eight pseudopatients were admitted to hospital. Immediately thereafter, they stopped complaining of the voices and denied any other symptoms of psychosis. Nonetheless, all were diagnosed as psychotic, and their subsequent behavior was construed in light of that label. Quite normal reactions they manifested, such as being wary of strange and perhaps menacing fellow patients, were characterized in chart notes and staff meetings as the products of paranoid and delusional processes. Summarizing his findings, Rosenhan concluded, “The normal are not detectably sane” (1973, p. 252), a damning assertion indeed. Clearly, psychiatric diagnosis had come as far as it possibly could as an “art” practiced in an arcane fashion by an elite group of the initiated. The time was ripe for its transformation into a science.
It was only in 1946 that representatives of the Veterans Administration, the War Department, and the civilian mental health community led by the American Psychiatric Association (APA) began to consider how to create a nomenclature that would meet their diverse needs. Their efforts led to the publication, in 1952, of the first edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-I). The DSM-I (APA, 1952) was the first comprehensive syndromal system developed. As such, it was designed to offer mental health professionals a common diagnostic language through which to communicate about their patients and their research findings. Its appearance sparked a similar effort in Europe that ultimately caused theWorld Health Organization (WHO) to add a mental disorders section to the eighth edition of the International Classification of Diseases (ICD-8; WHO, 1967). Despite its promise, DSM-I (and DSM-II [APA, 1968], which closely resembled it) shared serious problems that markedly compromised their diagnostic reliability, validity, and utility. Most obviously, the manuals contained relatively little textual material: The DSM-I contained 130 pages and fewer than 35,000 words; DSM-II was a mere four pages longer. As a consequence, these early efforts provided only brief descriptions of each syndrome, insufficient for reliable diagnoses. Moreover, the signs and symptoms of each syndrome were not empirically based. Instead, they represented the accumulated clinical wisdom of the small number of senior academic psychiatrists who staffed the DSM task forces. As a result, the diagnostic signs and symptoms that interested task force members were imperfectly related to the clinical experiences of mental health professionals working in public mental hospitals, mental health centers, and the like. Consequently, clinicians very often failed to agree with one another when assigning diagnoses based on DSM-I and DSM-II, whether they were presented with the same diagnostic information (interclinician agreement; Beck, Ward, Mendelson, Mock, & Erbaugh, 1962; Nathan, Andberg, Behan, & Patch, 1969) or they reevaluated the same patient after a period of time had passed (diagnostic consistency; Zubin, 1967). Not surprisingly, the low reliability of DSM-I and DSMII diagnoses affected both their validity and clinical utility. If clinicians could not agree on a diagnosis, they were unlikely to be able to validate it against other measures (Black, 1971), to have confidence in predictions of the future course of diagnosed disorders (Nathan, 1967), or to create the diagnostically homogeneous groups of patients necessary to spur substantive advances in etiological or treatment research (Nathan & Harris, 1980). Just as predictably, the low reliability and validity of DSMI and DSM-II diagnoses raised ethical concerns among practitioners and scholars. Psychiatrist Thomas Szasz (1960) created a national furor over what he considered the dehumanizing, stigmatizing consequences of psychiatric “labeling,” ultimately concluding that the modern categories of psychiatric illness were mere “myths.” Szasz’s ideas gained empirical substance in 1973 when psychologist David Rosenhan published, in the world’s most prestigious journal, Science, one of the most widely cited studies in psychiatry, “On Being Sane in Insane Places.” At Rosenhan’s behest, eight peers, friends, and graduate students presented for treatment to various psychiatric hospitals in northern California, complaining of “hearing voices.” Auditory hallucinations are, of course, a “first-rank” symptom of schizophrenia (Schneider, 1959), and all eight pseudopatients were admitted to hospital. Immediately thereafter, they stopped complaining of the voices and denied any other symptoms of psychosis. Nonetheless, all were diagnosed as psychotic, and their subsequent behavior was construed in light of that label. Quite normal reactions they manifested, such as being wary of strange and perhaps menacing fellow patients, were characterized in chart notes and staff meetings as the products of paranoid and delusional processes. Summarizing his findings, Rosenhan concluded, “The normal are not detectably sane” (1973, p. 252), a damning assertion indeed. Clearly, psychiatric diagnosis had come as far as it possibly could as an “art” practiced in an arcane fashion by an elite group of the initiated. The time was ripe for its transformation into a science.
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