DSM-III AND DSM-III-R
Spitzer and his colleagues developed computer programs called DIAGNO and DIAGNO-II that were designed to use the syndromalinformation gathered by the Mental Status Schedule to assign more reliable clinical diagnoses.To develop an empirically based, more reliable diagnostic system, researchers at Washington University published an importa,nt article in 1972 that set forth explicit diagnostic criteria—the so-called Feighner criteria—for 16major disorders. Their intent was to replace the vague and unreliable descriptions of DSM-I and DSM-II with systematically organized,.This help researchers to establish the diagnostically homogeneous and predictively valid experimental groups for which they had long striven in vain. The format of the Feighner criteria greatly influenced the format for diagnostic criteria adopted in DSM-III. A derivative of Feighner’s work, the Research Diagnostic Criteria (RDC), developed jointly by the New York State Psychiatric Institute and Washington University groups . Designed to permit empirical testing of the presumably greater reliability and validity of the Feighner criteria, the RDC criteria yielded substantially greater diagnostic reliability than the equivalent DSM-II disorders and so constituted a great step forward Drawing largely from the groups that formulated the RDC—psychiatry faculty at the Washington University School of Medicine in Saint Louis and the Columbia University College of Physicians and Surgeons in New York—neo-Kraepelinian diagnostic research during the 1970s laid the groundwork for the revolutionary advances of DSM-III. Like Kraepelin himself, the neo-Kraepelinians endorsed the existence of a boundary between “pathological functioning” and “problems in living,” viewed mental illness as the purview of medicine, and believed in the importance of applying the scientific method so
that the etiology, course, prognosis, morbidity, associated features, family dynamics, predisposing features, and treatment of psychiatric illnesses could be elucidated more clearly.
Five years after the RDC criteria were published, DSM-III appeared (APA, 1980), heralding substantial advances in the reliability, validity, and utility of syndromal diagnosis. Based in large part on the RDC, the inclusion in DSM-III of rigorously designed diagnostic criteria and, in an appendix, diagnostic decision trees, represented the new instrument’s most significant advance. The criteria were designed to organize each syndrome’s distinguishing signs and symptoms within a consistent format—they were, in scientific parlance, operationalized, so that each clinician who used them would define each sign and symptom the same way, and process the resulting diagnostic information in a consistent manner. This degree of detail in the diagnostic information available to DSM-III’s users contrasted sharply with the paucity of such detail in DSM-I and DSM-II.
Several structured and semistructured diagnostic interviews based on the DSM-III, very distant descendants of the Mental Status Schedule and the Psychiatric Status Schedule, were published around the time DSM-III appeared, in a related effort to enhance diagnostic reliability and, especially, to spur research. The best known of these was the NIMH Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981), a structured interview designed for nonclinician interviewers. The semistructured Structured Clinical Interview for DSM-III (SCID; Spitzer, 1983; Spitzer & Williams, 1986), designed for use by clinicians, was also published around the same time. These important, and in most ways unprecedented, new instruments provided the data-gathering structure both for major new epidemiologic efforts (e.g., Epidemiologic Catchment Area study [Regier et al., 1984], National Comorbidity Survey [e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler, Stein, & Berglund, 1998]) and for a host of clinical and preclinical studies, because they insured the internal validity of the research by helping ensure that the samples of human psychopathology were well characterized diagnostically. DSM-III-R, published in 1987, was a selective revision of DSM-III that retained the advances of the 1980 instrument and incorporated generally modest changes in diagnostic criteria that new clinical research (to a great extent dependent on findings produced by the application of the DIS and SCID to human research samples) suggested should be a part of the diagnostic system. It was in this way that diagnostic research “bootstrapped” its way from the dismal days of Rosenhan to the well-regarded science it is today, and its products, although not universally successful, have been impressive indeed.DSM-III and DSM-III-R addressed their predecessors’ disappointing diagnostic validity and utility in several ways (Spitzer et al., 1980). To begin with, both volumes are much larger than their predecessors, in part to accommodate inclusion of more than three times as many diagnoses, in part to provide detailed information on each syndrome along with its defining diagnostic criteria. The expansion of syndrome descriptions made it easier for clinicians to describe more precisely their patients’ behavior, and to understand their suffering in the context of their milieu.
Another advantage of DSM-III and DSM-III-R was that they assessed patients along five imensions, or axes: Psychopathology was diagnosed on Axes I and II; medical conditions
impacting on the mental disorders were noted on Axis III; the severity of psychosocial stressors affecting the patient’s behavior was noted on Axis IV; and the patient’s highest level of adaptive functioning was noted on Axis V. The additional information available from multiaxial diagnosis was presumed to be more useful for treatment planning and disposition than the single diagnostic label available from DSM-I and DSM-II.
A very substantial number of reliability studies of the DSMIII and DSM-III-R diagnostic criteria were published. Almost without exception, they pointed to much greater diagnostic stability and interrater agreement for these instruments than for their predecessors, DSM-I and DSM-II. Enhanced reliability was especially notable for the diagnostic categories of schizophrenia, bipolar disorder, major depressive disorder, and substance abuse and dependence; the reliability of the personality disorders, some of the disorders of childhood and adolescence, and some of the anxiety disorders has been less encouraging (e.g., Fennig et al., 1994; Klein, Ouimette, Kelly, Ferro, & Riso, 1994; Mattanah, Becker, Levy, Edell, & McGlashan, 1995), but this has been due to a variety of
reasons, including conceptual underspecification (in the case of the personality disorders), and the inherently transitory of self-correcting nature (diagnostic stability problems) of some others (disorders of childhood and adolescence and some forms of anxiety).
Thus, despite these explicit efforts to enhance the diagnostic utility and validity of DSM-III and DSM-III-R, it did not prove easy to document the impact of these efforts. The absence of documented etiological mechanisms, with associated laboratory findings, by which the diagnoses of many physical disorders are confirmed—the “gold standard”—made establishing the construct validity of many DSM-III and DSM-III-R diagnoses difficult (Faraone & Tsuang, 1994). As noted later in this chapter, the same problem continues to stand in the way of attempts to validate DSM-IV diagnoses.
Although the DSM-III and DSM-III-R diagnostic criteria enhanced the instruments’ diagnostic reliability, diagnostic stability continued to be an issue for diagnosticians because of changes in patient functioning over time. Thus, in a study of the six-month stability of DSM-III-R diagnoses in firstadmission patients with psychosis, Fennig et al. (1994) reported that whereas affective psychosis and schizophrenic disorders showed substantial diagnostic stability, stability for subtypes of these conditions was less stable. Changes in patient functioning were seen as responsible for 43 percent of these diagnostic changes. In like fashion, Nelson and Rice (1997) reported that the one-year stability of DSM-III lifetime diagnoses of obsessive-compulsive disorder (OCD) turned out to be surprisingly poor: Of OCD subjects in the ECA sample they followed, only 19 percent reported symptoms a year later that met the OCD criteria. Mattanah and his colleagues (1995) reported that the diagnostic stability of several DSM-III-R disorders was lower for a group of adolescents two years after hospitalization than for the same diagnoses given adults. These and similar studies of diagnostic stability emphasized the extent to which diagnostic reliability is dependent not only on the validity of diagnostic criteria but on the inherent symptom variability of disorders over time as well.
Also, researchers using DSM-III and DSM-III-R diagnostic criteria undertook research during the years following their appearance to validate several of the manual’s major diagnostic categories, including schizophrenia and major depressive disorder, despite the absence of a gold-standard criterion of validity. Our brief mention of validation studies includes only Kendler’s familial aggregation and coaggregation research findings, both because they represent a particularly powerful approach to validation and because the findings generally mirror those found by others, but many others could be adduced.
When Kendler, Neale, and Walsh (1995) examined the familial aggregation and coaggregation of five hierarchically defined disorders—schizophrenia, schizoaffective disorder, schizotypal/paranoid personality disorder, other nonaffective psychoses, and psychotic affective illness—in siblings, parents, and relatives of index and comparison probands, they reported that although schizophrenia and psychotic affective illness could be clearly assigned to the two extremes of the schizophrenia spectrum, the proper placement of schizoaffective disorder, schizotypal/paranoid personality disorder, and other nonaffective psychoses could not be clearly made. In a companion report, Kendler and his coworkers (1995) found that probands with schizoaffective disorder differed significantly from those with schizophrenia or affective illness in lifetime psychotic symptoms as well as outcome and negative symptoms assessed at follow-up. Moreover, relatives of probands with schizoaffective disorder had significantly higher rates of schizophrenia than relatives of probands with affective illness.
Although Kendler’s family research method validated only a portion of schizophrenic spectrum disorder diagnoses, he and his colleagues (Kendler et al., 1996; Kendler & Roy,
1995) were able by the same methods to strongly support the validity of the DSM-III major depression diagnostic syndrome. However, when Haslam and Beck (1994) tested the content and latent structure of five proposed subtypes of major depression, clear evidence for discreteness was found only for the endogenous subtype; the other proposed forms lacked internal cohesion or were more consistent with a continuous or dimensional account of major depression.
Criticisms
Although DSM-III and DSM-III-R represented major advances, they were widely criticized. This was particularly so for DSM-III, the first manual to truly shatter the mold in which prior nosologies had been cast. One major source of concern was that DSM-III incorporated more than three times the number of diagnostic labels in DSM I. Prominent clinical child psychologist Norman Garmezy expressed the concern that this proliferation of diagnostic labels would tempt clinicians to pathologize unusual but normal behaviors of childhood and adolescence, a criticism more recently directed at DSM-IV (Houts, 2002). In a similar vein, social workers Kirk and Kutchins (1992) accused the instrument’s developers of inappropriately labeling “insomnia, worrying, restlessness, getting drunk, seeking approval, reacting to criticism, feeling sad, and bearing grudges . . . [as] possible signs of a psychiatric illness” (p. 12). Thus, the definition of mental disorder developed for DSM-III (and retained in DSM-III-R and DSM-IV) has been criticized for being both too broad and encompassing of behaviors not necessarily pathological, and for offering poor guidance to clinicians who must distinguish between uncommon or unusual behavior and psychopathological behavior.
Addressing these concerns, Spitzer and Williams defended the DSM-III approach (and by extension, the entire ensuing DSM tradition) by noting that the intention of the framers was to construct a nomenclature that would cast as wide a clinical net as possible, in order that persons suffering from even moderately disabling or distressing conditions would receive the help they needed. But overdiagnosis was not the only rifle leveled at the DSM tradition. Schacht and Nathan ,Schacht , and others questioned the frequent emphasis in DSM-III on disordered brain mechanisms in its discussions of etiology, as well as its apparent endorsement of pharmacological treatments in preference to psychosocial treatments for many disorders. In response, Spitzer noted that the DSM-III text simply reflected the state of knowledge of etiology and treatment. Similar concerns have been voiced about DSM-IV by Nathan and Langenbucher .
DSM-III and its successors have also been criticized for their intentionally atheoretical, descriptive position on etiology. In a debate on these and related issues these critics charged that an atheoretical stance ignored the contributions of psychodynamic theory to a fuller understanding of the pathogenesis of mental disorders, as well as to the relationship between emotional conflict and the ego’s mechanisms of defense. But in the same debate, Spitzer questioned the empirical basis for the claim that psychodynamic theory had established the pathogenesis of many of the mental disorders.
Spitzer and his colleagues developed computer programs called DIAGNO and DIAGNO-II that were designed to use the syndromalinformation gathered by the Mental Status Schedule to assign more reliable clinical diagnoses.To develop an empirically based, more reliable diagnostic system, researchers at Washington University published an importa,nt article in 1972 that set forth explicit diagnostic criteria—the so-called Feighner criteria—for 16major disorders. Their intent was to replace the vague and unreliable descriptions of DSM-I and DSM-II with systematically organized,.This help researchers to establish the diagnostically homogeneous and predictively valid experimental groups for which they had long striven in vain. The format of the Feighner criteria greatly influenced the format for diagnostic criteria adopted in DSM-III. A derivative of Feighner’s work, the Research Diagnostic Criteria (RDC), developed jointly by the New York State Psychiatric Institute and Washington University groups . Designed to permit empirical testing of the presumably greater reliability and validity of the Feighner criteria, the RDC criteria yielded substantially greater diagnostic reliability than the equivalent DSM-II disorders and so constituted a great step forward Drawing largely from the groups that formulated the RDC—psychiatry faculty at the Washington University School of Medicine in Saint Louis and the Columbia University College of Physicians and Surgeons in New York—neo-Kraepelinian diagnostic research during the 1970s laid the groundwork for the revolutionary advances of DSM-III. Like Kraepelin himself, the neo-Kraepelinians endorsed the existence of a boundary between “pathological functioning” and “problems in living,” viewed mental illness as the purview of medicine, and believed in the importance of applying the scientific method so
that the etiology, course, prognosis, morbidity, associated features, family dynamics, predisposing features, and treatment of psychiatric illnesses could be elucidated more clearly.
Five years after the RDC criteria were published, DSM-III appeared (APA, 1980), heralding substantial advances in the reliability, validity, and utility of syndromal diagnosis. Based in large part on the RDC, the inclusion in DSM-III of rigorously designed diagnostic criteria and, in an appendix, diagnostic decision trees, represented the new instrument’s most significant advance. The criteria were designed to organize each syndrome’s distinguishing signs and symptoms within a consistent format—they were, in scientific parlance, operationalized, so that each clinician who used them would define each sign and symptom the same way, and process the resulting diagnostic information in a consistent manner. This degree of detail in the diagnostic information available to DSM-III’s users contrasted sharply with the paucity of such detail in DSM-I and DSM-II.
Several structured and semistructured diagnostic interviews based on the DSM-III, very distant descendants of the Mental Status Schedule and the Psychiatric Status Schedule, were published around the time DSM-III appeared, in a related effort to enhance diagnostic reliability and, especially, to spur research. The best known of these was the NIMH Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981), a structured interview designed for nonclinician interviewers. The semistructured Structured Clinical Interview for DSM-III (SCID; Spitzer, 1983; Spitzer & Williams, 1986), designed for use by clinicians, was also published around the same time. These important, and in most ways unprecedented, new instruments provided the data-gathering structure both for major new epidemiologic efforts (e.g., Epidemiologic Catchment Area study [Regier et al., 1984], National Comorbidity Survey [e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler, Stein, & Berglund, 1998]) and for a host of clinical and preclinical studies, because they insured the internal validity of the research by helping ensure that the samples of human psychopathology were well characterized diagnostically. DSM-III-R, published in 1987, was a selective revision of DSM-III that retained the advances of the 1980 instrument and incorporated generally modest changes in diagnostic criteria that new clinical research (to a great extent dependent on findings produced by the application of the DIS and SCID to human research samples) suggested should be a part of the diagnostic system. It was in this way that diagnostic research “bootstrapped” its way from the dismal days of Rosenhan to the well-regarded science it is today, and its products, although not universally successful, have been impressive indeed.DSM-III and DSM-III-R addressed their predecessors’ disappointing diagnostic validity and utility in several ways (Spitzer et al., 1980). To begin with, both volumes are much larger than their predecessors, in part to accommodate inclusion of more than three times as many diagnoses, in part to provide detailed information on each syndrome along with its defining diagnostic criteria. The expansion of syndrome descriptions made it easier for clinicians to describe more precisely their patients’ behavior, and to understand their suffering in the context of their milieu.
Another advantage of DSM-III and DSM-III-R was that they assessed patients along five imensions, or axes: Psychopathology was diagnosed on Axes I and II; medical conditions
impacting on the mental disorders were noted on Axis III; the severity of psychosocial stressors affecting the patient’s behavior was noted on Axis IV; and the patient’s highest level of adaptive functioning was noted on Axis V. The additional information available from multiaxial diagnosis was presumed to be more useful for treatment planning and disposition than the single diagnostic label available from DSM-I and DSM-II.
A very substantial number of reliability studies of the DSMIII and DSM-III-R diagnostic criteria were published. Almost without exception, they pointed to much greater diagnostic stability and interrater agreement for these instruments than for their predecessors, DSM-I and DSM-II. Enhanced reliability was especially notable for the diagnostic categories of schizophrenia, bipolar disorder, major depressive disorder, and substance abuse and dependence; the reliability of the personality disorders, some of the disorders of childhood and adolescence, and some of the anxiety disorders has been less encouraging (e.g., Fennig et al., 1994; Klein, Ouimette, Kelly, Ferro, & Riso, 1994; Mattanah, Becker, Levy, Edell, & McGlashan, 1995), but this has been due to a variety of
reasons, including conceptual underspecification (in the case of the personality disorders), and the inherently transitory of self-correcting nature (diagnostic stability problems) of some others (disorders of childhood and adolescence and some forms of anxiety).
Thus, despite these explicit efforts to enhance the diagnostic utility and validity of DSM-III and DSM-III-R, it did not prove easy to document the impact of these efforts. The absence of documented etiological mechanisms, with associated laboratory findings, by which the diagnoses of many physical disorders are confirmed—the “gold standard”—made establishing the construct validity of many DSM-III and DSM-III-R diagnoses difficult (Faraone & Tsuang, 1994). As noted later in this chapter, the same problem continues to stand in the way of attempts to validate DSM-IV diagnoses.
Although the DSM-III and DSM-III-R diagnostic criteria enhanced the instruments’ diagnostic reliability, diagnostic stability continued to be an issue for diagnosticians because of changes in patient functioning over time. Thus, in a study of the six-month stability of DSM-III-R diagnoses in firstadmission patients with psychosis, Fennig et al. (1994) reported that whereas affective psychosis and schizophrenic disorders showed substantial diagnostic stability, stability for subtypes of these conditions was less stable. Changes in patient functioning were seen as responsible for 43 percent of these diagnostic changes. In like fashion, Nelson and Rice (1997) reported that the one-year stability of DSM-III lifetime diagnoses of obsessive-compulsive disorder (OCD) turned out to be surprisingly poor: Of OCD subjects in the ECA sample they followed, only 19 percent reported symptoms a year later that met the OCD criteria. Mattanah and his colleagues (1995) reported that the diagnostic stability of several DSM-III-R disorders was lower for a group of adolescents two years after hospitalization than for the same diagnoses given adults. These and similar studies of diagnostic stability emphasized the extent to which diagnostic reliability is dependent not only on the validity of diagnostic criteria but on the inherent symptom variability of disorders over time as well.
Also, researchers using DSM-III and DSM-III-R diagnostic criteria undertook research during the years following their appearance to validate several of the manual’s major diagnostic categories, including schizophrenia and major depressive disorder, despite the absence of a gold-standard criterion of validity. Our brief mention of validation studies includes only Kendler’s familial aggregation and coaggregation research findings, both because they represent a particularly powerful approach to validation and because the findings generally mirror those found by others, but many others could be adduced.
When Kendler, Neale, and Walsh (1995) examined the familial aggregation and coaggregation of five hierarchically defined disorders—schizophrenia, schizoaffective disorder, schizotypal/paranoid personality disorder, other nonaffective psychoses, and psychotic affective illness—in siblings, parents, and relatives of index and comparison probands, they reported that although schizophrenia and psychotic affective illness could be clearly assigned to the two extremes of the schizophrenia spectrum, the proper placement of schizoaffective disorder, schizotypal/paranoid personality disorder, and other nonaffective psychoses could not be clearly made. In a companion report, Kendler and his coworkers (1995) found that probands with schizoaffective disorder differed significantly from those with schizophrenia or affective illness in lifetime psychotic symptoms as well as outcome and negative symptoms assessed at follow-up. Moreover, relatives of probands with schizoaffective disorder had significantly higher rates of schizophrenia than relatives of probands with affective illness.
Although Kendler’s family research method validated only a portion of schizophrenic spectrum disorder diagnoses, he and his colleagues (Kendler et al., 1996; Kendler & Roy,
1995) were able by the same methods to strongly support the validity of the DSM-III major depression diagnostic syndrome. However, when Haslam and Beck (1994) tested the content and latent structure of five proposed subtypes of major depression, clear evidence for discreteness was found only for the endogenous subtype; the other proposed forms lacked internal cohesion or were more consistent with a continuous or dimensional account of major depression.
Criticisms
Although DSM-III and DSM-III-R represented major advances, they were widely criticized. This was particularly so for DSM-III, the first manual to truly shatter the mold in which prior nosologies had been cast. One major source of concern was that DSM-III incorporated more than three times the number of diagnostic labels in DSM I. Prominent clinical child psychologist Norman Garmezy expressed the concern that this proliferation of diagnostic labels would tempt clinicians to pathologize unusual but normal behaviors of childhood and adolescence, a criticism more recently directed at DSM-IV (Houts, 2002). In a similar vein, social workers Kirk and Kutchins (1992) accused the instrument’s developers of inappropriately labeling “insomnia, worrying, restlessness, getting drunk, seeking approval, reacting to criticism, feeling sad, and bearing grudges . . . [as] possible signs of a psychiatric illness” (p. 12). Thus, the definition of mental disorder developed for DSM-III (and retained in DSM-III-R and DSM-IV) has been criticized for being both too broad and encompassing of behaviors not necessarily pathological, and for offering poor guidance to clinicians who must distinguish between uncommon or unusual behavior and psychopathological behavior.
Addressing these concerns, Spitzer and Williams defended the DSM-III approach (and by extension, the entire ensuing DSM tradition) by noting that the intention of the framers was to construct a nomenclature that would cast as wide a clinical net as possible, in order that persons suffering from even moderately disabling or distressing conditions would receive the help they needed. But overdiagnosis was not the only rifle leveled at the DSM tradition. Schacht and Nathan ,Schacht , and others questioned the frequent emphasis in DSM-III on disordered brain mechanisms in its discussions of etiology, as well as its apparent endorsement of pharmacological treatments in preference to psychosocial treatments for many disorders. In response, Spitzer noted that the DSM-III text simply reflected the state of knowledge of etiology and treatment. Similar concerns have been voiced about DSM-IV by Nathan and Langenbucher .
DSM-III and its successors have also been criticized for their intentionally atheoretical, descriptive position on etiology. In a debate on these and related issues these critics charged that an atheoretical stance ignored the contributions of psychodynamic theory to a fuller understanding of the pathogenesis of mental disorders, as well as to the relationship between emotional conflict and the ego’s mechanisms of defense. But in the same debate, Spitzer questioned the empirical basis for the claim that psychodynamic theory had established the pathogenesis of many of the mental disorders.
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