DSM-I AND DSM-II

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.

HISTORY OF DIAGNOSIS

HISTORY OF DIAGNOSIS
Diagnosis were made on the basis of presumed etiology, as when Hippocrates rooted the illnesses he diagnosed in various imbalances of black bile, yellow bile, blood, and phlegm. an influential Greek anatomist who lived more than 500 years later, took much the same view in his descriptions of both normal and abnormal sensations and perceptions as products of a spirit or vapor he called pneuma psychikon. Basing diagnostic assessments on such etiologic conceits changed only when the Swiss physician and natural philosopher Paracelsus developed the concept of syndromal diagnosis. Paracelsus defined the syndrome as a group of signs and symptoms that co-occur in a common pattern and thereby, presumably, characterize a particular abnormality or disease state, but for which etiology is unknown, perhaps even unknowable. Syndromal diagnosis is epitomized today in the DSM, which continues its focus on the signs and symptoms of diseases, rather than their presumed etiologies, which are unnecessary for diagnostic purposes.
Typically, psychiatric illnesses are organized hierarchically, by the principles of descriptive similarity or shared symptom pictures. Thus, following Paracelsus Thomas Sydenham an English physician for whom a childhood chorea is named, and a bit later by the French physician Franc¸ois de Sauvages. Shortly afterward, famed French hospital reformer Phillippe Pinel (1745–1826), pictured in almost every abnormal psychology textbook breaking the chains of the insane in Paris’s Biceˆtre and Salpeˆtrie`re hospitals, proposed a system that included melancholia, mania, mania with delirium, dementia, and idiotism. The appearance of this nomenclature coincided with the development of asylums for the insane, for which Pinel was partly responsible, and certainly contributed to both their humanity and their success. Building on this advance, both Pinel’s system and the new availability of large numbers of diagnostically differentiated patients in asylums paved the way for the marked increase in efforts to categorize psychopathology during the nineteenth century. The victims of serious, chronic psychopathology—what are today understood as organic mental disorders, severe developmental disabilities, dementia, schizophrenia, and bipolar disorder were permanent residents of these asylums for the mentally ill. the German psychiatrist Karl Kahlbaum) discovered that understanding the premorbid course of dementia praecox (which today we call schizophrenia), and the factors that conferred risk for it, helped predict its outcome. The roots of modern syndromal classification, including the Diagnostic and Statistical Manual of Mental Disorders, can be traced to Kahlbaum and to fellow German taxonomists Griesinger and Hecker. But no figure in descriptive psychopathology stands taller than Emil Kraepelin successive textbook editions at the end of the nineteenth and beginning of the twentieth centuries anticipated much of what modern-day diagnosticians would find familiar, including detailed medical and psychiatric histories ofpatients, mental status examination, emphasis on careful observation of signs and symptoms to establish diagnoses, and understanding the psychoses as largely diseases of the brain. Kraepelin’s taxonomy of mental illness has a strikingly contemporary feel and includes many of the terms used today. In the twentieth century, more and more mental health practice took place outside the mental asylums, to encompass the military services, private clinics and office practice, company-supported mental health and substance abuse services, and educational institutions at all levels. This was both fortunate and necessary, unexpectedly, most psychological casualties resulted from nonpsychotic, acute disorders like substance abuse, depression, and the anxiety disorders, with extraordinarily high base rates among combat personnel. Clearly, the impact of these conditions on the war effort required development of a nomenclature that provided substantially greater coverage of these conditions so that they could be accurately identified, treated, and their sufferers returned to service

DIAGNOSIS AND CLASSIFICATION IN PSYCHOPATHOLOGY

DIAGNOSIS AND CLASSIFICATION IN PSYCHOPATHOLOGY

The psychiatric diagnosis is essential to all clinical, research, and policy endeavors involving mental health. For clinicians, diagnostic systems identify at-risk individuals for prevention services; select other cases for referral and brief treatment; in more serious cases they may suggest special courses of treatment that have been empirically tested; and they confer on third-party payers the responsibility of honor charges for that treatment. most diagnostic systems are categorical or, like DSM-III, III-R, and IV, “classquantitative”. Such systems permit additional nuance, such as severity ratings, codes for the presence/absence of special features, and so on, but they require, above all, diagnostic classification. “Man is by nature a classifying animal. . . Indeed, the very development of the human mind seems to have been closely related to the perception of discontinuities in nature” .Raven and his colleagues used the term folk taxonomy to indicate the predisposition of subgroups, especially guildlikegroups of craftsmen, to establish categorical nomenclatures (folk taxonomies) for classifying objects in nature that are of special interest to them. Thus, potters have extensive taxonomies of clay, stonecutters of hardness and grain, and so forth. In a classic monograph, the cognitive psychologist .there are nonarbitrary or “natural” categories that form around perceptually salient natural prototypes. Such natural categories could, of course, serve as the basis for the folk taxonomies described by Raven and his coauthors. Rosch explained the key attributes of natural categories: (1) they are nonarbitrary; (2) they are partitioned from continua; (3) they cannot, by use of normal language, be further reduced to simpler attributes; (4) they are easily learned by novices; (5) they serve as natural structures for the organization of more knowledge; and 6) they have indistinct boundaries, encompassing both clear-cut and marginal examples.
human beings tend to categorize and classify things in roughly the same way, across cultures and, presumably, across historical eras. It seems a characteristically human thing to do. In a more recent monograph, Lilienfeld and Marino (1995) extended a Roschian analysis to psychiatric diagnosis, arguing that major psychopathologic entities such as schizophrenia or bipolar illness are, like Roschian or natural prototypes, partitioned from the continuum of human behavior, irreducible to simpler concepts, understood analogously across cultures, have good and bad examples, and so on. This view complements the conceptualization of psychiatric diagnosis as a problem in prototype categorization. Cantor and her colleagues proposed that psychiatric diagnosis follows not a classic categorization model (universally accepted criteria, high agreement about class membership, and within-class homogeneity of members) but rather a prototype categorization model. Prototype categorization assumes (1) correlated—not necessarily pathognomonic—criteria for class membership, (2) high agreement among classifiers only when classifying cases that demonstrate most of the correlated criteria for class membership (disagreement is expected when cases have a marginal number of category features, or when they bear features from more than one category), and (3) heterogeneity of class membership, because criteria are only correlated, not pathognomonic. Thus, whereas systems of psychiatric diagnosis have their critics—and many of their arguments will be reviewed later— there is nothing arcane, much less unprecedented, in the actions
of a mental health professsional who, encountering a new case, lifts a copy of the DSM from her desk, matches the properties of the new case to one or more of the DSM categories, and then uses the diagnostic result to select treatment, to make a referral, or to rule the case in or out of a research protocol. To the contrary, what the mental health professional is doing is as old, as honored, as universal, and as essentially human as the crafts themselves (Nathan & Langenbucher, 1999).