DSM: A History of Psychiatry’s Bible

The Diagnostic and Statistical Manual of the American Psychiatric Association has been called “the most important book of the twentieth century.” While this evaluation is debatable, the history of the DSM is certainly one of the most interesting stories in recent times. When its first edition appeared in 1952, the manual was a slight, spiral-bound pamphlet that required just 32 pages to define all of its 106 diagnosis. The most recent edition, the DSM-5, was published in 2013; it is a massive 947-page tome that defines about 300 conditions in precise detail. The imposing nature of the extant DSM-5, however, disguises the intense uncertainty, factionalism, hostility, and political wrangling that has accompanied the development of each DSM since its third edition in 1980.

By 1980, the cultural and institutional matrix of psychiatry had transformed from its post-World War II immersion in psychoanalytic theory, highly generalized concepts such as neuroses and psychoses, and psychoactive drugs that were targeted at a wide range of conditions. Psychiatry faced a host of interests that scorned the nebulous extant DSM diagnoses: third-party insurers demanded specific diagnoses before they would reimburse clinical treatment; the National Institute of Mental Health had turned from its initial social focus toward more traditional medical conceptions; the Food and Drug Administration mandated drug companies to demonstrate that their products targeted specific disease conditions; medical schools had come to require their disciplines adhere to commonly accepted scientific procedures rather than theoretical speculations. The existing DSM was a serious handicap in an environment that had changed from one that had no use for any but the most general conditions to one that required specific diagnostic entities.

The DSM-III marked the key change of psychiatric diagnoses from theoretically-infused to seemingly scientific and precisely defined mental disorders. Research psychiatrists, led by Robert Spitzer, developed descriptive criteria and decision rules to specify who should or should not receive each diagnosis. Its publication was hailed as a revolutionary development that transformed psychiatry from believing that something was true because Freud said so to deriving from evidence-based facts. For two decades the DSM-III conditions led the field to believe that is was on the verge of uncovering the biological basis that presumably underlay its diagnostic entities. Although clinicians initially resisted the manual’s exorcising of analytic concepts, they soon realized that the manual’s scientific-seeming diagnoses could garner reimbursement from third-party insurers as well as medical prestige.

The DSM quickly became the basis for the acceptable scope of thinking about mental disorders among researchers and clinicians alike. It was institutionalized among all mental health professions, government bureaucrats, hospital administrators, mental health educators, advocacy groups, pharmaceutical companies, the insurance industry, and the judicial system. Patients, too, acquired a new language to interpret their distressing conditions and explain their emotional lives. Specific diagnoses became foundational for mental health practice, research, and theory.

Toward the end of the twentieth century, a startling reversal came in the evaluation of the DSM’s diagnostic criteria. The same group of researchers who imposed the manual’s categorical entities on initially resistant clinicians became their most ardent critics. They had come to realize that the nature of mental disorder was more dimensional than categorical, generalized than specific, and overlapping than discrete. The DSM-III revolution was proving to be an obstacle to realizing understandings from neuroscientific studies.

The latest revision that resulted in the DSM-5 in 2013 featured political dynamics that were the diametric opposite of those that created the DSM-III revolution. Researchers strove to replace the manual’s categorical diagnoses with dimensional continua that viewed mental illnesses as gradients ranging from mild to moderate to severe. They were opposed by clinicians who had come to depend on the DSM entities for compensation, were unfamiliar with dimensional notions, and rejected the complicated system researchers wanted to impose. In addition, by the twenty-first century the value connotations of most psychiatric diagnoses had radically changed from stigmatizing labels imposed on resistant and often involuntary patients to valued resources that brought treatment, services, and, often, monetary compensation to patients and their families. Indeed, patient and family advocacy groups had become some of the most fervent defenders of the DSM categorical diagnoses.

The bitter controversies that marked the DSM’s latest revision sunk the credibility of the manual to levels not seen since the anti-psychiatric climate that marked the 1960s and 1970s. The new critics of the DSM-5 were not the anti-psychiatrists, feminists, and gay advocates who objected to earlier versions but eminent figures within the profession including former NIMH directors and the leaders of the DSM-5 Task Force itself. Ironically, the major guardians of the classification were clinicians who were initially the manual’s harshest critics. The future of the DSM is clearly at a crossroads, but the path it should take has no roadmap.

Order DSM: A History of Psychiatry’s Bible at the following link: https://jhupbooks.press.jhu.edu/title/dsm

Allan V. Horwitz is a Board of Governors Distinguished Professor of Sociology Emeritus at Rutgers University. He is the author or coauthor of eleven books, including DSM: A History of Psychiatry’s Bible, Anxiety: A Short History, PTSD: A Short History, and Creating Mental Illness.