The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a manual published by the American Psychiatric Association (APA) that details the diagnostic criteria for all of the recognized psychiatric disorders (Encyclopedia Britannica 2016). The DSM is the primary resource used by mental health professionals to diagnose patients with mental health disorders. The original DSM was published in 1952, and subsequently has been revised five times to incorporate the most up-to-date research on mental health. Because the manual historically has embodied much of society’s views on mental health, it has been criticized for its “medicalization of socially undesirable behaviors,” such as its classification of homosexuality as a psychiatric disorder (Encyclopedia Britannica 2016). Nevertheless, the DSM still is the most distinguished publications on mental health in the United States, and has helped to standardize the diagnoses and treatments of psychiatric disorders across the world.
For much of the nineteenth and twentieth centuries, mental disorders were not well-defined or treated (American Psychiatric Association 2017).The first attempt to catalogue mental illnesses was accomplished by the United State’s government, as it attempted to collect statistical information on health in the 1840 census (American Psychiatric Association 2017). Nevertheless, the census only recorded the frequency of “idiocy/insanity” in the country, so the information was not very useful (American Psychiatric Association 2017). There was not another attempt to classify mental illnesses until 1917. The American Medico-Psychological Association, with help from the National Commission of Mental Hygiene, attempted to gather health statistics from mental hospitals for clinical uses (American Psychiatric Association 2017). They developed a system to classify psychiatric disorders in order to help diagnose patients with severe mental illnesses. The American Medico-Psychological Association revised their classification system after the Second World War to better incorporate the psychological aftermath of war (American Psychiatric Association 2017). The revision included a section on mental health disorders that was heavily influenced by the Veteran Association’s classification system. Also, the term “reaction” was added throughout the DSM to imply that some disorders are reactions of personality to psychological, social, and biological factors (American Psychiatric Association 2017).
This revision led to the publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders. The manual contained “a glossary of description of the diagnostic categories and was the first official manual of mental disorders to focus on clinical use” (American Psychiatric Association 2017). It used the term “reaction” to describe the symptoms of mental disorders. The first and second editions of the DSM contained definitions of over one hundred psychological disorders, and were distributed to psychiatric hospitals and institutions (Encyclopedia Britannica 2016). The purpose of these first two editions was not to facilitate the treatment of mental illnesses, but rather to aid in the collection of public health statistics. The only difference between the two was the absence of the term “reaction” in the DSM-II.
In comparison, the third edition of the DSM, which was published in 1980 after six years of work, defined mental disorders in terms of symptoms instead of diseases (Encyclopedia Britannica 2016). Unlike the previous editions, it did not recommend treatments for each disorder, but rather provided mental health professionals with relevant information. This shift in emphasis from treatment to diagnostics gave the DSM greater credibility among the medical community. The committee revising the DSM worked extensively to formulate new diagnostic criteria, yet they were still not very clear and required further revision.
Subsequent editions of the DSM maintained this emphasis on diagnosis, while adding more disorders the list of recognized mental illnesses. The fifth edition, which took over ten years to produce, even incorporated some newly-popularized diseases like hoarding and skin-picking (American Psychiatric Association 2017). However, because of this acknowledgment of popularized disorders, this edition has been criticized for adopting broader diagnostic criteria and medicalizing behavior. So, as the American Psychiatric Association begins work on the sixth edition of the Diagnostic and Statistical Manual of Mental Disorders, they must tread this fine line between recognizing new disorders while not defining unusual behavior as an illness.
While medicalization of mental illnesses may seem like a recent phenomenon, the DSM has been medicalizing undesired behaviors since its inception. In the first edition, the editors included homosexuality in the list of nationally-recognized mental illnesses (Spitzer 1981, 210). This diagnosis reflected society’s view of homosexuality as unnatural and pathological conduct. Though the term homosexuality was removed from the second edition of the DSM, the sentiment remained. The category of “Homosexuality” was replaced by “Sexual Orientation Disturbance,” and non-heterosexual relations still was considered a symptom of a greater illness (Spitzer 1981, 210). This category encompassed “individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation” (Spitzer 1981, 210). While this description obviously alluded to homosexuals, the change of the category’s name represented a political compromise between the two extreme viewpoints about homosexuality held by mental health professionals at the time: the notion that homosexuality was a mental illness, and the notion that it was a normal attraction. However, the name of the category still implied that the absence of heterosexual feelings was a result of psychopathology.
Although the status of homosexuals was highly debated during the late 1960s, almost all of the members of the American Psychiatric Association still considered homosexuality to be a pathology in 1970 (This American Life 2002). According to the podcast “81 Words” from This American Life, even those APA members who were homosexuals themselves never questioned traditional psychiatric views of homosexuality. However, when the American Psychiatric Association decided to hold its annual convention in 1970 in San Francisco, which contains a large and vocal gay community, gay activists protested to no avail (This American Life 2002). These gay activists continued to protest until they saw change in late 1973 (This American Life 2002). That year, homosexuality was deleted from the list of psychiatric disorders in the DSM.
Another controversy surrounding the DSM occurred during the fifth revision of the manual. In 2007, five years before the DSM-V was published, an argument arose over the APA’s transparency during the revision process (History of Psychiatry 2010). Health advocates fought to make the DSM revision of a more open process, and utilized the Internet and other public forums to vocalize their claims. These activists called for an external review of the committee in charge of revisions to investigate their ties to pharmaceutical companies producing psychiatric drugs. There was suspicion among the health community that the medicalization of mental illnesses, represented by the huge increase in disorders cataloged in the DSM, was the result of drug companies’ influence. Despite the cries for transparency, the APA never made the minutes from their revision committee’s meetings available to the public (History of Psychiatry 2010). And, as expected, there were more mental disorders listed in the DSM-V than ever before.
It still is unclear whether this expansion of recognized psychiatric disease has been caused by the economic influence of the pharmaceutical industry or by the growing awareness of mental health as a whole. Health care analysts that we have studied in this course, such as the authors of “The Pharmaceuticalisation of Society? A Framework for Analysis,” Simon J. Williams, Paul Martin, and Jonathan Gabe, have argued that pharmaceuticalization has driven this medicalization of mental health problems, because it is in the best interest of drug companies to define more disorders that can be treated with pharmaceuticals. Regardless of what caused greater mental health awareness, it cannot be denied that the profound increase in the number of illnesses cataloged in the Diagnostic and Statistic Manual of Mental Disorders demonstrates a shift in the American biomedical perspective on mental health. References
2010. “A Moment of Crisis in the History of American Psychiatry.” History of Psychiatry website, April 27. Accessed February 6, 2017. https://historypsychiatry.com/2010/04/27/a-moment-of-crisis-in-the-history-of-american-psychiatry/
2017. “Diagnostic and Statistical Manual of Mental Disorders (DSM-5).” American Psychiatric Association website. Accessed February 6, 2017. https://www.psychiatry.org/psychiatrists/practice/dsm
2017. “DSM History.” American Psychiatric Association website. Accessed February 6, 2017. https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm
Editors of Encyclopedia Britannica. 2016. “Diagnostic and Statistical Manual of Mental Disorders (DSM).” Encyclopedia Britannica website, October 02. Accessed February 6, 2017. https://www.britannica.com/topic/Diagnostic-and-Statistical-Manual-of-Mental-Disorders
Glass, Ira, and Alix Speigel. 2002. “81 Words.” This American Life website, Jan. 18. Accessed April 17, 2017. https://www.thisamericanlife.org/radio-archives/episode/204/81-words
Spitzer, Robert L. 1981. “The Diagnostic Status of Homosexuality in DSM-III: A Reformulation of the Issues.” American Journal of Psychiatry 138 (2): 210-215. http://Spitzer 1981.psychiatryonline.org/doi/pdf/10.1176/Spitzer 1981.138.2.210
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