DIAGNOSTIC AND STATISTICAL MANUAL (DSM)

The Diagnostic and Statistical Manual of Mental Disorders is the most widely accepted diagnostic system in the United States. First published by the American Psychaiatric Association (APA) in 1952, the DSM is used by medical professionals, insurance companies, and the court system to diagnose and define mental illnesses and disorders, including substance abuse and dependence. In fact, the diagnosis code assigned to a case often determines insurance reimbursement for treatment. The book is also an important indicator of societal mores: until 1973 homosexuality was defined as a mental disorder.

The first tabulation of mental illness in the United States appeared in the 1840 census, when the category "idiots" and the category "insane" were first counted. By the 1880 census, seven types of mental illness were recognized, including epilepsy. In 1917 the American Medico-Psychological Association (now the APA), in conjunction with the National Commission on Mental Hygiene, further enlarged its categories of mental illness. This broader list, while certainly of greater clinical use, was still chiefly designed to count the numbers and types of patients in mental hospitals. Several years after this tabulation, the newly renamed APA released a compendium of nationally recognized psychiatric terms—most of which applied to psychotic disorders and severe neurological impairments—that would become part of the American Medical Association's standard classified nomenclature of disease.

After the end of World War II, the Veterans Administration (VA) added many more diagnoses to the APA inventory, incorporating the various psychological manifestations exhibited by servicemen. This expanded compilation proved to be influential, for shortly after its publication the World Health Organization (WHO) published the sixth edition of its International Classification of Diseases (ICD), which for the first time included information on mental disorders, much of it based on by the VA classifications.

The first edition of the DSM (DSM-I), published in 1952, was little more than a pamphlet. Its importance, however, lay in its description and definition of the approximately 100 diagnostic categories then recognized by clinicians. DSM-I, like its successor, DSM-II, was heavily influenced by the seventh and eighth editions of ICD. In fact, until the publication of of DSM-III, the American system for classifying psychiatric disorders was virtually identical to the ICD.

During the 1970s, however, researchers affiliated with the Washington University School of Medicine (Feighner et al., 1972) developed the "re-search diagnostic" approach to psychiatric diagnosis, which emphasized clearly formulated and observable signs and symptoms that could be used for both research and clinical practice. DSM-III, published in 1980, incorporated this approach, adding clear diagnostic standards and objective descriptions of symptoms and behaviors.

DSM-III also introduced a multiaxial system for diagnostic evaluation to ensure that all relevant clinical information was considered. Axis I describes syndromes, such as major Depression, Schizophrenia, and substance use disorders. Axis II covers childhood and personality disorders that often persist into adult life. Axis III refers to physical disorders or conditions that are potentially relevant to the understanding or management of the patient. Axis IV rates the severity of psychosocial stressors that have occurred in the year preceding the current evaluation and that may have contributed to the patient's symptoms. Axis V is a global assessment of psychological, social and occupational functioning, which should be taken into account in treatment planning.

For the first time DSM-III listed substance use disorders as a separate diagnosis category, distinguishing them from personality disorders, which they had previously been considered. In addition, the term dependence replaced the more generic alcoholism or addiction, and was distinguished from abuse by the presence of the symptoms of Tolerance or Withdrawal. Alcohol and drug abuse were assigned to separate subcategories, permitting a greater differentiation and range of severity for each.

Another important change to the substance use disorders section in DSM-III (Rounsaville, Spitzer, & Williams, 1986) was the adoption of a new dependence syndrome concept (Edwards, Arif, & Hodgson, 1981), in which dependence was defined as an interrelated cluster of psychological symptoms: a strong desire or Craving for the substance; physiological signs, especially tolerance and withdrawal; and behavioral indicators, particularly using the substance to relieve withdrawal discomfort. Significantly, the medical and social consequences of both acute intoxication and chronic substance use, such as Accidents and liver damage are not among the primary diagnostic criteria of dependence. They do, however, play a prominent role in defining the substance abuse category.

After the publication of a revised third edition in 1987 (DSM-III-R), a fourth edition (DSM-IV) was published in 1994. This version contained further changes in the diagnosis of substance-related disorders that were designed to assure compatibility between DSM and ICD. Both publications now define substance dependence as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three or more of the following symptoms occurring in the same twelve-month period:

Tolerance —the need for markedly increased amounts of the substance to achieve intoxication or the desired effect

Withdrawal —behavioral changes that occur when blood or tissue levels of the substance decline after a period of prolonged or heavy use; often accompanied by use of the substance to relieve withdrawal symptoms.

Increased use —taking the substance in larger amounts or over a longer period.

Unsuccessful attempts to cut down or control substance use.

Much time spent in activities related to procuring or using the substance.

Ignoring or reducing important social, occupational, or recreational activities because of substance use.

Continued use despite physical or psychological problems caused by the substance.

Patients can become dependent on any of the following: Alcohol, Tobacco, Sedatives-Hypnotics-Anxiolytics, Cannabis (Marijuana), Stimulants, Opioids, Cocaine, Hallucinogens, PCP (Phencyclidine), or a combination of drugs, which is known as Polysubstance abuse. The most important factor in determining dependence, according to the DSM-IV, is not simply abusing alcohol or drugs, but the patient's refusal to stop using the substance(s) despite recognizing the serious problems this causes.

(See also: Addiction: Concepts and Definitions ; Alcoholism: Origin of the Term ; Disease Concept of Alcoholism and Drug Abuse )

BIBLIOGRAPHY

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders-4th edition. Washington, DC: Author.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders-3rd edition-revised. Washington, DC: Author.

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders-3rd edition. Washington DC: Author.

Edwards, G., Arif, A., & Hodgson, R. (1981). Nomenclature and classification of drug- and alcohol-related problems: A WHO memorandum. Bulletin of the World Health Organization, 59, 225-242.

Feighner, J., et al. (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63.

Rounsaville, B. J., Spitzer, R. L., & Williams, J.B. (1986). Proposed changes in DSM-III substance use disorders: description and rationale. American Journal of Psychiatry, 143, 463-468.

Thomas F. Babor

Revised by Amy Loerch Strumolo