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The Diagnostic and Statistical Manual of Mental Disorders

Expert Witness: Steven N. Shapse, Ph.D.
The "bible" of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision, known as the DSM-IV-TR and published by the American Psychiatric Association is extensively used by psychiatrists, psychologists, social workers and most other mental health professionals in the U.S., Canada and abroad to provide a common nomenclature for diagnostic purposes and for communicating about mental disorders.

The "bible" of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision, known as the DSM-IV-TR and published by the American Psychiatric Association is extensively used by psychiatrists, psychologists, social workers and most other mental health professionals in the U.S., Canada and abroad to provide a common nomenclature for diagnostic purposes and for communicating about mental disorders. (In Europe the International Classification of Diseases (ICD-10), published by the World Health Organization, is more commonly used. The U.S. Department of Health and Human Services is moving towards utilizing ICD-10 codes resulting in compatibility between the two resources). The DSM-IV-TR provides a common language for illnesses of emotional and psychological origin. Its success and wide acceptance is reflected in its translation into over twenty languages including Japanese, French, Turkish, Greek and Arabic. The first edition, the DSM-I, appeared in 1952. It was superseded in 1968 by the DSM-II, which in turn was replaced, by the DSM-III in 1974, the DSM-IV in 1994, and currently, the DSM-IV-TR in 2000. The DSM-V is scheduled to supplant the current DSM-IV-TR in 2010.

Initially, about 60 different disorders were listed with little distinction between normal and abnormal as disorders existed along a continuum and were considered reactions to environmental stressors. The major distinction was between psychosis—a severe mental condition involving a break with reality— and neurosis—a disorder usually involving anxiety and depression. One applying the early DSM diagnoses may have found that no one was normal. When the DSM-III was published, there was a shift away from this binary classification to characterization of behaviors. Mental disorders today are conceptualized as behavioral or psychological syndromes that occur in a person in response to distress, disability or suffering, not merely the expectable or usual response to a particular event. Disorders are described in descriptive and behavioral terms and are not reflective of a particular theory or discipline. Additionally, a mental disorder is assumed not to be a discrete entity. People described as having the same disorder may not be alike although they minimally meet the defining features of the same emotional illness.

The DSM-IV-TR, properly utilized, affords a multiaxial diagnosis. Axis-I allows the diagnosis of major mental disorders such as Manic-Depressive Illness, Schizophrenia, Substance Abuse, Post-traumatic Stress and organically based mental illness. Axis-II is reserved for personality and developmental disorders. A personality disorder is diagnosed when personality traits become dysfunctional and maladaptive causing impairment in the individual's functioning. Often, personality disorders can be quite severe and debilitating. Axis-III is used to indicate the presence of physical conditions that potentially affect psychological functioning. Axis-IV assesses the severity of psychosocial stressors that may have contributed to the development or exacerbation or recurrence of a mental disorder. Axis-V permits an assessment of the individual's overall level of psychological, social and occupational functioning. Used correctly, the DSM-IV-TR helps us to understand the individual in context and allows ready communication between mental health professionals. It further serves to direct treatment including the use of medication.

The DSM is not without problems or controversy. One abiding issue is the difference in the description of diagnosis between the DSM-IV-TR and ICD-10. Clinicians describing a patient must read from the same “playbook” if they want to properly serve their patient. Another issue is that every decade, the DSM is revised whereby diagnostic descriptions may be modified, new diagnoses added, and obsolete ones deleted. In the DSM-II, homosexuality was listed as a disorder and Posttraumatic Stress Disorder was absent. As good as the current DSM may be in allowing clinicians to characterize mental conditions, the effect of “labeling” an individual may blind the psychologist from identifying other factors affecting the patient, or cause the clinician to conceptualize all of the client’s behavior from a single framework. Nonetheless, proper diagnosis, even if not fully comprehensive and imperfect, fosters effective treatment that best helps those in need.

Alternatives to the DSM-IV-TR, besides the ICD-10, include the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (DC:03-R) designed for diagnosing difficulties in very young children published by Zero to Three, and the Psychodynamic Diagnostic Manual (PDM, 2006) published by the Alliance of Psychoanalytic Organizations which is based upon neuroscience, treatment outcome studies and psychoanalytic thought.

The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association.


ABOUT THE AUTHOR: Steven N. Shapse, Ph.D.
Dr. Steven N. Shapse is a Licensed Psychologist in the Commonwealth of Massachusetts. He has over 30 years experience in the field of psychology as both a clinician and teacher which includes over twenty years as a forensic expert, psychometrist and child custody evaluator. He regularly presents at state and national associations, and often teaches at the Massachusetts School of Professional Psychology. He is a Senior Supervisor at the Justice Resource Institute Trauma Center and a principal founder and Past-President of the Massachusetts Association of Guardians ad Litem.

Copyright Steven N. Shapse, Ph.D.
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Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.

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