Diagnostic and Statistical Manual (DSM) Overview

What Is the DSM or DSM-5?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook widely used by clinicians and psychiatrists in the United States to diagnose psychiatric illnesses. Published by the American Psychiatric Association (APA), the DSM covers all categories of mental health disorders for both adults and children. The DSM-5 refers to the fifth edition of this handbook, though the DSM-5-TR (text revision) is the latest version used.

It contains descriptions, symptoms, and other criteria necessary for diagnosing mental health disorders. It also contains statistics concerning who is most affected by different types of illnesses, the typical age of onset, the development and course of the disorders, risks and prognostic factors, and other related diagnostic issues.

Just as with medical conditions, certain government agencies and many insurance carriers require a specific diagnosis in order to approve payment for support or treatment of mental health conditions. Therefore, in addition to being used for psychiatric diagnosis and treatment recommendations, mental health professionals also use the DSM to classify patients for billing purposes.

This article discusses the history of the DSM and how the most recent edition compares to past editions.

DSM History

The Diagnostic and Statistical Manual was first published in 1952. Since then, there have been several updates issued. In the DSM-I, there were 102 categories of diagnoses, increasing to 182 in the DSM-II, 265 in the DSM-III, and 297 in the DSM-IV.

A major issue with the DSM has been around validity. In response to this, the National Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system they feel will be more biologically based.

In 2013, then-NIMH director Thomas Insel and APA president-elect Jeffrey Lieberman issued a joint statement saying that the DSM-5 represents "the best information currently available for clinical diagnosis of mental disorders." They went on to say that both the DSM-5 and RDoC represent "complementary, not competing, frameworks" for the classification and treatment of mental disorders.

The National Institute on Mental Health also notes that the RDoC is not meant to be a diagnostic tool and should not be used to replace other diagnostic systems (such as the DSM). Instead, its goal is to serve as a framework for research on mental disorders in order to better understand mental health.

The Multiaxial System

The DSM-III introduced a multiaxial or multidimensional approach for diagnosing mental disorders. 

The multiaxial approach was intended to help clinicians and psychiatrists make comprehensive evaluations of a client's level of functioning because mental illnesses often impact many different life areas.

It described disorders using five DSM "axes" or dimensions to ensure that all factors—psychological, biological, and environmental—were considered when making a mental health diagnosis.

Axis I – Clinical Syndromes

Axis I consisted of mental health and substance use disorders that cause significant impairment. Disorders were grouped into different categories such as mood disorders, anxiety disorders, and eating disorders.

Axis II – Personality Disorders and Mental Retardation

Axis II was reserved for what we now call intellectual development disorders (intellectual disability) and personality disorders, such as antisocial personality disorder and histrionic personality disorder. Personality disorders cause significant problems in how a person relates to the world, while intellectual development disorders are characterized by intellectual impairment and deficits in other areas such as self-care and interpersonal skills.

Axis III – General Medical Conditions

Axis III was used for medical conditions that influence or worsen Axis I and Axis II disorders. Some examples include HIV/AIDS and brain injuries.

Axis IV – Psychosocial and Environmental Problems

Any social or environmental problems that may impact Axis I or Axis II disorders were accounted for in this axis. These include such things as unemployment, relocation, divorce, or the death of a loved one.

Axis V – Global Assessment of Functioning

Axis V is where the clinician gives their impression of the client's overall level of functioning. Based on this assessment, clinicians could better understand how the other four axes interacted and the effect on the individual's life.

Changes in the DSM-5

The fifth edition of the DSM contains a number of significant changes from the earlier DSM-IV and DSM-IV-TR. The most immediately obvious change is the shift from using Roman numerals to Arabic numbers in the name (i.e., it is now written as DSM-5, not DSM-V).

Perhaps most notably, the DSM-5 eliminated the multiaxial system. Instead, the DSM-5 lists categories of disorders along with a number of different related disorders. Example categories in the DSM-5 include anxiety disorders, bipolar and related disorders, depressive disorders, feeding and eating disorders, obsessive-compulsive and related disorders, and personality disorders.

A few other changes that came with the DSM-5 included:

• Asperger syndrome was eliminated as a diagnosis and, instead, incorporated under the category of autism spectrum disorder.
• Disruptive mood dysregulation disorder was added, in part to decrease the over-diagnosis of childhood bipolar disorders.
• Several diagnoses were officially added to the manual, including binge eating disorder, hoarding disorder, and premenstrual dysphoric disorder (PMDD).

While the DSM is an important tool, only those who have received specialized training and possess sufficient experience are qualified to diagnose and treat mental illnesses.

Changes in the DSM-5-TR

The DSM, fifth edition, text revision (DSM-5-TR) contains revised criteria for more than 70 disorders. The DSM-5-TR also includes the addition of a new diagnosis called prolonged grief disorder.

The DSM-5-TR uses more specific language to avoid reader confusion. For instance, it revised the wording of criterion A in autism spectrum disorder from "as manifested by the following" to "as manifested by all of the following" to indicate that all symptoms must be present in order for a diagnosis to be made.

The parenthetical "(social phobia)" next to social anxiety disorder was removed. The term "intellectual disability" was revised to intellectual development disorder. The DSM-5-TR also made significant revisions to terms surrounding gender dysphoria.

The DSM-5-TR also made changes aimed at reducing racial and cultural biases. These revisions include:

• The term "race" was replaced with "racialized" to call out that race is socially constructed.
• The term "ethnoracial" is used to refer to categories like Hispanic, White, and African American.
• The terms "minority" and "non-White" are not used because they imply that whiteness is prioritized over other social groups.
• The term "Caucasian" is not used. The APA notes that this term is based on erroneous views about the geographic origin of people who are called Caucasian.
• The term Latinx is used instead of Latino/Latina for gender inclusivity.

The DSM-5-TR also notes how symptoms of certain conditions manifest differently in people from varying demographic groups.

A Word From Verywell

When making a diagnosis, a doctor may rely on a variety of information sources including interviews, screening tools, psychological assessments, lab tests, and physical exams to learn more about the nature of your symptoms and how they are affecting you. A healthcare provider or mental health professional will then utilize the information they have learned to make a diagnosis based on DSM criteria.