Diagnostic and Statistical Manual (DSM) Overview

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.

It contains descriptions, symptoms, and other criteria necessary for diagnosing mental health disorders. It also contains statistics concerning which gender is most affected by the illness, the typical age of onset, the effects of treatment, and common treatment approaches.

Just as with medical conditions, the government and many insurance carriers require a specific diagnosis in order to approve payment for 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.

DSM History

The Diagnostic and Statistical Manual has been updated seven times since it was first published in 1952.

The newest version of the DSM, the DSM-5, was published in May of 2013. This latest revision was met with considerable discussion and some controversy.

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.

Later, 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.

DSM-IV-TR Multiaxial System

The DSM-IV was originally published in 1994 and listed more than 250 mental disorders. An updated version, called the DSM-IV-TR, was published in 2000. This version utilized 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, or eating disorders.

Axis II – Personality Disorders and Mental Retardation

Axis II was reserved for mental retardation (a term which has since been replaced by "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 disability is 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 DSM-5 contains a number of significant changes from the earlier DSM-IV. The most immediately obvious change is the shift from using Roman numerals to Arabic numbers.

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 in the DSM-5:

• Asperger's 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 over-diagnosis of childhood bipolar disorders.
• Several diagnoses were officially added to the manual, including binge eating disorder, hoarding disorder, and premenstrual dysphoric disorder.

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.