DSM-IV

DSM-IV
In 1952, the American Psychiatric Association (APA)
published its first official listing of mental diseases.
Titled the Diagnostic and Statistical Manual of
Mental Disorders  (DSM), it was conceived as a way
to establish a common diagnostic language and to
increase interclinician reliability, which ranged from
just over 20% to about 42%, depending on the study.
Largely ignored when it first appeared, the initial
DSM-IV———161DSM was a spiral-bound notebook with cursory
descriptions of about 100 disorders, and it was sold
primarily to mental institutions for a mere $3.50. The
third edition, the DSM-III  in 1980, and more recent
updates—the DSM-III-R in 1987, DSM-IV  in 1994,
and  DSM-IV-TR  in 2000—have expanded to 900
pages in length and sold hundreds of thousands of
copies at over $80 each.
THEORETICAL INFLUENCES
The first two versions of the manual—the DSM and
DSM-II—were heavily influenced by the psychoana-
lytic model. Mental disease terms, such as neurosis
and psychosis, derived from Freud’s view that psy-
chopathology resides within the person and can be
traced to unconscious conflicts. From this standpoint,
symptom profiles are comparatively worthless in
understanding the etiology of a patient’s intrapsychic
conflicts and designing an effective treatment.
In contrast, the DSM-III was compiled by research-
oriented psychiatrists who were intent on devising a
scientifically supportable system that could be widely
used by clinicians, regardless of their theoretical ori-
entation. Unfortunately, adequate research was still
lacking at the time the DSM-III was developed. In the
absence of reliable data, it was not unusual for the
editor of the DSM-III, psychiatrist Robert Spitzer, to
formulate new diagnoses with the help of only a few
committee members.
Carefully navigating a course away from psychoan-
alytic assumptions and terminology, Spitzer and his
colleagues retained, in a few instances, the traditional
psychoanalytic language while shifting to a method of
diagnosis contingent on explicit symptoms. For the first
time, each disorder was based on a list of operationally
worded criteria, on which a final diagnosis could be
determined. If a patient exhibited a certain number of
symptoms out of the total list, the diagnostic threshold
was crossed and the diagnosis was thus applied.
Critics have alleged that political and economic
agendas, not science, account for the changes in the
DSM’s emphasis over the last 50 years. When insur-
ance companies began to reimburse patients for men-
tal health treatment during the 1960s, they pressed for
a comprehensive list of specific and treatable disor-
ders. In response, the DSM’s formulators expanded
the diagnostic categories in the DSM-III to more than
300 disorders. Such compliance was amply rewarded.
Shortly after its publication, the DSM-III leapt into
prominence as insurers began to require  DSM-III
codes as a prerequisite for reimbursement. Alongside
the proliferation of disorders, the influence of phar-
maceutical companies may account, at least in part,
for the  DSM’s growing emphasis on the biological
basis of mental disorders. By the time the DSM-IV
was published in 1994, mental disorders had been
largely recast as biologically based disorders that
could be treated with medication. It was a convenient
transformation, considering the rising influence of
managed care and diminishing support for traditional
long-term psychodynamic therapy.
MULTICULTURAL ISSUES
From the standpoint of culture and gender sensitivity,
the DSM has been criticized for minimizing the impact
of contextual factors on the development of psycholog-
ical disorders. For example, the DSM-IV defines a per-
sonality disorder as an enduring pattern of behavior and
experience that deviates significantly from the individ-
ual’s culture, is stable over time, has an onset in ado-
lescence or early adulthood, and leads to impairment.
By implying that personality disorders originate within
the individual and remain relatively stable over time,
the DSM discounts the way that social norms can influ-
ence the way individuals behave. Consequently, the
DSM effectively renders exaggerated compliance with
gender and racial stereotypes a form of psychopathol-
ogy. For example, women who have been taught to be
more nurturing, more dependent on relationships, and
more emotional than men may be diagnosed with
dependent or histrionic personality disorders because
they exhibit exaggerated compliance with prescribed
gender roles. Similarly, African American men who
show resistance to authority may qualify for a diagno-
sis of antisocial personality disorder if the clinician
conducting the diagnostic interview fails to take into
account the environmental stressors contributing to the
patient’s defiance or the effect of identifying with pre-
vailing racial stereotypes. In contrast, the DSM does not
render Anglo male stereotypical behavior, such as
putting work above relationships and disregarding oth-
ers’ needs when making decisions, as a psychopatho-
logical disorder.
The influence of culture and gender bias in the for-
mulation of DSM disorders is especially apparent in
so-called mental disorders that have been revised,
stricken from later editions, or effectively challenged
prior to inclusion. For example, the DSM-III  treated
162———DSM-IVhomosexuality as a personality disorder, but the DSM-
III-R downgraded it to an ego-dystonic disorder. By
the time the DSM-IV was published, homosexuality
had been dropped as a mental disorder because of
social and political pressure to treat homosexuality as
a normal gender choice.
Two other controversial diagnoses would have
been enshrined in the  DSM-III  if women had not
objected. Under Spitzer’s editorship, which lasted
through the publication of the DSM-III-R, the diagno-
sis of masochistic personality disorder was briefly
considered before women expressed concern that it
would only serve to diagnose patients who had been
abused—especially women—with this disorder.
Another diagnosis that was considered would have
made premenstrual syndrome a mental disorder, but
again, outrage from women dissuaded Spitzer and his
colleagues from including it.
Beyond the possible biases inherent in the DSM’s
criteria, there is evidence that mental health profes-
sionals frequently misdiagnose on the basis of gender
and race. For example, DSM field trials revealed that
African American men are more likely to receive a
diagnosis of schizophrenia than Anglo men, and
Anglo males are more often diagnosed with affective
disorders than their African American counterparts.
Furthermore, African Americans are more likely to be
described as “paranoid” and Hispanics as “histrionic.”
When a structured interview approach is used to min-
imize clinician subjectivity, the African American/
Anglo differences disappear, leading to the conclusion
that misdiagnoses, not objective racial differences,
account for the skewed results.
In recent years, the APA has called for increased
cultural competency among its members. At an APA
symposium in New Orleans in 1999, APA president
Allan Tasman referred to cultural competency as one
of the most important and often neglected issues in
psychiatry. Speaking at the same conference, Francis
Lou, a clinical professor of psychiatry at the
University of California, San Francisco, said that psy-
chiatry needs to be concerned with the whole person
and to resist tendencies to reduce human experience to
mere diagnostic labels.
To its credit, the DSM-IV reflects a growing sensi-
tivity to the role of culture in influencing individual
behavior and how cultural competency is essential in
making accurate diagnoses. It contains a section at the
back of the book on dimensions of culture’s influence.
In it, clinicians are called on to consider the difficul-
ties of applying DSM-IV  criteria to members of dif-
ferent cultural or ethnic groups. A clinician who is
ignorant of the subtle aspects of an individual’s cul-
tural background may unwittingly overdiagnose
behaviors and beliefs that are considered normal in
the individual’s culture. In particular, the application
of personality disorder criteria across cultural settings
is especially susceptible to cultural bias because con-
cepts of the self, coping styles, and communication
patterns vary significantly across settings. To combat
such misuses of the DSM, the chapter addresses the
meaning of cultural or ethnic reference groups, the
impact of culture on psychosocial environment and
functioning, cultural explanations of illness, cultural
elements influencing the patient–therapist relation-
ship, and ways that an overall cultural assessment may
affect diagnosis and care.
Despite its universal use by clinicians seeking
third-party compensation and by the court system to
determine the sanity of defendants, the DSM remains
far from universally respected. Some critics argue that
the DSM  is an “emperor without clothes” and repre-
sents an unscientific system that enshrines the opin-
ions of a few powerful psychiatrists. Detractors also
point to the sobering fact that the initial premise on
which the  DSM  was conceived—that it would
increase interclinician diagnostic reliability—remains
unsupported by research. Indeed, reliability studies
indicate that interclinician reliability associated with
the DSM’s use is no higher than the levels produced
prior to its publication, and in some cases it is lower.
Although clinicians may endeavor to improve their
sensitivity to the influence of culture in the use of the
DSM, the refinement of the user can never entirely
compensate for the weakness of the tool itself.
—G. Scott Sparrow
See also Depression; Eating Disorders; Schizophrenia
FURTHER READING
American Psychiatric Association. (2000). Diagnostic and sta-
tistical manual of mental disorders (4th ed., text rev.).
Washington, DC: Author.
Brown, L. S. (1994). Subversive dialogues. New York: Basic
Books.
Caplan, P., & Cosgrove, L. (Eds.). (2004). Bias in psychiatric
diagnosis. Lanham, MD: Jason Aronson