Major Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) − Background of the Change and Conceptualization of Mental Disorders −Hana KUBOTA, Takeshi MATSUISHI
I. Purpose of Study
Autism is currently defined as "a developmental disorder
caused by brain damage". However, until the 1960s, it was generally viewed as "a psychological disorder resulting in closed mind" or "infantile type of
schizophrenia". How did this radical change occur? Not only the understanding of autism but the entire focus of mental disorders
studies had shifted from psychogenic theory to organic theory of biological
mental science and other psychiatry between the latter half of the 1960s
and the 1980s. I realized that a major revision of the widely used Diagnostic and Statistical
Manual of Mental Disorders (DSM), published by the American Psychiatric
Association, lies at the bottom of the change. In short, the manual switched from earlier psychology-based
psychoanalysis to an approach emphasizing scientific proof. This realization naturally led me to the question, "why did DSM undergo such a radical change?"
There is a major difference of approach towards mental disorders between the first and second versions of DSM and the third version (DSM-III). The first two versions prescribe diagnostic standards based on psychogenic theory that, in turn, have roots in psychodynamics. The diagnostic standards prescribed in the third version are, in contrast, based not on psychodynamics, but on objective facts and scientific grounds.
This paper aims at studying the background of the change and the evolution of approaches to mental disorders.
II Making of DSM−III and Its Background
１ Comparison between DSM−I・II and DSM−III
No. of disorders
based on patient's psychology
practical, symptomatological approach. multiaxis diagnosis
Scientific, medical, objective concepts
1 Comparison between DSM−I・II and DSM−III
２ Reasons for the Change to DSM−III
（１）Emergence of behavior therapy
Since the 1950s, behavior therapy, which emphasizes objective observation and experiments focusing on learning and environment, gained popularity in the Untied States.As a result, psychoanalysis, which emphasizes consciousness, internal observation and instinct, lost its stance.
（２）Emergence of biological mental science
Use of psychotropic drugs became common in the 1960s, causing radical change in mental treatment.Biological research was stirred up by the emergence of psychotropic drugs.
（３）Inconsistencies in diagnoses
Practitioners and a number of studies pointed out inconsistencies of diagnoses based on previous diagnostic standards (DSM−I and II, etc), resulting in calls for their revisions.
Accepted diagnostic standards of mental disorders had changed due to pressures from insurance companies, pharmaceutical companies and political lobby groups.(E.g., homosexuality, PTSD)
（５）Social integration of American Jews
It had become meaningless for the Jews to promote psychoanalysis because of the following reasons: a) Jewish culture had become diluted through intermarriage; b) the American society had become more tolerant towards other races.
３ From Psychoanalysis to Scientific Indications ―How to Describe Mental Disordersー
Psychiatry regained the status of a branch of medicine as it moved away from psychoanalysis-based psychogenetic theory to scientific indications. Unlike other illnesses, however, the diagnosis of mental disorders, which requires social contextualization, cannot ignore social relationships. Mental health is dependant on the relationships between an individual and society as well as on individuals themselves, and is not pertinent to a uniform definition. Consequently, mental disorders are not pertinent to a uniform definition either. It is very difficult to determine what is normal and what is abnormal.
The study found the following facts:
Regarding the change of approach to mental disorders from DSM−I・II to DSM−III;
１ Emergence of new treatments including behavior therapy and the revolution of treatments by psychotropic drugs resulted in the decline of psychodynamic, psychoanalytical paradigm (DSM−I and II) and facilitated the rise of biological psychiatry. The social integration of Jews to the American society influenced the process in the background.
２ The advancement of biological research technology (e.g. for researches of brain and genes) gave rise to biological psychiatry. This caused psychiatry to regain the status of a branch of medicine and, in turn, encouraged the fundamental revision of diagnostic classifications.
３ At the same time, social situations and political pressures forced the revision of diagnostic standards. The result is the current scientific diagnostic standards (DSM−III).
American Psychiatric Association, "DSM−II", 1968
American Psychiatric Association, "DSM-III, 1980
American Psychiatric Association, "DSM−IV", 1994
Edward Shorter, "History of Psychiatry: From the Era of the Asylum to the Age of Prozac" 1997
Herb Kutchins & Stuart A.Kirk, "MAKING US CRAZY" DSM-The Psychiatric Bible and the Creation of Mental Disorders" 1997
Emile Kraepelin: "Psychiatrie: Ein Lehrbuch für Studierende und Ärzte" Unveränderter Abdruck der Achte Auflage. 1909
Kurt Schneider: "Klinische Psychopathologie" 12 unveränderte Auflage. Georg Thieme Verlag Stuttgart・New York. 1980
(originally on Journal of disability and medico-pedagogy Vol7.2003:p11-13)