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The development of DSM, since the 1950's, has shaped the practice and training of psychiatry more than some of us may like. However, the need for a widely agreed-upon system of classification of mental illness was a preoccupation for psychiatrists long before the mid-20th century. A brief story of the evolution of our current nosology is presented in the following article.
-Dilip Ramchandani, M.D.
History Notes Editor
By Lucy D. Ozarin, M.D.
The need for a uniform nomenclature or nosology as a basis for communication and accurate statistics was apparent to the founders of the Association of Medical Superintendents of American Institutions for the Insane (APA's original name). They were confronted by widely disparate figures for cures of mental illnesses.
Isaac Ray, superintendent of the Butler Hospital in Rhode Island, read a paper at the Association's annual meeting in 1849 disputing current mental hospital statistics since no uniform definitions of terms existed.
"Until some. . .system is generally adopted with its classes and orders accurately defined," he said, "no one can be sure that the terms melancholia [and] moral insanity [are] understood precisely" by all who use the terms.
In 1840 the Bureau of the Census attempted a count of the insane. Ray called the result a useless collection of heterogeneous data. The bureau attempted similar counts in later years with little more success. Meanwhile, various states were compiling the statistics on the mentally ill in their hospitals for administrative purposes.
At the annual meeting of the Medico-Psychological Association (another previous name of APA) in 1913, Dr. James May of New York made a plea for a system of uniform statistical reports from mental hospitals. The Association responded by appointing a committee with Dr. Thomas Salmon, medical director of the National Association for Mental Hygiene, as chair. The committee presented a nomenclature for statistics keeping and appropriate forms for recording in 1917. The organization adopted the report and also made provision to continue the Committee on Statistics.
In 1933 efforts by the New York Academy of Medicine and the Association resulted in a revised nomenclature also adopted by the American Neurological Association. The Statistical Manual for Mental Diseases went through numerous editions until 1952, when the first Diagnostic and Statistical Manual was published by APA. Responsibility to collect mental hospital statistics was taken over by the Biometrics Branch of the National Institute of Mental Health after that organization became operational in 1949.
DSM-I maintained the coding system used by the earlier manuals and included brief descriptions of the coded entities, which in many cases were termed "reactions" following Adolf Meyers's psychobiological approach to mental illness.
DSM-II, published in 1968, was an effort to coordinate with the International Classification of Diseases (ICD) produced by the World Health Organization. The word "reactions" was dropped from diagnostic rubrics. Nine printings occurred through 1976.
A major change occurred with DSM-III in 1980. Earlier classifications had related to dynamic (psychoanalytical) approaches to etiology of the "nonorganic neuroses" and personality disorders. DSM-III was a descriptive approach based on symptoms and behavioral and clinical manifestations. Specific diagnostic criteria were delineated, and a multiaxial evaluation was introduced to facilitate treatment planning and prognosis. The rubric "neurosis" disappeared as well as some long-standing diagnoses as involutional melancholia (now subsumed under depression). DSM-III-R provided further specificity.
DSM-IV (1994) reflects new research data and is an effort to create greater consistency and clearer criteria. It also marks an effort to prepare for a new ICD.