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Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV‐TR)

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 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV-TR)
controversial. When he left, the leadership of the function-
alist chool passed to Angell. From 1904 to 1930 Dewey
was at Columbia University, working on applications of
psychology to educational and philosophical problems.
Dewey's paper ''The Reflex Arc Concept in Psychology"
i u ually credited with establishing functionalism as a
defined school of psychology, rather than just an orienta-
tion or attitude. The paper contained the seeds of all the
arguments against the use of the stimulus-response unit
a the building block of behavior in psychological theory.
In this paper, Dewey attacked the molecular reductionism
of elements in the reflex arc, with its distinction between
timulus and response. Dewey felt that behavior reduced
to its basic sensory-motor description was not meaningful.
He taught that behavior is continuous, not disjoined into
stimuli and response, and that sensory-motor behaviors
continuously blend into one another.
Dewey understood the organism not as a passive re-
ceptor of stimuli but as an active perceiver. He believed
that behavior should be studied in terms of its significant
adaptation to the environment. The proper subject matter
for psychology was the study of the total organism as it
{unctWned in its environment. His functionalistic point of
view was influenced by the theory of evolution and his
own instrumentalistic philosophy, which held that ideas
are plans for action rising to reality and its problems. The
struggle of the human intellect is to activate conscious
responses to bring about appropriate behavior that enables
the organism to survive, to progress, to function. ''Thus,
functional psychology is the study of the organism in use"
(Schultz, History, 1981, p. 163).
J ohn Dewey wrote the first American textbook of psy-
chology in 1886, called Psychology, which was popular until
William James's The Principles of Psychology came out in
1890. But Dewey did not spend many years in psychology
proper . After the 1896 paper, his interests turned to practi-
cal applications. In 1899, after retiring as president of the
American Psychological Association, he became the leader
of the progressive education movement. It was consis-
tent with the ideas inherent in his functional psychology
and his philosophy that he devoted most of his time to
American education and its pragmatic development.
Dewey was very much involved in American political
and social issues during the latter part of his life, influ-
encing education in particular. His positions gradually
evolved over the course of his career, and he was concerned
with individual rights, including those of minority individ-
uals and women. He was one of the few psychologists
pictured on a U.s. stamp.
SUGGESTED READING
Dewey, J . (1896). The reflex arc concept in psychology. Psyclwlogi-
col Review, 3, 357-370.
N. A. HAYNIE
495
DIAGNOSTIC AND STATISTICAL MANUAL
OF MENTAL DISORDERS (DSM-IV-TR)
The Diagnostic and Statistical Marw.a1 of Mental Disorders,
fourth edition, text revision (DSM-IV-TR) (American Psy-
chiatric Association [APAl, 2000) is a compendium of
mental disorders, a listing of the criteria used to diag-
nose them, and a detailed system for their definition,
organization, and classification. Put simply, it is the pri-
mary diagnostic manual for mental health professionals in
the United States and much of the Western world. Diag-
nosis refers to the identification and labeling of a mental
disorder by examination and analysis. Mental health pro-
fessionals diagnose individuals based on the symptoms
that they report experiencing and the signs of illness with
which they present. The DSM-IV-TR aids professionals in
understanding and diagnosing mental disorders through
its provision of explicit diagnostic criteria and an official
classification system.
General Features of the DSM-IV-TR
In the DSM-IV-TR classification system, mental disorders
are grouped into 17 diagnostic categories. The manual
increases accuracy of diagnosis because it lists the spe-
cific criteria for each mental disorder and the number of
criteria that must be met to reach the diagnostic thresh-
old. Empirical research and extensive literature reviews
have guided refinements in the diagnostic manual and
its continued development. Although far from perfect, the
DSM-IV-TR functions as one of the most comprehensive
and efficient manuals used to diagnose mental disorders
in the history of humankind. The only major competitor
in the developed world is the World Health Organization's
International Classification of Diseases 10th editWn aCD-10),
which is widely compatible with the DSM-IV-TR.
According to the DSM-IV-TR, individuals with a par-
ticular diagnosis (e.g. , major depressive disorder) need not
exhibit identical features, although they should present
with certain cardinal symptoms (e.g., either depressed
mood or anhedonia). In the DSM-IV-TR, the criteria for
many disorders are polythetic, meaning that an individual
must meet a minimum number of symptoms to be diag-
nosed, but not all symptoms need be present (e.g. , five of
nine symptoms must be present to diagnose depression).
Use ofpolythetic criteria allows for some variation among
people with the same disorder. However, individuals with
the same disorder should have a similar history in some
areas, for example, a typical age of onset, prognosis, and
common comorbid conditions.
The DSM-IV-TR aims to provide other important infor-
mation about each mental disorder (to the extent that
knowledge is available) including prevalence and course
data; the extent of its genetic loading (i.e., whether it con-
sistently runs in families; the concordance rates amo~g
twins); the extent to which it is affected by psYChOSOCIal
496 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV-TR)
forces; the extent to which the disorder varies according
to gender, age, and culture; the subtypes and specifiers
of the disorder; and associated laboratory findings, physi-
cal examination findings, and general medical conditions.
Another important feature of the DSM-IV-TR is that it
aids in the process of differential diagnosis by providing
guidance about how to discriminate one disorder from
another.
The DSM-IV-TR is the latest incarnation of the man-
ual in an evolving process that began with publication of
the original DSM (APA) in 1952 followed by DSM-II (APA,
1968), DSM-III (APA, 1980), and a revision of the third edi-
tion called DSM-III -R (APA, 1987). The DSM-IV (APA) was
published in 1994. In 2000, a "text revision" ofthe manual
was published, which updated slightly some of the content
in the manual. With each revision, the scope and magni-
tude of the manual has grown-DSM-IV-TR now includes
297 mental disorders and encompasses 943 pages. Work-
groups have already been organized for DSM-V, which is
expected to be published no later than 2012. The current
version, DSM-IV-TR, is much improved compared to ear-
lier editions in several ways including the provision of
operationalized, behaviorally specific, empirically derived,
and standardized criteria for each mental disorder and the
manual's attention to multicultural and diversity aware-
ness, which is necessary to diagnose individuals outside
the majority culture.
Regarding its multicultural applicability, international
experts were involved in the revision process to ensure
a wide pool of information on cultural factors in psy-
chopathology and diagnosis. The DSM-IV-TR includes
information about cultural factors that may influence some
disorders. For example, cultural considerations for conduct
disorder include immigrant youth who exhibit aggressive
behavior necessary for survival. Perhaps most impor-
tantly, a glossary of many culture-bound disorders are
described in an appendix of the DSM-IV-TR called "Outline
for Cultural Formulation and Glossary of Culture-Bound
Syndromes." In this section, information is provided about
the names of culture-bound syndromes, the cultures in
which it occurs, and a description ofthe main psychopatho-
logical features. For example, a disorder called "susto"
occurs mainly in South and Central America and is an
illness in which a traumatic event purportedly causes
the soul to leave the body. In all, 25 conditions are dis-
cussed, which is an important beginning to increasing the
cross-cultural validity ofthe DSM-IV-TR.
The Multiaxial System of the DSM-IV-TR
An important innovation to diagnosis in various earlier
editions of the manual and maintained in the DSM-IV-TR
is the application of a multiaxial approach. In the multiax-
ial system, each person is rated on five distinct dimensions
or axes, with each axis referring to a different domain of
the person's functioning. Although only Axis I and Axis
II cover the diagnosis of abnormal behavior, inclusion
of Axes III, IV, and V indicates awareness that factors
other than a person's symptoms should be considered in
a thorough mental health assessment. Each domain is
important in that it can help professionals understand the
experience of the person more fully, plan treatment, and
predict outcome. The multiaxial system also provides a
convenient and standard format for organizing and com-
municating clinical information, captures the complexity
of clinical phenomena, and describes potentially important
differences in functioning among persons with the same
diagnosis.
Axis I: Clinical Disorders and Other Conditions That May Be a
Focus of Clinical Attention. All men tal disorders experienced
by the client are reported on Axis I with the exception of
personality disorders and mental retardation, which are
coded on Axis II. Axis I is comprised of 16 broad categories
under which specific disorders are subsumed. Fifteen of
the 16 categories describe the classic mental disorders.
Examples include bipolar disorder, obsessive-compulsive
disorder, schizophrenia, anorexia nervosa, alcohol de-
pendence, attention-deficit/hyperactivity disorder, adjust-
ment disorder, pathological gambling, and dementia of
the Alzheimer's type. The final category called "Other
Conditions That May Be a Focus of Clinical Attention"
denotes conditions that are not mental disorders but may
prompt the need for psychological intervention. Examples
include parent-child relational problem, malingering, and
bereavement.
Axis II· Personnlity Disorders and Mental Retardation.
Personality disorders are inflexible and maladaptive
patterns of behavior reflecting extreme variants of
normal personality traits that have become rigid and
dysfunctional. Ten personality disorders are standard in
DSM-IV-TR: paranoid, schizoid, schizotypal, antisocial ,
borderline, histrionic, narcissistic, avoidant, dependent,
and obsessive-compulsive personality disorder. Person-
ality disorder not otherwise specified is also included
as a diagnostic option. Depressive personality disorder
and passive-aggressive personality disorder are included
in an appendix of the manual devoted to disorders that
are deserving of further study, some of which might be
included as official disorders in a future edition of the
manual should enough research bear out their usefulness .
Prominent dysfunctional personality traits can be listed
on Axis II when symptoms are noteworthy but below the
diagnostic threshold. Defense mechanisms can also be
noted on Axis II, although this application is relatively
uncommon in clinical practice.
Axis ill: General Medical Conditions. On this axis, the
professional lists any current physical disorders (e.g.,
epilepsy, lung cancer, diabetes) that could be relevant
to the understanding or management of the client's psy-
chiatric problems. Professionals are advised to list all
important medical conditions experienced by the client
and be inclusive rather than exclusive.
Axis N: Psychosocial and Erwironmental ProbleTr/$. All sig-
nificant social and environmental stressors experienced
 DlAG OSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV-TR)
by the client are reported on Axis IV. Examples include:
recently divorced, inadequate finances, and recent death
of parent. In general, only those stressors that have been
pre ent during the year preceding the current evaluation
are listed. However, stressors occurring prior to the pre-
vious year (e.g., childhood sexual abuse) may be listed if
they contribute significantly to the person's current mental
disorder or become a focus of treatment.
Axis V: Global Assessment of Functioning. Global Assess-
ment of Functioning (GAF) Scale ratings are recorded on
Axis V. On this axis, the professional rates the client's
overall level of functioning, described on a 0-100 scale.
Higher GAF scores indicate better functioning. Explicit
descriptions of functioning in 10 point increments are pro-
vided in the DSM-IV-TR. For example, a GAF range of
31-40 indicates "some impairment in reality testing or
communication," scores ranging 51-60 suggest "moderate
symptoms or moderate difficulty in social, occupational,
or school functioning," and scores between 71 and 80
denote mild symptoms that are "transient and expectable
reactions to psychosocial stressors" with slight functional
impairment (APA, 2000, p. 34). GAF ratings at the current
time are typically provided although professionals some-
times include the client's highest GAF within the past year
or at some other relevant time, such as at discharge from a
psychiatric hospital. GAF scale ratings (albeit subjective)
are useful in describing the overall level of impairment of a
client, tracking clinical progress over time, and predicting
prognosis.
Although the DSM-IV-TR arguably is the most sophisti-
cated and comprehensive diagnostic manual ever created,
it is not without significant limitations. Criticisms include
a narrow focus on enhancing the reliability or replicability
of diagnosis at the expense of improving validity or use-
fulness of diagnosis; the adoption of a categorical model
of diagnosis which assumes a "Yes/No" or "Sick/Well"
approach in which individuals either have the disorder
(i.e., they meet criteria, they are diagnosable) or they do
not (despite possibly having several symptoms but not
enough to meet formal criteria) rather than a dimensional
approach that classifies clinical presentations based on
quantitative descriptions of various domains of function-
ing; the fact that distinct boundaries between some mental
disorders is difficult to determine, and applying such def-
inite categories to mental disorders implies a uniformity
that does not exist; the substantial comorbidity of men-
tal disorders, which raises the question of whether or
not a single disorder is actually present instead of the
co-occurrence of several distinct disorders; the fact that
many individuals seen in mental health settings do not fit
neatly into any of the categories, suggesting poor clinical
utility of some diagnoses; the fact that the classification
system is based primarily on descriptive syndromes, which
largely ignores etiological and contextual factors; and the
improved although still limited cultural applicability of
the manual, which still appears to have a false assumption
that its primary syndromes represent universal disorders.
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497
For a more complete discussion of strengths and criticisms
of the DSM-IV-TR, the interested reader is referred to
Widiger and Clark (2000), Widiger and Mullins-Sweatt,
(2007), and Segal and Coolidge (2001). It is anticipated
that the forthcoming DSM-V will continue to improve upon
its predecessors and provide a state-of-the-art manual for
the diagnosis and classification of mental illness.
REFERENCES
American Psychiatric Association. (1952). Diagnostic and statistical
manual of menial. disorders. Washington, DC: Author.
American Psychiatric Association. (1968). Diagnostic and statis-
tical manual of menial. disorders (2nd ed.). Washington, DC:
Author.
American Psychiatric Association. (1980). Diagnostic and statis-
tical manual of mental disorders (3rd ed.). Washington, DC:
Author.
American Psychiatric Association. (1987). Diagnostic and statistical
manual of menial. disorders (3rd ed., revised). Washington, DC:
Author.
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.
Segal, D. L., & Coolidge, F. L. (2001). Diagnosis and classifi-
cation. In M. Hersen & V. B. Van Hasselt (Eds. ), Advanced
abrwrmol psychology (2nd ed., pp. 5-22). New York: Kluwer
AcademicIPlenum.
Widiger, T. A., & Clark, L. A. (2000). Toward DSM-V and the
classification of psychopathology. Psyclwlogica1 Bulletin, 126,
946-963.
Widiger, T. A., & Mullins-Sweatt, S. (2007). Mental disorders
as discrete clinical conditions: Dimensional versus categorical
classification. In M. Hersen, S. M. Turner, & D. C. Beidel
(Eds.), Adult psyclwpatlwlogy and diagnosis (5th ed., pp. 3-33).
Hoboken, NJ: John Wiley & Sons.
SUGGESTED READINGS
First, M. B., Francis, A., & Pincus, H. A. (2002). DSM-~-TR
handbook of differential diagnosis. Washington, DC: Amencan
Psychiatric Publishing.
Hersen, M., Turner, S. M., & Beidel, D. C. (Eds. ). (2007). Adultf!BY-
clwpatlwlogy and diagnosis (5th ed.). Hoboken, NJ: John Wiley
& Sons.
Thakk er, J ., & W ard , T '''~l~,
(1998). Culture and classification: The
cross-cultural application of the DSM-IV. Clinical PsycIWOVf5J
Review, 18, 501-529.
DANIEL L. SEGAL
University of Colorado at Colorado Springs
See also: Diagnostic Classification; Diagnostic Inter~iew.
Schedule for DSM-IV (DIS· IV); Psychodynamic DI.agnos~lc
Manual; Structured Clinical Interview for DSM DIagnOSIs