Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV-TR)

Diagnostic System

Class Conducted By-

Dr. Pragyesh Kumar Mishra
Early Foundations: Emil Kraepelin
(1856-1926)

Pioneered classification of mental illness

based on biological causes
Published 1st psychiatry text (1883)
Mental illness as syndrome
Cluster of symptoms that co-occur
Proposed two major syndromes
Dementia praecox
Manic-depressive psychosis
DSM
The Diagnostic and Statistical Manuals of
Mental Disorders (DSM) are handbooks
developed by the American Psychiatric
Association

These manuals contain listings and

descriptions of psychiatric diagnoses,
analogous to the International statistical
Classification of Diseases manual (ICD)
DSM-I and DSM-II
The DSMs have changed as the prevailing
concepts of mental disorders have
changed
DSM-I (1952) reflected Adolf Meyer’s
influence on psychiatry, and classified
mental disorders as various “reactions”
to stressors
DSM-II (1968) dropped the reactions
concept, but maintained a perspective
influenced by psychodynamic theory
DSM-I and DSM-II

Both the DSM-I and DSM-II had

problems with reliability in diagnosing
mental illness

Both lacked standardized diagnostic

criteria and assessment instruments
(Frances, Mack, Ross, First, 2000)
DSM-III & DSM-III R

DSM-III (1980) – A watershed event

American psychiatry
3rd edition revised in 1987
It outlined a research-based,
empirical, and phenomenological
approach to diagnosis, which
attempted to be a theoretical with
regard to etiology
DSM-IV
DSM-IV(1994) continues the DSM-III
tradition
It is characterized as the “biologic”
approach to diagnosis
It contains listings and descriptions of
psychiatric diagnoses
DSM-IV

The DSM-IV serves as:

Guide for clinical practice
Facilitates research and improved
communication between clinicians
and researchers
Is a tool used to teach
psychopathology
“It any event, DSM-IV is likely to remain
the diagnostic bible for the coming
decades.”
Seligman & Rosenhan (1998)
DSM-IV-TR: Diagnostic System

Diagnostic and Statistical Manual of Mental

Disorders –IV- Text portion Revised (DSM-IV-TR)
4th edition revised in 2000
Published by American Psychiatric
Association
Multiaxial system
Diagnosis based on 5 axes or dimensions.
Five Axes of DSM-IV
AXIS DESCRIPTION

1. All diagnostic categories except personality

disorders and mental retardation
2. Personality disorders and mental retardation
3. General medical conditions
4. Psychosocial and environmental problems
5. Global assessment of functioning scale (GAF)
Selected Axis I Diagnostic Categories
Axis I : All diagnostic categories except personality
disorders and mental retardation
Disorders usually first diagnosed in infancy, childhood or
adolescence
Learning Disorders
Pervasive Developmental Disorders
Substance-related disorders
Alcohol-related and Amphetamine-related Disorders
Schizophrenia and other Psychotic Disorders
Anxiety disorders
Panic, Generalized Anxiety, Obsessive-Compulsive
Disorders
Mood disorders
Major Depressive and Bipolar Disorders
Eating Disorders
Anorexia Nervosa and Bulimia Nervosa
Selected Axis II Diagnostic Categories
Axis II: personality disorders and mental
retardation

Also used to note maladaptive personality

traits and behavior problems
Selected Axis III Diagnostic Categories
Axis III: General medical conditions

Medical conditions which play a role in the

development, continuance, or exacerbation
of Axis I and II Disorders
Examples:
Asthma in patients with anxiety
AIDS in a patient with new-onset psychosis
(brain lesions)
Cirrhosis of the liver in a patient with alcohol
dependence
Selected Axis IV Diagnostic Categories
Axis IV: Psychosocial and environmental problems

Psychosocial stressors include

problems with:
Primary support group
Social environment
Education
Occupation
Housing
Economic
Access to health care services
Interaction with the legal
system
Environmental problems
Selected Axis V Diagnostic Categories
Axis V: Global assessment of functioning scale (GAF)

Patient’s global level of functioning both at the

time of evaluation and during the past year
Clinician consults the Global Assessment of
Functioning scale to determine the level of
functioning (Social, Occupational and Mental
Functioning)
The GAF is based on 0-100 scale
Improvements in the DSM-IV-TR
Specific diagnostic criteria
 Less vague, more explicit and concrete than DSM-
II (see Table 3.2)
 More extensive descriptions
 Essential features
 Associated features (e.g., lab findings)
 Differential diagnosis
 Increasing number of diagnostic categories
 Issues and possible diagnostic categories in need of
further study
Caffeine withdrawal or Premenstrual Dysphoric Disorder
Ethnic & Cultural Considerations
Mental illness universal
Culture can influence:
Risk factors
Types of symptoms experienced
Willingness to seek help
Availability of treatments
DSM-IV-TR includes:
Enhanced cultural sensitivity
Appendix of 25 culture-bound syndromes
Some researchers endorse looking for commonalities
rather than differences across cultures
Table 2: Number of Diagnostic Categories per
Edition of DSM
 Inter-Rater Reliability of Selected DSM
Diagnoses
For most DSM Diagnosis Reliability
diagnostic
categories, Bipolar Disorder .84
reliability is Major Depression .80
good Schizophrenia .79
Reliability in Alcohol Abuse 1.0
everyday
Any Eating Disorder .77
settings may be
lower than in Panic Disorder .65
formal research Avoidant PD .97
settings Dependent PD .86
 Criticisms of Classification
Stigma against mental illness
Treated differently by others
Difficulty finding a job
Categories do not capture the
uniqueness of a person.
The disorder does not define the
person.
She is an individual with schizophrenia,
not a “schizophrenic”
Classification may emphasize
trivial similarities
Relevant information may be
overlooked.
 Possible Changes for DSM-IV

Including a Personal Health Index

Reorganizing categories based on overlap
Dimensional approach to diagnoses
Organizing diagnoses by causes
Defining disability
 DSM-V
The Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) was
published on May 18, 2013, superseding the
DSM-IV-TR, which was published in 2000. In
most respects DSM-5 is not greatly changed
from DSM-IV-TR.
Changes from DSM-IV to DSM-V
Thanks