View source for Diagnostic and Statistical Manual of Mental Disorders

{{Short description|American psychiatric classification}}
{{Use mdy dates|date=February 2024}} {{Use American English|date=February 2024}}
[[File:DiagnosticAndStatisticalManualOfMentalDisorders.jpg|thumb|1952 edition of the DSM (DSM-I)]]

The '''''Diagnostic and Statistical Manual of Mental Disorders''''' ('''''DSM'''''; latest edition: ''[[DSM-5-TR]]'', published in March 2022<ref name=":1">{{Cite book|title=DSM-5 |url=http://repository.poltekkes-kaltim.ac.id/657/1/Diagnostic%20and%20statistical%20manual%20of%20mental%20disorders%20_%20DSM-5%20(%20PDFDrive.com%20).pdf|access-date=10 January 2022|via=Archive.Today}}{{pn|date=November 2024}}{{full|date=November 2024}}</ref>) is a publication by the [[American Psychiatric Association]] (APA) for the [[classification of mental disorders]] using a common language and standard criteria. It is an internationally accepted manual on the diagnosis and treatment of mental disorders, though it may be used in conjunction with other documents. Other commonly used principal guides of psychiatry include the [[International Classification of Diseases]] (ICD), [[Chinese Classification of Mental Disorders]] (CCMD), and the ''[[Psychodynamic Diagnostic Manual]]''. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world,<ref name ="Do mental health professionals use diagnostic classifications the way we think they do? A global survey">{{Cite journal|vauthors=First M, Rebello T, Keeley J, Bhargava R, Dai Y, Kulygina M, Matsumoto C, Robles R, Stona A, Reed G | display-authors = 3| title=Do mental health professionals use diagnostic classifications the way we think they do? A global survey|journal=World Psychiatry |volume=17|issue=2|pages= 187–195|pmid = 29856559| date = June 2018 | doi=10.1002/wps.20525|pmc= 5980454 }}</ref> and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.<ref name = "Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis">{{Cite journal|vauthors = Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner EH, Higgins JP, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JP, Geddes JR | display-authors = 3| title = Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis | journal = [[The Lancet]] | date = 7 April 2018 | volume = 391 | issue = 10128 | pages = 1357–1366 | doi = 10.1016/S0140-6736(17)32802-7 | pmid = 29477251 | pmc = 5889788 }}</ref><ref>{{cite journal | vauthors= Bandelow B, Reitt M, Röver C, Michaelis S, Görlich Y, Wedekind D | display-authors = 3| journal= International Clinical Psychopharmacology | title=Efficacy of treatments for anxiety disorders: a meta-analysis | volume=30 | issue=4 | pages=183–192 | date= July 2015 | doi=10.1097/YIC.0000000000000078| pmid= 25932596 }}</ref><ref>{{cite journal | vauthors= Schneider-Thoma J, Chalkou K, Dörries C, Bighelli I, Ceraso A, Huhn M, Siafis S, Davis JM, Cipriani A, Furukawa TA, Salanti G, Leucht S | journal=Lancet | display-authors = 3| title=Comparative efficacy and tolerability of 32 oral and long-acting injectable antipsychotics for the maintenance treatment of adults with schizophrenia: a systematic review and network meta-analysis | volume=399 | issue=10327 | date=26 February 2022 | pages=824–836 | doi=10.1016/S0140-6736(21)01997-8 | pmid=35219395 | doi-access=free }}</ref><ref>{{cite journal | vauthors=Gartlehner G, Crotty K, Kennedy S, Edlund MJ, Ali R, Siddiqui M, Fortman R, Wines R, Persad E, Viswanathan M | display-authors = 3| journal=CNS Drugs | title=Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis | volume=35 | issue=10 | pages=1053–1067 | date= October 2021 | doi=10.1007/s40263-021-00855-4| pmid=34495494 | pmc=8478737 }}</ref>

It is used by researchers, [[psychiatric drug]] regulation agencies, [[health insurance]] companies, [[pharmaceutical companies]], the legal system, and policymakers. Some mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients with mental disorders.  Health-care researchers use the DSM to categorize patients for research purposes.

The DSM evolved from systems for collecting census and [[psychiatric hospital]] statistics, as well as from a [[United States Army]] manual. Revisions since its first publication in 1952 have incrementally added to the total number of [[mental disorders]], while removing those no longer considered to be mental disorders.

Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound [[nosology]] (the branch of [[medical science]] that deals with the [[Medical classification|classification of diseases]]) used in DSM-III.{{Citation needed|reason= Reads as more of a marketing statement than academically sound claim. A citation from the APA declaring itself to be an authority would not be sufficient backing for this claim.|date=April 2023}} However, it has also generated [[#Criticisms|controversy and criticism]], including ongoing questions concerning the [[Reliability (statistics)|reliability]] and [[Validity (statistics)|validity]] of many diagnoses; the use of arbitrary dividing lines between mental illness and "[[Normality (behavior)|normality]]"; possible [[cultural bias]]; and the [[medicalization]] of human distress.<ref name="frana">{{cite journal |last1=Frances |first1=Allen |title=The New Crisis in Confidence in Psychiatric Diagnosis |journal=Annals of Internal Medicine |date=17 May 2013 |volume=159 |issue=3 |pages=221–222 |doi=10.7326/0003-4819-159-3-201308060-00655 |pmid=23685989 |author-link=Allen Frances }}</ref><ref name="concept&evolution">{{cite journal | vauthors = Dalal PK, Sivakumar T | title = Moving towards ICD-11 and DSM-V: Concept and evolution of psychiatric classification | journal = Indian Journal of Psychiatry | volume = 51 | issue = 4 | pages = 310–319 | year = 2009 | pmid = 20048461 | pmc = 2802383 | doi = 10.4103/0019-5545.58302 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Kendell R, Jablensky A | title = Distinguishing between the validity and utility of psychiatric diagnoses | journal = The American Journal of Psychiatry | volume = 160 | issue = 1 | pages = 4–12 | date = January 2003 | pmid = 12505793 | doi = 10.1176/appi.ajp.160.1.4 }}</ref><ref>{{cite journal | vauthors = Baca-Garcia E, Perez-Rodriguez MM, Basurte-Villamor I, Fernandez del Moral AL, Jimenez-Arriero MA, Gonzalez de Rivera JL, Saiz-Ruiz J, Oquendo MA | display-authors = 3 | title = Diagnostic stability of psychiatric disorders in clinical practice | journal = The British Journal of Psychiatry | volume = 190 | issue = 3 | pages = 210–216 | date = March 2007 | pmid = 17329740 | doi = 10.1192/bjp.bp.106.024026 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Pincus HA, Zarin DA, First M | title = 'Clinical significance' and DSM-IV | journal = Archives of General Psychiatry | volume = 55 | issue = 12 | pages = 1145; author reply 1147–1145; author reply 1148 | date = December 1998 | pmid = 9862559 | doi = 10.1001/archpsyc.55.12.1145 }}</ref> The APA itself has published that the inter-rater reliability is low for many disorders in the DSM-5, including [[major depressive disorder]] and [[generalized anxiety disorder]].<ref name ="DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses">{{Cite journal | vauthors = Regier D, Narrow W, Clarke D, Kraemer H, Kuramoto S, Kuhl E, Kupfer D| display-authors = 3| title=DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses|journal= American Journal of Psychiatry|volume= 170|issue=1|pages=59–70|doi=10.1176/appi.ajp.2012.12070999|year=2013|pmid=23111466 }}</ref>

==Distinction from ICD==
An alternate, widely used classification publication is the ''[[International Statistical Classification of Diseases and Related Health Problems|International Classification of Diseases]]'' (ICD), produced by the [[World Health Organization]] (WHO).<ref>''[[ICD-10|ICD-10 Classification of Mental and Behavioural Disorders]]:''

"[https://www.who.int/classifications/icd/en/bluebook.pdf Clinical descriptions and diagnostic guidelines]" (aka the "Blue Book"); and

"[https://www.who.int/classifications/icd/en/GRNBOOK.pdf Diagnostic criteria for research]" (aka the "Green Book").</ref> The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 6 of the ICD specifically covers mental, behavioral and neurodevelopmental disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM. An international survey of psychiatrists in sixty-six countries compared the use of the [[ICD-10]] and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research.<ref>{{cite journal |vauthors=Mezzich JE |year=2002 |title=International surveys on the use of ICD-10 and related diagnostic systems |journal=Psychopathology |volume=35 |issue=2–3 |pages=72–75 |doi=10.1159/000065122 |pmid=12145487 }}</ref> This may be because the DSM tends to put more emphasis on clear diagnostic criteria, while the ICD tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated. That is, the ICD descriptions of psychiatric disorders tend to be more qualitative information, such as general descriptions of what various disorders tend to look like. The DSM focuses more on quantitative and operationalized criteria; e.g., to be diagnosed with X disorder, one must fulfill 5 of 9 criteria for at least 6 months.<ref name=":2">{{Cite journal |last=Tyrer |first=Peter |date=2014 |title=A comparison of DSM and ICD classifications of mental disorder |journal=Advances in Psychiatric Treatment |volume=20 |issue=4 |pages=280–285 |doi=10.1192/apt.bp.113.011296 |doi-access=free }}</ref>

Since 1980, every code that has been listed in the DSM has been an [[ICD-9]] code. However, DSM-5, unlike previous versions of DSM, contains both ICD-9 and [[ICD-10]] codes.<ref>{{Cite web |url=https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/DSM5-transition-to-ICD10.pdf |title=Guide to using DSM-5 in the transition to ICD-10 |publisher=American Psychiatric Association |website=www.psychiatry.org |access-date=2025-01-23}}</ref><ref>In Appendix G: "ICD-9-CM Codes for Selected General Medical Conditions and Medication-Induced Disorders"</ref> Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other.<ref>{{cite journal | author = American Psychological Association | year = 2009 | title = ICD VS. DSM | url = http://www.apa.org/monitor/2009/10/icd-dsm.aspx | journal = Monitor on Psychology | volume = 40 | issue = 9|page = 63 }}</ref> For instance, the two manuals contain overlapping but substantially different lists of recognized [[culture-bound syndrome]]s.<ref>[https://www.who.int/entity/classifications/icd/en/GRNBOOK.pdf Diagnostic criteria for research], p. 213–225 ([[World Health Organization|WHO]] 1993)</ref>{{Update inline|reason=culture-bound syndromes or equivalent are no longer listed in ICD-11|date=December 2024}} The ICD also tends to focus more on primary-care and low and middle-income countries, as opposed to the DSM's focus on secondary psychiatric care in high-income countries.<ref name=":2" />

==Antecedents (1840–1949)==

===Census Office, AMA and ISI (1840–1911)===
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the [[United States census, 1840|1840 census]], which used a single category: "[[idiocy]]/[[insanity]]". Three years later, the [[American Statistical Association]] made an official protest to the [[U.S. House of Representatives]], stating that "the most glaring and remarkable errors are found in the statements respecting [[nosology]], prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that, in many towns, [[African Americans]] were all marked as insane, and calling the statistics essentially useless.<ref>{{cite journal | vauthors = Gorwitz K | title = Census enumeration of the mentally ill and the mentally retarded in the nineteenth century | journal = Health Services Reports | volume = 89 | issue = 2 | pages = 180–187 | date = March–April 1974 | pmid = 4274650 | pmc = 1616226 | doi = 10.2307/4595007 | jstor = 4595007 }}</ref>

The [[Association of Medical Superintendents of American Institutions for the Insane]] ("The Superintendents' Association") was formed in 1844.<ref>{{Cite journal |date=1976 |title=The original thirteen |journal=Hospital & Community Psychiatry |volume=27 |issue=7 |pages=464–467 |pmid=776775}}</ref>

In 1860, during the international statistical congress held in London, [[Florence Nightingale]] made a proposal that was to result in the development of the first international model of systematic collection of hospital data.<ref>. [https://www.britannica.com/biography/Florence-Nightingale/Homecoming-and-legacy]. Selanders, Louise. 2025, May 30. Florence Nightingale. Britannica. </ref>  

In 1872, the [[American Medical Association]] (AMA) published its ''Nomenclature of Diseases'', which included various "Disorders of the Intellect".<ref>{{Cite web |title=A nomenclature of diseases: with the reports of the majority and of the minority of the committee thereon: presented to the American Medical Association at the meeting held in Philadelphia, May 1872 |url=https://collections.nlm.nih.gov/catalog/nlm:nlmuid-31910070R-bk |archive-url=https://web.archive.org/web/20201129000700/https://collections.nlm.nih.gov/catalog/nlm:nlmuid-31910070R-bk |archive-date=November 29, 2020 |access-date=2022-11-06 |website=Digital Collections – National Library of Medicine |page=53}}</ref> Its use was short-lived however.<ref>{{Cite book |url=https://www.cdc.gov/nchs/data/misc/classification_diseases2011.pdf |archive-url=https://web.archive.org/web/20110505192204/http://www.cdc.gov/nchs/data/misc/classification_diseases2011.pdf |archive-date=2011-05-05 |url-status=live |title=History of the Statistical Classification of Diseases and Causes of Death |publisher=National Centre for Health Statistics |year=2011}}</ref>

Edward Jarvis and later [[Francis Amasa Walker]] helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880.<ref>{{Cite journal |vauthors=Grob GN |date=1976 |title=Edward Jarvis and the Federal Census: A Chapter in the History of Nineteenth-Century American Medicine |journal=Bulletin of the History of Medicine |publisher=The Johns Hopkins University Press |volume=50 |issue=1 |pages=4–27 |jstor=44450311 |pmid=769874 }}</ref>

In 1888, the [[United States Census Bureau|Census Office]] published Frederick H. Wines' 582-page volume called ''Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880)''. Wines used seven categories of mental illness, which were also adopted by the Superintendents: [[dementia]], [[dipsomania]] (uncontrollable craving for alcohol), [[epilepsy]], [[mania]], [[melancholia]], [[monomania]], and [[paresis]].<ref>[https://sites.google.com/site/psych54000/a History of the DSM] {{Webarchive|url=https://web.archive.org/web/20130911021653/https://sites.google.com/site/psych54000/a |date=2013-09-11 }} Nathaniel Deyoung, Purdue University. Retrieved 9 Sept 2013</ref>

In 1892, the Superintendents' Association expanded its membership to include other mental health workers, and renamed to the [[American Psychiatric Association|American Medico-Psychological Association]] (AMPA).<ref>{{Cite book |title=The history and influence of the American Psychiatric Association |vauthors=Barton WE |date=1987 |publisher=American Psychiatric Press |others=American Psychiatric Association |isbn=0-88048-231-1 |location=Washington, D.C. |page=89 |oclc=13945621}}</ref>

In 1893, a French physician, [[Jacques Bertillon]], introduced the ''Bertillon Classification of Causes of Death'' at a congress of the [[International Statistical Institute]] (ISI) in Chicago.<ref>[https://archive.org/search.php?query=%28%28subject%3A%22Bertillon%2C%20Jacques%22%20OR%20subject%3A%22Jacques%20Bertillon%22%20OR%20creator%3A%22Bertillon%2C%20Jacques%22%20OR%20creator%3A%22Jacques%20Bertillon%22%20OR%20creator%3A%22Bertillon%2C%20J%2E%22%20OR%20title%3A%22Jacques%20Bertillon%22%20OR%20description%3A%22Bertillon%2C%20Jacques%22%20OR%20description%3A%22Jacques%20Bertillon%22%29%20OR%20%28%221851-1922%22%20AND%20Bertillon%29%29%20AND%20%28-mediatype:software%29 Works of Jacques Bertillon], Internet Archive.</ref><ref name="History">{{cite web |title=''History of the development of the ICD''. |url=https://www.who.int/entity/classifications/icd/en/HistoryOfICD.pdf |access-date=11 December 2017 |website=Who.int}}</ref> (The ISI had commissioned him to create it in 1891).<ref name="History" /> A number of countries adopted the ISI's system. In 1898, the [[American Public Health Association]] (APHA) recommended that United States registrars also adopt the system.<ref name="History" />

In 1900, an ISI conference in Paris reformed the Bertillion Classification, and created the ''[[International Classification of Diseases|International List of Causes of Death]]'' (ILCD)''.<ref name="History" />'' Another conference would be held every ten years, and a new edition of the ILCD would be released. Five were ultimately issued. Non-fatal conditions were not included.

In 1903, New York's [[Bellevue Hospital]] published "The Bellevue Hospital nomenclature of diseases and conditions", which included a section on "Diseases of the Mind". Revisions were released in 1909 and 1911. It was produced with the assistance of the AMA and Bureau of the Census.<ref>{{Cite book |url=https://wellcomecollection.org/works/u4swa3m3/ |title=The Bellevue Hospital nomenclature of diseases and conditions |publisher=Bellvue and Allied Hospitals |year=1911 |edition=3rd |location=New York}}</ref>

===APA Statistical Manual (1917) and AMA Standard (1933)===
In 1917, together with the National Commission on Mental Hygiene (now [[Mental Health America]]), the American Medico-Psychological Association developed a new guide for mental hospitals called the ''Statistical Manual for the Use of Institutions for the Insane''. This guide included twenty-two diagnoses. It would be revised several times by the Association, and by the tenth edition in 1942, was titled ''Statistical Manual for the Use of Hospitals of Mental Diseases''.<ref>[https://archive.org/details/statisticalmanu00assogoog Statistical manual for the use of institutions for the insane (1918)] University of Michigan via Internet Archive</ref><ref>{{cite journal | vauthors = Clark LA, Cuthbert B, Lewis-Fernández R, Narrow WE, Reed GM | title = Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health's Research Domain Criteria (RDoC) | journal = Psychological Science in the Public Interest | volume = 18 | issue = 2 | pages = 72–145 | date = September 2017 | pmid = 29211974 | doi = 10.1177/1529100617727266 | doi-access = free }}</ref>

In 1921, the AMPA became the present [[American Psychiatric Association]] (APA).<ref>{{Cite book |title=The history and influence of the American Psychiatric Association |vauthors=Barton WE |date=1987 |publisher=American Psychiatric Press |others=American Psychiatric Association |isbn=0-88048-231-1 |location=Washington, D.C. |page=168 |oclc=13945621}}</ref>

The first edition of the DSM notes in its foreword: "In the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution."<ref name=":8">{{cite web | url=https://archive.org/details/dsm-1 | title=DSM-1 Full PDF | year=1952 }}</ref>

In 1933, the AMA's general medical guide the ''Standard Classified Nomenclature of Disease'', (referred to as the ''Standard),'' was released.<ref>{{cite journal |last1=Logie |first1=H. B. |title=A Standard Classified Nomenclature of Disease |journal=The Journal of Nervous and Mental Disease |date=December 1933 |volume=78 |issue=6 |page=679 |doi=10.1097/00005053-193312000-00075 |doi-access=free }}</ref> Along with the [[New York Academy of Medicine]], the APA provided the psychiatric [[nomenclature]] subsection.<ref>{{cite journal | vauthors = Greenberg SA, Shuman DW, Meyer RG | title = Unmasking forensic diagnosis | journal = International Journal of Law and Psychiatry | volume = 27 | issue = 1 | pages = 1–15 | year = 2004 | pmid = 15019764 | doi = 10.1016/j.ijlp.2004.01.001 }}</ref> It became well adopted in the US within two years.<ref name=":8" /> A major revision of the Statistical Manual was made in 1934, to bring it in line with the new Standard.<ref name=":8" /> A number of revisions of the Standard were produced, with the last in 1961.<ref>{{Cite book |title=Standard nomenclature of diseases and operations |publisher=McGraw Hill |year=1961 |editor-last=Thompson |editor-first=ET |edition=5th |location=New York |editor-last2=Hayden |editor-first2=AC}}</ref>

===Medical 203 (1945)===
[[World War II]] saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers.<ref>{{Cite book |last= |first= |url=https://books.google.com/books?id=BHEwAAAAIAAJ |title=The Medical Department of the United States Army in World War II. |collaboration=United States Army Medical Service |date=1966 |publisher=Office of the Surgeon General, Department of the Army |page=756 }}</ref> This moved the focus away from mental institutions and traditional clinical perspectives. The U.S. armed forces initially used the Standard, but found it lacked appropriate categories for many common conditions that troubled troops. The [[US Navy|United States Navy]] made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance."<ref name=":8" />

Under the direction of [[James Forrestal]],<ref name="NavyPsyc2">{{cite web |vauthors=Sobocinski A |title=A Brief History of U.S. Navy Psychiatric Diagnoses, Part II |url=https://navymedicine.navylive.dodlive.mil/archives/7192 |website=Navy Medicine Live |publisher=U.S. Navy Bureau of Medicine and Surgery |access-date=28 April 2020 |archive-date=20 April 2020 |archive-url=https://web.archive.org/web/20200420113904/https://navymedicine.navylive.dodlive.mil/archives/7192 }}</ref> a committee headed by psychiatrist [[Brigadier General (United States)|Brigadier General]] [[William C. Menninger]], with the assistance of the Mental Hospital Service,<ref>{{Cite journal |pmc = 2015553|year = 1953| vauthors = Sandison RA, Spencer AM |title = Mental Hospital Service|journal = British Medical Journal|volume = 1|issue = 4809|page = 560|doi = 10.1136/bmj.1.4809.560}}</ref> developed a new classification scheme in 1944 and 1945.

Issued in War Department Technical Bulletin, Medical, 203 (TB MED 203); ''Nomenclature and Method of Recording Diagnoses'' was released shortly after the war in October 1945 under the auspices of the [[Office of the Surgeon General]].<ref name="Houts2000">{{cite journal |last1=Houts |first1=Arthur C. |title=Fifty years of psychiatric nomenclature: Reflections on the 1943 War Department Technical Bulletin, Medical 203 |journal=Journal of Clinical Psychology |date=July 2000 |volume=56 |issue=7 |pages=935–967 |doi=10.1002/1097-4679(200007)56:7<935::aid-jclp11>3.0.co;2-8 |pmid=10902952 }}</ref> It was reprinted in the [[Journal of Clinical Psychology]] for civilian use in July 1946 with the new title ''Nomenclature of Psychiatric Disorders and Reactions''.<ref>{{cite journal |title=Nomenclature of psychiatric disorders and reactions |journal=Journal of Clinical Psychology |date=July 1946 |volume=2 |issue=3 |pages=289–296 |doi=10.1002/1097-4679(194607)2:3<289::aid-jclp2270020316>3.0.co;2-o |pmid=20992064 }}</ref> This system came to be known as "Medical 203".

This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty."<ref name=":8" /> The [[United States Department of Veterans Affairs|Veterans Administration]] also adopted a slightly modified version of the standard in 1947.<ref name="NavyPsyc2" />

The further developed ''Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions'' was released in 1949.<ref>{{Cite book |last=U.S. Army. U.S. Navy. U.S. Air Force |url=http://archive.org/details/NOMENCLATUREANDMETHODOFRECORDINGPSYCHIATRICCONDITIONS |title=Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions |date=1949}}</ref>

===ICD-6 (1948)===
In 1948, the newly formed [[World Health Organization]] took over the maintenance of the ILCD. They greatly expanded it, included non-fatal conditions for the first time, and renamed it the ''[[International Statistical Classification of Diseases]]'' (ICD). The foreword to the DSM-I states the ICD-6 "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature."<ref name=":8" />

== Early versions (20th century) ==

===DSM-I (1952)===
The APA Committee on Nomenclature and Statistics was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the ''Standard''{{'}}s nomenclature, and the VA system's modifications of the ''Standard'' to approximately 10% of APA members. 46% of members replied, with 93% approving the changes. After some further revisions, the ''Diagnostic and Statistical Manual of Mental Disorders'' was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical.<ref name="Houts2000"/> The manual was 130 pages long and listed 106 mental disorders.<ref>{{cite journal | vauthors = Grob GN | title = Origins of DSM-I: a study in appearance and reality | journal = The American Journal of Psychiatry | volume = 148 | issue = 4 | pages = 421–431 | date = April 1991 | pmid = 2006685 | doi = 10.1176/ajp.148.4.421 }}</ref> These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, [[egodystonic]]).<ref name="Oldham">{{cite journal| vauthors = Oldham JM |title=Personality Disorders|journal=FOCUS|year=2005|volume=3|issue=3 |pages=372–382 |doi=10.1176/foc.3.3.372 }}</ref>

The foreword to this edition describes itself as being a continuation of the ''Statistical Manual for the Use of Hospitals of Mental Diseases.<ref name=":8" />'' Each item was given an ICD-6 equivalent code, where applicable.
[[File:Statistical card for use in hospitals for mental illness.jpg|thumb]]
The DSM-I centers on three classes of symptoms: psychotic, neurotic, and behavioral.<ref name=":9">{{Cite web |date=1952 |title=Diagnostic and Statistical Manual |url=http://www.turkpsikiyatri.org/arsiv/dsm-1952.pdf |access-date=April 25, 2023 |website=American Psychiatric Association |publisher=The Committee on Nomenclature and Statistics}}</ref>  Within each class of mental disorder, classifying information is provided to differentiate conditions with similar symptoms.  Under each broad class of disorder (e.g. "Psychoneurotic Disorders" or "Personality Disorders"), all possible diagnoses are listed, generally from least to most severe.<ref name=":9" /> The 1952 DSM version also includes sections detailing how to record patients' disorders along with their demographic details.<ref name=":9" />  The form includes information like a patient's area of residence, admission status, discharge date/condition, and severity of disorder.<ref name=":9" />  See Figure 1. for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information.<ref name=":9" />

Furthermore, the APA [[Homosexuality in the DSM|listed homosexuality in the DSM]] as a [[Antisocial personality disorder|sociopathic]] personality disturbance. ''[[Homosexuality: A Psychoanalytic Study of Male Homosexuals]]'', a large-scale 1962 study of homosexuality by [[Irving Bieber]] and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession.<ref name=":0">{{Cite book| vauthors = Edsall NC |title=Toward Stonewall: Homosexuality and Society in the Modern Western World|publisher=University of Virginia Press|year=2003}}</ref> In 1956, however, the psychologist [[Evelyn Hooker]] performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference.<ref name=":0" /> Her study stunned the medical community and made her a heroine to many gay men and lesbians,<ref>{{Cite book | vauthors = Marcus E |title=Making Gay History |publisher=Harper Collins |year=2009 |location=Print |pages=58–59}}</ref> but homosexuality remained in the DSM until May 1974.<ref>{{cite book|chapter-url=https://books.google.com/books?id=drBejRLWkHkC&pg=PA76 |chapter=The Transformation of Mental Disorders in the 1980s: The DSM-III, Managed Care, and "Cosmetic Psychopharmacology" |page=76 |title=Medicating Children: ADHD and Pediatric Mental Health | vauthors = Mayes R, Bagwell C, Erkulwater JL |publisher=Harvard University Press |date= 2009 |access-date=2013-12-03 |isbn=978-0-674-03163-0 }}</ref>

===DSM-II (1968)===
In the 1960s, there were many challenges to the concept of [[mental illness]] itself. These challenges came from psychiatrists like [[Thomas Szasz]], who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as [[Erving Goffman]], who said mental illness was another example of how society labels and controls non-conformists; from [[behavioural psychologist]]s who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder.

The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "[[neurosis]]" was retained. Both the DSM-I and the DSM-II reflected the predominant [[psychodynamic]] psychiatry,<ref name = "Revolution">{{cite journal | vauthors = Mayes R, Horwitz AV | title = DSM-III and the revolution in the classification of mental illness | journal = Journal of the History of the Behavioral Sciences | volume = 41 | issue = 3 | pages = 249–267 | year = 2005 | pmid = 15981242 | doi = 10.1002/jhbs.20103 }}</ref> although both manuals also included biological perspectives and concepts from [[Emil Kraepelin|Kraepelin]]'s system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and [[psychosis]] (roughly, anxiety/depression broadly in touch with reality, as opposed to [[hallucinations]] or [[delusions]] disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality.<ref name="Transformation">{{cite journal | vauthors = Wilson M | title = DSM-III and the transformation of American psychiatry: a history | journal = The American Journal of Psychiatry | volume = 150 | issue = 3 | pages = 399–410 | date = March 1993 | pmid = 8434655 | doi = 10.1176/ajp.150.3.399 }}</ref> The idea that personality disorders did not involve emotional distress was discarded.<ref name=Oldham/>

A study published in ''Science'' in 1973, the [[Rosenhan experiment]], received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis.<ref name="Kirk & Kutchins"/>
An influential 1974 paper by [[Robert Spitzer (psychiatrist)|Robert Spitzer]] and [[Joseph L. Fleiss]] demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool.<ref name=SpitzerFleiss1974>{{cite journal | vauthors = Spitzer RL, Fleiss JL | title = A re-analysis of the reliability of psychiatric diagnosis | journal = The British Journal of Psychiatry | volume = 125 | pages = 341–347 | date = October 1974 | issue = 587 | pmid = 4425771 | doi = 10.1192/bjp.125.4.341 }}</ref> Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and [[schizophrenia]] and is poor for the remaining categories".<ref name="Kirk & Kutchins">{{cite journal |last1=Kirk |first1=Stuart A. |last2=Kutchins |first2=Herb |title=The Myth of the Reliability of DSM |journal=The Journal of Mind and Behavior |date=1994 |volume=15 |issue=1/2 |pages=71–86 |jstor=43853633 }}</ref>

====Seventh printing of the DSM-II (1974)====
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by [[gay rights]] activists against the APA began in 1970, when the organization held its convention in [[San Francisco]]. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist [[Frank Kameny]] worked with the [[Gay Liberation Front]] collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."<ref>Bayer, Ronald (1981). [https://archive.org/details/homosexualityame00bayerich ''Homosexuality and American Psychiatry: The Politics of Diagnosis'']  Princeton University Press p. 105.</ref>

This gay activism occurred in the context of a broader [[anti-psychiatry]] movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists.<ref>{{cite journal | vauthors = McCommon B | title = Antipsychiatry and the gay rights movement | journal = Psychiatric Services | volume = 57 | issue = 12 | pages = 1809; author reply 1809–1809; author reply 1810 | date = December 2006 | pmid = 17158503 | doi = 10.1176/appi.ps.57.12.1809 }}</ref><ref>{{cite journal | vauthors = Rissmiller DJ, Rissmiller J | year = 2006 | title = Letter in reply | journal = Psychiatr Serv | volume = 57 | issue = 12| pages = 1809–1810 | doi = 10.1176/appi.ps.57.12.1809-a }}</ref>

Taking into account data from researchers such as [[Alfred Kinsey]] and [[Evelyn Hooker]], the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder.{{efn|Determining the correct DSM-II printing where the change occurred can be confusing because the American Psychiatric Association publication that announced the change is titled, in part, "Proposed change in DSM-II, 6th printing, page 44". However, a notice in that publication indicates that "the change appears on page 44 of this, the seventh printing."}} After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".<ref>{{cite journal | vauthors = Spitzer RL | title = The diagnostic status of homosexuality in DSM-III: a reformulation of the issues | journal = The American Journal of Psychiatry | volume = 138 | issue = 2 | pages = 210–215 | date = February 1981 | pmid = 7457641 | doi = 10.1176/ajp.138.2.210 }}</ref><ref>[https://pages.uoregon.edu/eherman/teaching/texts/DSM-II_Homosexuality_Revision.pdf Homosexuality and sexuality orientation disturbance: Proposed change in DSM-II, 6th printing, page 44. Position Statement (Retired)]. APA Document Reference No. 730008. Arlington, VA: American Psychiatric Association, 1973. ("Since the last printing of this Manual, the trustees of the American Psychiatric Association, in December 1973, voted to eliminate Homosexuality per se as a mental disorder and to substitute therefor a new category titled Sexual Orientation Disturbance. The change appears on page 44 of this, the seventh printing.").</ref>

===DSM-III (1980)===
The emergence of DSM-III represented a "quantum leap" in terms of the scale and reach of the manual.<ref name="Coolidge and Segal 1998">{{cite journal |last1=Coolidge |first1=Frederick L. |last2=Segal |first2=Daniel L. |title=Evolution of personality disorder diagnosis in the Diagnostic and statistical manual of mental disorders |journal=Clinical Psychology Review |date=August 1998 |volume=18 |issue=5 |pages=585–599 |doi=10.1016/s0272-7358(98)00002-6 |pmid=9740979 }}</ref>  In 1974, the decision to revise the DSM was made, and psychiatrist [[Robert Spitzer (psychiatrist)|Robert Spitzer]] was selected as chair of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the [[International Classification of Diseases]] (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members.<ref>{{cite magazine | vauthors = Spiegel A |url= http://www.newyorker.com/fact/content/articles/050103fa_fact?050103fa_fact |title=The Dictionary of Disorder: How one man revolutionized psychiatry |date=3 January 2005 |magazine=The New Yorker |archive-url=https://web.archive.org/web/20061212180933/http://www.newyorker.com/fact/content/articles/050103fa_fact?050103fa_fact |archive-date=12 December 2006 }}</ref> One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous [[Rosenhan experiment]]. There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States.<ref name="PMID5774702">{{cite journal | vauthors = Cooper JE, Kendell RE, Gurland BJ, Sartorius N, Farkas T | title = Cross-national study of diagnosis of the mental disorders: some results from the first comparative investigation | journal = The American Journal of Psychiatry | volume = 10 Suppl | issue = 10 Suppl | pages = 21–29 | date = April 1969 | pmid = 5774702 | doi = 10.1176/ajp.125.10s.21 }}</ref> The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process.

The criteria adopted for many of the mental disorders were influenced by the [[Research Diagnostic Criteria]] (RDC) and [[Feighner Criteria]], which had just been developed by a group of research-orientated psychiatrists based primarily at [[Washington University School of Medicine]] and the [[New York State Psychiatric Institute]]. However, the influence of clinical psychiatrists, themselves often working with psychoanalytic ideas, were still strong.<ref name="Decker (2013)"/> Other criteria, and potential new categories of disorder, were established by debate, argument and consensus  during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "[[Emil Kraepelin|neo-Kraepelinian]]"). The [[psychodynamic]] view was marginalised, although still influential, in favor of a [[regulatory]] or [[legislative]] model that emphasised observable symptoms.<ref name="Decker (2013)">{{cite book |last1=Decker |first1=Hannah S. |title=The making of DSM-III®: a diagnostic manual's conquest of American psychiatry |date=2013 |publisher=Oxford University Press |location=Oxford New York Auckland |isbn=978-0-19-538223-5}}</ref> A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple [[medical diagnosis|diagnosis]]. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome."<ref name="Revolution"/> [[Personality disorders]] were placed on axis II along with "mental retardation".<ref name=Oldham/>

The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light.<ref>{{cite book| vauthors = Lane C | title = Shyness: How Normal Behavior Became a Sickness| year = 2007| publisher = Yale University Press| isbn = 978-0-300-12446-0| page = [https://archive.org/details/shynesshownormal00lane/page/263 263]| url-access = registration| url = https://archive.org/details/shynesshownormal00lane/page/263}}</ref> Field trials sponsored by the U.S. [[National Institute of Mental Health]] (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of [[psychoanalytic]] theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of [[Ego-dystonic sexual orientation|ego-dystonic homosexuality]] replaced the DSM-II category of "sexual orientation disturbance". The [[Gender dysphoria in children|gender identity disorder in children]] (GIDC) diagnosis was introduced in the DSM-III; prior to the DSM-III's publication in 1980, there was no diagnostic criteria for [[gender dysphoria]].<ref>{{cite book | publisher = American Psychiatric Association | date = 1980 | title = Diagnostic and statistical manual of mental disorders | edition = 3rd | location = Washington, DC }}</ref><ref name="Need">{{cite journal |last1=Butler |first1=Catherine |last2=Hutchinson |first2=Anna |title=Debate: The pressing need for research and services for gender desisters/detransitioners |journal=Child and Adolescent Mental Health |date=February 2020 |volume=25 |issue=1 |pages=45–47 |doi=10.1111/camh.12361 |pmid=32285632 |url=https://researchportal.bath.ac.uk/en/publications/240156cb-5b85-42dd-83a3-d1cf475bc1bd }}</ref>

Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry.<ref name="Revolution"/><ref name="Transformation"/>

When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by [[Stuart A. Kirk]]:

{{blockquote|Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalizability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator ...<ref name="Kirk & Kutchins"/>}}

===DSM-III-R (1987)===
In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as [[Premenstrual dysphoric disorder|Premenstrual Dysphoric Disorder]] and [[Self-defeating personality disorder|Masochistic Personality Disorder]], were considered and discarded. (Premenstrual Dysphoric Disorder was later reincorporated in the DSM-5, published in 2013).<ref>American Psychological Association. (2013). ''Highlights of Changes from DSM-IV-TR to DSM-5'' [Fact sheet]. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf</ref> "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation."<ref name="Revolution"/><ref>{{cite web | vauthors = Spiegel A, Glass I |date=18 January 2002 |url=http://www.thisamericanlife.org/radio-archives/episode/204/81-words |title=81 Words |website=This American Life |location=Chicago |publisher=WBEZ Chicago Public Radio }}</ref> Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer" [page&nbsp;xxiii].<ref name=Oldham/>

===DSM-IV (1994)===
In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by [[Allen Frances]] and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multi-center field trials relating diagnoses to clinical practice.<ref>{{cite book |vauthors=Frances A, Mack AH, Ross R, First MB |date=2000 |orig-date=1995 |chapter-url=http://www.acnp.org/G4/GN401000082/CH081.html |chapter=The DSM-IV Classification and Psychopharmacology |title=Psychopharmacology: The Fourth Generation of Progress |publisher=American College of Neuropsychopharmacology |veditors=Bloom FE, Kupfer DJ |access-date=2007-02-28 |archive-date=2007-03-23 |archive-url=https://web.archive.org/web/20070323150804/http://www.acnp.org/G4/GN401000082/CH081.html }}</ref><ref>{{cite journal | vauthors = Shaffer D | title = A participant's observations: preparing DSM-IV | journal = Canadian Journal of Psychiatry | volume = 41 | issue = 6 | pages = 325–329 | date = August 1996 | pmid = 8862851 | doi = 10.1177/070674379604100602 }}</ref> A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix.<ref name=Oldham/>

==== DSM-IV definitions ====
{{See also|DSM-IV codes}}

The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom".<ref>{{cite web | vauthors = Maisel ER | date = 23 July 2013 | title = The New Definition of a Mental Disorder | work = Psychology Today |url = https://www.psychologytoday.com/us/blog/rethinking-mental-health/201307/the-new-definition-mental-disorder }}</ref> It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder."<ref name="pmid20624327">{{cite journal | vauthors = Stein DJ, Phillips KA, Bolton D, Fulford KW, Sadler JZ, Kendler KS | title = What is a mental/psychiatric disorder? From DSM-IV to DSM-V | journal = Psychological Medicine | volume = 40 | issue = 11 | pages = 1759–1765 | date = November 2010 | pmid = 20624327 | pmc = 3101504 | doi = 10.1017/S0033291709992261 }}</ref>

==== DSM-IV categorization ====
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance.<ref>{{cite journal | vauthors = Maser JD, Patterson T | title = Spectrum and nosology: implications for DSM-V | journal = The Psychiatric Clinics of North America | volume = 25 | issue = 4 | pages = 855–885 | date = December 2002 | pmid = 12462864 | doi = 10.1016/s0193-953x(02)00022-9 }}</ref> Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from [[tic disorder]]s and several of the [[paraphilia]]s due to their [[egosyntonic]] nature. Each category of disorder has a numeric code taken from the [[ICD coding system]], used for health service (including insurance) administrative purposes.

==== {{anchor|DSM-IV-TR multi-axial system}}DSM-IV multi-axial system ====
The DSM-IV was organized into a five-part axial system:<ref>{{cite book |title=DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet] |date=June 2016 |publisher=Substance Abuse and Mental Health Services Administration (US) |chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK519711/ |chapter=DSM-IV to DSM-5 Changes: Overview }}</ref>
{{olist|list_style_type=upper-roman
|Clinical disorders, or any mental condition outside Axis II
|Personality disorders and what was referred to in DSM editions prior to DSM-5 as "mental retardation"
|Medical conditions that could impact a person's disorder or treatment of a disorder
|Psychosocial and environmental factors affecting the person
|Global assessment of functioning (GAF), which was a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life
}}

==== DSM-IV sourcebooks ====
The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials.<ref>{{cite book|title=DSM-IV Sourcebook|date=1994|publisher=American Psychiatric Association|isbn=978-0-89042-065-2|volume=1|location=Washington, DC|url-access=registration|url=https://archive.org/details/dsmivsourcebook0000unse}}</ref><ref>{{cite book|title=DSM-IV Sourcebook|date=1996|publisher=American Psychiatric Association|isbn=978-0-89042-069-0|volume=2|location=Washington, DC|url-access=registration|url=https://archive.org/details/dsmivsourcebook0000unse}}</ref><ref>{{cite book|title=DSM-IV Sourcebook|date=1997|publisher=American Psychiatric Association|isbn=978-0-89042-073-7|volume=3|location=Washington, DC|url-access=registration|url=https://archive.org/details/dsmivsourcebook0000unse}}</ref><ref>{{cite journal |last1=Sadock |first1=Benjamin J. |title=DSM-IV Sourcebook, vol. 4 |journal=American Journal of Psychiatry |date=October 1999 |volume=156 |issue=10 |page=1655 |doi=10.1176/ajp.156.10.1655 }}</ref> The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification.<ref name="Poland01vol1">{{cite book | vauthors = Poland JS | date = 2001 | url = http://mentalhelp.net/books/books.php?type=de&id=557 | title = Review of Volume 1 of DSM-IV sourcebook | archive-url =https://web.archive.org/web/20050501182254/http://mentalhelp.net/books/books.php?type=de&id=557| archive-date = May 1, 2005}}</ref><ref name="Poland01vol2">{{cite book | vauthors = Poland JS | date = 2001 | url = http://mentalhelp.net/poc/view_doc.php?id=996&type=book&cn=74 | title = Review of vol 2 of DSM-IV sourcebook | archive-url = https://web.archive.org/web/20070927005022/http://mentalhelp.net/poc/view_doc.php?id=996&type=book&cn=74| archive-date= September 27, 2007}}</ref>

===DSM-IV-TR (2000)===
A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but nine diagnoses.<ref>{{cite web | title = DSM-IV replaced by DSM-IV-TR: changes in diagnostic criteria | work = Behavenet |url=https://behavenet.com/dsm-iv-replaced-dsm-iv-tr-changes-diagnostic-criteria}}</ref> The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. An editorial change in DSM-IV's description of PDDNOS had had an unintended effect on the definition of this disorder, which was revised in DSM-IV-TR.<ref>{{Cite journal |last=First |first=Michael B. |last2=Pincus |first2=Harold Alan |date=March 2002 |title=The DSM-IV Text Revision: Rationale and Potential Impact on Clinical Practice |url=https://psychiatryonline.org/doi/10.1176/appi.ps.53.3.288 |journal=Psychiatric Services |volume=53 |issue=3 |pages=288–292 |doi=10.1176/appi.ps.53.3.288 |issn=1075-2730|url-access=subscription }}</ref> The text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, and course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM.<ref name="pmid11875221">{{cite journal | vauthors = First MB, Pincus HA | title = The DSM-IV Text Revision: rationale and potential impact on clinical practice | journal = Psychiatric Services | volume = 53 | issue = 3 | pages = 288–292 | date = March 2002 | pmid = 11875221 | doi = 10.1176/appi.ps.53.3.288 }}</ref>

==DSM-5 (2013)==
{{Main|DSM-5}}

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the [[DSM-5]], was approved by the Board of Trustees of the APA on December 1, 2012.<ref>{{cite news | vauthors = Cassels C |date=2 December 2012 |url=http://www.medscape.com/viewarticle/775496 |title=DSM-5 Gets APA's Official Stamp of Approval |publisher=WebMD, LLC |website=Medscape |access-date=2012-12-05}}</ref> Published on May 18, 2013,<ref>{{cite web|title=Explainer: what is the DSM?|url=http://theconversation.com/explainer-what-is-the-dsm-14127|work=The Conversation Australia|publisher=The Conversation Media Group|access-date=2013-05-21| vauthors = Kinderman P |date=20 May 2013}}</ref> the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases.<ref>{{cite news|title=Books blast new version of psychiatry's bible, the DSM|url=https://www.usatoday.com/story/news/nation/2013/05/12/dsm-psychiatry-mental-disorders/2150819/|access-date=2013-05-21|newspaper=USA Today|date=12 May 2013| vauthors = Jayson S }}</ref> The DSM-5 is the first major edition of the manual in 20 years.<ref>{{cite news|title=DSM-5 Changes: What Parents Need To Know About The First Major Revision In Nearly 20 Years|url=http://www.huffingtonpost.com/2013/05/20/dsm5-changes-what-parents-need-to-know_n_3294413.html|access-date=2013-05-21|newspaper=The Huffington Post|date=20 May 2013| vauthors = Pearson C }}</ref> DSM-5, and the abbreviations for all previous editions, are [[Trademark#Registration|registered trademarks]] owned by the American Psychiatric Association.<ref name="concept&evolution" /><ref name="titleTrademark''' Electronic Search System (TESS)">{{cite web |title=Trademark Electronic Search System (TESS) |url=http://tess2.uspto.gov/ |access-date=2010-02-03}}</ref>

A significant change in the fifth edition is the deletion of the subtypes of [[schizophrenia]]: [[paranoid schizophrenia|paranoid]], [[disorganized schizophrenia|disorganized]], [[catatonic schizophrenia|catatonic]], [[undifferentiated schizophrenia|undifferentiated]], and [[residual schizophrenia|residual]].<ref>{{cite web|title=Highlights of Changes from DSM-IV-TR to DSM-5 |website=American Psychiatric Association |date=17 May 2013 |url=http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/Changes-from-DSM-IV-TR--to-DSM-5.pdf |access-date=2015-01-04 |archive-url=https://web.archive.org/web/20150226050453/http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/Changes-from-DSM-IV-TR--to-DSM-5.pdf |archive-date=2015-02-26 }}</ref> The deletion of the subsets of [[Autism spectrum|autistic spectrum disorder]]{{snd}}namely, [[Asperger's syndrome]], [[classic autism]], [[Rett syndrome]], [[childhood disintegrative disorder]] and [[pervasive developmental disorder not otherwise specified]]{{snd}}was also implemented, with specifiers regarding intensity: mild, moderate, and severe.

Severity is based on social communication impairments and restricted, repetitive patterns of behavior, with three levels:

# requiring support
# requiring substantial support
# requiring very substantial support

During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.<ref>{{Cite web|url=https://www.psychiatry.org/psychiatrists/practice/dsm|title=DSM-5|website=psychiatry.org|access-date=2019-08-29}}</ref>

The [[National Board of Medical Examiners]] (NBME), which is responsible for creating and publishing board exams for medical students around the United States, conforms to the use of DSM-5 criteria.<ref>{{cite journal |title=Update: Exams to Transition to DSM-5 |journal=Psychiatric News |date=21 November 2014 |volume=49 |issue=22 |page=1 |doi=10.1176/appi.pn.2014.10a19 }}</ref>

===Future revisions and updates===
After the release of the fifth edition, the APA communicated that they intended to add subsequent revisions more often, to keep up with research in the field.<ref>{{Cite web|url=https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions|title=DSM-5 FAQ|website=psychiatry.org|access-date=2019-08-29}}</ref> It is notable that DSM-5 uses [[Arabic numerals|Arabic]] rather than [[Roman numerals]]. Beginning with DSM-5, the APA planned to use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2){{efn|However, this planned change was not adopted for the initial revision of the DSM-5, which is named DSM-5-TR, in accordance with past convention.}} and whole numbers for new editions (e.g., DSM-5, DSM-6),<ref>{{cite press release | vauthors = Harold E, Valora J |title=APA Modifies ''DSM'' Naming Convention to Reflect Publication Changes |location=Arlington, VA |publisher=American Psychiatric Association |date=9 March 2010 |url=http://psych.org/MainMenu/Newsroom/NewsReleases/2010-News-Releases/DSM-Name-Change.aspx |format=PDF |archive-url=https://web.archive.org/web/20100613144808/http://psych.org/MainMenu/Newsroom/NewsReleases/2010-News-Releases/DSM-Name-Change.aspx |archive-date=13 June 2010 |quote=Beginning with the upcoming fifth edition, new versions of the ''Diagnostic and Statistical Manual of Mental Disorders (DSM)'' will be identified with Arabic rather than Roman numerals, marking a change in how future updates will be created, ... Incremental updates will be identified with decimals, i.e. ''DSM-5.1'', ''DSM-5.2'', etc., until a new edition is required.}}</ref> similar to the scheme used for [[software versioning]].

=== DSM-5-TR (2022) ===
{{Main|DSM-5-TR}}
A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and [[ICD-10-CM]] codes.<ref name=":3">{{Cite web |title=Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR™) |url=https://www.appi.org/products/dsm |website=American Psychiatric Association |access-date=April 18, 2022}}</ref> The diagnostic criteria for [[avoidant/restrictive food intake disorder]] was changed,<ref name=":5">{{Cite journal |last1=Appelbaum |first1=Paul S. |last2=Leibenluft |first2=Ellen |author-link2=Ellen Leibenluft |last3=Kendler |first3=Kenneth S. |date=2021-11-01 |title=Iterative Revision of the ''DSM'': An Interim Report From the ''DSM-5'' Steering Committee |journal=Psychiatric Services |volume=72 |issue=11 |pages=1348–1349 |doi=10.1176/appi.ps.202100013 |pmid=33882702 }}</ref> along with adding entries for [[prolonged grief disorder]], [[Unspecified Mood Disorder|unspecified mood disorder]] and [[Stimulant-Induced Mild Neurocognitive Disorder|stimulant-induced mild neurocognitive disorder]].<ref name=":6">{{Cite journal |last1=First |first1=Michael B. |last2=Yousif |first2=Lamyaa H. |last3=Clarke |first3=Diana E. |last4=Wang |first4=Philip S. |last5=Gogtay |first5=Nitin |last6=Appelbaum |first6=Paul S. |date=2022-05-07 |title=DSM-5-TR: overview of what's new and what's changed |journal=World Psychiatry |volume=21 |issue=2 |pages=218–219 |doi=10.1002/wps.20989 |pmid=35524596 |pmc=9077590 }}</ref><ref>{{Cite news |date=2022-09-08 |title=Prolonged grief disorder recognized as official diagnosis. Here's what to know about chronic mourning |newspaper=[[The Washington Post]] |url=https://www.washingtonpost.com/lifestyle/2021/10/21/prolonged-grief-disorder-diagnosis-dsm-5/ }}</ref> Prolonged grief disorder, which had been present in the ICD-11, had criteria agreed upon by consensus in a one day in-person workshop sponsored by the APA.<ref name=":5" /> A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD-11 could be explained by the DSM-5-TR criteria requiring symptoms persist for 12 months, and the ICD-11 requiring only 6 months.<ref>{{Cite journal |date=2022 |title=Supplemental Material for Same Name, Same Content? Evaluation of DSM-5-TR and ICD-11 Prolonged Grief Criteria |journal=Journal of Consulting and Clinical Psychology |doi=10.1037/ccp0000720.supp }}</ref>

Three review groups for sex and gender, culture and suicide, along with an "ethnoracial equity and inclusion work group" were involved in the creation of the DSM-5-TR which led to additional sections for each mental disorder discussing sex and gender, racial and cultural variations, and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self-injury for mental disorders.<ref name=":6" /><ref name=":5" />

Other changed disorders included:<ref name=":4">{{Cite web |title=Updates to DSM-5 Criteria & Text |url=https://www.psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm/updates-to-dsm-5-criteria-text |access-date=April 18, 2022 |website=American Psychiatric Association}}</ref>
* [[Autism spectrum disorder]]
* [[Bipolar I disorder]], [[Bipolar II disorder]], and related [[bipolar disorder]]s
* [[Obsessive–compulsive personality disorder]] in the [[alternative DSM-5 model for personality disorders]]
* [[Major depressive episode|Depressive episodes]] with short-duration [[hypomania]]
* [[Intellectual developmental disorder]]
* [[Delusional disorder]]
* [[Disruptive mood dysregulation disorder]]
* [[Brief psychotic disorder]]

==DSM Library==
The APA have supplemented the DSM with supporting works, collectively forming the "DSM Library."<ref name=":7">{{Cite web |title=Psychiatry Online |url=https://dsm.psychiatryonline.org/ |access-date=2022-11-07 |website=DSM Library }}</ref> As of 2022, the other books in the library are "DSM-5 Handbook of Differential Diagnosis", "DSM-5 Clinical Cases", "DSM-5 Handbook on the Cultural Formulation Interview" and "Guía De Consulta De Los Criterios Diagnósticos Del DSM-5".<ref name=":7" />

==Criticisms==
Many criticisms have been leveled against the DSM and its usefulness as a diagnostic manual.

===Reliability and validity===
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with [[Inter-rater reliability|diagnostic reliability]]{{snd}}the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Neither the issue of reliability or validity was settled.<ref>{{cite web | vauthors = Ghaemi SN, Knoll IV JL, Pearlman T |date=14 October 2013 |title=Why DSM-III, IV, and 5 are Unscientific |website=Psychiatric Times: Couch in Crisis Blog |url=https://www.psychiatrictimes.com/view/why-dsm-iii-iv-and-5-are-unscientific }}</ref><ref>{{cite journal | vauthors = Khoury B, Langer EJ, Pagnini F | title = The DSM: mindful science or mindless power? A critical review | journal = Frontiers in Psychology | volume = 5 | page = 602 | date = 2014 | pmid = 24987385 | pmc = 4060802 | doi = 10.3389/fpsyg.2014.00602 | doi-access = free }}</ref>

In 2013, shortly before the publication of DSM-5, the director of the [[National Institute of Mental Health]] (NIMH), [[Thomas R. Insel]], declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity.<ref>{{cite web |vauthors=Insel T |date=29 April 2013 |title=Transforming Diagnosis |url=http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml |website=Director's Blog |publisher=National Institute of Mental Health |access-date=2013-09-02 |archive-date=2013-05-29 |archive-url=https://web.archive.org/web/20130529152509/http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml }}</ref> Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response."<ref>{{Cite web|url=https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml|title= Transforming Diagnosis|website=NIMH |first1=Thomas |last1=Insel |date=April 29, 2013 |access-date=2019-02-25|archive-date=2019-02-23|archive-url=https://web.archive.org/web/20190223235629/https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml}}</ref><ref>{{cite magazine| last1= Lane |first1=C |title=The NIMH Withdraws Support for DSM-5|url=http://www.psychologytoday.com/blog/side-effects/201305/the-nimh-withdraws-support-dsm-5 |date=May 4, 2013 |magazine=Psychology Today |url-status=live |archive-url= https://archive.today/20150703003356/https://www.psychologytoday.com/blog/side-effects/201305/the-nimh-withdraws-support-dsm-5 |archive-date= 3 July 2015  }}</ref>

Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of [[major depressive disorder]], a common mental illness, had a poor reliability [[Cohen's kappa|kappa]] statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.<ref>{{cite journal | vauthors = Freedman R, Lewis DA, Michels R, Pine DS, Schultz SK, Tamminga CA, Gabbard GO, Gau SS, Javitt DC, Oquendo MA, Shrout PE, Vieta E, Yager J | display-authors = 6 | title = The initial field trials of DSM-5: new blooms and old thorns |doi-access=free | journal = The American Journal of Psychiatry | volume = 170 | issue = 1 | pages = 1–5 | date = January 2013 | pmid = 23288382 | doi = 10.1176/appi.ajp.2012.12091189 }}</ref>

===Diagnosis based on superficial symptoms===
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect these disorders based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages.<ref>{{cite journal | vauthors = McHugh PR | title = Striving for coherence: psychiatry's efforts over classification | journal = JAMA | volume = 293 | issue = 20 | pages = 2526–2528 | date = May 2005 | pmid = 15914753 | doi = 10.1001/jama.293.20.2526 }}</ref> The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. Proponents argue this absence of explanatory classification is necessary, but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria.<ref name="concept&evolution" /><ref>Fadul. J. A. (2014) Diagnostic and Statistical Manual of Mental Disorders. In ''Encyclopedia of Theory & Practice in Psychopathology & Counseling.'' (p. 143). Raleigh, NC: Lulu Press.</ref> As [[DSM-III]] chief architect [[Robert Spitzer (psychiatrist)|Robert Spitzer]] and [[DSM-IV]] editor Michael First outlined in 2005, "little progress has been made toward understanding the [[pathophysiology|pathophysiological]] processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."<ref>{{cite journal | vauthors = Davis JB | title = Classification of psychiatric disorders | journal = Canadian Medical Association Journal | volume = 122| issue = 7| date = April 1980 | page = 750 | pmid = 20313414 | pmc = 1801862| doi = }}</ref>

While there is generally a lack of consensus on underlying causation for most psychiatric disorders, some proponents of specific [[psychopathology|psychopathological]] paradigms have faulted the DSM for failing to incorporate evidence from other disciplines. For instance, [[evolutionary psychology]] distinguishes between genuine cognitive malfunctions and malfunctions due to psychological [[adaptations]] (that is learned behaviors may be adaptive in one context but maladaptive in another). However, this distinction is one that is challenged within general psychology.<ref>{{cite web | vauthors = Murphy D, Stich S |date=16 December 1998 |url=http://ruccs.rutgers.edu/ArchiveFolder/Research%20Group/Publications/Mad/Madhouse.html |title=Darwin in the Madhouse: Evolutionary Psychology and the Classification of Mental Disorders |access-date=2013-12-03 |archive-url=https://web.archive.org/web/20131205122638/http://ruccs.rutgers.edu/ArchiveFolder/Research%20Group/Publications/Mad/Madhouse.html |archive-date=5 December 2013 }}</ref><ref>{{cite journal | vauthors = Cosmides L, Tooby J | title = Toward an evolutionary taxonomy of treatable conditions | journal = Journal of Abnormal Psychology | volume = 108 | issue = 3 | pages = 453–464 | date = August 1999 | pmid = 10466269 | doi = 10.1037/0021-843x.108.3.453 }}</ref><ref>{{cite journal | vauthors = McNally RJ | title = On Wakefield's harmful dysfunction analysis of mental disorder | journal = Behaviour Research and Therapy | volume = 39 | issue = 3 | pages = 309–314 | date = March 2001 | pmid = 11227812 | doi = 10.1016/S0005-7967(00)00068-1 }}</ref>

There is also criticism of the strong [[Operationalization|operationalist]] viewpoint of the DSM. The DSM relies on [[operational definition]]s, which means that intuitive concepts like [[Depression (mood)|depression]] are defined by specific measurable criteria (observable behavior, specific timelines). Some have argued that instead of replacing metaphysical terms like "desire" or "purpose" the DSM chose to legitimize them by giving them operational definitions. However, this may have served only to provide a "reassurance fetish" for mainstream methodological practice, rather than representing a substantial and meaningful alteration of mainstream psychiatric practice.<ref>{{cite journal | vauthors = Hands DW |date=December 2004 |title=On Operationalisms and Economics |journal=Journal of Economic Issues |volume=38 |issue=4 |pages=953–968 |doi=10.1080/00213624.2004.11506751 }}</ref>

A central problem with the use of superficial symptoms is that psychiatry deals with the [[phenomenology (psychology)|phenomena]] of [[consciousness]], which adds much more complexity than the [[somatic symptom disorder|somatic]] [[symptom]]s and [[medical sign|signs]] used by most of medicine. A 2013 review published in the ''[[European Archives of Psychiatry and Clinical Neuroscience]]'' gives the example of the problem of superficial characterization of psychiatric signs and symptoms. If a patient says they "feel depressed, sad, or down" there are actually a wide variety of underlying experiences they could be referencing: "not only [[depression (mood)|depressed mood]] but also, for instance, [[irritability|irritation]], [[anger]], loss of meaning, varieties of [[fatigue (medical)|fatigue]], [[ambivalence]], [[rumination (psychology)|ruminations]] of different kinds, hyper-reflectivity, thought pressure, psychological [[anxiety]], varieties of [[depersonalization]], and even [[auditory hallucination|voices]] with negative content, and so forth." This criticism is especially pertinent to the [[structured interview]], as simple "yes or no" questions may not be specific enough to truly confirm or deny the [[diagnostic criteria|diagnostic criterion]] at issue. That is, whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience. There is thus danger in being overconfident in the face value of the answers. The authors of the 2013 review give an example: A [[patient]] who was being administered the [[Structured Clinical Interview for DSM-IV|Structured Clinical Interview for the DSM-IV Axis I Disorders]] denied [[thought insertion]], but during a "conversational, [[phenomenology (psychology)|phenomenological]] interview", a [[semi-structured interview]] tailored to the patient, the same [[patient]] admitted to experiencing [[thought insertion]], along with a [[delusion|delusional elaboration]]. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own [[qualia|experience]] in the rather blunt, implicitly either/or formulation of the structured-interview question", or the [[qualia|experience]] did not "fully articulate itself" until the patient started talking about his experiences.<ref name = nordgaard1>{{cite journal | vauthors = Nordgaard J, Sass LA, Parnas J | title = The psychiatric interview: validity, structure, and subjectivity | journal = European Archives of Psychiatry and Clinical Neuroscience | volume = 263 | issue = 4 | pages = 353–364 | date = June 2013 | pmid = 23001456 | pmc = 3668119 | doi = 10.1007/s00406-012-0366-z | author-link2 = Louis Sass | author-link1 = Julie Nordgaard }}</ref>

===Obscuring root causes===

==== Economic causes ====
The DSM-5 has been criticized for overlooking [[capitalism]]'s interconnectivity with pathology.<ref>{{Cite journal |last=Olivier |first=B |date=2015 |title=Capitalism and suffering |journal=Psychology in Society |volume=48 |pages=1–21 |doi=10.17159/2309-8708/2015/n48a1|doi-access=free }}</ref> One example is the development and treatment of diagnoses: around 69% of psychiatrists involved in the development of the [[DSM-5]] were reported to have financial ties to the [[pharmaceutical industry]].<ref>{{cite journal |last1=Cosgrove |first1=Lisa |last2=Wheeler |first2=Emily E |title=Industry's colonization of psychiatry: Ethical and practical implications of financial conflicts of interest in the DSM-5 |journal=Feminism & Psychology |date=February 2013 |volume=23 |issue=1 |pages=93–106 |doi=10.1177/0959353512467972 }}</ref> These ties situate many care services within the [[Medical–industrial complex|medical-industrial complex]], a framework that prioritizes profit instead of the care of individuals.<ref>{{Cite book |last=Magee |first=Mike |title=Code blue: inside America's medical industrial complex |publisher=[[Atlantic Monthly Press]] |year=2019 |isbn=978-0-8021-4687-8 |edition=1st |location=New York}}</ref> Lane found the [[Medical–industrial complex|medical-industrial complex]] intertwined with setting the parameters to diagnose conditions such as [[social anxiety disorder]].<ref>{{Cite book |last=Lane |first=Christopher |title=Shyness: how normal behavior became a sickness |date=2007 |publisher=Yale University Press |isbn=978-0-300-14317-1 |location=New Haven}}</ref> Other authors have supported similar findings.<ref>{{cite book |last1=Tone |first1=Andrea |title=The Age of Anxiety: A History of America's Turbulent Affair with Tranquilizers |date=2012 |publisher=Basic Books |isbn=978-0-465-02520-6 }}{{pn|date=November 2024}}</ref><ref>{{cite journal |last1=Timler |first1=Kelsey |title=Distorted Thinking or Distorted Realities? The Social Construction of Anxiety for Women in Neoliberal Late-Stage Capitalism |journal=Hypatia |date=2022 |volume=37 |issue=4 |pages=726–742 |doi=10.1017/hyp.2022.60 |doi-access=free }}</ref> Kincaid and Sullivan estimate that the cost of the industry surrounding diagnosis will rise to around six trillion dollars by 2030.<ref>{{cite book |doi=10.7551/mitpress/8942.001.0001 |title=Classifying Psychopathology |date=2014 |isbn=978-0-262-32243-0 |editor-last1=Kincaid |editor-last2=Sullivan |editor-first1=Harold |editor-first2=Jacqueline A. }}</ref>

Scholars differ in the extent of [[capitalism]]'s influence on diagnosis. Davies supports the [[social model of disability]] in explaining that diagnosis at present relies on considering conditions a consequence of a "broken brain."<ref name=":10">{{Cite book |last=Davies |first=James |title=Sedated: How Modern Capitalism Created our Mental Health Crisis |date=March 3, 2022 |publisher=[[Atlantic Books]] |isbn=978-1-78649-987-5 |edition=1st |location=London}}</ref> His wider logic on mental illness in response to societal issues problematizes diagnosis as a tool of the [[Medical–industrial complex#:~:text=December 2022),and services for a profit.|medical-industrial complex]].<ref name=":10" /> His previous book, ''Cracked'', demonstrates the market interactions within the [[Medical–industrial complex#:~:text=December 2022),and services for a profit.|medical-industrial complex]], as diagnosis becomes a source for monetization.<ref>{{Cite book |last=Davies |first=James |title=Cracked: why psychiatry is doing more harm than good |date=2014 |publisher=[[Icon Books|Icon]] |isbn=978-1-84831-654-6 |location=London}}</ref>

Others find that the dependency of patients on their psychiatric care providers makes the industry vulnerable to economic exploitation under [[capitalism]].<ref name=":11">{{Cite journal |last=U'Ren |first=Richard |date=1997 |title=Psychiatry and Capitalism |journal=The Journal of Mind and Behavior |volume=18 |issue=1 |pages=1–11 |jstor=43853806 }}</ref> These individuals argue that diagnosis is manipulated, but not caused, by capitalistic forces.<ref name=":11" /> Academics have critiqued the directness of the association between the [[medical model]], [[capitalism]], and diagnosis, but generally agree that characteristics of the capitalist system contribute to poor [[mental health]].<ref>{{Cite journal |last=Barney |first=Ken |date=1994 |title=Limitations of the Critique of the Medical Model |journal=The Journal of Mind and Behavior |volume=15 |issue=1/2 |pages=19–34 |jstor=43853630 }}</ref>

==== Institutional causes ====
Diagnoses of mental conditions have been used to obscure institutional practices of [[discrimination]].<ref>{{cite journal |last1=Lebowitz |first1=Matthew S. |last2=Ahn |first2=Woo-kyoung |title=Effects of biological explanations for mental disorders on clinicians' empathy |journal=Proceedings of the National Academy of Sciences |date=16 December 2014 |volume=111 |issue=50 |pages=17786–17790 |doi=10.1073/pnas.1414058111 |doi-access=free |pmc=4273344 |pmid=25453068 |bibcode=2014PNAS..11117786L }}</ref> Late nineteenth-century diagnoses of white women with [[hysteria]], for instance, were said to be caused by "overcivilization," shaped by racially discriminatory [[Social Darwinism]].<ref>{{Cite journal |last=Briggs |first=Laura |date=June 2000 |title=The Race of Hysteria: 'Overcivilization' and the 'Savage' Woman in Late Nineteenth-Century Obstetrics and Gynecology |id={{Project MUSE|2437}} |journal=American Quarterly |volume=52 |issue=2 |pages=246–273 |doi=10.1353/aq.2000.0013 |pmid=16858900 }}</ref> Similarly, American physician [[Samuel A. Cartwright|Samuel Cartwright]] coined "[[drapetomania]]" in 1851 as a mental condition which "caused" slaves to escape captivity.<ref>{{Cite book |last=Hogarth |first=Rana A. |title=Medicalizing blackness: making racial difference in the Atlantic world, 1780-1840 |date=2017 |publisher=The University of North Carolina Press |isbn=978-1-4696-3286-5 |location=Chapel Hill}}{{pn|date=November 2024}}</ref> In the present day, Brinkmann finds that "contemporary diagnostic cultures," whereby humans assess their conditions through a psychiatric lens, can "risk losing sight of the larger historical and social forces that affect [their] lives."<ref name=":12">{{Cite book |last=Brinkmann |first=Svend |title=Diagnostic cultures: a cultural approach to the pathologization of modern life |date=2016 |publisher=Routledge, Taylor Francis Group |isbn=978-1-4724-1319-2 |series=Classical and contemporary social theory |location=London; New York}}{{pn|date=November 2024}}</ref> Contemporary diagnostic cultures help explain how diagnosis reflect larger historical biases.<ref name=":12" /><ref name=":13">{{Cite book |last=Metzl |first=Jonathan Michel |title=The protest psychosis: how schizophrenia became a black disease |date=2011 |publisher=Beacon |isbn=978-0-8070-0127-1 |location=Boston, Mass}}{{pn|date=November 2024}}</ref>

Critics have argued that the DSM-5's criteria pathologize a wide range of people with distress or impairment. Chapman et al. discuss the implications for obscuring distress in the [[Imprisonment|incarceration and confinement]] of "intellectually disabled" populations; they argue that "differentiation based on [[Intellectual disability|psychiatric and intellectual disability]]" is arbitrarily set and altered based on [[capitalism]]'s needs for "mobile and free workers."<ref>{{Cite book |title=Disability incarcerated: imprisonment and disability in the United States and Canada |date=2014 |publisher=Palgrave Macmillan |isbn=978-1-137-39323-4 |editor-last=Ben-Moshe |editor-first=Liat |location=New York, NY |editor-last2=Carey |editor-first2=Allison C.}}</ref> Metzl demonstrates that the shifting diagnostic parameters of [[schizophrenia]] became a method for institutionalizing Black men during the [[Civil rights movement|Civil Rights Movement]].<ref name=":13" /> In sum, those who have experienced "domination" or "exploitation" based on an identity trait are more likely to be pathologized through diagnosis.<ref>{{Cite journal |last1=Prins |first1=Seth J. |last2=Bates |first2=Lisa M. |last3=Keyes |first3=Katherine M. |last4=Muntaner |first4=Carles |date=November 1, 2015 |title=Anxious? Depressed? You might be suffering from capitalism: contradictory class locations and the prevalence of depression and anxiety in the USA |journal=Sociology of Health & Illness |volume=37 |issue=8 |pages=1352–1372 |doi=10.1111/1467-9566.12315 |pmc=4609238 |pmid=26385581}}</ref>

===Overdiagnosis===
[[Allen Frances]], an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]."<ref>{{Cite news|url=https://psychcentral.com/blog/overdiagnosis-mental-disorders-and-the-dsm-5/|title=Overdiagnosis, Mental Disorders and the DSM-5|date=2010-07-26|work=World of Psychology|access-date=2018-09-18 }}</ref><ref>{{Cite web|url=https://www.psychologytoday.com/us/blog/dsm5-in-distress/201006/psychiatric-fads-and-overdiagnosis|title=Psychiatric Fads and Overdiagnosis|website=Psychology Today |access-date=2018-09-18}}</ref> Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and [[Autism spectrum|autism spectrum disorder]].<ref>{{cite journal | vauthors = Thomas R, Mitchell GK, Batstra L | title = Attention-deficit/hyperactivity disorder: are we helping or harming? | journal = BMJ | volume = 347 | issue = nov05 1 | article-number = f6172 | date = November 2013 | pmid = 24192646 | doi = 10.1136/bmj.f6172 | url = http://www.bmj.com/cgi/content/short/348/jul01_1/g4377 | url-access = subscription }}</ref><ref name="bruchmuller 2012">{{cite journal | vauthors = Bruchmüller K, Margraf J, Schneider S | title = Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis | journal = Journal of Consulting and Clinical Psychology | volume = 80 | issue = 1 | pages = 128–138 | date = February 2012 | pmid = 22201328 | doi = 10.1037/a0026582 }}</ref><ref>{{cite journal | vauthors = Vande Voort JL, He JP, Jameson ND, Merikangas KR | title = Impact of the DSM-5 attention-deficit/hyperactivity disorder age-of-onset criterion in the US adolescent population | journal = Journal of the American Academy of Child and Adolescent Psychiatry | volume = 53 | issue = 7 | pages = 736–744 | date = July 2014 | pmid = 24954823 | doi = 10.1016/j.jaac.2014.03.005 | pmc = 11503659 }}</ref><ref>{{cite journal | vauthors = Wing L, Potter D | title = The epidemiology of autistic spectrum disorders: is the prevalence rising? | journal = Mental Retardation and Developmental Disabilities Research Reviews | volume = 8 | issue = 3 | pages = 151–161 | date = 2002 | pmid = 12216059 | doi = 10.1002/mrdd.10029 }}</ref> Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by [[heuristic]]s.<ref name="bruchmuller 2012"/>

===Dividing lines===
Despite caveats in the introduction to the DSM, it has long been argued that its [[Classification of mental disorders|system of classification]] makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM [[syndromes]], or between a common DSM syndrome and normality, have failed.<ref name="concept&evolution"/> Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.<ref>{{cite web | vauthors = Spitzer RL, Williams JB, First MB, Gibbon M |title=Biometric Research |website= Psychiatric Institute 2001-2002 |publisher=New York State Psychiatric Institute |url=http://nyspi.org/AR2001/Biometrics.htm |archive-url=https://web.archive.org/web/20030307205740/http://nyspi.org/AR2001/Biometrics.htm |archive-date=7 March 2003 }}</ref><ref>{{cite journal | vauthors = Maser JD, Akiskal HS | title = Spectrum concepts in major mental disorders | journal = The Psychiatric Clinics of North America | volume = 25 | issue = 4 | pages = xi–xiii | date = December 2002 | pmid = 12462854 | doi = 10.1016/S0193-953X(02)00034-5 }}</ref><ref>{{cite journal | vauthors = Krueger RF, Watson D, Barlow DH | title = Introduction to the special section: toward a dimensionally based taxonomy of psychopathology | journal = Journal of Abnormal Psychology | volume = 114 | issue = 4 | pages = 491–493 | date = November 2005 | pmid = 16351372 | pmc = 2242426 | doi = 10.1037/0021-843X.114.4.491 }}</ref>

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations.<ref>{{cite journal | vauthors = Wakefield JC, Schmitz MF, First MB, Horwitz AV | title = Extending the bereavement exclusion for major depression to other losses: evidence from the National Comorbidity Survey | journal = Archives of General Psychiatry | volume = 64 | issue = 4 | pages = 433–440 | date = April 2007 | pmid = 17404120 | doi = 10.1001/archpsyc.64.4.433 | doi-access =  }}</ref> The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.

Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives.<ref>{{cite journal | vauthors = Spitzer RL, Wakefield JC | title = DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? | journal = The American Journal of Psychiatry | volume = 156 | issue = 12 | pages = 1856–1864 | date = December 1999 | pmid = 10588397 | doi = 10.1176/ajp.156.12.1856 }}</ref> On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

===Cultural bias===
Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables.<ref name=Widiger2000/> Advocating a more [[culturally sensitive]] approach to psychology, critics such as [[Carl Bell (physician)|Carl Bell]] and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals.<ref name="wash-post">{{cite news | vauthors = Vedantam S |date= June 26, 2005 |title = Psychiatry's Missing Diagnosis: Patients' Diversity Is Often Discounted |url= https://www.washingtonpost.com/wp-dyn/content/article/2005/06/25/AR2005062500982.html |newspaper= [[The Washington Post]] }}</ref> In addition, current diagnostic guidelines have been criticized<ref>{{cite journal | vauthors = Sashidharan SP, Francis E | title = Racism in psychiatry necessitates reappraisal of general procedures and Eurocentric theories | journal = BMJ | volume = 319 | issue = 7204 | page = 254 | date = July 1999 | pmid = 10417096 | pmc = 1116337 | doi = 10.1136/bmj.319.7204.254 }}</ref> as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy.<ref name="Widiger2000">{{cite journal | vauthors = Widiger TA, Sankis LM | title = Adult psychopathology: issues and controversies | journal = Annual Review of Psychology | volume = 51 | issue = 1 | pages = 377–404 | year = 2000 | pmid = 10751976 | doi = 10.1146/annurev.psych.51.1.377 }}</ref> [[Cross-cultural psychiatry|Cross-cultural]] psychiatrist [[Arthur Kleinman]] contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal.<ref>{{cite journal | vauthors = Kleinman A | title = Triumph or pyrrhic victory? The inclusion of culture in DSM-IV | journal = Harvard Review of Psychiatry | volume = 4 | issue = 6 | pages = 343–344 | year = 1997 | pmid = 9385013 | doi = 10.3109/10673229709030563 }}</ref> Other cross-cultural critics largely share Kleinman's negative view toward the [[culture-bound syndrome]], common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.<ref>Bhugra, D. & Munro, A. (1997) ''Troublesome Disguises: Underdiagnosed Psychiatric Syndromes'' Blackwell Science Ltd {{ISBN missing|date=August 2016}}</ref>{{Page needed|date= August 2016}}

Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.<ref name="Widiger2000" />

Historically, the DSM tended to avoid issues involving [[religion]]; the DSM-5 relaxed this attitude somewhat.<ref>
{{cite journal | vauthors = Chandler E | title = Religious and spiritual issues in DSM-5: matters of the mind and searching of the soul | journal = Issues in Mental Health Nursing | volume = 33 | issue = 9 | pages = 577–582 | date = September 2012 | pmid = 22957950 | doi = 10.3109/01612840.2012.704130 | quote = Given the important role that spirituality and religion play for many people in the experiences of coping with health and illness, it seems odd that such important elements are in the margins of the powerful and commanding nosology of the DSM. Explanations for understanding the glaring absence are complex and impacted by some very powerful political and sociological forces, including contributory elements from within the mental health disciplines. This article invites the reader to explore salient issues in the emergence of a broader recognition of religion, spirituality and psychiatric diagnosis in the DSM-5. }}
</ref>

===Medicalization and financial conflicts of interest===
There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing [[medicalization]] of human nature, very possibly attributable to [[disease mongering]] by psychiatrists and [[pharmaceutical companies]], the power and influence of the latter having grown dramatically in recent decades.<ref>{{cite journal |last1=Healy |first1=David |title=The Latest Mania: Selling Bipolar Disorder |journal=PLOS Medicine |date=11 April 2006 |volume=3 |issue=4 |article-number=e185 |doi=10.1371/journal.pmed.0030185 |doi-access=free |pmid=16597178 |pmc=1434505 }}</ref> In 2005, then APA President [[Steven Sharfstein]] released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model".<ref>{{cite journal | vauthors = Cosgrove L, Krimsky S, Vijayaraghavan M, Schneider L | title = Financial ties between DSM-IV panel members and the pharmaceutical industry | journal = Psychotherapy and Psychosomatics | volume = 75 | issue = 3 | pages = 154–160 | date = 2006 | pmid = 16636630 | doi = 10.1159/000091772 }}</ref> It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct [[Conflict of interest#Relationship to medical research|conflict of interest]]. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.

[[William Glasser]] referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money".<ref>{{cite web |url=http://nationalpsychologist.com/2006/11/glasser-headlines-psychotherapy-conference/10879.html |title=(Susan Bowman, 2006) |publisher=The National Psychologist |date=2006-11-01 |access-date=2013-12-03 |archive-date=2017-06-26 |archive-url=https://web.archive.org/web/20170626220701/http://nationalpsychologist.com/2006/11/glasser-headlines-psychotherapy-conference/10879.html }}</ref> A 2012 article in ''[[The New York Times]]'' commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100&nbsp;million.<ref name="Greenberg">
{{cite news | url= https://www.nytimes.com/2012/01/30/opinion/the-dsms-troubled-revision.html | work= The New York Times | vauthors = Greenberg G | title = The D.S.M.'s Troubled Revision | date = January 29, 2012}} The article's closing words: "it [the APA] will be laughing all the way to the bank."</ref>

However, although the number of identified diagnoses had increased by more than 200% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients.<ref name="concept&evolution"/>

===Potential harm of labels===
A core function of the DSM is the categorization of people's experiences into diagnoses based on symptoms. However, there is disagreement about the use of diagnoses as labels. Some individuals are relieved to find they have a recognized condition that they can apply a name to, and this has led to many people [[Self-diagnosis|self-diagnosing]].<ref>{{Cite journal | vauthors = Giles DC, Newbold J |date= March 2011 |title=Self- and Other-Diagnosis in User-Led Mental Health Online Communities |journal=Qualitative Health Research |volume=21 |issue=3 |pages=419–428 |doi=10.1177/1049732310381388 |pmid=20739589 }}</ref> Others, however, question the accuracy of diagnosis, or feel they have been given a label that invites [[social stigma]] and [[discrimination]] (the terms "[[mentalism (discrimination)|mentalism]]" and "sanism" have been used to describe such discriminatory treatment).<ref name="Sane">[http://www.socialinequities.ca/wordpress/wp-content/uploads/2011/07/Ingram.Sanism-in-Theory-and-Practice.CI_.2011.pdf Sanism in Theory and Practice] {{Webarchive|url=https://web.archive.org/web/20140317045503/http://www.socialinequities.ca/wordpress/wp-content/uploads/2011/07/Ingram.Sanism-in-Theory-and-Practice.CI_.2011.pdf |date=2014-03-17 }} May 9/10, 2011. Richard Ingram, Centre for the Study of Gender, Social Inequities and Mental Health. [[Simon Fraser University]], Canada</ref>

Diagnoses can become [[Internalization (psychology)|internalized]] and affect an individual's [[self-identity]], and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result.<ref>{{cite journal |last1=Honos-Webb |first1=Lara |last2=Leitner |first2=Larry M. |title=How Using the Dsm Causes Damage: A Client's Report |journal=Journal of Humanistic Psychology |date=October 2001 |volume=41 |issue=4 |pages=36–56 |doi=10.1177/0022167801414003 }}</ref> Some members of the [[psychiatric survivors movement]] (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general.<ref name="CapeTown">{{cite web
 | url=https://madpridect.wordpress.com/2013/06/08/known-as-the-psychiatric-bible-the-diagnostic-and-statistical-manual-of-mental-disorders-appears-in-a-fifth-edition/
 | title=Known as the 'psychiatric bible', the Diagnostic and Statistical Manual of Mental Disorders appears in a fifth edition
 | author=Cape Town Mad Pride
 | author-link=Mad Pride
 | access-date=28 Feb 2019
 | date=2013-06-08
 }}</ref><ref name="Medscape">
Michael T. Compton (2007) [http://www.medscape.com/viewarticle/565489_print Recovery: Patients, Families, Communities] Conference Report, Medscape Psychiatry & Mental Health, October 11–14, 2007
</ref> Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a [[recovery model]], and such content can erroneously imply excess psychopathology (e.g. multiple "[[comorbid]]" diagnoses) or [[Chronic (medicine)|chronicity]].<ref name="Medscape"/>

===Critiques of DSM-5===
Psychiatrist [[Allen Frances]] has been critical of proposed revisions to the DSM–5. In a 2012 ''New York Times'' editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription."<ref name="nyt">{{cite news | vauthors = Frances A |date=11 May 2012 |url=https://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html |title=Diagnosing the D.S.M. |newspaper=New York Times |edition=New York |page=A19 }}</ref>

In a December 2012, blog post on ''[[Psychology Today]]'', Frances provides his "list of DSM 5's ten most potentially harmful changes:"<ref name="dsm5GuideNotBible">{{cite web| vauthors = Frances AJ |title=DSM 5 Is Guide Not Bible{{snd}}Ignore Its Ten Worst Changes: APA approval of DSM-5 is a sad day for psychiatry|url=http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes|access-date=2013-03-09|website=Psychology Today|date=December 2, 2012}}</ref>
* Disruptive Mood Dysregulation Disorder, for temper tantrums
* Major Depressive Disorder, includes normal grief
* Minor Neurocognitive Disorder, for normal forgetfulness in old age
* Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
* Binge Eating Disorder, for excessive eating
* Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
* First-time drug users will be lumped in with addicts
* Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
* Generalized Anxiety Disorder, includes everyday worries
* Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."<ref name="dsm5GuideNotBible" />

A group of 25 psychiatrists and researchers, among whom were Frances and [[Thomas Szasz]], have published debates on what they see as the six most essential questions in psychiatric diagnosis:<ref name="Phillips">{{cite journal | vauthors = Phillips J, Frances A, Cerullo MA, Chardavoyne J, Decker HS, First MB, Ghaemi N, Greenberg G, Hinderliter AC, Kinghorn WA, LoBello SG, Martin EB, Mishara AL, Paris J, Pierre JM, Pies RW, Pincus HA, Porter D, Pouncey C, Schwartz MA, Szasz T, Wakefield JC, Waterman GS, Whooley O, Zachar P | display-authors = 6 | title = The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis | journal = Philosophy, Ethics, and Humanities in Medicine | volume = 7 | issue = 1 | page = 3 | date = January 2012 | pmid = 22243994 | pmc = 3305603 | doi = 10.1186/1747-5341-7-3 | doi-access = free }}</ref>
* Are they more like theoretical constructs or more like diseases?
* How to reach an agreed definition?
* Should the DSM-5 take a cautious or conservative approach?
* What is the role of practical rather than scientific considerations?
* How should it be used by clinicians or researchers?
* Is an entirely different diagnostic system required?

In 2011, psychologist [[Brent Robbins]] co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and [[mental health]] professionals have signed a petition in support of the letter.<ref name = "pointpark"/> Thirteen other APA divisions have endorsed the petition.<ref name = pointpark>{{cite web |url=http://www.pointpark.edu/NewsArtsSciences.aspx?id=467 |title=Professor co-authors letter about America's mental health manual |date=December 12, 2011 |work=Point Park University |access-date=2012-04-04 |archive-url=https://web.archive.org/web/20120329184708/http://www.pointpark.edu/NewsArtsSciences.aspx?id=467 |archive-date=2012-03-29 }}</ref> Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.<ref>{{cite news |url=http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/11/26/MNJJ1M3DFK.DTL |title=Revision of psychiatric manual under fire| vauthors = Allday E |date=November 26, 2011 |work=San Francisco Chronicle }}</ref>

=== Cultural responses to the DSM ===
There are several works written in recent years by scholars of the disabled community that specifically critique the cultural impact of the DSM-5. These pieces criticize the DSM-5 from different cultural perspectives, integrating the experiences of disabled people identifying as [[Crip (disability term)|crip]], [[Feminism|feminists]], [[Asian Americans]], [[Black Americans]] and other marginalized viewpoints.

==== ''DSM CRIP'' ====
DSM CRIP is a collection of essays by various authors that explore the critiques of the DSM-5 from feminist and crip perspectives. These essays tackle the critiques of the DSM using specific diagnoses such as [[gender dysphoria]], [[transvestic disorder]], complex [[somatic symptom disorder]], hypoactive sexual desire disorder, schizophrenia and autism. These are used as case studies to tackle the topics of the potential harm of labels, [[overmedicalization]], [[overdiagnosis]], pathologizing normality and various other critiques informed by the feminist and crip lens.<ref>{{cite web | url=https://socialtextjournal.org/periscope_article/label-crip/ | title=Label C/Rip – Social Text }}</ref>

==== ''Open in Emergency'' ====
Open in Emergency is a multimedia collaborative project of the [[Asian American Literary Review]] that takes the lens of an Asian American Experience and redefines wellness in terms of care instead of focusing on diagnosis, unlike the original DSM V. This included mock versions of DSM diagnoses such as gender dysphoria, social anxiety disorder and cannabis use disorder that mean to recharacterize the disorders under the lens of wellness and care.<ref>{{Cite book |last=Khúc |first=Mimi |title=Open in Emergency: A Special Issue on Asian American Mental Health |publisher=Asian American Literary Review |year=2016}}{{pn|date=November 2024}}</ref> The project was said{{by whom|date=November 2024}} to contextualize mental disorders with their relationship to [[Power structure|structures of power]] like [[patriarchy]], [[colonialism]] and [[violence]] (here).{{fact|date=November 2024}}

==== ''The Protest Psychosis: How Schizophrenia became a Black disease'' ====
[[The Protest Psychosis|The Protest Psychosis: How Schizophrenia became a Black disease]] is a critically acclaimed book that was written to analyze the history of schizophrenia and how perceptions of the condition have changed. In this book, Metzl shows how the condition of schizophrenia was experienced against the backdrop of the [[Civil rights movement|Civil Rights Movement]].<ref name=":13"/> This book was recognized by the [[Disability Studies Quarterly]] academic journal as an excellent analysis of schizophrenia's link to black history.<ref>{{cite journal |last1=Richardson |first1=Nadia |title=Metzl, Jonathan. The Protest Psychosis: How Schizophrenia Became a Black Disease |journal=Disability Studies Quarterly |date=11 January 2012 |volume=32 |issue=1 |doi=10.18061/dsq.v32i1.3021 |doi-access=free }}</ref>

== See also ==
{{col div|colwidth=30em}}
* [[Chinese Classification and Diagnostic Criteria of Mental Disorders]]
* [[Classification of mental disorders]]
* [[Diagnostic classification and rating scales used in psychiatry]]
* [[DSM-IV codes]]
* [[Global Assessment of Functioning|Global Assessment of Functioning (GAF) Scale]]
* [[International Statistical Classification of Diseases and Related Health Problems|International Statistical Classification of Diseases and Related Health Problems (ICD)]]
* [[Kraepelinian dichotomy]]
* [[Psychodynamic Diagnostic Manual]]
* [[Relational disorder]] (proposed DSM-5 new diagnosis)
* [[Research Domain Criteria]] (RDoC), a framework being developed by the National Institute of Mental Health
* [[Rosenhan experiment]]
* [[Structured Clinical Interview for DSM-IV]] ''(SCID)''
* [[Homosexuality in DSM]]
{{colend}}

== Notes ==
{{Notelist}}

== References ==
{{Reflist|30em}}

== Further reading ==
{{refbegin}}
* {{cite book| author = American Psychiatric Association| title = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR® | year = 2000| publisher = American Psychiatric Pub| isbn = 978-0-89042-025-6 }}
* {{cite book| vauthors = Spitzer RL | title = Dsm-Iv-Tr Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders | year = 2002| publisher = American Psychiatric Pub| isbn = 978-1-58562-059-3 }}
{{refend}}

== External links ==
* [http://www.dsm5.org/pages/default.aspx Official DSM-5 development website]
* [https://archive.today/20120527015056/http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm Diagnostic Criteria from DSM-IV-TR] (archived)
* [https://apicalhealth.com/illness-and-recovery/dsm-iv/ The Multiaxial System of Diagnosis in DSM-IV Criteria]. {{Webarchive|url=https://web.archive.org/web/20210116142849/https://apicalhealth.com/illness-and-recovery/dsm-iv/ |date=2021-01-16 }}.
{{DSM personality disorders}}
{{Medical classification}}
{{Modern medical textbooks}}
{{italic title}}

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[[Category:American Psychiatric Association]]
[[Category:Data coding framework]]
[[Category:Medical manuals]]
[[Category:Medical statistics]]
[[Category:Psychiatric assessment]]
[[Category:Classification of mental disorders]]
[[Category:Psychiatric diagnosis]]
[[Category:Psychopathology]]
[[Category:Publications established in 1952]]
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