DSM-II Diagnostic and Statistical Manual of Mental Disorders (Second Edition)
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Even before the manual was released in , many people with autism and their caregivers worried about its effect on their lives.
Many were concerned that after their diagnosis disappeared from the book, they would lose services or insurance coverage. Those who identified themselves as having Asperger syndrome said the diagnosis gave them a sense of belonging and an explanation for their challenges; they feared that removing the diagnosis was synonymous to losing their identity. A growing body of evidence, however, shows that its criteria do exclude more people with milder traits, girls and older individuals than the DSM-IV did. Clinicians in many countries, including the United Kingdom, use the International Classification of Diseases.
Experts continue to view autism as a continuous spectrum of conditions.
Autism diagnosis — The evolution of 'autism' as a diagnosis, explained
Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry,  although they also included biological perspectives and concepts from Kraepelin 's system of classification. Symptoms were not specified in detail for specific disorders. Sociological and biological knowledge was incorporated, in a model that did not emphasize a clear boundary between normality and abnormality.
An influential paper by Robert Spitzer and Joseph L. In reviewing previous studies of eighteen major diagnostic categories, Fleiss and Spitzer concluded "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.
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The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories". As described by Ronald Bayer , a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in , 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. At the 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. This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the s and was challenging the legitimacy of psychiatric diagnosis.
Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations. Presented with data from researchers such as Alfred Kinsey and Evelyn Hooker , the sixth printing of the DSM-II, in , no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in , and confirmed by the wider APA membership in , the diagnosis was replaced with the category of "sexual orientation disturbance".
In , the decision to create a new revision of the DSM was made, and Robert Spitzer was selected as chairman of the task force. The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. There was also a need to standardize diagnostic practices within the US and with other countries after research showed psychiatric diagnoses differed between Europe and the US. The criteria adopted for many of the mental disorders were taken from 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 in St.
Other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee, as chaired by Spitzer. A key aim was to base categorization on colloquial English descriptive language which would be easier to use by federal administrative offices , rather than assumptions of cause, although its categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology an approach described as " neo-Kraepelinian ".
The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders" but the task force decided on the DSM statement: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.
It introduced many new categories of disorder, while deleting or changing others. A number of the unpublished documents discussing and justifying the changes have recently come to light. 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, the DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some capacity; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".
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It rapidly came into widespread international use and has been termed a revolution or transformation in psychiatry. 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 article by Stuart A. Kirk :.
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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 generalisability 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 Categories were renamed and reorganized, and significant changes in criteria were made.
Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual dysphoric disorder and masochistic personality disorder , were considered and discarded.
Diagnostic and Statistical Manual of Mental Disorders
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" p. The task force was chaired by Allen Frances. A steering committee of twenty-seven people was introduced, including four psychologists. The steering committee created thirteen work groups of five to sixteen members.
Each work group had about twenty advisers. 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 multicenter field trials relating diagnoses to clinical practice. Some personality disorder diagnoses were deleted or moved to the appendix. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged.
Updating the Diagnostic and Statistical Manual of Mental Disorders
The first axis incorporated clinical disorders. The second axis covered personality disorders and intellectual disabilities. The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments. The DSM-IV-TR characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual [which] is associated with present distress It states "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder" APA, and 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. 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 disorders and several of the paraphilias due to their egosyntonic nature.