How Does the Diagnostic and Statistical Manual of Mental Disorders (DSM) Work?

The DSM is a manual that U.S. healthcare professionals use to identify and diagnose mental health issues -- and it’s a continual work in progress because our understanding of mental health is continually developing. Learn how the DSM works in this episode of BrainStuff, based on this article: https://health.howstuffworks.com/mental-health/mental-disorders/dsm-diagnostic-and-statistical-manual-mental-disorders.htm

See omnystudio.com/listener for privacy information.

Episode Transcript

Speaker 1 (00:01):
Welcome to Brainstuff, a production of iHeartRadio, Hey brain Stuff,
Lauren Bogelbaum. Here in the United States, if you go
to a medical professional looking for help with mental health,
one of the guides they're going to turn to in
helping you identify what's going on is the Diagnostic and
Statistical Manual of Mental Disorders, or the DSM. The DSM

(00:25):
is a living document. It's currently in its fifth edition,
known appropriately as the DSM five, having been updated about
once every fifteen years by its governing body, the American
Psychiatric Association, since they first published it in nineteen fifty two.
It's updated so often because our understanding of the human
mind keeps updating based on science. For example, before the

(00:47):
nineteen seventies, homosexuality was often considered to be a mental illness.
The American Psychiatric Association, or APA, classified it as such
in the first iteration of the DSM. This held with
prevaill and cultural norms, but then activists started protesting at
annual meetings of the APA and presented scientific evidence opposing
those norms. In nineteen seventy three, it was put to

(01:11):
the vote and a majority of APA members agreed that
home sexuality should no longer be considered a mental disorder.
Although it took baby steps to get there, this change
was a huge leap for gay rights and helped shift
sidal thinking on home sexuality. It also demonstrated the power
of the DSM on public opinion. The DSM doesn't offer

(01:32):
advice on medications or other treatments for the one hundred
and fifty seven disorders currently described in its pages. Rather,
it was designed to help healthcare professionals identify and diagnose
mental health conditions, such as those that impact personality, cognition,
and mood. The manual also provides uniform diagnostic codes for
each issue, which are used to facilitate medical billing and

(01:54):
data collection. Often, if a condition isn't listed in the
DSM US, health and chure companies won't pay for the
treatment of it. The manual is primarily used in the
United States, with much of the rest of the world's
health professionals turning instead to the World Health Organization's International
Classification of Diseases or ICD, which covers all diseases, not

(02:15):
only those psychological in nature. The APA encourages healthcare professionals
to consider the DSM five and the ICD as companion
publications designed to be compatible with each other. The ICD
is currently in its eleventh edition, having started up in
the eighteen nineties and been updated about every ten years.

(02:36):
The history of the DSM goes back way further than
the nineteen fifties. It was developed in response to an
obvious need for systems by which to classify mental health.
The US Census of eighteen forty took small steps toward
the eventual development of the manual by adding a question
about incidents of what they called idiocy or insanity to
their survey. This was possibly the first attempt statistical information

(03:01):
gathering related to mental health. In eighteen eighty, the Census
flushed out the mental health category to include issues like dementia, melancholia, epilepsy,
and mania. In nineteen seventeen, the American Medico Psychological Association,
the forerunner of the APA, and the National Commission on
Mental Hygiene came up with a plan for gathering uniform

(03:23):
health statistics and mental hospitals, which was then adopted by
the Census Bureau in nineteen twenty one. The APA started
to develop psychiatric classifications for various severe psychiatric disorders. After
World War Two. They shifted to a bigger classification system
developed by the US Army as it was treating veterans

(03:44):
with these systems as guides. They released the first official
version of the DSM in nineteen fifty two. Each update
is the result of years of task force meetings, discussion
by work groups, and input by many psychiatric experts around
the world. Each listing the manual includes diagnostic criteria including
a disorder symptoms and their duration necessary for a diagnosis,

(04:07):
plus any other disorders to screen, four with common symptoms,
and any antithetical symptoms that can help rule a diagnosis out.
The listing also includes information about the prevalence, development, and
course of the disorder, the risk, the prognostic factors, and
other relevant information. Finally, each disorder has that diagnostic code

(04:27):
in common with the ICDs codes, which is helpful for
the collection of data as well as streamlining the billing
process for care providers and insurance agencies. It's no small
feat for a mental health issue to be added to
the DSM. The DSM four wasn't all that different from
the DSM five, but the changes that did make the
cut were thoroughly reviewed and discussed by some of the

(04:49):
foremost minds in the psychiatric field. The DSM four was
published in nineteen ninety four, so the DSM five Task
Force had to review all scientific studies published on psychiatric
disord orders since then. Since the DSM five wasn't published
until twenty thirteen, that's nearly twenty years worth of ongoing
research to look at. Following comprehensive review, proposals to modify

(05:13):
existing diagnoses were made, which required vigorous discussion and debate
among the committee members plus input from outside experts. All
proposals were examined by the Task Force, as well as
two additional committees created for a more independent opinion, being
the Scientific Review Committee and a Clinical and Public Health Committee. However,

(05:34):
since then, new changes to the process have streamlined it.
Rather than waiting decades between issues, experts can now submit
changes online, helping to make the manual more timely and current.
Once approved by the APA Board of Trustees, clinicians and
other DSM users are notified about the edit. Users can
hover over the change in the online version to find

(05:56):
out the pertinent details, what the previous material was, and
the support arding scientific evidence that inspired the edit. For
the article this episode is based on has to work,
spoke doctor Philip Wang, director of the APA's Research Division,
which supervises the DSM. He said, this has been a
major advance. Let's say there is enough scientific evidence, and

(06:18):
let's say there is a valid change. To have to
wait fifteen or twenty years for clinicians and patients to
benefit from that change is unconscionable. The new system is
completely transparent, continuous, and at the end of the day,
it hopefully is good for clinicians and benefits patients. The
changes from the fourth edition to the fifth edition were

(06:39):
small but significant to address advances in scientific research and
issues with diagnoses that clinicians had been reporting. The DSM
five combined nearly thirty disorders, eliminated two diagnoses entirely, and
added fifteen. The DSM five has also revamped disorders into
a lifespan approach. Instead of classifying certain issues as solely

(07:03):
childhood disorders, it discusses how they change and manifest at
all stages, and the DSM five emphasizes the importance of
parents in diagnosis and treatment. This new version also introduced
Section three, which is for conditions where there's not enough
scientific data yet to determine whether they should be classified

(07:23):
as psychiatric disorders. Among these conditions are things like Internet
gaming disorder and caffeine use disorder. Section three also contains
cross cutting measures and models that have potential to help
clinicians better evaluate patients when they show symptoms that could
be indicative of multiple disorders, and it also includes a

(07:43):
Cultural Formulation Interview guide with questions to help clinicians identify
how a patient's cultural background affects their perception and presentation
of psychiatric symptoms, treatment, and diagnosis. The APA's fact sheet
about it explains a quote the interview provides, it's an
opportunity for individuals to define their distress in their own
words and then relate this to how others who may

(08:05):
not share their culture see their problems. This gives the
clinician a more complete foundation on which to base both
diagnosis and care. Some key about faces that occurred in
this update are proof that the DSM isn't opposed to
changing with the times. Here's some examples of major turnarounds.
Consenting adults who enjoy relatively unconventional BDSM fetishes or cross

(08:30):
dressing need not fear being diagnosed with mental illness anymore.
The DSM five update depathologized kinky sex. They're now just
people with a preference. It also removed the diagnosis of
Asperger's syndrome and classified the symptoms associated with it and
three other previous diagnoses under the umbrella autism spectrum disorder,

(08:52):
and it codifies medical acceptance of transgender people. The DSM
five replaced the diagnosis of gender identity disorder with gender dysphoria,
so those who don't identify with their assigned sex at
birth are no longer considered to have a mental disorder.
The new diagnosis spells out some of the challenges of
living with gender dysphoria and the paths that people may

(09:15):
choose to resolve it. One complaint about the DSM is
that once a condition is included in the manual, it
may turn what once was considered normal behavior into a
pathological illness that must be treated, often with medication. But
Wang pointed out that the DSM five has incorporated an

(09:36):
acuity measure to help with that. Since so many disorders
range widely in their severity, these scales help clinicians better
evaluate symptoms and levels of impairment. For example, let's say
you're grieving the death of a loved one, are you
still able to cope with life? Or are you barely
able to get out of bed? Once assessed, clinicians will

(09:57):
be better able to land on the appropriate treatment, whether
that's medication, watchful waiting, talk, therapy, or a combination of these.
After all, the human mind is a marvelous thing, but
mental wellness doesn't come automatically or easily for all of us.
People dealing with that, and not to mention the loved

(10:17):
ones who support them deserve and up to date and
fully vetted guide to help them and their care providers
find the best treatments. The value in the decades of
research and intense consideration that have gone into the DSM
is one of the many reasons why the gold standard
advice for anyone who's concerned about the mental health of
themselves or a loved one is to reach out to

(10:39):
a healthcare professional. Access to tools like the DSM helps
those professionals help us on a path towards having a
better time in this sometimes difficult world. Today's episode is
based on the article how the Diagnostic and Statistical Manual
of Mental Disorders Works on how stufforks dot com, written

(11:01):
by A. Leah Hoyt brain Stuff is production by heart
Radio in partnership with HowStuffWorks dot Com and is produced
by Tyler Klang. Four more podcasts by heart Radio, visit
the heart Radio app, Apple Podcasts, or wherever you listen
to your favorite shows.