History of Psychiatric Diagnoses and the Diagnostic and Statistical Manual of Mental Disorders

Psychiatric diagnoses are not only stigmatizing, but they are also subjective, invalid, and useless. A great argument can be made that diagnosis in mental health is also harmful, which we will explore moving forward. Diagnoses are the foundation of the flawed disease model of mental health.

We will begin our discussion on the topic of mental health with a history of psychiatric diagnoses and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Understanding the basis of diagnosis will give us a greater understanding of the field, as well as a foundation to work off. Largely, we will be concerned with the DSM-5, the most recent publication of this manual, which is, of course, the most medicalized version, and most accepted by modern medicine.

The DSM-5 treats mental illness like any other sort of physical illness. That there is a diagnosis and a treatment plan, regardless of the cause. The prevailing neurochemical imbalance/dysfunction theory of mental illness is the leading school of thought in the DSM-5 as well as medicine in general, although the literature does not align with this belief. Due to this reductionist view of mental health, and the nature of diagnosis, medicine meets mental illness nowadays in the same respect as all other illnesses, with a pharmaceutical approach. The nature of diagnosis, which we will explore here in this post, has moved away from the individual's experience to a large focus on the diagnosis itself.

The field of psychiatry has long been criticized as being unscientific and unmedical. We will see that there is an attempt to medicalize mental illness, throughout the progression of the DSM. Largely, this was done to validate the field of psychiatry as an established medical practice, in the view of modern science and medicine. Upon exploration of this topic, you will see that it is most acceptable to criticize the field of psychiatry, compared to other fields of medicine, due to its novelty. Generally, in the view of the modern scientist, governing bodies of scientific organizations, as well as medical practitioners, the DSM-5, the neurochemical imbalance theory, and the use of psychiatric drugs are accepted and utilized. Most problematically, the academic establishments are teaching the use of the DSM-5, neurochemical imbalance theory, as well as the use of pharmaceutical drugs.

As a disclaimer, I want to ensure that my personal view is known. Of course, there exist mental health states that may be viewed as undesirable, but largely I do not regard them as diseases or disorders, especially caused by brain dysfunction. These conditions do not occur at random, there is a reason for their occurrence. This will require further elaboration, but for now, let’s dive into the history of diagnosis related to mental health and build from there.

Prior to Greek physicians, mental illnesses were largely thought to be caused by evil spirits, demons, gods, or witches who took control of the person. Of course, the mental illnesses recognized were largely those with severe implications, such as psychoses related illnesses as well as things like epilepsy. This theory prevailed throughout history, even after the times of the Greek physicians. Largely, this notion was pushed by the church and other religious circles.

Hippocrates was a proponent of the somatogenic theory of illness, essentially that these conditions arise from the body. He classified mental disorders into categories like epilepsy, melancholia, mania, and phrenitis (brain fever). Of course, he believed these conditions arose from an imbalance in the body's four humors. The concept of humorism persisted as a prevalent theory until the 1800s.

Galen, who did not disagree with Hippocrates, proposed that psychological stress and trauma could lead to the development of mental disorders as well. Specifically, Galen believed that emotional factors like grief, fear, and anger could disrupt the body's natural humoral balance, leading to mental health issues. He suggested that treatments targeting the psychological and emotional aspects of the individual, rather than just physical remedies, could be effective. However, Galen's psychogenic perspective was largely ignored in favor of the dominant somatogenic theories of mental illness at the time. The idea that psychological and emotional factors could directly cause mental disorders was not widely accepted or investigated further until the days of psychoanalysis.

Concerning more recent history, in the 1840 US census, the only mental health categories recorded were "idiocy” and “insanity". In the 1880 US census, mental health categories included mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917, the American Medico-Psychological Association and National Commission on Mental Hygiene developed a plan for gathering uniform health statistics across mental hospitals, but it was still primarily an administrative classification rather than clinically focused.

The field of psychology and psychiatry had little pull in the well-established medical field, and so a need for a standardized psychological nosology was created. This eventually led to the creation of the first official manual for mental disorders. This was the American Medico-Psychological Association's "Standard Classified Nomenclature of Disease" developed in 1921. It was designed for diagnosing severe psychiatric and neurological disorders in inpatients. This had many editions, but at this point, are not worth a detailed review. Eventually, this led to the creation of the popular DSM, which we will explore now.

The first edition, published in 1952, contained 102 diagnostic categories. Overall, the DSM-I is now seen by the establishment as an early, flawed attempt to systematize psychiatric diagnosis, with a heavy reliance on psychoanalytic theory and a lack of empirical validation for the diagnostic categories. In its time, it was not accepted largely by the medical community. This highlighted the need for a more scientifically grounded and clinically useful approach to psychiatric classification, which would be the focus of later revisions. However, it was seen as a step in the right direction for establishing psychiatry as a medical practice.

The diagnostic categories were heavily influenced by the psychoanalytic perspective that was dominant at the time, with many disorders classified based on presumed underlying psychological conflicts or disturbances. There was a lack of clear, operationalized diagnostic criteria, with many categories relying on vague, subjective descriptions of symptoms and behaviors. Essentially, the manual was largely criticized for being overly broad and lacking scientific rigor in its diagnostic framework.

The second edition, published in 1968, contained 182 diagnostic categories. Like the DSM-I, the DSM-II maintained a strong psychoanalytic influence, with many disorders still classified based on presumed underlying psychological conflicts or disturbances. The diagnostic criteria remained relatively vague and subjective, lacking clear, operationalized definitions similarly to DSM-I. One significant change was the elimination of homosexuality as a mental disorder, replacing it with the new category of "sexual orientation disturbance". Notably, the number of recognized mental disorders increased by 80 categories. The DSM-II continued to face criticism for its lack of scientific rigor and empirical validation of the diagnostic categories.

The third edition, published in 1980, contained 265 diagnostic categories, an increase of 83 from DSM-II, raising concerns about potential diagnostic inflation. It represented a major shift in the approach to psychiatric diagnosis compared to the previous DSM-I and DSM-II editions. DSM-III moved away from the psychoanalytic orientation of the earlier editions and adopted a more descriptive, atheoretical approach to diagnosis. The manual introduced the use of explicit, operationalized diagnostic criteria for each disorder, aiming to improve the reliability of psychiatric diagnoses. The manual eliminated the term "neurosis" and made other changes that reflected a shift towards a more medical, biological model of mental disorders.

Most notably, the DSM-III adopted a multiaxial system. The concept of multiaxial evaluation involves assessing an individual across several different domains of information that are considered clinically valuable. This system evaluated patients across 5 different axes, namely, clinical disorders, personality disorders and intellectual disabilities, general medical conditions, psychosocial and environmental problems, and Global Assessment of Functioning (GAF) scale. The multiaxial system was intended to provide a more comprehensive assessment of the patient's clinical presentation and relevant factors. However, in actual clinical practice, clinicians often did not utilize the full multiaxial system, and tended to focus primarily on Axis I, clinical diagnoses.

Arguably, the multiaxial system was the helpful part of the DSM, as it considered the individual's situation and experience in a more holistic manner. In practice, this should have led to more ‘accurate’ and fewer diagnoses. But this was not the case.

Now it might be helpful to add that the neurochemical imbalance theory, particularly the idea that depression is caused by a serotonin deficiency, was first proposed in the 1960s. This was largely influenced by the ideas of Emil Kraepelin who is known as the founder of modern scientific psychiatry, psychopharmacology, and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. This theory was then heavily promoted in the late 1980s and 1990s, as pharmaceutical companies around this time also started developing and marketing a new class of antidepressants (SSRIs), tailored to this theory.

Specific biomarkers are not explicitly mentioned in DSM-III, such as serotonin, dopamine, etc. However, the gaining traction of the neurochemical imbalance cause of mental illness was prevalent in the public's eye as well as practitioners. Many say that the DSM-III was largely influenced by this up-and-coming theory. It is no doubt that the field of psychiatry was largely influenced by this theory.

Although the DSM-III remained atheoretical, the practice of psychiatry was concerned with treating these conditions as neurochemical imbalance, as the prevailing drugs aimed to correct these imbalances. During the time of DSM-III, the common drugs were lithium, Chlorpromazine and other antipsychotics, Tricyclic antidepressants, Monoamine oxidase inhibitors, Benzodiazepines, etc. All of which aimed to correct neurochemical imbalances. At the very least, the diagnostic manual was largely atheoretical and impartial on the use of these drugs. The time of the DSM-III was the rebranding of psychiatry. Where psychiatrists went from the client laying down and undergoing analysis, to the psychiatrist wearing white coats and prescribing magic bullets to cure their illnesses.

The revised third edition, published in 1987, represented an incremental revision of the DSM-III, making some changes to diagnostic categories and criteria but largely building upon the framework established in the previous edition.

The development of the DSM-III-TR addressed criticisms of the DSM-III, such as including the old DSM-II terminology for "neurotic disorders" in parentheses. And so, by the time of the DSM-III-TR, the old DSM-II terminology for "neurotic disorders" was dropped entirely, reflecting the reduced influence of psychoanalytic concepts. The DSM-III-TR removed hierarchical exclusion rules. In the DSM-III, you had to list the patient’s conditions in order of significance, but not in the DSM-III-R. This increased comorbidity by default, as conditions could be diagnosed side by side.

By this time, SSRIs were developed and gaining rapid traction for treating depression. This was the drug known as Prozac. Here, there was a huge push by pharmaceutical companies for practitioners to utilize these drugs.

The fourth edition was published in 1994, containing 297 diagnostic categories. The development of the DSM-IV placed a stronger emphasis on using available research findings and empirical evidence as the basis for changes, rather than relying solely on expert consensus as in earlier editions. The DSM-IV represented an incremental update to the DSM-III-TR, making changes to diagnostic categories and criteria based on available research, but without any major conceptual shifts. Like the DSM-III, the DSM-IV maintained the multiaxial assessment system, evaluating patients across different domains such as clinical disorders, personality disorders, and general medical conditions. The level of evidence required to make changes in the DSM-IV was set quite high, with the chair of the revision process stating that the "major innovation" would be in the systematic and explicit method used, rather than surprising new content.

In relation to the use of neurochemical imbalance, the DSM-IV in many cases, notably, bipolar disorder, panic disorder, OCD, ADHD, depression, etc., do not admit to having identified laboratory markers that are able to diagnose such illnesses. However, they do mention associations of abnormalities in laboratory findings which include neurochemicals, hormones, metabolites, brain scans, etc. Largely, laboratory markers are not used to diagnose individuals, other than brain scans that are sometimes used to help classify diagnoses and help diagnose sleep-related disorders. Laboratory findings related to biochemistry are only helpful in diagnosis in the case of mental disturbances admittedly caused by substances. In the DSM-IV, no disorder is diagnosable by biomarker. Here, we can see the growing influence of the neurochemical imbalance reflected in the DSM itself. But the text remained partially atheoretical, although the insinuation of brain defects and neurochemical imbalance was growing.

The text revision of the fourth edition, published in 2000, contained minor updates and revisions. No changes to diagnostic criteria were made. The text revision process was focused on updating the descriptive text, to reflect new information that became available since the initial DSM-IV literature review process in 1992. The text revision also updated the diagnostic codes. The text revision was an opportunity to correct errors and significant ambiguities that had been identified in the original DSM-IV. Background information such as prevalence and familial patterns were updated, as well as updated statistics were added.

The fifth edition of the DSM was published in 2013, and it's the most problematic one so far. The DSM-5 was a return to a theoretical framework and ideology. The central focus of the DSM-5 is neurobiology, and a great reductionism to genetics, neurochemical imbalances, and brain dysfunction. This is explicitly stated in the DSM-5. In brief, they eliminated the multiaxial system and made several other significant changes, including the addition of new disorders and the modification or elimination of existing ones. It also harnessed a complete reorganization and reclassification of known disorders. Let’s address the more problematic changes in depth.

Let’s first cover the elimination of the multiaxial system. We will remember that the multiaxial system was added in DSM-III. The multiaxial system provided a contextual understanding of diagnosis. Largely, the removal of the multiaxial system was influenced by the field of psychiatry wanting to establish themselves and resemble the medical field. Medicine does not have multiple axes for diagnoses. They have but the clinical diagnosis. Treatment in medicine is not concerned with the etiology or cause of the illness; it is concerned with the diagnosis to determine the treatment. This change was also to align with the World Health Organization's International Classification of Diseases (ICD), which the DSM has increasingly attempted to harmonize with throughout the years.

Axis 1 was clinical diagnosis. This is the only axis left. The DSM now explicitly indicates that psychiatric diagnoses are treated as any other medical condition. Of course, psychiatrists have been treating mental illness like this since the 1950s and the discovery of chlorpromazine and lithium. This notion really gained traction in the 1980s with the discovery of Prozac and SSRIs.

Axis 2 was consideration of developmental and personality disorders. The argument for the removal of this axis was that many thought that these diagnoses were pejorative, meaning that we were diagnosing somebody for who they are and not for what they have. Many didn’t believe in personality disorders. There was also an insurable issue. There was a lack of reimbursement for people diagnosed with personality or developmental disorders as they had implications and indications before adulthood but could not be diagnosed until they were adults, thus insurance wouldn’t pay if an individual was treated in childhood. This axis was not a major loss.

Axis 3 considered general medical conditions. They removed this axis because psychiatry is trying to establish itself as a medical profession. They are trying to classify mental illnesses as disorders or diseases, thus they need mental illnesses to be regarded as general medical conditions and not as something separate from them. According to the DSM five anxiety and appendicitis are regarded as the same, diabetes and explosive personality disorder are regarded as the same, depression and coronary disease are regarded as the same.

Axis 4 considered psychosocial problems. Interestingly, David Kupfer chair of the task force for the creation of the DSM-5 stated that this section of the multiaxial system was the job of social workers and not medical healthcare practitioners. In essence, removal of this axis meant that all depression is the same regardless of the social factors present in your life. Doesn’t matter if you’re homeless, jobless, no family, no friends, vs. rich, living in a mansion, large family, large social support circle, depression is depression, there is a standardized course of treatment.

The rationale here again was that only the diagnosis matters, a heart attack is a heart attack, regardless of what causes it and depression is depression regardless of what causes it therefore no distinction needs to be made about the cause of any of these disorders when diagnosing them.

Essentially, the DSM-5 does away with the cause of a diagnosis because doesn’t matter, only the diagnosis matter. The prevailing neurochemical imbalance theory is not used to diagnose mental health conditions either, but rather used as a framework for treatment and drug development.

Axis 5 represents the global adaptive functioning scale. Essentially, a score of 0 being guaranteed self-harm or harm to others, 100 being the most perfectly self-actualized individual ever to walk the planet. This was not a big loss. This is something that should be considered by practitioners every time their client walks through the door. The score would change, of course, from day-to-day, week-to-week, hour-to-hour. However, removal of this as a standardized practice exacerbates the issue of treating people as their diagnoses and not individuals.

Beyond the loss of the multiaxial system, the DSM presented many more issues. In the DSM-5, it became easier to access diagnoses of developmental disorders. Largely, this occurred through placing disorders on a spectrum which loosened the borders of diagnosis, but was also facilitated by other methods. For example, ADHD is considered a childhood-onset disorder, but may only present itself in adulthood. When ADHD did present in adults, practitioners had to trace the disorder back to the age of 7. In the DSM-5, however, practitioners only have to trace symptoms back to the age of 12. Essentially, an individual only must remember back to what they were like in middle school rather than second grade. This has made the diagnosis much more accessible. The symptom threshold for ADHD has also been reduced from 6 to 5, meaning that you only need to present five of the categorized symptoms of ADHD to be diagnosed with it.

Most of the changes to the DSM-5 were to create more leniency in the diagnosis, making them more accessible to practitioners. The more lenient the criteria, the more you include; the more stringent, the more you exclude. Interestingly, those pushing the DSM-5 explained that the changes made would not increase diagnosis. However, we can blatantly see within the statistics of mental health conditions that they’ve increased exponentially. The changes in diagnostics being more lenient would decrease false negatives but increase the number of false positives.

Additionally, this was the first time that disorders were added out of the blue rather than being added from the appendix of previous editions, that were stated conditionally upon further study. An example of this is disruptive mood dysregulation disorder. Which is the chronic overreaction to common stressors. This was created and added de novo for the DSM-5. No mention of this in any earlier DSM. This addition essentially was a reclassification of pediatric bipolar, essentially decreasing the amount of pediatric bipolar diagnoses, which is treated with antipsychotics, to now being treated with stimulants, antidepressants, and atypical antipsychotics.

Largely, the DSM-5 was a return to theoretical orientation. DSM-5 presents a neuroscience foundation to diagnosing mental illness. In the DSM-5, there is blatant mention of neural causes and treatments of mental illnesses. There is a devout dedication to biological reductionism and neurochemical imbalance theory, essentially in all mental illnesses except those admittedly known to be caused by substances such as illicit drugs, pharmaceutical drugs, or other toxins. The DSM-5 was a return to ideology. It moved away from empiricism, as there is no conclusive empirical evidence of biological reductionism to neurochemical imbalances and brain defects. The literature on genetic implications is quite thin as well, which we will cover in future posts.

The text revision of the fifth edition, published in 2022, contains revised criteria for over 70 disorders and the addition of a new diagnosis called prolonged grief disorder. The DSM-5-TR was largely an update to politically correct language surrounding gender, racism, and discrimination. The addition of new diagnostic categories, such as prolonged grief disorder, has been criticized as potentially pathologizing normal human experiences. There has also been lots of talk about financial interests in the creation of the DSM-5-TR, as a means to sell more copies of the DSM. Realistically, it was a relatively minor text revision, with the majority of changes being updates to the descriptive text rather than substantive changes to the diagnostic criteria.

Diagnosing in mental health has a lengthy past. Those with mental health conditions have been mistreated since the dawn of time as they are portrayed as being abnormal. This is not the right approach to take when attempting to help and heal individuals. The Diagnostic and Statistical Manual has exacerbated this problem, especially in its fifth edition. We can see through this review of the history of the DSM that there has been a successful, although unfounded, attempt to medicalize mental health.

The DSM-I and II were based on psychoanalytical theory and pushed their ideologies. These were rather subjective documents based on theory and ideology. These works were not very influential. During these times, the use of pharmaceuticals to treat mental health was beginning but didn’t gain huge traction until the DSM-III. DSM-III and IV were more concrete in their diagnostic criteria and attempted to consider contextual factors, although this was not done in practice. The treatments for these conditions were pharmaceutical-based, although the DSM-III and IV remained atheoretical for the most part. Although these documents did indicate that we were dealing with abnormalities and brain defects.

Of course, the DSM-5 presented major issues with the return to theory and ideology. The loss of the multiaxial system was representative of the medicalization of mental health. DSM-III and IV may have insinuated that mental health conditions were brain diseases, but due to their atheoretical construct, it was not explicitly stated. The DSM-5 explicitly states that psychiatric conditions and distress are results of an underlying brain pathology. This is evermore problematic as this ideology is taught in academic institutions from undergraduate degrees to medical doctorates. There is absolutely no evidence or literature that supports this neurochemical imbalance theory. The DSM-5 also made the diagnostic criteria much more lenient in the grand majority of mental health conditions, increasing the accessibility of these diagnoses to practitioners.

Some say that the psychiatric community had already largely abandoned the neurochemical imbalance theory because the literature does not support these claims. However, this ideology persists in the public and academic consciousness, likely due to pharmaceutical marketing efforts. The industrial-medico-pharmaceutical complex still pushes these drugs, tailored to the neurochemical imbalance theory, despite a lack of evidence to support the theory or use of the drugs.

Moving forward, we will delve deeper into the philosophical implications of diagnoses and how that can impact the mental health of individuals. This text serves as a foundation for understanding diagnoses from the perspective of medical and psychiatric practices. Largely, this text told the story of how mental health became medicalized.

For more on DSM read: DSM: A History of Psychiatry's Bible 1st Edition by Allan V. Horwitz

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