The Development of DSM-III

Abstract

The Diagnostic and Statistical Manual of Mental Disorders (DSM-III), the third diagnostic manual of the American Psychiatric Association (APA), was mainly a response to the vehement, insistent, and often persuasive antipsychiatry movement that had developed in the 1960s and 1970s. Coming from a number of directions, sociologists, lawyers, judges, social critics, and even some psychiatrists themselves, the movement challenged the medical model of psychiatry, the involuntary commitment of patients to mental hospitals, the “warehousing” of patients in hospitals without receiving effective treatment, and even whether patients with mental disorders had any illness at all. Additionally, psychiatrists were accused by some authors of “controlling” people to accrue power over them. Psychiatry as a profession was thrown on the defensive. The publication of an article in the prestigious journal Science in 1973 charging—through seemingly inspired experiments—that psychiatrists could not even diagnosis a mentally ill patient, created a sensation. This was the last straw for the beleaguered APA. Though only five years had passed since the last revision of the DSM, and little had changed, the Board of Trustees of the APA commissioned a revision that would show that psychiatry was a legitimate medical and scientific endeavor and thus counter the attacks of the antipsychiatry movement. The irony here is that in 2019, the Science article was shown to be in large part fraudulent. DSM-III turned out to be not a revision but a large, brand-new manual based solely on observable signs and symptoms, the “diagnostic criteria.” It upended the diagnosis and treatment of mental disorders in North America and in many other places as well. The Task Force that produced the manual was led by Robert Spitzer, a talented and energetic man, with an empirical bent, who never shied away from a fight. The Task Force he led shared his empiricism, and many of its members were determinedly antipsychoanalytic. There is no doubt that DSM-III helped to dethrone psychoanalysis as a leading method of thought and treatment in North America. Analysts had relied heavily on the diagnosis of neurosis, which Spitzer removed from the manual. Spitzer and the Task Force were strongly supported in their decisions by Melvin Sabshin, the APA’s new medical director, who himself wanted to rid psychiatry of “ideology,” and promote the profession more clearly as scientific and medical. The manual itself featured many new diagnoses because Spitzer wanted to include diagnoses that were important to clinicians. Thus, he prized reliability (psychiatrists agreeing on the same diagnosis) over validity (the accuracy of the diagnosis). A positive feature of DSM-III was its five-pronged diagnostic system, which, if used properly and completely, helped psychiatrists arrive at a deeper knowledge of their patients, as well as a more accurate prognosis. On the other hand, relying solely on diagnostic criteria encouraged some clinicians to practice a relatively quick “checklist” psychiatry instead of taking time to understand patients as human beings in all their complexity. Another shortcoming was the strict categorical approach of the diagnostic system which often led to comorbidity or “not elsewhere specified” diagnoses. Nevertheless, since the appearance of DSM-III, the DSMs have achieved an outsized influence over many key areas of life.