Cleg Article: Teaching About Mental Health and Illness Through the History of the DSM

Overview

• Purpose: Use the history of the DSM to show how mental health concepts have evolved and how culture, policy, and economics shape classification.

• Key idea: Students often view mental illness as fixed; the DSM history reveals a dynamic, contested landscape.

• Core questions guiding the article: theory-neutrality, assumptions about illness, socio-political influences, and the relationship between illness and its classification system.

Key Concepts

• DSM history frames mental health as a social and political product as much as a medical one.

• Early manuals (early 20th century) were biologically oriented; later shifts moved toward psychodynamic language and then back to medical/biomedical approaches with emphasis on empirical validation.

• The DSM should be viewed as a classification tool shaped by its era, not as a timeless map of disease.

• The term

  • "disorder" vs "reaction" reflected changing conceptions of psychopathology (static vs dynamic/reactive).

• The shift from a psychodynamic to a symptoms-based, atheoretical framework aimed to improve cross-theoretical utility and clinical practicality.

• Culture and context became explicit concerns in later editions (e.g., DSM‑IV’s culture, context, and culture-bound syndromes).

Timeline of DSM History

• 1918: Statistical Manual for the Use of Institutions for the Insane; 22 major diagnostic categories; predominantly biological orientation; only one category was clearly psychogenic. 1918

• WWII era: War-related trauma and reactions influenced a move toward psychodynamic interpretations; Medical 203 (1946/2000) introduced a dynamic, largely psychological language with
  "disorder" and "reactions" terminology.

• DSM‑I (1952): Prolonged psychodynamic language; content closely mirrored Medical 203; disorders described in a way that reflected a psychodynamic view.

• DSM‑II (1968): Sought more ICD compatibility; added childhood disorders; largely retained psychodynamic roots, though some terminology shifted.

• DSM‑III (1980): Major break from prior editions; re-emphasized diagnosis as medical and moved to explicit diagnostic criteria; categorical approach; emphasized that disorders are things individuals have, not simply reactions. Key change: evidence-based and data-driven approach to validity; removed explicit theoretical etiologies.

  • Quote:

  • 
    "the approach that was adopted by the DSM–III Task Force … was the use of specified diagnostic criteria for virtually all of the disorders".

  • Disorder terminology shifted to third-person language (e.g., "an individual with Schizophrenia").

• DSM‑III‑R (1987): Minor revisions; added developmental disorders; adjusted criteria and organization based on new data.

• DSM‑IV (1994): Systematic revision process; cross-cultural considerations; introduction of culture-specific discussions; explicit adoption of a biopsychosocial model; emphasis on empirical review via literature, data analyses, and field trials (three distinct stages).

  • Process aimed to base decisions on evidence rather than opinion; later acknowledged that consensus still played a large role. 3 stages

• DSM‑IV‑TR (2000): No major category changes; few criteria changes.

• DSM‑V planning: Work began after DSM‑IV‑TR; anticipated publication around 2012.

Shifts in Diagnostic Philosophy by Edition

• DSM‑I to DSM‑II: Continuity with medical/psychodynamic language; still framed disorders as disorders of functioning but with evolving terminology.

• DSM‑III: Movement toward medicalized, discrete, criteria-based diagnoses; explicit distancing from etiological theories; emphasis on operationalized criteria and clinical utility.

• DSM‑III‑R to DSM‑IV: Revisions largely reorganized categories and criteria; increased attention to culture and context; shift toward a biopsychosocial understanding of illness.

• DSM‑IV‑TR: Refinement and process transparency; retained core structure while updating evidence bases.

• DSM‑V ( planned): Ongoing debate about balancing empirical data with clinical utility and cultural validity.

Drivers of Change

• Intellectual and professional challenges:

  • Antipsychiatry critiques and concerns about validity of diagnoses.

  • Decline of psychodynamic explanations in favor of empiricism and data-driven approaches.

• Political and social pressures:

  • Activism (e.g., homosexuality in DSM‑II) prompted re-evaluation of classifications.

  • Insurance and funding needs favored clearly defined, discrete, and measurable categories for reimbursement and research.

• Economic and policy influences:

  • Drug-based therapies and third-party payer systems incentivized definable, targetable syndromes.

• Process and consensus dynamics:

  • DSM revisions are committee-driven and reflect the views and influence of those in power; even with more transparent processes, bias and negotiation shape outcomes.

Assumptions About Mental Illness Across Editions

• Early DSMs: Saw mental health on a continuum—from healthy to unhealthy—rather than as separate diseases.

• DSM‑III: Treated mental illnesses as distinct, separate disorders, even though the boundaries between them weren’t always clear.

• Modern DSMs: Use a biopsychosocial approach, considering biological, psychological, and social factors. They also pay attention to culture, context, and research evidence, while acknowledging that causes of many disorders are still unknown.Relationship Between Illness and Its Classification

• Diagnoses are not straightforward mapping onto biological diseases; no singular, clear etiological identity for major categories.

• Mental illnesses are socially embedded and shaped by political and economic forces; diagnoses evolve with societal change.

• The DSM reflects how clinicians, researchers, and policymakers conceptualize mental health at a given historical moment, not an immutable natural kind.

Pedagogical Takeaways for Teaching

• Use the DSM history to illustrate that concepts of mental illness are malleable and context-driven.

• Demonstrate how classification systems respond to professional legitimacy challenges and external pressures.

• Encourage critical thinking about how diagnostic criteria influence treatment, research funding, and insurance coverage.

• Use historical examples (e.g., homosexuality as a diagnosis) to discuss social and political context in psychology.

Practical Implications for Students

• Understand why DSM diagnostics are useful tools but must be interpreted within their historical and socio-political context.

• Recognize that current classifications are the result of ongoing debates about validity, utility, and cultural relevance.

• Be prepared to discuss how changes in classification might affect research design, clinical practice, and policy.

References (Selected)

• American Psychiatric Association. (1952). Diagnost¡c and statistical manual: Mental disorders. 1952

• American Psychiatric Association. (1968). Diagnost¡c and statistical manual of mental disorders (2nd ed.). 1968

• American Psychiatric Association. (1980). Diagnost¡c and statistical manual of mental disorders (3rd ed.). 1980

• American Psychiatric Association. (1987). Diagnost¡c and statistical manual of mental disorders (3rd ed., rev.). 1987

• American Psychiatric Association. (1994). Diagnost¡c and statistical manual of mental disorders (4th ed.). 1994

• American Psychiatric Association. (2000). Diagnost¡c and statistical manual of mental disorders (4th ed., text rev.). 2000

• First, M. B., & Pincus, H. (2002). The DSM‑IV text revision: Rationale and potential impact on clinical practice. 2002

• Spitzer, R. L. (1982, 1991). References on DSM development and consensus vs data.

• Mayes, R., & Horowitz, A. V. (2005). DSM‑III and the revolution in the classification of mental illness.

• Rogler, L. H. (1997). Propositions on historical changes in the DSM.

• Pilecki, B., Clegg, J., & McKay, D. (2011). The influence of corporate and political interests on models of illness in the evolution of the DSM.

• Widiger, T. A., Frances, A. J., et al. (1991). Toward an empirical classification for the DSM‑IV.

• Szasz, T. (1960). The myth of mental illness.