Before the DSM

The clear need for a classification system for mental disorders has been present long before the arrival of the DSM system. As far back as 1818, Christian Friedrich Nasse is credited with attempting organize how mental disorders were conceptualized by establishing the Journal for the Healing and Diagnosis of Pathological Mental Disorders (Wunderlich, 1999). However, there was very little agreement regarding how psychopathology should be classified. Nasses's summed up the situation accurately by stating that every worker dealing with mental disorders felt he had to offer a classification system of his own (Stengel, 1956). This appears to be an true with the identification of 39 official and unofficial classifications systems described by Stengel in a 1959 review areticle. The proposed classification systems varied drastically because they focused on different aspects of psychopathology (e.g. phenomonology,  etiology, prognosis, or course) as the defining features of mental illnesses (APA, 2000). 
 
 Christian Friedrich Nasse (1778-1851)

However, the development of the official DSM classification system does not involve the vast majority of those classification systems. Within the United States, the classification of mental disorders began with the U.S. marshals, who served as the census enumerators prior to establishment of the Department of the Interior's census bureau, when they decided to include a question about "idiocy/insanity" on the 1840 census (underlined text are hyperlinks to new pages). Individuals falling into this category were then identified as either being under private or public charge. This was done to gather information regarding the prevalence of mental illness within the United States at the time and had almost nothing to do with understanding the organization of psychopathology (APA, 2000). It is important to note that the U.S. marshals were given no instructions on how to conduct their count, so there were no definitions for the terms "idiocy" and "insanity." Additionally, there were no attempts to separate the individuals who were insane from those who were retarded (Gorwitz, 1974). Not surprisingly, it only took the American Statistical Association three years to send an official protest to the U.S. House of Representatives. It read, "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation." The letter went on to complain that in many towns African-Americans were all marked as insane, and that the statistics were essentially useless (Gorwitz, 1974). While the letter of protest did not lead to swift and substantive change in how the Census was conducted, social scientists continued to see the census as an important tool for understanding mental illness. 

Over the next 30 year, the involvement of Edward Jarvis, M.D., who served as an adviser to the census, was instrumental as the census underwent revisions. He worked to change the census form to create a useful and valid document that could aid practitioners in the mental health field (Grobe, 1985). He was considered to be an atypical physician because of his firm dedication to applying statistical analyses to social problems and his belief that the census could be used to help understand mental illness (Groube, 1985). His efforts gained steam with the appointment of Francis A. Walker as the superintendent of the 1870 census.

Edward Jarvis (1796-1886)


Walker, later a president of the Massachusetts Institute of Technology, used his position to change the census in order to collect information that was useful for individuals working on public policy issues. For the 1870, he included data on the insane which was separated by race, age, and sex (Grobe 1985). Under Walker, the census results grew from two volumes in 1870 to 25 volumes for the 1880 census. In the 1880 census, Walker appointed Frederick H. Wines to write a complete volume focused strictly on dependency. the 582-page volume was published in 1888 Under the title Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880).  Wines went beyond reporting the simple reporting of prevalence of insanity by starting to discuss the relationships between mental illness and demographic variables such as race, gender, age, ect. (Grobe 1985). Within the volume, he divided mental illness into seven discrete categories; these included dementia, dispsomania, epilepsy, mania, melancholia, monomania, paresis (Grob, 1985)1.  These changes helped mental health providers organize material and communicate with one another, but this system did not take into account etiology. While Wines's categories were adopted by the American Psychiatrists Association, many members did not believe this system was strong enough to withstand the test of time (Grobe, 1985).

Francis A. Walker (1840-1897)


The next major change in the tracking of mental illness within the United States occurred in 1917. The American Psychological Association, called the American Medico-Psychological Association until 1921,  helped the Bureau of the Census develop a standardized form to collect uniform information across all mental hospitals (APA, 2000). This form was still used primarily for the collection of data, but was developed and designed to aid mental health providers in diagnosing specific disorders (APA, 2000). From this collaboration, the first edition of the American Medical Association's Standard Classified Nomenclature of Disease, MASCND, became the first standardized classification system used in the United States (APA, 2000; Grobe, 1985; National Committee for Mental Hygiene, 1918). This particular classification system was designed intentionally to be used in institutional settings for the diagnosing of individuals with severe psychiatric disorders (APA, 2000). This made sense because at the time psychiatrists believed that when mental illness was present it was almost always so severe in nature that hospitalization was required. This strict focus on severe psychopathology was ultimately what made this classification fail.


The next large step towards the current DSM classification system came in 1946 when the U.S. army developed their own classification system. The need for a different system specifically for the army was necessary since many service members were observed to have mental illness symptoms that did not fit under the content covered by the MASCND (Houts, 2000). The War Department Technical Bulletin, Medical 203 (to be called Medical 203 from this point forward) first appeared in October of 1943. The link will take you to the actual document available through PsychInfo. The committee responsible for the work was chaired by William C. Menninger (Houts, 2000). Reportedly, Menninger was a pivotal figure in the rapid expansion in mental health services following World War II (Houts, 2000). He both supported the quickly emerging clinical psychology field and believed that assessment and treatment services could improved the mental health of veterans and society (Houts 2000; Menninger, 1950). Post World War II, there was a large influx of returning service men and veterans that needed outpatient services, and the The Medical 203 was the answer to this problem. This movement was not supported by the chairman of the American Psychiatric Association's Committee on Nomenclature, and the work was never published in the association's official journal (Houts, 2000). 



William C. Menninger (1899-1966)

The Medical 203 was one of the first classification systems that fully embraced the concept that life circumstances and stressful events could lead to mental illness in normal people (Houts, 2000). This idea was enforced dramatically by the waves of service men returning home who were struggling with psychopathology. The rise of psychoanalytic theory also took firm root in the Medical 203 and helped to expand the idea that psychological treatment could help benefit those suffering from the mental illness. In the end, the Medical 203 consisted of 52 specific disorders grouped into five categories; 1) Transient personality reactions to acute or special stress, 2) Psychoneurotic disorders, 3) Character and behavior disorders, 4) Disorders of intelligence, and 5) Psychotic disorders (Stengel, 1959).


The influence  of the Medical 203 on the DSM-I was substantial and will be discussed in the next section on the DSM-I


1. It should be noted that these seven categories were the result of the 1880 census. Thus the statement, "By the 1880 census, seven categories of of mental illness were disguised" is misleading. (APA, 2000 p. xxv)