The DSM I and DSM II

DSM-I

By the end of World War II, psychiatrists again faced a problem regarding the nomenclature for psychopathology. Within the United States, there were three different classification systems for mental illness in use. The first was the Standard Classified Nomenclature of Disease - 1942 revision. The second was the Armed Forces Nomenclature (Medical 203). Third was the Veterans Administration Nomenclature which was a slightly different version of the Medical 203. To add to the confusion, none of these classification systems matched the systems used by hospitals for reporting purposes (APA, 1952; Houts, 2000).  All in all, this created a confusing scene where professionals had trouble communicating with each other and had to learn multiple systems depending on the type of work they were conducting. Military and Veterans Administration psychiatrists stated that the nomenclature they were using was ill-adapted for 90 percent of their patients (Grob, 1991).

As such, the representatives from all areas met to begin forming the new classification system (APA, 1952). George N. Raines, chair of the APA Committee on Nomenclature and Statistics wrote the forward for the DSM-I in which he outlines the revision process and creation of the new DSM nomenclature. The forward paints a very favorable picture of the different organizations working together without much discord (APA, 1952). As the release date of the DSM approached, the committee sent it for review to approximately 10 percent  of the APA membership. Of the surveys that were returned, almost all (93%) approved of the DSM-I draft. The second draft was then approved by the APA membership in 1951 (Houts, 2000). The DSM-I was 145 pages long and included a total of 106 disorders (APA 1952).

In many ways, the DSM-I mirrored the Medical 203 classification system. As in the Medical 203, each specific disorder was described in paragraph form so that psychologists and psychiatrists could compare their patients to the provided description. Here is a link to the description given for the Paranoid personalty disorderMany of the passages of the DSM-I were taken directly from the Medical 203 and both relied heavily on psych-dynamic concepts of diagnosing psychopathology. The DSM-I and Medical 203 divided psychological pathology into the standard psychoanalytic categories of neurotic, psychotic, and character disorders. The only differences in between the structure of the two documents was that the DSM-I placed somatization reactions in a separate category where the Medical 203 placed these disorders in the psycho-neurotic division (Houts, 2000). The DSM-I also added an additional six somatization disorders that were not included in the Medical 203. The only other stucutral difference between the two was that the DSM-I included a section for Nondiagnostic Terms that mental health professionals could use for coding test results and other observations. Interestingly, neither system dedicated space for childhood specific disorders. 

The largest controversy from the the DSM-I was the dropping of the Combat Exhaustion disorder. While the specific disorder was gone, the concept was replaced with a tempered version called Gross Stress Reaction. While this allowed for non-combat traumas to be diagnosed, it also shifted the focus away identifying the negative reactions that many individuals had after experiencing combat (Houts, 2000). The central diagnosis of Combat Exhaustion became an afterthought in the DSM-I and was dropped all together by the DSM-II. While not exactly the same as our current understanding of PTSD, Combat Exhaustion was a particular concern for the army becasue of World War-II. This link will take you to a 50 minute movie created by the Department of Defense that was used to train psychiatrist about Combat Exhaustion (Department of Defense, 1964). You will quickly here the underlying psychoanalytic themes in the video that correspond accurately to the DSM-I.

One of the hallmark features of the DSM-I was the use of the term "reaction" throughout the manual (APA, 2000). The concept that life circumstances could produce mental illness started in the Medical 203 system and became fully incorporated into the DSM-I. The use of this specific term reflects the influence of Adolf Meyer on the manual (APA, 2000). Adolf Meyer initially believed that mental illness could be explained with chemistry and physiology, but after all his studies he concluded that  this was not true. He came to view Psychopathology as reaction as habit patterns of the total person in response to emotional states brought on the the circumstances of life (Houts, 2000). His final psychobiological view of mental illness incorporated reactions of the personality to psychological, social and biological factors (APA, 2000). 


 Adolf Meyer (1866-1950)


DSM-II

The DSM-II was published in 1968. It was only 136 pages long, but it now included 182 disorders (APA, 1968). The manual could be ordered for $3.50, or 2.80 per copy for orders larger than 50.This edition of the DSM retained the overall approach used in the DSM-I and continued to conceptualize psychopathology from a psychodynamic perspective (First, 2010). This was the first edition to included a section on the behavioral disorders of childhood and adolescence. Withdrawing reaction, Overanxious reaction, Runaway reactions, Unsocialized aggressive reaction, Group deliquent reaction, and other reaction of childhood were listed within this section. Hyperkinetic reaction of childhood was identified, and servered as the precursor to the current Attention Deficit Hyperactivity Disorder of the current DSM-IV-TR. The DSM-II also included a new section on Sexual deviations. Homosexuality, Fetishism, Pedophilia, Transvestism, Exhibitionism, Voyeurism, Sadism, and Masochism were listed as official forms of mental illness (APA, 1952).   

By 1970, there was a growing movement opposing the inclusion of Homosexuality as a mental illness. The movement grew strong enough that protesters rallied at the 1970 APA conference and created a human chain that prevented the psychiatrists from entering the meeting (McCommon, 2006). The protesters stood on the platform that, "homosexuality is a normal variant of human sexuality" (APA, 1973). Among psychiatrist, there was a large divide of opinion about the matter. The matter was sent to a committee headed by Robert Spitzer. The final report the committee generated presented the four tenants about homosexuality. The tenants were: 1) Some experts believed homosexuality was pathological while other experts considered it to be a normal variant; 2) Many homosexuals are satisfied with their sexual orientation; 3) a significant portion of homosexuals with to change their orientation; 4) Modern treatment allows a significant proportion of homosexuals who wish to change there orientation to do so (APA, 1973). Overall, it became clear that homosexuality within itself did not meet the requirements needed to be considered a specific mental disorder, and the committee strong encouraged the APA to remove the diagnosis. The APA adopted the committees recommendations and the homosexual diagnosis was removed in the seventh printing of the DSM-II (McCommon, 2006).


Robert Spitzer (1932-)

The first step towards making the DSM an atheoretical also appeared in the DSM-II. While the term "neurosis" was used in the manual, the psychoanalytic term "reaction" was dropped from all of the adult disorder names in this edition (Houts, 2000).  Robert Sptizer and Paul Wilson wrote an essay that was published at the end of the DSM-II which described the rational for dropping the term (Spitzer & Wilson, 1968). They specifically stated that term had term had been dropped because it wanted to avoid adhereing to any specific theory when labeling disorders (Houts, 2000). Shortly after the release of the DSM-II, it was under attack from many groups who did not agree with the psychoanalytic influence that remained (Houts, 2000). By 1973, it was clear that a new edition was necessary to remove the psychoanalytic concepts (Blashfield, 1984). The influence of Neo-Krapelians was described as a successful coup within the APA, and the influence of the Medical 203 never reached the pages of the DSM-III (Houts, 2000).


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