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`r1
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`DIAGNOSTIC AND STATISTICAL
`
`MANUAL OF
`
`MENTAL DISORDERS
`
`FOURTH EDITION
`
`DSM-IVTM
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`
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`PUBLISHED BY THE
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`AMERICAN PSYCHIATRIC ASSOCIATION
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`WASHINGTON, DC
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`Copyright © 1994 American Psychiatric Association
`
`ALL RIGHTS RESERVED. Unless authorized in writing by the APA, no part of this book may be
`reproduced or used in a manner inconsistent With the APA’s copyright. This prohibition applies
`to unauthorized uses or reproductions in any form, including electronic applications.
`
`Manufactured in the United States of America on acid-free paper
`
`American Psychiatric Association
`1400 K Street, N.W., Washington, DC 20005
`
`Correspondence regarding copyright permissions should be directed to the Division of Publica—
`tions and Marketing, American Psychiatric Association, 1400 K Street, N.W., Washington, DC
`20005.
`
`DSM and DSM-IV are trademarks of the American Psychiatric Association. Use of these terms is
`prohibited Without permission of the American Psychiatric Association.
`
`The correct citation for this book is American Psychiatric Association: Diagnostic and Statistical
`Manual ofMenml Disorders, Fourth Edition. Washington, DC, American Psychiatric Association,
`1994.
`
`Library of Congress Catalogmg-in-Publication Data
`Diagnostic and statistical manual of mental disorders : DSM-IV. — 4th ed.
`p.
`cm.
`Prepared by the Task Force on DSM-IV and other committees and work
`groups of the American Psychiatric Association.
`Includes index.
`
`i
`
`ISBN 0-89042-061-0 (hard : alk. paper). — ISBN 0-89042-062-9 (paper : alk. paper)
`1. Mental illness—Classification. 2. Mental illness—Diagnosis.
`1. American Psychiatric Association.
`II. American Psychiatric
`Association. Task Force on DSM-IV.
`111. Title: DSM—IV.
`[DNLMz
`1. Mental Disorders—classification.
`2. Mental Disorders—
`diagnosis. WM 15 D536 1994]
`RC455.2.C4D54
`1994
`616.89’075—dc20
`DNLM/DLC
`for Library of Congress
`
`94—6504
`CIP
`
`
`
`
`
`
`
`British Library Cataloguing in Publication Data
`A CIP record is available from the British Library.
`
`First printing 150,000, May 1994
`Second printing 150,000, July 1994
`
`Text Design—Jane H. Davenport
`Manufacturing—R. R. Donnelley 8: Sons Company
`
`
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`To Melvin Subs/9m,
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`a momfor all seasons
`
`
`
`: book may be
`u‘bition applies
`)l'lS.
`
`on of Publica-
`ashington, DC
`
`these terms is
`
`and Statistical
`C Association,
`
`per)
`
`94-6304
`CIP
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`Task Force on DSM—IV
`
`Acknowledgments
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`Introduction
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`II
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`ix
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`xiii
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`XV
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`II
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`II
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`II
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`II
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`Cautionary Statement
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`Use of the Manual
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`DSM—IV Classification
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`Multiaxial Assessment
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`Disorders Usually First Diagnosed in Infancy, Childhood, or
`Adolescence
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`Delirium, Dementia, and Amnestic and Other Cognitive Disorders
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`15
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`25
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`37
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`123
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`165
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`Mental Disorders Due to a General Medical Condition .
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`Substance—Related Disorders
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`Schizophrenia and Other Psychotic Disorders
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`Mood Disorders
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`175
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`Anxiety Disorders
`Somatoforrn Disorders
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`Factitious Disorders
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`Dissociative Disorders
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`Sexual and Gender Identity Disorders
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`Eating Disorders
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`Sleep Disorders
`Impulse—Control Disorders Not Elsewhere Classified
`Adjustment Disorders
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`471
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`477
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`495
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`II Personality Disorders
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`
`675
`ll Other Conditions That May Be a Focus of Clinical Attention
`
`ll Additional Codes
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`ll Appendixes
`
`Appendix A
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`Appendix 8
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`Decision Trees for Differential Diagnosis
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`Criteria Sets and Axes Provided for Further Study
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`Outline for Cultural Formulation and Glossary of
`Culture-Bound Syndromes
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`687
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`689
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`703
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`763
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`773
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`795
`
`803
`
`813
`
`829
`
`845
`
`851
`
`Appendix C
`
`Glossary of Technical Terms
`
`Appendix D
`
`Annotated Listing of Changes in DSM—IV
`
`Appendix E
`
`Alphabetical Listing of DSM—IV Diagnoses and
`Codes
`
`Appendix F
`
`Numerical Listing of DSM—IV Diagnoses and
`Codes
`
`Appendix G
`
`ICD-9—CM Codes for Selected General Medical
`Conditions and Medication-Induced Disorders
`
`DSM-IV Classification With ICD—lO Codes
`
`Appendix H
`
`Appendix 1
`
`Appendix]
`
`DSM-IV Contributors
`
`ll
`
`Index
`
`
`
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`629
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`675
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`687
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`689
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`703
`
`763
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`775
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`795
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`803
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`813
`
`829
`
`843
`
`851
`
`875
`
`TASK FORCE ON DSM~IV
`
`ALLEN FRANCES, MD.
`Chairperson
`
`HAROLD ALAN PINCUS, MD.
`Vice—Chairperson
`
`MICHAEL E. FIRST, MD.
`Editor, Text and Criteria
`
`Nancy Coover Andreasen, MD, Ph.D.
`David H. Barlow, Ph.D.
`Magda Campbell, MD.
`Dennis P. Cantwell, MD
`Ellen Frank, Ph.D.
`Judith H. Gold, MD.
`John Gunderson, MD.
`Robert E. Hales, MD.
`Kenneth S. Kendler, MD.
`David J. Kupfer, MD.
`Michael R. Liebowitz, MD.
`Juan Enrique Mezzich, M.D., Ph.D.
`Peter E. Nathan, Ph.D.
`Roger Peele, MD.
`Darrel A. Regier, MD, MPH.
`
`A. John Rush, MD.
`Chester W. Schmidt, M.D.
`Marc Alan Schuckit, MD.
`David Shaffer, MD.
`Robert 1.. Spitzer, M.D., Special Adviser
`Gary J. Tucker, MD.
`B. Timothy Walsh, MD.
`Thomas A. Widiger, Ph.D.,
`Research Coordinator
`
`Janet B. W. Williams, D.S.W.
`John C. Urbaitis, M.D., Assembly Liaison
`James J. Hudziak, M.D.,
`Resident Fellow (1 990—1 993)
`Junius Gonzales, M.D.,
`Resident Fellow (1 988— 1 990)
`
`Ruth Ross, M.A.,
`Nancy E. Vettorello, M.U.P.,
`Wendy Wakefield Davis, Ed.M.,
`Cindy D. Jones,
`Nancy Sydnor—Greenberg, M.A.,
`Myriam Kline, M.S.,
`James W. Thompson, M.D., M.P.H.,
`
`Science Editor
`Administrative Coordinator
`Editorial Coordinator
`Administrative Assistant
`Administrative Consultant
`Focused Field Trial Coordinator
`
`Videotape Field Trial Coordinator
`
`
`
`
`
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`x DSM—IV Work Groups
`
`Anxiety Disorders Work Group
`
`Michael R. Liebowltz, M.D., Chairperson
`David H. Barlow, PhD., Vice—Cbairpemon
`James C. Ballenger, M.D.
`
`Jonathan Davidson, MD.
`Edna Foa, PhD.
`Abby Fyer, M.D.
`
`Delirium, Dementia, and Amnestic and
`Other Cognitive Disorders Work Group
`
`Gary]. Tucker, M.D., Cbainberson
`Michael Popkin, M.D., Vice—Chairperson
`Eric Douglas Caine, M.D.
`Marshall Folstein, MD.
`
`Gary Lloyd Gottlieb, M.D.
`Igor Grant, M.D.
`Benjamin Liptzin, M.D.
`
`Disorders Usually First Diagnosed During Infancy,
`Childhood, or Adolescence Work Group
`
`David Shaffer, M.D., Co—Cbm'rperson
`Magda Campbell, M.D., Co-Cbairperson
`Susan J. Bradley, M.D.
`Dennis P. Cantwell, M.D.
`Gabrielle A. Carlson, M.D.
`Donald Jay Cohen, MD.
`Barry Garfinkel, MD.
`Rachel Klein, PhD.
`
`Benjamin Lahey, PhD.
`Rolf Loeber, PhD.
`Jeffrey Newcorn, M.D.
`Rhea Paul, PhD,
`Judith H. L. Rapoport, M.D.
`Sir Michael Rutter, MD.
`Fred Volkmar, MD.
`John S. Werry, M.D.
`
`Eating Disorders Work Group
`
`B. Timothy Walsh, M.D., Chairperson
`Paul Garfinkel, M.D.
`Katherine A. Halmi, MD.
`
`James Mitchell, MD.
`G. Terence Wilson, PhD.
`
`Mood Disorders Work Group
`
`A. John Rush, M.D., Chairperson
`Martin B. Keller, M.D., Wee—Chaimemon
`Mark S. Bauer, M.D,
`
`David Dunner, MD.
`Ellen Frank, PhD.
`Donald F. Klein, M.D.
`
`_
`‘- __J_
`a' — -—*
`
`1- ____ _‘
`
`H -
`
`'.
`-= m.
`
`1.
`
`..
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`ncy,
`
`DSM-IV Work Groups
`
`xi
`
`Multiaxial Issues Work Group
`
`Janet B. W. Williams, D.S.W.,
`Chairperson
`Howard H. Goldman, MD, Ph.D.,
`Vice-Chaimerson
`Alan M. Gruenberg, MD.
`
`Juan Enrique Mezzich, MD, Ph.D.
`Roger Peele, M.D.
`Stephen Setterberg, MD.
`Andrew Edward Skodol H, MD.
`
`Personality Disorders Work Group
`
`John Gunderson, M.D., Cbaiiperson
`Robert M. A. Hirschfeld, M.D.,
`Vice—Chairperson
`Roger Blashfield, PhD.
`Susan Jean Fiester, MD.
`
`Theodore Millon, PhD.
`Bruce Pfohl, MD.
`Tracie Shea, PhD.
`Larry Siever, M.D.
`Thomas A. Widiger, PhD.
`
`Premenstrual Dysphoric Disorder Work Group
`
`Judith H. Gold, M.D., Chairperson
`Jean Endicott, PhD.
`Barbara Parry, M.D.
`
`Sally Severino, M.D.
`Nada Logan Stotland, M.D.
`Ellen Frank, Ph.D., Consultant
`
`Psychiatric Systems Interface Disorders
`(Adjustment, Dissociative, Factitious, Impulse—Control, and
`Somatoform Disorders and Psychological Factors
`Affecting Medical Conditions) Work Group
`
`Robert E. Hales, M.D.,‘Cbai1person
`C. Robert Cloninger, M.D.,
`Vice-Cbniiperson
`Jonathan F. Borus, M.D.
`Jack Denning Burke, Jr., MD, M.P.H.
`Joe P. Fagan, MD.
`Steven A. King, MD.
`
`Ronald L. Martin, MD.
`Katharine Anne Phillips, M.D.
`David Spiegel, MD.
`Alan Stoudemire, M.D.
`James J. Strain, M.D.
`Michael G. Wise, MD.
`
`Schizophrenia and Other Psychotic Disorders Work Group
`
`Nancy Coover Andreasen, M.D., Ph.D.,
`Chairperson
`John M. Kane, M.D., Vice-Chairperson
`
`Samuel Keith, M.D.
`Kenneth S. Kendler, MD.
`Thomas McGlashan, M.D.
`
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`...L
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`xii DSM-IV Work Groups
`
`Sexual Disorders Work Group
`
`Chester W. Schmidt, M.D., Chairperson
`Raul Schiavi, MD.
`Leslie Schover, Ph.D.
`
`Taylor Seagraves, M.D.
`Thomas Nathan Wise, MD.
`
`Sleep Disorders Work Group
`
`David]. Kupfer, M.D., Cbalnberson
`Charles F. Reynolds III, M.D.,
`Vice-Cbaz‘tperson
`Daniel Buysse, MD.
`
`Roger Peele, MD.
`Quentin Regestein, M.D.
`Michael Sateia, MD.
`Michael Thorpy, M.D.
`
`Substance~Related Disorders Work Group
`
`Marc Alan Schuckit, M.D., Cbattperson
`John E. Helzer, M.D., Vtce—C/oalnberson
`Linda B. Cottler, Ph.D.
`
`Thomas Crowley, MD.
`Peter E. Nathan, PhD.
`George E. Woody, M.D.
`
`Committee on Psychiatric Diagnosis and Assessment
`
`Layton McCurdy, M.D., Chairperson
`(1987—1994)
`Kenneth Z. Altshuler, M.D. (1987—1992)
`Thomas F. Anders, M .D. (1988—1994)
`Susan Jane Blumenthal, MD.
`(1990—1993)
`Leah Joan Dickstein, MD. (1988—1991)
`Lewis J. Judd, MD. (1988—1994)
`Gerald L. Klerman, M.D. (deceased)
`(1988—199 1)
`Stuart C. Yudofsky, MD. (1992—1994)
`Jack D. Blaine, M.D., Consultant
`(1987—1992)
`Jerry M. Lewis, M.D., Consultant
`(1988—1994)
`
`Daniel J. Luchins, M.D., Consultant
`(1987—1991)
`Katharine Anne Phillips, M.D.,
`Consultant (1992—1994)
`Cynthia Pearl Rose, M.D., Consultant
`(1990—1994)
`Louis Alan Moench, M.D.,
`Assembly Liaison (1991—1994)
`Steven K. Dobscha, M.D., Resident
`Fellow (1990—1992)
`Mark Zimmerman, M.D., Resident Fellow
`(1992-1994)
`
`Joint Committee of the Board of Trustees
`and
`
`Assembly of District Branches on Issues Related to DSM~IV
`
`Ronald A. Shellow, M.D., Cbaitperson
`Harvey Bluestone, MD.
`Leah Joan Dickstein, MD.
`
`Arthur John Farley, MD.
`Carol Ann Bernstein, MD.
`
`
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`
`
`Acknowledgments
`
`sment
`
`sultan:
`
`) ')
`
`msultant
`
`994)
`ardent
`
`idem Fellow
`
`) DSM~lV
`
`DSM~IV is a team effort. More than 1,000 people (and numerous professional
`organizations) have helped us in the preparation of this document. Members of
`the Task Force on DSM-IV and DSM-IV Staff are listed on p. ix, members of the DSM—IV
`Work Groups are listed on pp. X—xii, and a list of other participants is included in
`Appendix J.
`The major responsibility for the content of DSM—IV rests with the Task Force on
`DSM-IV and members of the DSM-IV Work Groups. They have worked (often much
`harder than they bargained for) with a dedication and good cheer that has been
`inspirational to us. Bob Spitzer has our special thanks for his untiring efforts and unique
`perspective. Norman Sartorius, Darrel Regier, Lewis Judd, Fred Goodwin, and Chuck
`Kaelber were instrumental in facilitating a mutually productive interchange between the
`American Psychiatric Association and the World Health Organization that has improved
`both DSM—IV and ICD-lO, and increased their compatibility. We are grateful to Robert
`Israel, Sue Meads, and Amy Blum at the National Center for Health Statistics and Andrea
`Albaum—Feinstein at the American Health Information Management Association for
`suggestions on the DSM—IV coding system. Denis Prager, Peter Nathan, and David Kupfer
`helped us to develop a novel data reanalysis strategy that has been supported with
`funding from the John D. and Catherine T. MacArthur Foundation.
`Many individuals within the American Psychiatric Association deserve recognition.
`Mel Sabshin’s special wisdom and grace made even the most tedious tasks seem worth
`doing. The American Psychiatric Association Committee on Psychiatric Diagnosis and
`Assessment (chaired by Layton McCurdy) provided valuable direction and counsel. We
`would also like to thank the American Psychiatric Association Presidents (Drs. Fink,
`Pardes, Benedek, Hartmann, English, and McIntyre) and Assembly Speakers (Drs. Cohen,
`Flamm, Hanin, Pfaehler, and Shellow) who helped with the planning of our work.
`Carolyn Robinowitz and Jack White, and their respective staffs in the American
`Psychiatric Association Medical Director’s Office and the Business Administration Office,
`have provided valuable assistance in the organization of the project.
`Several other individuals have our special gratitude. Wendy Davis, Nancy Vettorello,
`and Nancy Sydnor-Greenberg developed and implemented an organizational structure
`that has kept this complex project from spinning out of control. We have also been
`blessed with an unusually able administrative staff, which has included Elisabeth
`Fitzhugh, Willa Hall, Kelly McKinney, Gloria Miele, Helen Stayna, Sarah Tilly, Nina
`Rosenthal, Susan Mann, Joanne Mas, and, especially, CindyJones. Ruth Ross, our tireless
`Science Writer, has been responsible for improving the clarity of expression and
`
`xiii
`
`
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`xiv Acknowledgments
`
`organization of DSM—IV. Myriam Kline (Research Coordinator for the NIH-funded DSM-IV
`Focused Field Trials), Jim Thompson (Research Coordinator for the MacArthur Founda—
`tion—funded Videotape Field Trial), and Sandy Ferris (Assistant Director for the Office
`of Research) have made many valuable contributions. We would also like to acknow—
`ledge all the other staff persons at the American Psychiatric Association who have helped
`with this project. Ron McMillen, Claire Reinburg, Pam Harley, and Jane Davenport of
`American Psychiatric Press have provided expert production assistance.
`
`Allen Frances, M.D.
`Chair, Task Force on DSM—IV
`
`Harold Alan Pincus, M.D.
`Woe—Chair, Task Force on DSM-IV
`
`Michael B. First, MD.
`Editor, DSM—IV Text and Criteria
`
`Thomas A. Widiger, Ph.D.
`Research Coordinator
`
`
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`ided DSM-IV
`hur Founda-
`)r the Office
`to acknow—
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`have helped
`)avenport of
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`95M—1V
`
`Introduction
`
`This is the fourth edition of the American Psychiatric Association’s Diagnostic and
`Statistical Manual ofMental Disorders, or DSM-IV. The utility and credibility of
`DSM-IV require that it focus on its clinical, research, and educational purposes and be
`supported by an extensive empirical foundation. Our highest priority has been to provide
`a helpful guide to clinical practice. We hoped to make DSM—IV practical and useful for
`clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements
`of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate
`research and improve communication among clinicians and researchers. We were also
`mindful of the use of DSM-IV for improving the collection of clinical information and
`as an educational tool for teaching psychopathology.
`An official nomenclature must be applicable in a wide diversity of contexts. DSM—IV
`is used by clinicians and researchers of many different orientations (e.g., biological,
`psychodynamic, cognitive, behavioral,
`interpersonal, family/systems).
`It
`is used by
`psychiatrists, other physicians, psychologists, social workers, nurses, occupational and
`rehabilitation therapists, counselors, and other health and mental health professionals.
`DSM—iV must be usable across settings—inpatient, outpatient, partial hospital, consulta—
`tion—liaison, clinic, private practice, and primary care, and with community populations.
`It
`is also a necessary tool for collecting and communicating accurate public health
`statistics. Fortunately, all these many uses are compatible with one another.
`DSM-IV was the product of 13 Work Groups (see Appendix J), each of which had
`primary responsibility for a section of the manual. This organization was designed to
`increase participation by experts in each of the respective fields. We took a number of
`precautions to ensure that the Work Group recommendations would reflect the breadth
`of available evidence and opinion and not just the views of the specific members. After
`extensive consultations with experts and clinicians in each field, we selected Work Group
`members who represented a wide range of perspectives and experiences. Work Group
`members were instructed that they were to participate as consensus scholars and not as
`advocates of previously held views. Furthermore, we established a formal evidence—
`based process for the Work Groups to follow.
`The Work Groups reported to the Task Force on DSM-IV (see p. ix), which consisted
`of 27 members, many of whom also chaired a Work Group. Each of the 13 Work Groups
`was composed of 5 (or more) members whose reviews were critiqued by between 50
`and 100 advisers, who were also chosen to represent diverse clinical and research
`expertise, disciplines, backgrounds, and settings. The involvement of many international
`experts ensured that DSM—IV had available the widest pool of information and would
`be applicable across cultures. Conferences and workshops were held to provide
`XV
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`XVi Introduction
`
`conceptual and methodological guidance for the DSM-IV effort. These included a
`number of consultations between the developers of DSM-IV and the developers of
`ICED—10 conducted for the purpose of increasing compatibility between the two systems.
`Also held were methods conferences that focused on cultural factors in the diagnosis of
`mental disorder, on geriatric diagnosis, and on psychiatric diagnosis in primary care
`settings.
`To maintain open and extensive lines of communication, the Task Force on DSM—IV
`established a liaison with many other components within the American Psychiatric
`Association and with more than 60 organizations and associations interested in the
`development of DSM—IV (cg, American Health Information Management Association,
`American Nurses’ Association, American Occupational Therapy Association, American
`Psychoanalytic Association, American Psychological Association, American Psychologi-
`cal Society, Coalition for the Family, Group for the Advancement of Psychiatry, National
`Association of Social Workers, National Center for Health Statistics, World Health
`Organization). We attempted to air issues and empirical evidence early in the process
`in order to identify potential problems and differences in interpretation. Exchanges of
`information were also made possible through the distribution of a semiannual newsletter
`(the DSMvIV Module), the publication of a regular column on DSM—IV in Hospital and
`CommunityPsyc/az‘aml, frequent presentations at national and international conferences,
`and numerous journal articles.
`Two years before the publication of DSM—IV, the Task Force published and widely
`distributed the DSM—IVOptions Boo/e. This volume presented a comprehensive summary
`of the alternative proposals that were being considered for inclusion in DSM—IV in order
`to solicit opinion and additional data for our deliberations. We received extensive
`correspondence from interested individuals who shared with us additional data and
`recommendations on the potential impact of the possible changes in DSM—IV on their
`clinical practice, teaching, research, and administrative work. This breadth of discussion
`helped us to anticipate problems and to attempt to find the best solution among the
`various options. One year before the publication of DSM-IV, a near—final draft of the
`proposed criteria sets was distributed to allow for one last critique.
`In arriving at final DSM-IV decisions, the Work Groups and the Task Force reviewed
`all of the extensive empirical evidence and correspondence that had been gathered. It
`is our belief that the major innovation of DSM-IV lies not in any of its specific content
`changes but rather in the systematic and explicit process by Which it was constmcted
`and documented. More than any other nomenclature of mental disorders, DSM—IV is
`grounded in empirical evidence.
`
`Historical Background
`
`The need for a classification of mental disorders has been clear throughout the history
`of medicine, but there has been little agreement on which disorders should be included
`and the optimal method for their organization. The many nomenclatures that have been
`developed during the past two millennia have differed in their relative emphasis on
`phenomenology, etiology, and course as defining features. Some systems have included
`only a handful of diagnostic categories; others have included thousands. Moreover, the
`various systems for categorizing mental disorders have differed with respect to whether
`their principle objective was for use in clinical, research, or statistical settings. Because
`
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`Introduction xvii
`
`:se included a
`
`developers of
`re two systems.
`ne diagnosis of
`1 primary care
`
`:rce on DSM-IV
`
`:an Psychiatric
`:erested in the
`nt Association,
`tion, American
`an Psychologi—
`1iatry, National
`World Health
`
`in the process
`Exchanges of
`lual newsletter
`
`1 Hospital and
`11 conferences,
`
`ed and widely
`isive summary
`SM—IV in order
`ved extensive
`onal data and
`SM-IV on their
`'1 of discussion
`
`on among the
`al draft of the
`
`orce reviewed
`
`in gathered. It
`)ecific content
`is constructed
`ers, DSM—IV is
`
`)ut the history
`.d be included
`hat have been
`emphasis on
`have included
`Moreover, the
`act to whether
`
`:ings. Because
`
`the history of classification is too extensive to be summarized here, we focus briefly only
`on those aspects that have led directly to the development of the Diagnostic and
`Statistical Manual ofMenial Disorders (DSM) and to the “Mental Disorders" sections in
`the various editions of the International Classification ofDiseases (1CD).
`In the United States, the initial impetus for developing a classification of mental
`disorders was the need to collect statistical information. What might be considered the
`first official attempt to gather information about mental illness in the United States was
`the recording of the frequency of one category—“idiocy/insanity” in the 1840 census.
`By the 1880 census, seven categories of mental illness were distinguished—mania,
`melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917, the
`Committee on Statistics of the American Psychiatric Association (at that time called the
`American Medico-Psychological Association [the name was changed in 1921]), together
`with the National Commission on Mental Hygiene, formulated a plan that was adopted
`by the Bureau of the Census for gathering uniform statistics across mental hospitals.
`Although this system devoted more attention to clinical utility than did previous systems,
`it was still primarily a statistical classification. The American Psychiatric Association
`subsequently collaborated with the New York Academy of Medicine to develop a
`nationally acceptable psychiatric nomenclature that would be incorporated within the
`first edition of the American Medical Association’s Standard Classified Nomenclature of
`Disease. This nomenclature was designed primarily for diagnosing inpatients with severe
`psychiatric and neurological disorders.
`A much broader nomenclature was later developed by the US. Army (and modified
`by the Veterans Administration) in order to better incorporate the outpatient presenta—
`tions of World War II servicemen and veterans (e.g., psychophysiological, personality,
`and acute disorders). Contemporaneously,
`the World Health Organization (WHO)
`published the sixth edition of 1CD, which, for the first time, included a section for mental
`disorders. ICD-6 was heavily influenced by the Veterans Administration nomenclature
`and included 10 categories for psychoses, 9 for psychoneuroses, and 7 for disorders of
`character, behavior, and intelligence.
`The American Psychiatric Association Committee on Nomenclature and Statistics
`developed a variant of the ICD—6 that was published in 1952 as the first edition of the
`Diagnostic and StatisticalManual: MentalDisora’ers (DSM—I). DSM—I contained a glossary
`of descriptions of the diagnostic categories and was the first official manual of mental
`disorders to focus on clinical utility. The use of the term reaction throughout DSM—I
`reflected the influence of Adolf Meyer’s psychobiological View that mental disorders
`represented reactions of the personality to psychological, social, and biological factors.
`In part because of the lack of widespread acceptance of the mental disorder
`taxonomy contained in ICD-6 and [CD-7, WHO sponsored a comprehensive review of
`diagnostic issues that was conducted by the British psychiatrist Stengel. His report can
`be credited with having inspired many of the recent advances in diagnostic methodol—
`ogy—most especially the need for explicit definitions as a means of promoting reliable
`clinical diagnoses. However, the next round of diagnostic revision, which led to DSM—II
`and ICD—S, did not follow Stengel’s recommendations to any great degree. DSM-II was
`similar to DSM-I but eliminated the term reaction.
`As had been the case for DSM-I and DSM—II, the development of DSM—III was
`coordinated with the development of the next (ninth) version of 1CD, which was
`published in 1975 and implemented in 1978. Work began on DSM—III in 197/1, with
`publication in 1980. DSM-TTI introduced a number of important methodological innova-
`tions,
`including explicit diagnostic criteria, a multiaXial system, and a descriptive
`
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`
`Xviii Introduction
`
`approach that attempted to be neutral with respect to theories of etiology. This effort
`was facilitated by the extensive empirical work then under way on the construction and
`validation of explicit diagnostic criteria and the development of semistructured inter—
`views. ICD—9 did not include diagnostic criteria or a multiaxial system largely because
`the primary function of this international system was to delineate categories to facilitate
`the collection of basic health statistics. In contrast, DSM—III was developed with the
`additional goal of providing a medical nomenclature for clinicians and researchers.
`Because of dissatisfaction across all of medicine with the lack of specificity in ICD-9, a
`decision was made to modify it for use in the United States, resulting in ICD-9-CM (for
`Clinical Modification).
`Experience with DSM~III revealed a number of inconsistencies in the system and a
`number of instances in which the criteria were not entirely clear. Therefore, the American
`Psychiatric Association appointed a Work Group to Revise DSM-III, which developed
`the revisions and corrections that led to the publication of DSM-III-R in 1987.
`
`The DSM—lV Revision Process
`
`The third edition of the Diagnostic and StatisticalManual ofMem‘al Disorders (DSM—III)
`represented a major advance in the diagnosis of mental disorders and greatly facilitated
`empirical research. The development of DSM—IV has benefited from the substantial
`increase in the research on diagnosis that was generated in part by DSM—III and
`DSM-HI—R. Most diagnoses now have an empirical literature or available data sets that
`are relevant to decisions regarding the revision of the diagnostic manual. The Task Force
`on DSM—IV and its Work Groups conducted a three-stage empirical process that included
`1) comprehensive and systematic reviews of the published literature, 2) reanalyses of
`already-collected data sets, and 3) extensive issue—focused field trials.
`
`Literature Reviews
`
`Two methods conferences were sponsored to articulate for all the Work Groups a
`systematic procedure for finding, extracting, aggregating, and interpreting data in a
`comprehensive and objective fashion. The initial tasks of each of the DSM-IV Work
`Groups were to identify the most pertinent issues regarding each diagnosis and to
`determine the kinds of empirical data relevant to their resolution. AWork Group member
`or adviser was then assigned the responsibility of conducting a systematic and
`comprehensive review of the relevant literature that would inform the resolution of the
`issue and also document the teXt of DSM-IV. The domains considered in making
`decisions included clinical utility, reliability, descriptive validity, psychometric perfor—
`mance characteristics of individual criteria, and a number of validating variables.
`Each literature review specified 1) the issues or aspects of the text and criteria under
`consideration and the significance of the issues with respect to DSM-IV; 2) the review
`method (including the sources for identifying relevant studies, the number of studies
`considered, the criteria for inclusion and exclusion from the review, and the variables
`catalogued in each study); 3) the results of the review (including a descriptive summary
`of the studies with respect to methodology, design, and substantive correlates of the
`findings, the relevant findings, and the analyses conducted on these findings); and 4) the
`various options for resolving the issue, the advantages and disadvantages of each option,
`
`__
`
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`Introduction xix
`
`. This effort
`:ruction and
`:tured inter-
`
`ely because
`. to facilitate
`ed with the
`researchers.
`in ICD~9, a
`D-9—CM (for
`
`ystem and a
`re American
`
`1 developed
`i7.
`
`'rs (DSM—III)
`ly facilitated
`substantial
`)SM—III and
`ata sets that
`: Task Force
`lat included
`
`:analyses of
`
`k Groups a
`g data in a
`iM—IV Work
`osis and to
`
`iup member
`ematic and
`ution of the
`
`in making
`attic perfor-
`ables.
`'iteria under
`| the review
`rr of studies
`he variables
`ve summary
`:lates of the
`); and 4) the
`each option,
`
`recommendations, and suggestions for additional research that would be needed to
`provide a more conclusive resolution.
`The goal of the DSM-IV literature reviews was to provide comprehensive and
`unbiased information and to ensure that DSM-IV reflects the best available clinical and
`research literature. For this reason, we used systematic computer searches and critical
`reviews done by large groups of advisers to ensure that the literature coverage was
`adequate and that the interpretation of the results was justified. Input was solicited
`eSpecially from those persons likely to be critical of the conclusions of the review. The
`literature reviews were revised many times to produce as comprehensive and balanced
`a result as possible. It must be noted that for some issues addressed by the DSM—IV Work
`Groups, particularly those that were more conceptual in nature or for which there were
`insufficient data, a review of the empirical literature had limited utility. Despite these
`limitations, the reviews were helpful in documenting the rationale and empirical support
`for decisions made by the DSM—IV Work Groups.
`
`Data Reanalyses
`
`When a review of the literature revealed a lack of evidence (or conflicting evidence) for
`the resolution of an issue, we often made use