`
`Exhibit 2016
`
`Slayback v. Sumitomo
`|PR2020-01053
`
`1
`
`Exhibit 2016
`Slayback v. Sumitomo
`IPR2020-01053
`
`

`

`DSM-III
`
`2
`
`

`

`First Printing, February 1980
`Second Printing, May 1980
`
`3
`
`

`

` Diagnostic
`
`and Statistical Manual
`of Mental Disorders
`
`
`
`
`
`(Third Edition)
`
`
`
`4
`
`

`

`Library of Congress Catalogue Number 79-055368
`Copyright © The American Psychiatric Association, 1980
`
`All rights reserved. No part of this book may
`be reproduced in any form without permission
`in writing from the American Psychiatric
`Association, except by a reviewer who may
`quote brief passages in a review to be
`published in a journal, magazine, or news-
`paper. Correspondence regarding copyright
`should be directed to the Division of
`
`Public Affairs, American Psychiatric Associa-
`tion, 1700 13th Street, N.W., Washington,
`D.C. 20009.
`
`ACKNOWLEDGMENTS
`
`This manual was prepared with the help of many people. Special thanks are
`given to the members of the Task Force on Nomenclature and Statistics, the
`various Advisory Committees and Other Consultants, and the members of the
`Assembly Liaison Task Force on DEM-Ill and the Board of Trustees Ad Hoc
`Committee on DSM—lll. In addition, the work of the Field Trial participants,
`who are listed in Appendix F, is gratefully appreciated.
`The following members of the American Psychiatric Association provided
`valuable help in arriving at creative solutions to difficult problems at various
`stages in the development of DEM-III: Drs. Alan A. Storm, President, and
`Chair, Board of Trustees; Donald G. Langsley, President-elect, and Chair, Ref—
`erence Committee; Lester Grinspoon, Chair, Council on Research and Develop
`ment; Edward I. Sachar, DSM-III
`liaison frorn Council on Research and
`Development; Melvin Sabshin, Medical Director; and Henry H. Work, Deputy
`Medical Director and DSM-III staff liaison.
`
`Janet B. W. Williams, M.S.W., was invaluable in coordinating the Field
`Trials, in working with members of the Advisory Committees preparing sections
`of DSM-III ml in integrating the extensive critiques of draft versions in the
`preparation of the final manual. Harriet Ayers’s skill in keeping track of a volu-
`minous correspondence and in typing revision after revision is deeply appre-
`ciated.
`
`A final word of thanks must be given to the many other participants in this
`effort who have not received formal recognition, but who provided critiques and
`suggestions that were helpful in the preparation of DSM-III.
`
`Robert L. Spitzer, MD.
`Chairperson, Task force on
`Nomenclature and Statistics
`
`5
`
`

`

`TASK FORCE ON NOMENCLATURE AND STATISTICS
`
`Robert L. Spitzer, M.D., Chairperson
`Nancy Andreasen, M.D., Ph.D.
`Robert L. Amstein, M.D.
`Dennis Cantwell, M.D.
`
`Morton Kramer, SC.D."'
`
`2.]. Lipowski, M.D.
`Michael L. Mavroidis, M.D.
`Theodore Millon, Ph.D.*
`
`Paula J. Clayton, M.D.
`Jean Endicott, Ph.D.*
`William A. Prosch, M.D.
`Rachel Gittelman, Ph.D.*
`Donald W. Goodwin, M.D.
`Donald F. Klein, M.D.
`* Consultants
`
`ADVISORY COMNIITTEES
`
`ORGANIC MENTAL DISORDERS
`
`Robert Byck, M.D.
`Paula J. Clayton, M.D.
`Gene D. Cohen, M.D.
`William A. Frosch, MD.
`Donald W. Goodwin, MD.
`
`Barry Gurland, M.D.
`
`SUBSTANCE USE DISORDERS
`
`Sidney Cohen, MD.
`Everett Ellinwood, M.D.
`William A. Prosch, M.D.
`Michael I. Good, M.D.
`D0nalcl W. Goodwin, M.D.
`Jerome H. Jaffe, MD.
`Edward J. Khantzian, MD.
`John Kuehnle, M.D.
`Roger E. Meyer, M.D.
`
`Henry Pinsker, MD.
`George Saslow, M.D., PhD.
`Michael Sheehy, MD.
`Robert Woodruff, M.D. (deceased)
`Lyman C. Wynne, M.D., PhD.
`
`John Kuehnle, M.D.
`Z.J. Lipowski, MD.
`Benjamin Seltzer, MD.
`Robert L. Spitzer, M.D.
`Phillip Zeidenberg, M.D., Ph.D.
`
`Robert M. Morse, M.D.
`William M. Petrie, MD.
`Richard B. Resnick, M.D.
`Lee N. Robins, PhD.
`Henry L. Rosett, MD.
`Robert L. Spitzer, M.D.
`Phillip Zeidenberg, M.D., PhD.
`Sheldon Zimberg, M.D.
`Janet B.W. Williams, M.S.W.
`
`SCHIZOPHRENIC, PARANOID, AND AFFECTIVE DISORDERS
`
`Nancy Andreasen, M.D., PhD.
`Paula J. Clayton, M.D.
`Jean Endicott, PhD.
`Joseph F. Lipinski, MD.
`Michael L. Mavroidis, M.D.
`
`Harrison G. Pope, Jr., MD.
`Robert L. Spitzer, M.D.
`Janet B.W. Williams, M.5.W.
`
`Robert Woodruf-F, M.D. (deceased)
`Lyman C. Wynne, M.D., PhD.
`
`ANXIETY AND DISSOCIATIVE DISORDERS
`
`Jean Endicott, PhD.
`Michael Golder, M.D.
`Donald F. Klein, M.D.
`Isaac Marks, M.D.
`
`George Saslow, MD., PhD.
`Michael Sheehy, M.D.
`Robert L. Spitzer, M.D.
`
`6
`
`

`

`FACTITIOUS AND SOMATOFORM DISORDERS
`
`Paula J. Clayton, MD.
`Steven E. Hyler, MD.
`Paul Luisada, M.D.
`Roger Peele, M.D.
`
`PERSONALITY DISORDERS
`
`Allen J. Frances, M.D.
`Steven E. Hyler, M.D.
`Donald F. Klein, MD.
`
`John Lion, M.D.
`Roger A. MacKinnon, M.D.
`
`PSYCHOSEXUAL DISORDERS
`
`Anke A. Ehrhardt, PhD.
`
`Diane S. Fordney-Settlage, M.D.
`Richard Friedman, M.D.
`Paul Gebhard, PhD.
`Richard Green, M.D.
`
`Helen 5. Kaplan, M.D., PILD.
`Judith B. Kuriansky, Ed.M.
`Harold I. Lief, M.D.
`
`David A. Soskis, M.D.
`Robert L. Spitzer, M.D.
`Norman Sussrnan, MD.
`
`Theodore Millon, PhD.
`Henry Pinsker, MD.
`Lee N. Robins, PI'LD.
`
`Michael Sheehy, MD.
`Robert L. Spitzer, MD.
`
`Jon K. Meyer, MD.
`John Money, PhD.
`Ethel Person, M.D.
`
`Lawrence Sharpe, MD.
`Robert L Spitzer, M.D.
`Robert J. Stolier, M.D.
`Arthur Zitrin, M.D.
`
`INFANCY, CHILDHOOD AND ADOLESCENCE DISORDERS
`
`Robert L. Arnstein, MD.
`Justin D. Call, M.D.
`Dennis Cantwell, M.D.
`Stella Chess, MD.
`Everett Dulit, M.D.
`Rachel Gittelman, PhD.
`Richard Jenkins, M.D.
`
`EATING DISORDERS
`
`Hilde Bmch, M.D.
`James M. Ferguson, M.D.
`
`REACTIVE DISORDERS
`
`Nancy Andreasen, M.D., PhD.
`Robert J. Lifton, M.D.
`Chaim F. Shatan, M.D.
`
`IMPULSE CONTROL DISORDERS
`
`Robert L. Custer, MD.
`John Frosch, M.D.
`William A. Frosch, M.D.
`Donald F. Klein, MD.
`
`J. Gary May, M.D.
`Joaquim Puig-Antich, M.D.
`Judith Rapoport, M.D.
`David Shaffer, M.D.
`Richard Ward, M.D.
`Paul Wender, M.D.
`
`Katherine Halrni, M.D.
`
`Albert James Stunkard, M.D.
`
`Jack Smith
`Robert L. Spitzer, M.D.
`Lyman C. Wynne, M.D., PhD.
`
`John Lion, M.D.
`Nicholas D. Rizzo, M.D.
`
`Robert L. Spitzer, M.D.
`
`7
`
`

`

`PSYCHOSOMATIC DISORDERS
`
`James Brophy, MD.
`lgor Grant, MD.
`E.K. Gundereon, M.D.
`
`Martin R. Lipp, MD.
`John G. Looney, MD.
`Edwin J. Olsen, MD.
`
`MULTIAXIAL DIAGNOSIS
`
`Dennis Cantwell, MD.
`William Carpenter, MI).
`Jean Endicott, PhD.
`Miriam Gibbon, M.S.W.
`Frederic W. Ilfeld, Jr., MD.
`Frederic Kass, MD.
`Juan E. Mezzich, M.D., PhD.
`
`James Morgan, MD.
`David Shaffer, MD.
`Robert Simon, MA.
`Robert L. Spitzer, M.D.
`John S. Strauss, MD.
`Janet B.W. Williams, M. 5.W.
`
`GLOSSARY OF TECHNICAL TERMS
`
`Nancy Andreasen, M.D., PhD.
`Steven E. Hyler, MD.
`Jerrold S. Maxmen, MD.
`Lawrence Sharpe, M.D.
`
`Michael Sheehy, MD.
`Robert L. Spitzer, MD.
`Janet B.W. Williams, M.S.W.
`
`OTHER CONSULTANTS
`
`Lorian Baker, Ph.D.
`Robert Cloninger, M.D.
`John E. Coolaer, MD.
`Irving Gottesman, PhD.
`Samuel Guze, MD.
`Assen Jablensky, MD.
`Gerald Klerman, M.D.
`Eli Robins. MD.
`Howard Rotfwarg, MD.
`Michael Rutter, MD.
`
`Norman Sartorius, M.D., Ph.D.
`Robert H. Seaman, M.A.
`Arthur Shapiro, MD.
`Elaine Shapiro, PhD.
`Abby Sher, M.A.
`Andrew E. Skodol, MD.
`Richard A. Sternbach, PhD.
`John K. Wing, M.D., PhD.
`George Winokur, MD.
`
`ASSEMBLY LIAISON TASK FORCE ON DSM-I'II
`
`Hector J aso, M.D., Chairperson
`Howard Berk, MD.
`Robert Bittle, MD.
`Harvey Bluestone, MD.
`Richard Finn, MD.
`Jerry Morrow, MD.
`K.C.R. Nair, M.D.
`
`Roger Peele, MD.
`Kenneth Pitts, MD.
`Erwin R. Smarr, MD.
`Granville Tolley, MD.
`Stephen Washburn, MD.
`Walter Winslow, MD.
`
`BOARD OF TRUSTEES AD HOC COMMITTEE ON DSM-III
`
`[-1. Keith H. Brodie, M.D., Chairperson
`Robert Campbell, MD.
`Lew Robbins, MD.
`
`John A. Talbott, MD.
`Jules H. Masserman, M.D. (ex officio)
`
`8
`
`

`

`TEXT EDITOR
`
`Janet B.W. Williams, M.S.W.
`
`PRODUCTION
`Ronald E. McMillan
`Kenneth B. Hausman
`
`9
`
`

`

`Contents
`
`Introduction
`
`CHAPTER 1 DSM-III Classification: Axes I and II Categories and Codes
`
`CHAPTER 2 Use of This Manual
`
`CHAPTER 3 The Diagnostic Categories: Text and Criteria
`Disorders Usually First Evident in Infancy, Childhood, or
`Adolescence
`
`Organic Mental Disorders
`Substance Use Disorders
`
`Schizophrenic Disorders
`Paranoid Disorders
`
`Psychotic Disorders Not Elsewhere Classified
`Affective Disorders
`
`Anxiety Disorders
`Somatoforrn Disorders
`
`Dissociative Disorders (Hysterical Neuroses, Dissociative
`Type)
`Psychosexual Disorders
`Factitious Disorders
`
`Disorders of Impulse Control Not Elsewhere Classified
`Adjustment Disorder
`Psychological Factors Affecting Physical Condition
`Personality Disorders
`V Codes for Conditions Not Attributable to a Mental
`Disorder That Are a Focus of Attention or Treatment
`Additional Codes
`
`Appendix A Decision Trees for Differential Diagnosis
`
`Appendix B Glossary of Technical Terms
`
`Appendix C Annotated Comparative Listing of DSM-Ii and DSM~III
`
`Appendix D Historical Review, ICD-9 Glossary and Classification, and
`ICD-9-CM Classification
`
`Appendix E Classification of Sleep and Arousal Disorders
`
`Appendix F DEM-III Field Trials: Interrater Reliability and Listing of
`Participants
`
`Index
`
`Page
`1
`
`15
`
`23
`
`35
`
`35
`
`101
`163
`
`181
`195
`
`199
`205
`
`225
`241
`
`2.53
`261
`285
`
`2.91
`299
`303
`305
`
`331
`335
`
`339
`
`353
`
`371
`
`399
`
`461
`
`467
`
`483
`
`10
`
`10
`
`

`

`This page infemmnalbr lejfl blank
`
`11
`
`11
`
`

`

`
`
`12
`
`

`

`This page infemmnalbr lejfl blank
`
`13
`
`13
`
`

`

`Introduction
`
`Robert L. Spitzer, Chairperson
`Task Force on Nomenclature and Statistics
`
`American Psychiatric Association
`
`This is the third edition of the Diagnostic and Statistical Manual of Mental
`Disorders of the American Psychiatric Association, better known simply as
`DEM-Ill. The development of this manual over the last five years has not gone
`unnoticed; in fact, it is remarkable how much interest (alarm, despair, excite-
`ment, joy] has been shown in successive drafts of this document. The reasons
`For this interest are many.
`First of all, over the last decade there has been growing recognition of the
`importance of diagnosis for both clinical practice and research. Clinicians and
`research investigators must have a common language with which to communicate
`about the disorders for which they have professional responsibility. Planning a
`treatment program must begin with an accurate diagnostic assessment. The
`efficacy of various treatment modalities can be compared only if patient groups
`are described using diagnostic terms that are clearly defined.
`Secondly, from its very beginning, drafts of DSM-III have been widely
`circulated for critical review and use by clinicians and investigators. This made
`them aware of the many fundamental ways in which DSM-III differs from its
`predecessor, DSM—Il, and from its international contemporary, the mental dis—
`orders chapter of the ninth revision of the internationai Classification of Diseases
`{KID-9). For example, DSM-III includes such new features as diagnostic criteria,
`a multiaxial approach to evaluation, much-expanded descriptions of the disorders
`and many additional categories (some with newly-coined names); and it does
`not include several time-honored categories.
`Finally, interest in the development of this manual is due to awareness that
`DSM-III reflects an increased commitment in our field to reliance on data as the
`
`basis for understanding mental disorders.
`
`BACKGROUND”
`
`The first edition of the American Psychiatric Association’s Diagnostic and Statis-
`ticai Manual of Mentai Disorders appeared in 1952. This was the first official
`manual of mental disorders to contain a glossary of descriptions of the diagnostic
`categofies. The use of the term "reaction” throughout the classification reflected
`the influence of Adolf Meyer’s psychobiologica] view that mental disorders
`represented reactions of the personality to psychological, social, and biological
`factors. In the development of the second edition (DSM-II), a decision was made
`to base the classification on the mental disorders section of the eighth revision
`of the international Classification of Diseases, for which representatives of the
`American Psychiatric Association had provided consultation. Both DSM-II and
`
`' SOme readers may wish, for now, to skip Background and The Process of Dovciopment of DEM-HI
`and plunge directly into Basic Concepts on [3.5.
`
`14
`
`14
`
`

`

`
`
`2 Introduction
`
`lCD-8 went into effect in 1968. The DEM-ll classification did not use the term
`
`"reaction” and used diagnostic terms that by and large did not imply a particular
`theoretical framework for understanding the nonorganic mental disorders.
`In 1974 the American Psychiatric Association, through its Council on Re-
`search and Development, appointed a Task Force on Nomenclature and Statistics
`to begin work on the development of DSM-lll, recognizing that [CD-9 was
`scheduled to go into effect in January 1979. By the time this new Task Force
`was constituted, the mental disorders section of [CD-9, which included its own
`
`glossary, was nearly completed. Although representatives of the American Psy-
`chiatric Association had worked closely with the World Health Organization in
`the development of [CD—9, there was some concern that the ICU-9 classification
`and glossary would not be suitable for use in the United States. Most impor-
`tantly, many specific areas of the classification did not seem sufficiently detailed
`For clinical and research use. For example, the ICDn9 classification contains only
`one category for “frigidity and impotence”—despite the substantial work in the
`area of psychosexual dysfunctions that has identified several specific types with
`different clinical pictures and treatment implications. In addition, the glossary of
`lCD-9 was believed by many to be less than optimal in that it had not made use
`of such recent major methodological developments as specified diagnostic criteria
`and the multiaxial approach to evaluation.
`For these reasons the Task Force was directed to prepare a new classification
`and glossary that would, as much as possible, reflect the most current state of
`knowledge regarding mental disorders while maintaining compatibility with
`[CD-9. Like its predecessors, DSM-l and DSM~lL DEM-III had to be, first of all,
`clinically useful, while also providing a basis for research and administrative use.
`
`The Task Force. Task Farce members, and consultants from the fields of
`psychology and epidemiology, were selected because of their special interest in
`various aspects of diagnosis. Most had made significant contributions to the
`literature on diagnosis. As the work progressed, additional members were added
`to ensure representation of different perspectives and areas of expertise.
`From the beginning, the Task Force functioned as a steering committee to
`oversee the ongoing work. All of its members shared a commitment to the attain-
`ment in DSM-III of the following goals:
`
`—clinical usefulness for making treatment and management decisions in varied
`clinical settings;
`—reliability of the diagnostic categories;
`—acceptability to clinicians and researchers of varying theorEtical Orientations;
`—-useFulness for educating health professionals;
`—-maintaining compatibility with ICU-9, except when departures are unavoid-
`able;
`—avoiding the introduction of new terminology and concepts that break with
`tradition, except when clearly needed;
`—-reaching consensus on the meaning of necessary diagnostic terms that have
`been used inconsistently, and avoiding the use of terms that have outlived
`their use Pulness:
`
`—consistency with data from research studies bearing on the validity of
`diagnostic categories;
`
`15
`
`15
`
`

`

`
`
`Introduction 3
`
`—suitability for describing subjects in research studies;
`—being responsive during the development of DSMFIII to critiques by clini-
`cians and researchers.
`
`The major job of the Task Force has been to determine the most effective
`strategies for ensuring that the final document attained each goal to as great an
`extent as possible without compromising the other goals. Thus, the Task Force
`evaluated all proposals for changes in DSM—III that might affect the attainment
`of these goals. These proposals came from members of the Task Force, advisory
`committees, liaison committees with professional organizations, and participants
`in the DSM-III Field Trials. Finally, the Task Force reviewed drafts of the text
`and diagnostic criteria.
`
`In attempting to resolve various diagnostic issues, the Task Force relied, as
`much as possible, on research evidence relevant to various kinds of diagnostic
`validity. For example, when discussing a problematic diagnostic category, the
`Task Force considered how the disorder, if defined as proposed, provided in-
`formation relevant to treatment planning, course, and familial pattern. It should
`come as no surprise to the reader that even when data were available from
`relevant research studies, Task Force members often differed in their interpreta-
`tions of the findings.
`
`Advisory Committees and Other Consultants. Successive drafts of DSM-III
`were prepared by fourteen advisory committees composed of individuals with
`special expertise in each substantive area. In addition, a group of consultants
`provided advice and information on a variety of special areas.
`
`Council on Research and Development. This component of the American
`Psychiatric Association appointed the Task Force and regularly reviewed progress
`being made in the development of DSM—III. In addition, in the fall of 1978 the
`Council held an all—day meeting at which some APA members voiced concerns
`about certain aspects of DSM-III. After reviewing these concerns, the Council
`approved the Task Force’s approach to solutions of the problems that had been
`raised.
`
`Assembly Liaison Committee. In early 1976, the APA Assembly, composed
`of representatives from all of the APA's district branches, appointed a Liaison
`Committee to review the development of DSM-III and to report regularly to the
`Assembly. This committee received correspondence on major issues, reviewed
`successive drafts of DSM-III, and met a number of times with the chairperson
`of the Task Force. On several occasions the Assembly Liaison Committee ar-
`ranged for the chairperson of the Task Force to discuss a particular controversial
`issue with the entire Assembly. The Assembly Liaison Committee was invaluable
`in articulating the concerns of the membership of the APA, which is composed
`largely of clinicians whose primary professional activity is patient care.
`
`Other Components of the APA. The chairperson of the Task Force reported
`on several occasions to the Reference Committee and the Board of Trustees on
`
`specific issues of concern. In addition, in April 1979, a meeting was held with an
`
`16
`
`16
`
`

`

`4
`
`introduction
`
`Ad Hoc Committee on DEM-III of the Board of Trustees to review specific
`concerns about DSM-lll that had been expressed by members of the APA. Other
`components of the APA, such as the Committee on Confidentiality and the Com—
`mittee on Women, also reviewed DSM-III from their own persPectives as it was
`being developed.
`
`liaison with Other Professional Organizations. The following groups that
`were particularly interested in the development of DSM-III established liaison
`committees with the Task Force: the Academy of Psychiatry and the Law, the
`American Academy of Child Psychiatry,
`the American Academy of Psycho-
`analysis, the American Association of Chairmen of Departments of Psychiatry,
`the American College Health Association, the American OrthOpsychiatric Asso-
`ciation, the American Psychoanalytic Association, and the American Psychologi-
`cal Association. These committees received drafts of DSM-Ill and were invited
`
`to make comments and suggestions and to express their concerns. In most
`instances, differences in points of view between a liaison committee and the
`Task Force were resolved to the satisfaction of all concerned. When this was not
`
`possible and differences were left unresolved, the issues were at least clarified.
`
`THE PROCESS OF DEVELOPMENT OF DSMolll
`
`in May 1975, at a special session of the Annual Meeting of the APA, an initial
`draft of the DEM-Ill classification was presented. At each subsequent Annual
`Meeting a special session was held on some aspect of DSM-ill. In addition, a
`special conference was held in St. Louis, Missouri, in June 1976, to examine
`“DSM-III in Midstream.” This conference, co—sponsored by the Missouri Insti-
`tute of Psychiatry and the American Psychiatric Association, was attended by
`approximately 100 professionals with expertise or special interests in various
`aspects of DEM-Ill, most of whom had previously had no direct involvement
`in the development of DSM-III. As a result of di5cussions at this conference,
`additional diagnostic categories were added, some were deleted, and a decision
`was made to proceed with the development of the multiaxial system.
`The DSM-IH classification and the rationale for the strategies used in its
`development have been presented throughout the past four years at local, na-
`tiOnal, and international professional meetings. In addition, the 4X15”? draft
`and successive drafts of DSM-III have been available to the profession for
`critical review. Throughout this period there has been continual consideration of
`various solutions to difficult diagnostic problems, often based on summaries of
`actual cases submitted to the Task Force from all quarters. Whenever possible,
`attempts have been made to seek the advice of experts in each specific area
`under consideration.
`
`Field Trials. In the past, new classifications of mental disorders have not
`been extensively subjected to clinical trials before official adaption. The Task
`Force believed that field trials using drafts of DEM-III should be conducted
`during the development process to identify problem areas in the classification
`and to try out solutions to these problems. In addition, because of the many
`proposed changes in the classification, it was important to demonstrate its clini-
`
`17
`
`17
`
`

`

`Introduction 5
`
`cal acceptability and usefulness in a variety of settings by clinicians of varying
`theoretical orientations.
`
`For these reasons, a series of field trials was conducted, beginning in 1977
`and culminating in a two year NIMH-sponsored field trial from September
`1977 to September 1979. In all, 12,667 patients were evaluated by approxi-
`mately 550 clinicians, 474 of whom were in 212. different facilities, using suc-
`cessive drafts of DEM-III. Critiques of all portions of DSM-III by the field trial
`participants resulted in numerous changes, as did revievvs of case summaries sub-
`mitted by those participants. Frequently, participants completed questionnaires
`regarding specific diagnostic issues and their attitudes toward DSM-III and its
`innovative features. The results indicated that the great majority of participants,
`regardless of theoretical orientations, had a Favorable response to DSM-III.
`Perhaps the most important part of the study was the evaluation of diag-
`nostic reliability by having pairs of clinicians make independent diagnostic
`judgments of several hundred patients. The results, which are presented in an
`appendix, generally indicate far greater reliability than had previously been
`obtained with DEM-II.
`
`ICD—Q-CM. Because of dissatisfaction with ICD-9 expressed by organiza—
`tions representing subspecialties of medicine (not including the American Psychi—
`atric Association], a decision was made to modify the ICU-9 for use in the
`United States by expanding the four—digit ICU-9 codes to five-digit ICD~9-CM
`(for clinical modification) codes whenever greater specificity was required. This
`modification was prepared for the United States National Center for Health
`Statistics by the Council on Clinical Classifications. The American Psychiatric
`Association,
`in December 1976, was invited to submit recommendations for
`
`alternate names and additional categories based on subdivisions of already exist-
`ing ICU-9 Categories. This made it possible for the developing DEM-III classifi-
`cation and its diagnostic terms to be included in the ICD-Q-CM classification,
`which in January 1979 became the official system in this country for recording
`all "diseases, injuries, impairments, symptoms, and causes of death.” The 1CD-
`9-CM codes and diagnostic terms for mental disorders are included in Appendix
`D.
`
`Many ICD-Q-CM codes and terms are not included in the DSM-lll classi-
`fication. However, these are generally acceptable to third party payers and most
`record-keeping systems.
`
`Final Approval. In May 1979, at the Annual Meeting of the APA in Chi-
`cago, the Assembly and the Council on Research and Development formally
`approved the final draft of DSM-III. In June, it was approved by the Reference
`Committee and the Board of Trustees.
`
`BASIC CONCEPTS
`
`Mental Disorder. Although this manual provides a classification of mental dis-
`orders, there is no satisfactory definition that specifies precise boundaries for the
`concept “mental disorder” (also true for such concepts as physical disorder and
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`6
`
`introduction
`
`mental and physical health). Nevertheless, it is useful to present concepts that
`have influenced the decision to include certain conditions in DSM-lll as mental
`disorders and to exclude others.
`
`In DSM-III each of the mental disorders is conceptualized as a clinically
`significant behavioral or psychological syndrome or pattern that occurs in an
`individual and that is typically associated with either a painful symptom (dies
`tress) or impairment in one or more important areas of functioning (disability).
`In addition, there is an inference that there is a behavioral, psychological, or
`biological dysfunction, and that the disturbance is not only in the relationship
`between the individual and sooiety. (When the disturbance is limited to a. mu—
`flict between an individual and sodety, this may represent social deviance, which
`may or may not be commendable, but is not by itself a mental disorder.)
`In DSM-lll there is no assumption that each mental disorder is a discrete
`entity with sharp boundaries (discontinuity) between it and other mental dis-
`orders, as well as between it and No Mental Disorder. For example, there has
`been a continuing controversy as to whether or not severe depressive disorder
`and mild depressive disorder differ from each other qualitatively [discontinuity
`between diagnostic entities) or quantitatively [a difference on a severity con-
`tinuum). The inclusion of Major Depression With and Without Melancholia as
`separate categories in DEM-III is justified by the clinical usefulness of the dis-
`tinction. This does not imply a resolution of the controversy as to whether or not
`these conditions are in fact quantitatively or qualitatively different.
`A common misconception is that a classification of mental disorders classi-
`fies individuals, when actually what are being classified are disorders that
`individuals have. For this reason, the text of DSM-III avoids the use of such
`
`phrases as ”a schizophrenic” or “an alcoholic,” and instead uses the more
`accurate, but admittedly more wordy “an individual with Schizophrenia” or ”an
`individual with Alcohol Dependence.”
`Another misconception is that all individuals described as having the same
`mental disorder are alike in all important ways. Although all the individuals
`described as having the same mental disorder show at least the defining features
`of the disorder, they may well differ in other important ways that may affect
`clinical management and outcome.
`
`Conditions Not Attributable to :1 Mental Disorder. in DSM-III it is recog-
`nized that a behavioral or psychological problem may appropriately be a focus
`of professional attention or treatment even though it is not attributable to a
`mental disorder. A limited listing of codes, taken from the V codes section of
`lCD-9-CM, is provided for noting such problems.
`
`Descriptive Approach. For some of the mental disorders, the etiology or
`pathophysiological processes are known. For example, in the Organic Mental
`Disorders, organic factors necessary for the development of the disorders have
`been identified or are presumed. Another example is Adjustment Disorder, in
`which the disturbance is a reaction to psychosocial stress.
`For most of the DSM—Ill disorders, however, the etiology is unknown. A
`variety of theories have been advanced, buttressed by evidencea—not always
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`introduction
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`7
`
`convincing—to explain how these disorders come about. The approach taken in
`DSM-Ill is atheoretical with regard to etiology or pathophysiological process
`except for those disorders for which this is well established and therefore in-
`cluded in the definition of the disorder. Undoubtedly, with time, some of the
`disorders of unknowu etiology will be f0und to have specific biological etiologies,
`others to have specific psychological causes, and still others to result mainly from
`a particular interplay of psychological, social and biological factors.
`The major justification for the generally atheoretical approach taken in
`DSM-III with regard to etiology is that the inclusion of etiological theories would
`be an obstacle to use of the manual by clinicians of Varying theOretical orienta-
`tions, since it would not be possible to present all reasonable etiological theories
`for each disorder. For example, Phobic Disorders are believed by many to repre-
`sent a displacement of anxiety resulting from the breakdown of defensive opera-
`tions for keeping internal conflict out of consciousness. Other investigators
`explain phobias on the basis of learned avoidance responses to conditioned
`anxiety. Still others believe that certain phobias result from a dysregulation of
`basic biological systems mediating separation anxiety. In any case, as the field
`trials have demonstrated, clinicians can agree on the identification of mental
`disorders on the basis of their clinical manifestations without agreeing on how
`the disturbances come about.
`
`Because DSM-lll is generally atheoretical with regard to etiology, it at;
`tempts to describe comprehensively what the manifestations of the mental dis
`orders are, and only rarely attempts to account for how the disturbances come
`abOut, unless the mechanism is included in the definition of the disorder. This
`
`approach can be said to be “descriptive” in that the definitions of the disorders
`generally consist of descriptions of the clinical features of the disorders. These
`features are described at the lowest order of inference necessary to describe the
`characteristic features of the disorder. Frequently the order of inference is rela-
`tively low, and the characteristic features consist of easily identifiable behavioral
`signs or symptoms, such as disorientation, mood disturbance, or psychomotor
`agitation. For some disorders, however, particularly the Personality Disorders, a
`much higher order of inference is necessary. For example, one of the criteria for
`Borderline Personality Disorder is "identity disturbance manifested by uncer-
`tainty about several issues relating to identity, such as self-image, gender iden-
`tity, long~term goals or career choice, friendship patterns, values and loyalties."
`This descriptive approach is also used in the division of the mental disorders
`into diagnostic classes. All of the disorders without known etiology or patho—
`physiological process are grouped together on the basis of shared clinical features.
`The subdivision of each diagnostic class into specific disorders, with even
`further subdivision in some cases, reflects the best judgment of the Task Force
`and its Advisory Committees that such subdivision will be useful. In this regard
`we have been guided by the judgments of those clinicians who will be making
`most use of each portion of the classification. For example, the subdivision of
`Psychosexual Dysfunctions into seven specific disorders is in response to the ex-
`pressed needs of clinicians who specialize in the treatment of these conditions.
`(It soon became apparent that the criticism that a subdivision in a particular
`area of the classification was useless aIWays came from clinicians who specialized
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`8
`
`introduction
`
`in other areas.) It should be noted, however, that the judgments of clinicians con-
`cerning the necessity for including new categories were not accepted uncritically.
`Although initially many new categories were added in an effort to be inclusive,
`experience in the field trials and lack of validity evidence from the literature re-
`sulted in the elimination of several proposed categories.
`
`Diagnostic Criteria. Since in DEM-I, DEM-II, and ICU-9 explicit criteria
`are not provided, the clinician is largely on his or her own in defining the
`content and boundaries of the diagnostic categories. In contrast, DSM-III pro-
`vides specific diagnostic criteria as guides for making each diagnosis since
`such criteria enhance interiudge diagnostic reliability. It should be understood,
`however, that for most of the categories the diagnostic criteria are based on
`clinical judgment, and have not yet been fully validated by data about such
`important correlates as clinical course, outcome