DSM and ICD – two psychiatric classifications on the block - Peter Tyrer
What are these acronyms and are they of value to psychiatry? The answers to the first question are simple. DSM stands for Diagnostic and Statistical Manual for Mental Disorders, and its 5th revision was published in May 2013, and ICD is short for the International Classification of Diseases, the 11th revision which is due to be published in 2015 or 2016. The value question is a matter of debate. Only the complete anti-psychiatry zealots believes neither classification is of value, but the amount of confidence we have in both of them varies from almost religious belief to extreme scepticism.
Where do I stand? In the middle, wobbling on top of a rickety fence. I have rechristened the acronym, DSM as both Diagnosis for Simple Minds, and Diagnosis as a Source of Money (Tyrer, 2012), as both are true. The ‘operational criteria’ are listed for each disorder and can be ticked off simply, and the American Psychiatric Association relies on the income from DSM for much of its core work. But I am being slightly unfair; DSM is a noble but flawed attempt to give order to a very disordered subject. Psychiatric classification involves much more guesswork than medical classification and filling the gaps is a task that all can criticise successfully with all getting prizes. DSM-5 has come in for heavier criticism than other revisions, as it planned originally on making the classification a true beacon of science – a ‘paradigm shift ‘ in which biological measures would be used to describe the new disorders. But it never got to first base. Instead we have a reshuffle of disorders, and new ones that tend to increase pathology in the population. These include premenstrual dysphoric disorder, disruptive mood dysregulation disorder, illness anxiety, hoarding, binge eating and minor neurocognitive disorder. Allen Frances, the chair of DSM-IV, berates the new DSM masters as being out of control and has led the campaign to save the world from being diagnosed with a DSM disorder (Frances, 2013).
ICD is in somewhat better odour, not least as it is the official classification of disease across the world. But the revision of the classification is badly resourced and it is difficult for it not to follow the much better funded studies that back up DSM. But it is fighting back, and when I spoke in Vilnius in April at a meeting of the Lithuanian Psychiatric Association (Lietuvos psychiatry asociacija) there was much more enthusiasm for a reinvigorated classification that was not linked to any one country and which could be embraced by practitioners across the world. And there are benefits from a world-wide approach. Russia uses ICD and at a meeting of the Serbian Psychiatric Association two years ago Valery Krasnov of the Moscow Research Institute of Psychiatry presented data on the epidemiology of ‘sluggish schizophrenia’. Although this was never an ICD diagnosis it was widely used to imprison dissidents in psychiatric institutions, and Valery’s statistics showed that this strange disorder had almost completely disappeared from national figures since its heyday 40 years ago – mainly being replaced by personality and mood disorders. One of the essential tasks of a good psychiatric diagnostic system is to be embraced sufficiently to be independent of political pressures of all sorts and we hope that ICD-11 when it appears will be a much cleaner and well-organised diagnostic system than it has been in the past.
Tyrer P. (2012). DSM – in 100 words. British Journal of Psychiatry, 200, 67.
Frances A. (2013). Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. New York: William Morrow.