This article discusses examples of some specific changes in the most recent edition of the Diagnostic & Statistical Manual of Mental Disorders, the DSM-IV, the official mental health diagnostic scheme used in the U.S. and their implications for criminal defense team members and their clients.

Published in 1994, the fourth edition of the DSM is the American Psychiatric Association's (APA) most current delineation of diagnostic nomenclature and mental health disorders. The DSM-IV is the fifth version of the official diagnostic scheme endorsed by the APA and adopted in the U.S. over the past forty years. Its most recent predecessor, the DSM-III-R, had been in use since 1987.

Procedural safeguards were instituted by the DSM-IV Task Force and its Work Groups to ensure that proposed changes in the DSM-IV have a clear scientific and/or conceptual evidentiary basis. Toward that end, a three-stage empirical process was adopted: (a) compre-hensive reviews of the existing empirical and clinical literature on particular disorders; (b) data re-analyses of previously conducted re-search; and (c) implementation of extensive field trials to address concerns about diagnostic issues in particular disorders.

A secondary but no less important goal of the revision process was to extensively document the empirical and/or conceptual bases of changes. Documentation of the revisions was proposed to minimize concerns about arbitrary and idiosyncratic changes that had plagued earlier versions of the DSM¹ and to maintain historical continuity with the DSM-III and DSM-III-R.

A major vehicle for documentation of the evidentiary bases for DSM-IV text and diagnostic criteria sets is the planned publication of the DSM-IV Sourcebook, a five-volume synopsis of the clinical and empirical support for various decisions reached by Work Groups and the Task Force. Volume I has been published and the remaining volumes are expected out over the next few years.

Before identifying some of the major types of changes in the DSM-IV, it might be helpful to include basic information about the structure of the DSM. Since publication of the DSM-III in 1980, the DSM has described psychiatric ill-nesses and mental disorders through a five-dimensional descriptive system, labeled, in DSM language, the "multiaxial system." The five "axes" listed in the DSM involve five different but intimately related ways of describing psychiatric symptoms. The axes identify a complex range of psychiatric and psychosocial phenomena, including delineation of major mental illness, enduring personality traits and maturational delays, and the description of medical, developmental, psychosocial and environmental phenomena that may exacerbate or mitigate the effects of mental disorders. See, Table 1, Multiaxial System - DSM-III and DSM-III-R.

The DSM is composed of sixteen major classes of mental illnesses, within which particular disorders are subsumed. For example, the class of mood disorders includes such disorders as major depression, bipolar I and II, and dysthymia; the class of anxiety disorders includes, among others, post-traumatic stress disorder, obsessive-compulsive disorder, and phobic disorders (e.g., simple phobia, social phobia, and agoraphobia).
 
 

Multiaxial System -  DSM-III and DSM-III-R Axis I - Includes the "clinical syndromes," i.e., the major mental disorders. This axis comprises what most people think of as mental illnesses. It is composed of approximately 15 categories of mental disorders, each comprising a distinct group or class of mental illness (e.g., Mood, anxiety, psychotic, or dissociative disorders). Each group or class (e.g., mood disorders/anxiety disorders) contains distinct disorders (e.g., major depressive disorder, bipolar I and II disorders, etc./panic and anxiety disorders, phobias, PTSD) which make up that group. Axis II - Includes longstanding and en-during personality traits and matura-tional/developmental deficits and delays. Personality traits are "enduring patterns of perceiving, relating to, and thinking about the environment and oneself, "and are exhibited in a wide range of important social and personal contexts. It is only when personality traits are inflexible, maladaptive and cause either significant functional impairment or subjective distress that they constitute an actual disorder. The essence of maturational/developmental delays is a disturbance in the acquisition of "cognitive, language, motor, or social skills." Such disturbances may be pervasive (as with mental retardation), involve delays or deficits in specific skills (reading, arithmetic, language), or involve qualitative distortions in multiple areas of normal development (autism). Axis III - Includes physical disorders and medical conditions that may affect psychological functioning. Axis IV - Includes psychosocial stressors that may influence psychological functioning, they are rated on a five-point scale from "mild" (relationship breakup) to "catastrophic" (death of a child or spouse). Axis V - Includes the delineation of a longitudinal context (known as the Global Assessment of Functioning [GAF]) within which to appraise psychological functioning. Social, psychological and occupational functioning is rated on a 100-point scale of mental illness which includes 90 (absent or minimal symptoms, "good functioning in all areas"), through 50 (serious symptoms, "suicidal ideation, severe obsessional rituals...serious impairment in some functioning") to 20-10 ("persistent danger of severely hurting self or others...persistent inability to maintain minimal personal hygiene [smears feces]...serious suicidal acts with clear expectation of death).

Individual disorders are placed in a particular class of mental illness on the basis of shared phenomenological features. That is, two disorders within the same class of mental illness may share a predominant emotion or behavioral symptom, may respond similarly to medi-cation, may be genetically linked, and/or may consistently occur together with other disorders. For example, Post-traumatic Stress Disorder (PTSD) and Panic Disorder with Agora-phobia (PDWA) are both in the anxiety disorder class of mental illness, and share similar emotional, behavioral, and physiological symptoms. These disorders have in common a pre-dominant emotion (fear); a similar behavioral pattern (phobic avoidance of feared situations, people or events); and similar physiological responses (increased autonomic arousal when confronted with anxiety-provoking or feared stimuli). Additionally, a similar mode of psychotherapy (behaviorally-based "exposure therapy") has been effective for some patients in reducing distress significantly for both disorders. Finally, evidence suggests a possible biomedical and/or psychophysiological link between PTSD and PDWA, as both disorders occur together with depressive disorders and respond similarly and positively to a certain class of drugs.

The purpose of grouping disorders on the basis of shared features is to facilitate the process of "differential diagnosis," the term used to de-scribe the hierarchial decision-making process required to differentiate a particular disorder from other disorders which have one or more similar presenting features. For example, Attention Deficit Hyperactivity Disorder (a disruptive behavior disorder), Major Depression (a mood disorder) and Post-traumatic Stress Disorder (an anxiety disorder) may all share characteristics of concentration difficulty and agitated behavior. To determine whether these characteristics are symptoms of a particular disorder, and, if so, to identify that disorder, a careful evaluation of present symptoms, as well as a careful history are needed.²

The description of particular disorders occurs through clearly specified "criteria sets" which outline such factors as the type, number, duration, and severity of symptoms required to war-rant a diagnosis. See Table 2 for criteria sets for PTSD. A wealth of additional information is provided in the text which accompanies criteria set definitions. One area of further information detailed in the text includes factors predisposing individuals to particular disorders, e.g., family history, exposure to extremely stressful environmental events, and in-utero exposure to trauma and/or toxins. Additional information might also address the nature, subtypes and specific course of particular disorders, e.g., age of onset (early vs. late); mode of onset (abrupt vs. insidious); severity of disorder (mild, mod-erate or severe); and chronicity and duration of the disorder (episodic vs. continuous, single event vs. recurring episodes, or full vs. partial remission).

Changes to the Axes - DSM-IV includes a number of conceptually distinct changes. Revisions were made in the content of two axes within the multiaxial system as the learning, communication and motor skills, and pervasive developmental disorders were moved from Axis II to Axis I. Another change involved the desig-nation of Axis III as relating to "general medical" conditions rather than only "physical" conditions, in order to deemphasize the some-what inaccurate distinction between "organic" (or biological) and "psychological" factors that was implicit in DSM-III-R. Very minor changes were made in Axes IV and V regarding the specification of psychosocial stressors and general psychological functioning.

Changes to the Criteria Sets and Disorders - With respect to major mental illnesses (Axis I) and enduring personality traits (Axis II), modifications included, among other things:

(1) Changes in the names of major diagnostic classes and disorders. For example, there is no longer a class of disorders known as "organic mental syndrome and disorders." The rationale for this change was that this category, as employed in DSM-III and DSM-III-R suggested a deceptive distinction between disorders caused by psychiatric (mental, emotional or behavioral) versus organic (physical or bodily) factors.

Of additional interest is the fact that the name of a disorder which has received much public and media attention, Multiple Personality Disorder, has been changed to "Dissociative Identity Disorder." This change was based in part on the recognition that distinct personality entities (e.g., the "Three Faces of Eve") are per se less common than the presence of different and dissociated personality states (e.g., passive, aggressive, gregarious, etc.)

(2) Changes in diagnostic criteria for particular disorders. See, discussion of PTSD, infra.

(3) The creation of several new diagnoses, such as bipolar II, acute stress disorder, and several new childhood disorders; and

(4) The deletion of some diagnoses, including self-defeating personality disorder.

The current version also lists certain syndromes in an appendix with recommendations for further study, such as post-concussional disorder and mixed anxiety-depressive disorder. Additional axes are also proposed for study, and certain disorders are delineated as subsumed by other diagnoses. In addition, developers of the DSM-IV placed greater emphasis on the importance of variables such as culture and gender in the development and expression of mental illness (which will be discussed in the next article in this series). Below, a closer look is taken at the types of changes made through a description of the revisions made regarding PTSD.

PTSD was one of twelve disorders targeted for intensive study through field trials prior to publication of the DSM-IV. The following is an overview of two issues discussed among PTSD researchers and clinicians involved in the revision process. This example is offered merely to illustrate the kinds of concerns faced by mental health practitioners making diagnoses, and the conceptual underpinnings of the impetus for re-consideration of existing diagnostic definitions. See, Table 2 for descriptions of the diagnostic criteria for PTSD in DSM-III-R and DSM-IV.

DSM-III-R Diagnostic Criteria for Post-traumatic Stress Disorder (309.89) A. Person has experienced an event that is outside the range of usual human experience and would be markedly distressing to almost anyone, e.g., serious threat to the life or physical integrity of oneself, one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing a person who has recently been, or is being, seriously injured or killed as a result of an accident or physical violence. B. The traumatic event is persistently re-experienced in at least one of the following ways: (1) recurrent and intrusive distressing recollections of the event (young children may express themes or aspects of the trauma in repetitive play); (2) recurrent distressing dreams of the event; (3) sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes); (4) intense psychological distress at exposure to events that symbolize ore resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness, not present be-fore the trauma, indicated by at least three of the following: (1) efforts to avoid thoughts or feelings associated with the trauma; (2) efforts to avoid activities or situations that arouse recollections of the trauma; (3) inability to recall an important aspect of the trauma; (4) markedly diminished interest in significant activities (in young children, loss of recently acquired develop-mental skills); (5) feeling of detachment or estrangement; (6) restricted range of affect or feelings; (7) sense of foreshortened future, e.g., does not expect to have a career, marriage, etc. D. Persistently increased arousal, not present be-fore the trauma, indicated by at least two of the following: (1) difficulty falling asleep or staying asleep; (2) irritability or outbursts of anger; (3) difficulty concentrating; (4) hyper-vigilance; (5) exaggerated startle response; (6) physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman raped in an elevator breaks out in a sweat when entering any elevator). E. Duration of the disturbance (symptoms in B, C and D) of at least one month.

As can be seen in Table 2, criterion A for a PTSD diagnosis is the experiencing of a traumatic event. The definition of a traumatic event, called the "gatekeeper" to PTSD, is clearly of considerable importance; if an event does not qualify as traumatic, one cannot, by definition, be diagnosed with PTSD. Thus, the definition of criterion A, a traumatic event, has significant implications for assessment of the prevalence of PTSD in both clinical and community samples. If the description of the trauma is overly inclusive, estimates of PTSD would likely increase; if the description is too narrow, estimates of PTSD would likely decrease.

In DSM-III and III-R, a traumatic stressor was defined as an event "outside the range of usual human experience" that would be "markedly distressing to almost anyone." Several limitations of this definition were noted and investigated, and led to the changes in definition apparent in Table 3. First, epidemiological data about the prevalence of certain traumatic stres-sors (rape, childhood sexual abuse, assault and batter) consistently indicate that they are a common part of human experience in our society and, thus, cannot be deemed "outside the range of usual human experience." Second, the DSM-III-R definition did not recognize the possibility that relatively low magnitude stressors (e.g., a minor car accident), perceived as trau-matic by susceptible individuals, could cause the full spectrum of PTSD symptoms.

The DSM-IV definition of traumatic event has been both expanded and made more explicit. The definition is more explicit by virtue of the requirement that a stressor involve actual or threatened death or injury, or a threat to physical integrity. The definition is more expansive by virtue of including events that a person has witnessed or "confronted" as qualifying events. Finally, the person's reaction to the event must include "intense fear, helplessness or horror," thus, the traumatic stressor is now in part de-fined by the subjective emotional response to an event, rather than by the more objective DSM-III-R standard of an event that would be "markedly distressing to almost anyone."

The debate over this issue concerns the appropriate disorder classification of PTSD, or its "nosological home." PTSD was categorized as an anxiety disorder in DSM-III and III-R. In the development of DSM-IV, it was considered for possible placement in two other classes of disorders. First, some researchers and clini-cians argued that PTSD more appropriately be-longs in the class of dissociative disorders because, while it shares features with other anxiety disorder (e.g., fear, avoidance, hyper-vigilance, poor concentration, etc.), it also shares symptoms with the dissociative disorders (e.g., flashbacks, memory disruption and amnesia). A second proposal was to create a new cause-based class of disorders that share common symptoms arising from exposure to a stress or stressors. Mentioned for possible inclusion in this proposed class, in addition to PTSD, were the adjustment disorders, which by definition involve a maladoptive response to an identifiable psychosocial stressor. Following discussions, it was decided that the most appropriate placement of PTSD in the DSM-IV was in the class of anxiety disorders, with which it shares many symptoms.

Kathleen Wayland, Ph.D.

Kathleen Wayland is a clinical psychologist who is working as a consultant to the California Appellate Project on social history and mental health issues. Kathy has trained capital defense team members for both the NLADA and the NAACP Legal Defense & Educational Fund, Inc. This article first appeared in the NLADA Capital Report #44 (Sept./Oct. 1995), NLADA, 1625 K Street, N.W., Washington, D.C. 20006; Tel: (212) 452-0620. This article was reprinted with permission.
 
 

Notable Changes in Diagnostic Criteria for Post- Traumatic Stress Disorder (309.81) in DSM-IV A. Person has been exposed to a traumatic event in which both of the following were present: (1) person experienced, witnessed, or was confronted with an event or events involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others; (2) response involved intense fear, helplessness, or horror (children may express by dis-organized or agitated behavior). B. the traumatic event is persistently re-experienced in one (or more) of the following ways: (1)-(4) Only minor changes; (5) phy-siological  reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsive-ness (not present before the trauma), as indicated by three (or more) of the following: (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma; (2) efforts to avoid activities, places, or people that arouse recollections of the trauma; (4) markedly diminished interest or participation in significant activities; (3), (5), (6), (7) same as in DSM-III-R. D. Same as in DSM-III-R, but with number six (6) deleted. E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than 1 month. F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than 3 months. Chronic: if duration of symptoms is 3 months or more. With Delayed Onset: if on-set of symptomsis at least 6 months after the stressor.

¹It has been argued that earlier versions of the DSM proposed diagnostic criteria sets that were the result of "expert" consensus or "group" opinion, and were therefore necessarily subject to the limitations of group processes.
²As noted by Kaplan and Sadock, one of the essential cornerstones of an adequate and reliable mental health evaluation is a thorough review of history and systems. Kaplan, H.I.; Sadock, B.G., Comprehensive Textbook of Psychiatry, (Williams and Williams, 5th Ed. 1989). Unfortunately, it is still frequently the case in criminal cases, especially in death penalty litigation that superficial evaluations are con-ducted based largely on self reports of clients, with no attempt made to obtain and review in-formation about the client and his/her family history.

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