Frequently Asked Questions About DSM

A:         DSM stands for “Diagnostic and Statistical Manual of Mental Disorders” and is published by the American Psychiatric Association, the professional membership organization representing United States psychiatrists.  It is utilized by mental health professionals from a variety of disciplines and backgrounds for a wide range of purposes, including clinical, research, administrative, and educational. 

The DSM is a manual that contains a listing of psychiatric disorders and their corresponding diassgnostic codes.   Each disorder included in the manual is accompanied by a set of diagnostic criteria and text containing information about the disorder, such as associated features, prevalence, familial patterns, age-, culture- and gender-specific features, and differential diagnosis.   No information about treatment or presumed etiology is included.  

Diagnostic criteria have been included in the DSM because their provision has been shown to increase diagnostic agwreement.   It is important to understand that the appropriate use of the diagnostic criteria requires clinical training and that they cannot be simply applied in a cookbook fashion.

The primary purpose of the DSM is to facilitate communication among mental health professionals.  The diagnostic terms in the manual provide a convenient shorthand when communicating about patients.  For example, when a clinician making a referral uses the term “Major Depressive Disorder” to indicate the patient's diagnosis, he or she is communicating in three words a great deal of clinical information.   One can expect that the patient's primary complaint is a sustained period of depressed mood or loss of interest in activities and that a number of other symptoms may occur as part of the depression, including sleep disturbances, changes in appetite or weight, low energy, difficulty concentrating, and very low self-esteem.   The clinician should also be on the alert to look for suicidal ideas or plans because this feature is often present in patients with this diagnosis.   Furthermore, use of the diagnostic term “Major Depressive Disorder” also indicates what NOT to expect.  For example, using this term indicates the absence of significant manic periods now or in the past; otherwise, the clinician would have used the term Bipolar Disorder. 

Another important aspect of the DSM diagnostic system is that the diagnoses are described strictly in terms of patterns of symptoms that tend to cluster together; the symptoms can be observed by the clinician or reported by the patient or family members.  Since the cause of most mental disorders is currently unknown and subject to much speculation, the DSM avoids incorporating unproven theories in its diagnostic definitions.  This feature has been an important element in the widespread acceptance of the DSM.   Clinicians from widely differing theoretical orientations can still use the DSM because it focuses on manifest symptoms.

This is also an important limitation of the DSM system.   Patients sharing the same diagnostic label do not necessarily have disturbances that share the same etiology nor would they necessarily respond to the same treatment.   It is therefore critical to understand that the diagnostic terms and categories in the DSM represent only our current knowledge about how symptoms cluster together.   We fully expect that, over the coming decades, the DSM system will be radically reorganized as the etiologies of mental disorders become better understood.

Q:        What does it mean if a diagnosis is not included in the DSM?

A:         It only means that, as of 1994, there was not sufficient data to justify its inclusion in the DSM-IV.   Just because a category is not included in DSM-IV does not necessarily mean that it is invalid, or not worthy of being a focus of research or treatment.

There are many ways diagnoses have ended up in the DSM.   During the time of the publication of DSM-I and DSM-II (1952 and 1968 respectively), there was very little empirical data available about psychiatric disorders.   Since the primary purpose of the early versions of the DSM was to standardize data collection administratively and to facilitate communication among clinicians, the diagnostic makeup of these early versions represented a consensus of those disorders that were being seen by psychiatrists in the United States in the 1950's and 1960's.   Starting with DSM-III, with the explosion of research in psychiatry, attempts have been made to make the DSM as empirically-based as possible.  While DSM-III and DSM-III-R relied primarily on expert consensus that was informed by the experts' familiarity with then-current psychiatric research, DSM-IV was developed based on a comprehensive review of the literature.   

As the DSM has become increasingly more informed by research, so has the basis for inclusion of new categories in the DSM.   As stated above, originally categories were included because they were felt to represent what psychiatrists were treating.   In later editions of the DSM (DSM-III-R and DSM-IV), new categories were only considered for inclusion if there was significant data available to allow critical consideration of the relevant merits and risks of inclusion.   In contrast, some categories that date back to older editions of the DSM may have relatively little empirical data.  Thus, because the data requirement for consideration of new categories has become more stringent, some proposed categories that were ultimately rejected may have had more data available than grandfathered categories already in the DSM. 

Q:        Aren't some of the diagnoses included in the DSM there for political reasons? 

A:         Decisions to include a diagnosis in the DSM are based on a careful consideration of the research underlying the disorder.  This is not to say that decisions are made without regard to other considerations.  Scientific data cannot be interpreted in a vacuum.  Sociological and other considerations must also be taken into account.   For example, each proposed new diagnosis carries with it the risk of making a false positive diagnosis (i.e., making a diagnosis when no disorder is present).  Since false positives can never be completely eliminated, we must consider instead how to balance the advantages of including the diagnosis in the DSM (e.g., increased detection of a treatable disorder with consequent reduction in morbidity and cost to the patient, his or her family, and to society at large) against the risks of making a false positive diagnosis (e.g., risk of stigmatization, cost and potential morbidity of unnecessary treatment, etc.).  However, the overall driving force in the decision to include or exclude a potential diagnosis from the DSM is the availability of scientific data.

Q:        What is the most recent version of the DSM?

A:         The current version of the DSM, called the DSM-IV-TR, was published in July 2000.  This is considered to be a minor revision in that changes were, for the most part, confined to the descriptive text that accompanied each disorder.  The most recent major revision was DSM-IV, published in 1994.  In all, there have been 4 major revisions of the DSM.   The first edition of the DSM was published in 1952.  Subsequent revisions included DSM-II, (published in 1968), DSM-III (published in 1980), DSM-III-R (published in 1987), and DSM-IV (published in 1994).   

Q:        What's so “Statistical” about the Diagnostic and Statistical Manual of Mental Disorders?  

A:         The word “statistical” in the name of the manual is a throwback to one of the original uses of the DSM—to facilitate the collection of hospital statistics in the early 1950's and 1960's.  Although psychiatric diagnoses are still an important part of record keeping, the primary use of the DSM is “diagnostic.”  For historical reasons, we have kept the name “DSM.”

Q:        How can I quickly find out the changes between DSM-IV and DSM-IV-TR?

A:         The DSM-IV-TR includes an appendix (Appendix D), that provides an overview of the important changes in the text.  Click here for summary of changes to DSM-IV-TR text.  In addition, some changes were made in the diagnostic codes in order to keep the codes compatible with the ICD-9-CM, the diagnostic coding system required by the U.S. Government and by most insurance carriers for reporting health care data.  Click here for a crosswalk from DSM-IV codes to the new DSM-IV-TR codes.  Finally, there were minor changes made to the criteria sets and disorder definitions in order to correct errors and ambiguities in the DSM-IV.  Click here for a summary of practice-relevant changes in DSM-IV-TR.

Q:        Sometimes different disorders or subtypes of disorders have the same diagnostic code.  Is there an error here?

A:         A number of individuals have contacted us about possible “clerical errors” in the diagnostic codes, namely, that certain disorders and subtypes have the same diagnostic code.  Although this situation is certainly not optimal, it was necessary at times (particularly in coding substance-related disorders) to use the same code for more than one disorder.  The DSM-IV-TR diagnostic codes are limited to those contained within the ICD-9-CM coding system, which is required by most governmental agencies and private insurers.  DSM-IV-TR contains more diagnostic entities than there are official codes in ICD-9-CM.  Therefore, by necessity, some DSM-IV-TR diagnoses share diagnostic codes.

Q:        Medicare, Medicaid, other third party payers, and HIPAA regulations require ICD-9-CM codes for diagnosis/reimbursement.  Do I need a table to convert from DSM-IV-TR codes to ICD-9-CM codes?

A:         No. Unlike DSM-III and DSM-III-R, all of the diagnostic codes in DSM-IV  and DSM-IV-TR were selected so as to be valid ICD-9-CM codes.  However, since minor revisions are made to the ICD-9-CM system on a yearly basis (with changes becoming mandatory each January 1^st), subsequent printings of DSM-IV-TR have incorporated the few minor changes in ICD-9-CM codes that have occurred since October 2000.  Click here for a list of coding changes in DSM-IV-TR that have taken effect since October 2000.

 Q:        Since DSM-IV-TR has not been officially adopted as a “HIPAA Code Set,” can I still use the DSM-IV-TR criteria for making psychiatric diagnosis?

A;         Yes.  The US Government has officially sanctioned the continued use of the DSM-IV-TR diagnostic criteria.  Two entries on the Frequently Asked Questions section of the Center for Medicare Services web site address this issue.   In response to the question “Can clinicians continue current practice and use the DSM-IV diagnostic criteria?,” the site states “clinicians may continue to base their diagnostic decisions on the DSM-IV criteria, and, if so, to crosswalk those decisions to the appropriate ICD-9-CM codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV codes, descriptors and diagnostic criteria for other purposes, including medical records, quality assessment, medical review, consultation and patient communications.”  (Click here for the complete entry on the CMS web site) Furthermore, in response to the question “Can mental health practitioners, agencies, institutions and others still use DSM-IV diagnostic criteria, even though DSM-IV has not been adopted as a HIPAA code set?,” the site notes that “the basic purpose for adopting code sets under HIPAA is to standardize the ‘data elements' used in the electronic processing of certain administrative and financial health care transactions. While the patient's diagnosis is a data element used in such transactions, the criteria considered by the clinician in reaching a diagnosis are not. Practitioners are free to use the DSM-IV diagnostic criteria—or any other diagnostic guidelines—without any HIPAA-related concerns.” (Click here for the complete entry on the CMS web site)

Q:        The last big revision was DSM-IV in 1994.  How do I find out about the reasons for making these changes?

A:         The five-year revision process that culminated in the publication of DSM-IV is documented in the four volume DSM-IV Sourcebook.  

·        Volume 1 of the Sourcebook (which contains literature reviews on delirium, dementia, amnestic, and other cognitive disorders; schizophrenia and other psychotic disorders; medication-induced movement disorder; and sleep disorder) was published by APPI in 1994. 

·        The second volume of the Sourcebook, published in 1996, contains reviews on mood disorders, late luteal phase dysphoric disorder, anxiety disorders, personality disorders, psychiatric system interface disorders and sexual disorders. 

·        Volume 3 of the Sourcebook, published in 1996, presents literature reviews on eating disorders, disorders first usually diagnosed in infancy, childhood or adolescence, family/relational problems, the DSM-IV multiaxial system and cultural issues. 

·        The final volume of the Sourcebook, published in 1998, contains the reports from the MacArthur Data Reanalysis, the reports from the NIMH sponsored DSM-IV Field Trials and final integrative summaries from each of the DSM-IV work groups.  This volume is currently out-of-print  

Q:        I understand that there is a primary care version of the DSM-IV — please tell me about it.

A.        In October of 1995, the APA published the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–Primary Care version (DSM-IV–PC).  The DSM-IV–PC was designed specifically for use by primary care clinicians.  Mental disorders and conditions most frequently encountered in primary care comprise the majority of the manual.  These disorders are presented in nine algorithms (depressed mood, anxiety, unexplained physical symptoms, cognitive disturbance, problematic substance use, sexual dysfunction, sleep disorders, weight change/eating problems, and psychotic symptoms).  The algorithms were determined by clustering common symptom presentations.  The DSM-IV–PC also includes sections on psychosocial problems that are a focus of clinical attention but that are not considered a mental disorder, and disorders rarely first identified in primary care (e.g., dissociative disorders, psychotic disorders and a section on disorders usually first diagnosed in infancy, childhood, or adolescence).

Q:        I have heard that the APA has developed a manual on psychiatric measures.  What is included in the Handbook?

A:         The APA published the Handbook of Psychiatric Measures in May 2000.  The main purpose of the manual is to provide clinicians working in mental health or care settings with a compendium of some of the available rating scales and tests that may be useful in the clinical care of their patients or for their use in the interpretation and implementation of services research studies.  In addition, the manual is designed to provide guidance to clinicians, policy makers and planners on how to select, use and interpret clinical measures.  The primary audience for the manual is psychiatrists and other mental health professionals.

The manual describes how to select and use psychiatric assessment tools and evaluate available measures.  It is envisioned as a “toolbox with instructions” or a “consumer's guide” to the various psychiatric measures.  These measures cover a range of domains of assessment including: symptoms, functioning and outcomes, and are evaluated for their components, reliability, validity, strengths, weaknesses, and clinical utility.

Q:        What is the ICD-9-CM and how does it relate to the DSM-IV-TR?

A:         The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the official coding system of the United States used to track morbidity and mortality of diseases.  The system is maintained by the federal government.  For more information about ICD-9-CM and to download a copy, click here. The ICD-9-CM codes are also used to code diagnoses for reimbursement of medical care.  The DSM-IV-TR is a diagnostic manual that employs the ICD-9-CM codes to assist the clinician in medical record keeping.   Because the DSM-IV-TR includes a number of subtypes that were added since ICD-9-CM was originally developed in the 1970's, most of the subtypes and specifiers included in DSM-IV-TR cannot be indicated through the diagnostic codes.  Click here for more information about Diagnostic Coding and DSM-IV-TR.

Q:        What is the status of the ICD-10?

A:         ICD-10, the tenth revision of the International Classification of Diseases, was published by the World Health Organization in 1993.  Although DSM-IV and DSM-IV-TR were developed with the explicit goal of ICD-10 compatibility, they include ICD-9-CM codes since implementation of ICD-10 in the United States has been significantly delayed.  Currently, the National Center for Health Statistics is developing a modification of ICD-10 for use in the United States to be known as ICD-10-CM that will be field-tested over the next several years.  It is currently anticipated that it will be officially implemented in 2008.   (For more information about ICD-10-CM, click here). Around that time, a DSM-IV Coding Revision (DSM-IV-CR) will be published which will include the ICD-10-CM codes in place of the ICD-9-CM codes.

Q:       Has the DSM-IV been translated into any other language?

A:         DSM-IV-TR has been translated into 22 languages.  Click here for a list of languages and the publishers.

Q:        Whom do I contact if I find a mistake or inconsistency in the DSM-IV Text Revision?

A:         The DSM-V web page (http://www.dsm5.org/) provides you with an opportunity to provide comments and critiques about DSM-IV-TR as well as an opportunity to make suggestions for DSM-V.   Alternatively, you can email us at DSM@psych.org.

Q:        What kinds of materials are available to help me use DSM-IV-TR more effectively?

A:         There are a number of books, structured diagnostic interviews, audiotapes, and videotapes that are available for this purpose.  Click here for a list of books and other resources related to the DSM-IV that are published by American Psychiatric Press, Inc.

Q:        How do I obtain copyright permission to use the DSM-IV-TR?

A:         To obtain copyright permission, send you request to Kathy Stein at APPI (703-907-7875) or  kstein@psych.org