were many challenges to the concept of mental illness itself. these challenges came from psychiatrists like thomas szasz, who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as erving goffman, who said mental illness was another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the apa's listing of homosexuality as a mental disorder. a study published in science, the rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis. the apa was closely involved in the next significant revision of the mental disorder section of the icd (version 8 in 1968). it decided to go ahead with a revision of the dsm, which was published in 1968. dsm-ii was similar to dsm-i, listed 182 disorders, and was 134 pages long. the term "reaction" was dropped, but the term "neurosis" was retained. both the dsm-i and the dsm-ii reflected the predominant psychodynamic psychiatry, although both manuals also included biological perspectives and concepts from kraepelin's system of classification. symptoms were not specified in detail for specific disorders. many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. the idea that personality disorders did not involve emotional distress was discarded. an influential 1974 paper by robert spitzer and joseph l. fleiss demonstrated that the second edition of the dsm (dsm-ii) was an unreliable diagnostic tool. spitzer and fleiss found that different practitioners using the dsm-ii rarely agreed when diagnosing patients with similar problems. in reviewing previous studies of eighteen major diagnostic categories, spitzer and fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. the level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories". seventh printing of the dsm-ii (1974) as described by ronald bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the apa began in 1970, when the organization held its convention in san francisco. the activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. in 1971, gay rights activist frank kameny worked with the gay liberation front collective to demonstrate at the apa's convention. at the 1971 conference, kameny grabbed the microphone and yelled: "psychiatry is the enemy incarnate. psychiatry has waged a relentless war of extermination against us. you may take this as a declaration of war against you." this gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. anti-psychiatry activists protested at the same apa conventions, with some shared slogans and intellectual foundations as gay activists. taking into account data from researchers such as alfred kinsey and evelyn hooker, the seventh printing of the dsm-ii, in 1974, no longer listed homosexuality as a category of disorder. after a vote by the apa trustees in 1973, and confirmed by the wider apa membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance". dsm-iii (1980) in 1974, the decision to create a new revision of the dsm was made, and robert spitzer was selected as chairman of the task force. the initial impetus was to make the dsm nomenclature consistent with that of the international classification of diseases (icd). the revision took on a far wider mandate under the influence and control of spitzer and his chosen committee members. one added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous rosenhan experiment. there was also felt a need to standardize diagnostic practices within the united states and with other countries, after research showed that psychiatric diagnoses differed between europe and the united states. the establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process. the criteria adopted for many of the mental disorders were taken from the research diagnostic criteria (rdc) and feighner criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at washington university school of medicine and the new york state psychiatric institute. other criteria, and potential new categories of disorder, were established by consensus during meetings of the committee chaired by spitzer. a key aim was to base categorization on colloquial english (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-kraepelinian"). the psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model. a new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the dsm: "each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." personality disorders were placed on axis ii along with "mental retardation". the first draft of dsm-iii was ready within a year. it introduced many new categories of disorder, while deleting or changing others. a number of unpublished documents discussing and justifying the changes have recently come to light. field trials sponsored by the u.s. national institute of mental health (nimh) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. a controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the dsm task force. faced with enormous political opposition, dsm-iii was in serious danger of not being approved by the apa board of trustees unless "neurosis" was included in some form; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. additionally, the diagnosis of ego-dystonic homosexuality replaced the dsm-ii category of "sexual orientation disturbance". the gender identity disorder in children (gidc) diagnosis was introduced in the dsm-iii; prior to the dsm-iii's publication in 1980, there was no diagnostic criteria for gender dysphoria. finally published in 1980, dsm-iii listed 265 diagnostic categories and was 494 pages long. it rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry. when dsm-iii was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. however, according to a 1994 article by stuart a. kirk: twenty years after the reliability problem became the central focus of dsm-iii, there is still not a single multi-site study showing that dsm (any version) is routinely used with high reliably by regular mental health clinicians. nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. there are important methodological problems that limit the generalizability of most reliability studies. each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator ... dsm-iii-r (1987) in 1987, dsm-iii-r was published as a revision of the dsm-iii, under the direction of spitzer. categories were renamed and reorganized, with significant changes in criteria. six categories were deleted while others were added. controversial diagnoses, such as premenstrual dysphoric disorder and masochistic personality disorder, were considered and discarded. (premenstrual dysphoric disorder was later be reincorporated in the dsm-5, published in 2013). "ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." altogether, the dsm-iii-r contained 292 diagnoses and was 567 pages long. further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the personality disorders, the criteria require much more inference on the part of the observer" . dsm-iv (1994) in 1994, dsm-iv was published, listing 410 disorders in 886 pages. the task force was chaired by allen frances and was overseen by a steering committee of twenty-seven people, including four psychologists. the steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. the work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multi-center field trials relating diagnoses to clinical practice. a major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". some personality-disorder diagnoses were deleted or moved to the appendix. further information can be found in the journal of personality and mental health. dsm-iv definitions