diagnostic and statistical manual of mental disorders diagnostic and statistical manual of mental disorders the diagnostic and statistical manual of mental disorders (dsm; latest edition: dsm-5-tr, published in march 2022) is a publication by the american psychiatric association (apa) for the classification of mental disorders using a common language and standard criteria. it is the main book for the diagnosis and treatment of mental disorders in the united states and is considered one of the principal guides of psychiatry, along with the icd, ccmd, and the psychodynamic diagnostic manual. however, not all providers rely on the dsm-5 as a guide, since the icd's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in dsm-5 criteria to determine the real-world effects of mental health interventions. 1952 edition of the dsm (dsm-1) it is used – mainly in the united states – by researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policymakers. some mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. hospitals, clinics, and insurance companies in the united states may require a dsm diagnosis for all patients with mental disorders. health-care researchers use the dsm to categorize patients for research purposes. the dsm evolved from systems for collecting census and psychiatric hospital statistics, as well as from a united states army manual. revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, while removing those no longer considered to be mental disorders. recent editions of the dsm have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound nosology (the branch of medical science that deals with the classification of diseases) used in dsm-iii. however, it has also generated controversy and criticism, including ongoing questions concerning the reliability and validity of many diagnoses; the use of arbitrary dividing lines between mental illness and "normality"; possible cultural bias; and the medicalization of human distress. the apa itself has published that the inter-rater reliability is low for many disorders in the dsm-5, including major depressive disorder and generalized anxiety disorder. distinction from icd an alternate, widely used classification publication is the international classification of diseases (icd) is produced by the world health organization (who). the icd has a broader scope than the dsm, covering overall health as well as mental health; chapter 5 of the icd specifically covers mental and behavioral disorders. moreover, while the dsm is the most popular diagnostic system for mental disorders in the us, the icd is used more widely in europe and other parts of the world, giving it a far larger reach than the dsm. an international survey of psychiatrists in sixty-six countries compared the use of the icd-10 and dsm-iv. it found the former was more often used for clinical diagnosis while the latter was more valued for research. this may be because the dsm tends to put more emphasis on clear diagnostic criteria, while the icd tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated. that is, the icd descriptions of psychiatric disorders tend to be more qualitative information, such as general descriptions of what various disorders tend to look like. the dsm focuses more on quantitative and operationalized criteria; e.g. to be diagnosed with x disorder, one must fulfill 5 of 9 criteria for at least 6 months. the dsm-iv-tr (4th. ed.) contains specific codes allowing comparisons between the dsm and the icd manuals, which may not systematically match because revisions are not simultaneously coordinated. though recent editions of the dsm and icd have become more similar due to collaborative agreements, each one contains information absent from the other. for instance, the two manuals contain overlapping but substantially different lists of recognized culture-bound syndromes. the icd also tends to focus more on primary-care and low and middle-income countries, as opposed to the dsm's focus on secondary psychiatric care in high-income countries. antecedents (1840–1949) census office, ama and isi (1840–1911) the initial impetus for developing a classification of mental disorders in the united states was the need to collect statistical information. the first official attempt was the 1840 census, which used a single category: "idiocy/insanity". three years later, the american statistical association made an official protest to the u.s. house of representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns african americans were all marked as insane, and calling the statistics essentially useless. the association of medical superintendents of american institutions for the insane ("the superintendents' association") was formed in 1844. in 1860, during the international statistical congress held in london, florence nightingale made a proposal that was to result in the development of the first international model of systematic collection of hospital data. in 1872, the american medical association (ama) published its nomenclature of diseases, which included various "disorders of the intellect". its use was short-lived however. edward jarvis and later francis amasa walker helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880. in 1888, the census office published frederick h. wines' 582-page volume called report on the defective, dependent, and delinquent classes of the population of the united states, as returned at the tenth census (june 1, 1880). wines used seven categories of mental illness, which were also adopted by the superintendents: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis. in 1892, the superintendents' association expanded its membership to include other mental health workers, and renamed to the american medico-psychological association (ampa). in 1893, a french physician, jacques bertillon, introduced the bertillon classification of causes of death at a congress of the international statistical institute (isi) in chicago. (the isi had commissioned him to create it in 1891). a number of countries adopted the isi's system. in 1898, the american public health association (apha) recommended that united states registrars also adopt the system. in 1900, an isi conference in paris reformed the bertillion classification, and created the international classification of causes of death (icd). this would later be known as the icd-1. another conference would be held every ten years, and a new edition of the icd would be released. non-fatal conditions were not included. in 1903, new york's bellevue hospital published "the bellevue hospital nomenclature of diseases and conditions," which included a section on "diseases of the mind". revisions were released in 1909 and 1911. it was produced with the assistance of the ama and bureau of the census. apa statistical manual (1917) and ama standard (1933) in 1917, together with the national commission on mental hygiene (now mental health america), the american medico-psychological association developed a new guide for mental hospitals called the statistical manual for the use of institutions for the insane. this guide included twenty-two diagnoses. it would be revised several times by the association and its successor, the american psychiatric association (apa), and by the tenth edition in 1942, was titled statistical manual for the use of hospitals of mental diseases. in 1921, the ampa became the present american psychiatric association (apa). the first edition of the dsm notes in its foreword: "in the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution." in 1933, the ama's general medical guide the standard classified nomenclature of disease, (referred to as the standard), was released. along with the new york academy of medicine, the apa provided the psychiatric nomenclature subsection. it became well adopted in the us within two years. a major revision of the statistical manual was made in 1934, to bring it in line with the new standard. a number of revisions of the standard were produced, with the last in 1961. medical 203 (1945) world war ii saw the large-scale involvement of u.s. psychiatrists in the selection, processing, assessment, and treatment of soldiers. this moved the focus away from mental institutions and traditional clinical perspectives. the u.s. armed forces initially used the standard, but found it lacked appropriate categories for many common conditions that troubled troops. the united states navy made some minor revisions but "the army established a much more sweeping revision, abandoning the basic outline of the standard and attempting to express present-day concepts of mental disturbance." under the direction of james forrestal, a committee headed by psychiatrist brigadier general william c. menninger, with the assistance of the mental hospital service, developed a new classification scheme in 1944 and 1945. issued in war department technical bulletin, medical, 203 (tb med 203); nomenclature and method of recording diagnoses was released shortly after the war in october 1945 under the auspices of the office of the surgeon general. it was reprinted in the journal of clinical psychology for civilian use in july 1946 with the new title nomenclature of psychiatric disorders and reactions. this system came to be known as "medical 203". this nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the armed forces nomenclature introduced into many clinics and hospitals by psychiatrists returning from military duty." the veterans administration also adopted a slightly modified version of the standard in 1947. the further developed joint armed forces nomenclature and method of recording psychiatric conditions was released in 1949. icd-6 (1948) in 1948, the newly formed world health organization took over the maintenance of the icd. they greatly expanded it, included non-fatal conditions for the first time, and renamed it the international statistical classification of diseases. the foreword to the dsm-i states the icd-6 "categorized mental disorders in rubrics similar to those of the armed forces nomenclature." early versions (20th century) dsm-i (1952) the apa committee on nomenclature and statistics was empowered to develop a version of medical 203 specifically for use in the united states, to standardize the diverse and confused usage of different documents. in 1950, the apa committee undertook a review and consultation. it circulated an adaptation of medical 203, the standard's nomenclature, and the va system's modifications of the standard to approximately 10% of apa members. 46% of members replied, with 93% approving the changes. after some further revisions, the diagnostic and statistical manual of mental disorders was approved in 1951 and published in 1952. the structure and conceptual framework were the same as in medical 203, and many passages of text were identical. the manual was 130 pages long and listed 106 mental disorders. these included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic). the foreword to this edition describes itself as being a continuation of the statistical manual for the use of hospitals of mental diseases. each item was given an icd-6 equivalent code, where applicable. the dsm-i centers around three classes of symptoms: psychotic, neurotic, and behavioral. within each class of mental disorder, classifying information is provided to differentiate conditions with similar symptoms. under each broad class of disorder (e.g. "psychoneurotic disorders" or "personality disorders"), all possible diagnoses are listed, generally from least to most severe. the 1952 dsm version also includes sections detailing how to record patients' disorders along with their demographic details. the form includes information like a patient's area of residence, admission status, discharge date/condition, and severity of disorder. see figure 1. for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information. furthermore, the apa listed homosexuality in the dsm as a sociopathic personality disturbance. homosexuality: a psychoanalytic study of male homosexuals, a large-scale 1962 study of homosexuality by irving bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. this view was influential in the medical profession. in 1956, however, the psychologist evelyn hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. her study stunned the medical community and made her a heroine to many gay men and lesbians, but homosexuality remained in the dsm until may 1974. dsm-ii (1968) in the 1960s, there