Curr Psychiatry Rep (2013) 15:409 DOI 10.1007/s11920-013-0409-9 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS (SJ SIEGEL, SECTION EDITOR) Defining Psychosis: The Evolution of DSM-5 Schizophrenia Spectrum Disorders Mahendra T. Bhati Published online: 22 September 2013 # Springer Science+Business Media New York 2013 Abstract Descriptions of mental illness exist throughout Introduction recorded history. However, until the mid-twentieth cen- tury, there was no standard nosology or diagnostic stan- Descriptions of mental illness exist throughout recorded his- dard for mental disorders. This limited understanding of tory and across cultures and civilizations. Written records of these disorders and development of better treatments. As mental illnesses such as depression and dementia are found in conditions such as dementia praecox and schizophrenia ancient texts including the ancient Egyptian Eber Papyrus (c. were being described, collaborative efforts were made in 1550 BC) [1] and Hindu scriptures such as the Mahabharata the twentieth century to develop the first Diagnostic and (c. 400 BC) [2]. Psychiatric disorders, including schizophre- Statistical Manual of Mental Disorders (DSM). This nia, are widely recognized throughout recorded history and review provides an overview of the history of psychiat- long recognized as a significant public health concern. How- ric diagnosis with a focus on the history of schizophre- ever, through most of history the lack of both systematic, nia as a diagnosis in the DSM. DSM-5 updates to evidence-based diagnoses and nosology for mental disorders diagnostic criteria for schizophrenia and related disor- posed significant limitations for understanding and develop- ders are provided. Limitations to diagnostic validity and ing better treatments for mental illnesses. Physicians such as reliability are discussed in addition to changes in diag- Emil Kraepelin began characterizing mental illnesses such as nostic approaches to schizophrenia spectrum and other schizophrenia in the early twentieth century, and the Diagnos- psychotic disorders in an effort to improve diagnostic tic and Statistical Manual of Mental Disorders (DSM) pub- validity and reliability. The DSM-5 reflects the culmi- lished in 1952 represented the first coordinated effort to create nation of an ongoing collaborative effort to improve the a diagnostic manual solely dedicated for use in psychiatric diagnosis of mental disorders, and future research in disorders and integrated with the International Classification Research Domain Criteria (RDoC) will help provide of Diseases (ICD) published by the World Health Organiza- convergent validity when understanding and treating tion (WHO). The DSM has since undergone five major revi- mental illnesses. sions over its 60 year history, and the DSM-5 published in 2013 now serves as the main clinical and research reference for diagnosing mental illnesses. This article provides a review Keywords Schizophrenia . Schizophrenia spectrum of the history of psychiatric diagnosis and development of the disorders . Psychotic disorders . Psychiatric diagnosis . DSM [3] with a focus on the evolution of diagnostic criteria Psychiatric nosology . ICD . DSM . DSM-5 . RDoC . for schizophrenia spectrum and other psychotic disorders as Psychiatry published in the DSM-5 [4••]. Limitations to using the DSM-5 will be discussed in addition to future research to improve the understanding and nosology of mental illnesses. This article is part of the Topical Collection on Schizophrenia and Other Psychotic Disorders History of Psychiatric Diagnosis M. T. Bhati (*) Department of Psychiatry, Perelman School of Medicine, University Prior to the twentieth century there was no standard definition of Pennsylvania, 3535 Market Street, 2nd floor, Philadelphia, PA 19104, USA or classification of mental disorders. This posed a challenge to e-mail: [email protected] clinicians who had difficulty accurately diagnosing and 409, Page 2 of 7 Curr Psychiatry Rep (2013) 15:409 treating mental illnesses and researchers who recognized the standard for clinicians and researchers. The central and ongo- significance of mental illnesses, specifically schizophrenia, on ing goal of the DSM is to aid diagnosis and assessment of public health but could not accurately characterize and study psychiatric disorders, and it does not make recommendations such conditions. For the majority or history, psychiatric ill- regarding treatments. nesses were poorly characterized, treatments were insuffi- There was little difference in the DSM-I compared to the cient, and prognosis poor. DSM-II published in 1968 [6]. Both versions largely reflected The first attempt to systematically study mental illness was a psychodynamic approach to psychiatric diagnosis. The in the 1840 U.S. Census when an effort was made to collect DSM-II included 182 disorders and attempted to achieve information on the frequency of “idiocy” and “insanity.” greater uniformity of diagnostic classification at an interna- These efforts were intended to account for the number of tional level with nomenclature based on the ICD-8. The individuals in the U.S. who lived in mental institutions and validity of psychiatric diagnoses has been based on expert provided invaluable data for epidemiologists. By the 1880 clinical consensus since the 1970s drawn from a wide-range census, seven categories of mental health were identified of clinical experience and available basic, clinical, and epide- including 1) mania, 2) melancholia, 3) monomania, 4) paresis, miological research [7]. Robert Spitzer was chair of the task 5) dementia, 6) dipsomania, and 7) epilepsy. In 1917 the force leading to the publication of the DSM-III in 1980. The American Medico-Psychological Association (now known initial aim of the DSM-III was to better align DSM nomen- as the American Psychiatric Association), together with the clature with the ICD, but Spitzer and colleagues lead a broader National Commission on Mental Hygiene, formulated a plan effort to improve the uniformity and validity of psychiatric adopted by the U.S. Bureau of the Census for gathering diagnoses. Criteria adopted for many DSM-III disorders were uniform statistics across mental hospitals. Together both taken from Feighner [8] and Research Diagnostic Criteria groups developed the first psychiatric diagnostic manual in- (RDC) [9], both used in psychiatric research to provide more cluding 22 diagnoses and titled the Statistical Manual for the reliable diagnosis of mental disorders. Significant changes in Use of Institutions for the Insane. Post-World War II, a much the DSM-III included 265 diagnostic categories with intro- broader psychiatric nomenclature and classification scheme duction of explicit diagnostic criteria, a multi-axial system, was developed by the U.S. Army and led by psychiatrist, and a descriptive approach that attempted to be neutral with Brigadier General William C. Menniger. This nomenclature respect to theories of etiology (e.g., neurobiological, cogni- was called the Medical 203 and adopted and later modified by tive, psychodynamic, etc.). These changes were the result of the Veterans Administration (VA) to better incorporate outpa- extensive empirical work on the construction and validation of tient psychiatric presentations of World War II servicemen and explicit diagnostic criteria and the development of semi- veterans with illnesses including psychophysiological, per- structured interviews. Field trials sponsored by the NIMH sonality, and acute disorders. The World Health Organization were first performed for the DSM-III in an effort to establish (WHO) published the 6th edition of the International Classi- clinical reliability of DSM-defined psychiatric diagnoses [10]. fication of Diseases (ICD-6) in 1949, and it included for the Areas of inconsistency and further clarification of diagnostic first time a section on mental disorders. The ICD-6 was criteria led to a revision in 1987, the DSM-III-R, with 292 heavily influenced by the Medical 203 and included ten diagnoses. The DSM-IV, published in 1994, was the culmina- categories for psychoses and psychoneuroses in addition to tion of a 6-year effort involving constructing a comprehensive seven categories for disorders of character, behavior, and review of the literature to establish an empirical basis for intelligence. modifications. It contained 297 disorders, and numerous The American Psychiatric Association (APA) formed a changes were made in the DSM-IV including the addition, Committee on Nomenclature and Statistics who developed a reorganization, and elimination of psychiatric disorders in variant of the ICD-6 published in 1952 as the first DSM [5]. addition to updated diagnostic criteria and descriptive text. A The DSM-I was largely derived from the section on mental largely unchanged text revision, the DSM-IV-TR, was pub- disorders in the Standard Classified Nomenclature of Disease lished in 2000. developed at the National Conference on Nomenclature of The development of the recently published DSM-5 (2013) Disease in 1933 and included 106 mental disorders. The was the culmination of more than a decade of work by DSM-I contained a glossary of descriptions of mental illnesses thousands of clinicians and patients. Development of the arranged in diagnostic categories and emerged as the first DSM-5 began in 1999 among leaders of the NIMH and the official clinical manual of mental disorders. It attempted to APA who worked together to expand the scientific basis for use epidemiological