Name : Tanvi Tripathi

Class : TYBA
Roll number: TA2324463
Subject: Abnormal Psychology
Subject code : SIUAPSY52
Semester: 6

Journey of DSM and ICD

Introduction
Diagnosis holds paramount significance in all medical undertakings: it is essential for
the implementation of effective and suitable therapeutic interventions, it shapes the
patient’s prognostic outlook, it facilitates discourse regarding illnesses among
healthcare professionals and researchers, it serves as a cornerstone of medical
education, and it is indispensable for the execution of scientific inquiry . A dependable
diagnostic process is equally crucial for generating precise estimations of disorder
prevalence rates, planning health services, and documenting essential public health
data such as morbidity and mortality outcomes associated with diseases . Prior to the
establishment of organized diagnostic classification systems, the medical profession
lacked a formalized foundation to substantiate the validity of its practices, a
circumstance that contributed to the historical devaluation of public trust in the
profession . The emergence of classification systems for medical diseases was
instrumental in the evolution of the medical field and the progression of medical
knowledge.1

History of ICD

In the decade of the 1940s, the World Health Organization assumed responsibility for
the Bertillon classification system and subsequently broadened its scope to encompass
statistical data regarding the etiology of injuries and diseases, culminating in the
inaugural edition of the International Statistical Classification of Diseases, Injuries
and Causes of Death (ICD). This development facilitated, for the first time, the

1
Surís, A., Holliday, R., & North, C. (2016). The Evolution of the Classification of Psychiatric
Disorders. Behavioral Sciences, 6(1), 5. https://doi.org/10.3390/bs6010005
systematic aggregation of both morbidity and mortality data, thereby enabling the
analysis of disease patterns and the elucidation of mortality factors.2

A comprehensive understanding of diseases, which facilitates prevention, treatment,

and the judicious allocation of resources, necessitates precise measurement. For such
measurement to be deemed effective, it must exhibit reliability, permit valid
comparisons across different locations and temporal periods, and enable the coherent
aggregation of extensive datasets. Consequently, a systematic classification of
diseases and associated entities is imperative for the attainment of such measurement.

The International Classification of Diseases (ICD) has its origins in 1763, when
François Bossier de Sauvages de Lacroix, a French physician and botanist, created a
system that categorized diseases into 10 classes and 2,400 distinct types. Sauvages,
influenced by the English physician Thomas Sydenham, applied methods similar to
those used in botanical classification. A contemporary of Carl von Linné, the father of
modern taxonomy, Sauvages shared Linné’s focus on organizing knowledge
systematically. Recognizing the value of classifying diseases, the International
Statistical Congress in Brussels in 1853 assigned Jacob Marc d’Epine and William
Farr to develop a standardized system for recording causes of death across nations and
languages. This effort became the foundation of what was known as the “International
List of Causes of Death.”

In 1893, Jacques Bertillon, a Parisian statistician, formalized this list with the help of a
committee. By 1898, several North American countries, including the United States,
had adopted it. Over the years, the system underwent regular updates in 1900, 1910,
1920, 1929, and 1938. While standardizing morbidity reporting posed challenges, the
World Health Organization (WHO) took over the classification system in 1948. A
year later, it expanded to include causes of illness alongside causes of death and
became known as the International Classification of Diseases (ICD).
Evolution of ICD

The ICD evolved steadily. Its first five editions were contained in single volumes, but
the sixth edition was a turning point. It introduced a section on psychiatric disorders
and was renamed the Manual of the International Statistical Classification of Diseases,
Injuries, and Causes of Death. Subsequent editions—ICD-7 in 1957 and ICD-8 in
1968—continued this trajectory. Meanwhile, in the United States, the Public Health
Service adapted the system for hospital and clinical use, creating the International
Classification of Diseases Adapted for Hospital Records and Clinical Use (ICDA) in
1962. A later version, ICDA-8, addressed the unique needs of the U.S. healthcare
system, focusing more on both illness and death data.

In 1977, the WHO released ICD-9, which added more detail through 4-digit categories
and optional 5-digit subdivisions. This version was pivotal, as it made the ICD a
public resource. The U.S. National Center for Health Statistics then created the ICD-
2
https://www.who.int/news-room/spotlight/international-classification-of-diseases
9-Clinical Modification (ICD-9-CM), tailored for hospitals, outpatient facilities, and
doctors’ offices. Updated annually on October 1, the ICD-9-CM became a three-
volume set. The first two volumes included diagnostic codes, while the third covered
procedural codes—though the latter wasn’t widely adopted, as most preferred the
Current Procedural Terminology system.

The ICD-9-CM played a crucial role in Medicare’s Inpatient Prospective Payment

System, introduced in 1983 to standardize hospital payments for elderly and
chronically ill patients. Hospitals used ICD-9-CM codes to group diagnoses and
determine reimbursement amounts. Oversight of the ICD-9-CM was managed by the
Centers for Medicare and Medicaid Services (CMS) and the National Center for
Health Statistics. This progression paved the way for the ICD’s continued
development as a cornerstone of global health.

conclusion for icd

The International Classification of Disease (ICD) system was created for the
accurate tracking of diseases within a population. Across the years, it has become
an integral part of the payment infrastructure of the US health care system along with
the Current Procedural Terminology (CPT) coding system for medical procedures.
As our knowledge of disease advances and the US health care system payment
policy evolves from volume to value, so must the ICD system.

The ICD is revised roughly every decade to accommodate new medical knowledge
and allow countries to develop detailed adaptations suited to their healthcare systems.
While countries cannot alter the core code, they can add specificity and sell their
versions to others, often training practitioners in their use. Specialized fields like
dermatology or mental health may also create tailored adaptations.

WHO updates the ICD to reflect medical advancements, but not all countries
implement these changes promptly, leading to incompatible data. WHO standardizes
this data annually, but over time, discrepancies grow, necessitating a new version to
reset the system.

ICD-11, developed digitally as a “living document,” addresses these challenges with

enhanced adaptability and longevity. It reflects advancements since ICD-10, with a
modern design suited for the digital era. Its architecture includes a semantic
knowledge base, biomedical ontology, and derived classifications like ICD-11-MMS
for mortality and morbidity statistics. Innovations include an online coding tool, API
access, multilingual support, and improved capability to capture clinical details.3

3
Harrison, J. E., Weber, S., Jakob, R., & Chute, C. G. (2021). ICD-11: an international classification of
diseases for the twenty-first century. BMC Medical Informatics and Decision Making, 21(S6).
https://doi.org/10.1186/s12911-021-01534-6
HISTORY OF DSM

By the late 1800s, medical science significantly advanced in understanding the

biological roots of illness, particularly with the identification of bacteria causing
infectious diseases. During this period, German doctors Kraepelin and Alzheimer
developed methods to pinpoint neurological causes of diseases in their patients. They
distinguished conditions like dementia from other psychiatric disorders through
biological markers. Their research suggested that mental illness might have a
biological foundation. They began to create a structured framework for psychiatric
disorders by systematically observing illness patterns, including symptoms,
progression, and patient outcomes. However, their contributions were largely
overlooked by American psychiatry at that time..

Psychiatry was first recognized as a medical specialty in the United States in 1844,
with the establishment of the Association of Medical Superintendents of American
Institutions for the Insane, later renamed the American Psychiatric Association
(APA) in 1921. At that time, American institutions relied on in-house diagnostic
systems based on prototypical case studies, with diagnoses determined by
consensus among treating physicians.

By the 1940s, psychoanalytic theory dominated American psychiatry, emphasizing

individual differences in mental illnesses and assuming similar mental processes in
health and illness. This era, which lasted about two decades, lacked a unified
classification system and a biological understanding of psychiatric conditions. As a
result, American psychiatry became increasingly isolated from the broader field of
medicine.

Psychoanalysis faced significant challenges with two major developments. First,

the discovery of psychiatric medications revolutionized the treatment of severe
mental illnesses. Second, advances in biological research introduced
groundbreaking findings, such as the identification of neurotransmitter systems,
which shifted the focus toward a biological understanding of mental disorders.
These changes marked a turning point in American psychiatry, steering it closer to
a medical and scientific foundation.
The first American effort to create standardized diagnostic criteria was initiated by
the U.S. Census Bureau to estimate the prevalence of mental disorders for the 1920
census. This led to the development of the Statistical Manual for the Use of
Institutions for the Insane (SMUII), which categorized 21 disorders, 19 of which
were psychotic. Despite its potential utility, this manual was largely disregarded by
American psychiatrists, even as it evolved through 10 editions by 1942.

In 1952 and 1968, the American Psychiatric Association released the first two
editions of its diagnostic criteria for psychiatric disorders. However, the
establishment of diagnostic reliability and validity remained a challenge and was
not achieved until decades later.4

The World Health Organization (WHO) has historically included mental disorder
classifications in Chapter V of the International Classification of Diseases (ICD),
primarily used for reimbursement and compiling health statistics. However, after a
1982 international conference in Copenhagen, there was global consensus for the ICD
to adopt more explicit diagnostic criteria for mental disorders, aligning with the 1980
model of the DSM-III.

This agreement initiated a decade-long collaboration between the American

Psychiatric Association (APA), responsible for the DSM-IV, and the WHO, which
was developing the ICD-10. The cooperative effort was facilitated by an agreement
between the National Institute of Mental Health and the WHO, ensuring alignment
and consistency across the two classification systems.5

As psychiatry expanded its focus beyond mental institutions to encompass broader

mental health concerns, interest in creating a comprehensive classification system for
psychopathological conditions grew. In 1918, the American Medico-Psychological
Association (now the American Psychiatric Association), supported by the Bureau of
the Census and the National Committee for Mental Hygiene, made its first formal
attempt to standardize the nomenclature of mental disorders. This effort led to the
publication of the Statistical Manual for the Use of Institutions for the Insane,
considered the forerunner of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) series.

The manual included 22 diagnostic categories, predominantly psychotic conditions

thought to have somatic origins. This biologically-oriented framework reflected the
Kraepelinian approach of linking abnormal behavior to organic brain dysfunctions. It
also mirrored the psychiatric profession’s focus at the time, as most clinicians worked

4
Surís, A., Holliday, R., & North, C. (2016c). The Evolution of the Classification of Psychiatric
Disorders. Behavioral Sciences, 6(1), 5. https://doi.org/10.3390/bs6010005
5
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM 5: Classification and criteria changes.
World Psychiatry, 12(2), 92–98. https://doi.org/10.1002/wps.20050
in mental asylums, treating patients with severe mental disturbances often
accompanied by evident physical impairments and diseases.

Psychiatric diagnosis has turned out to be far more complex than anticipated when the
first edition of the Diagnostic and Statistical Manual (DSM) was introduced 50 years
ago. Psychiatry has long had a nosology—a classification of diseases—starting with
broad categories established in the early 19th century. From the late 19th to the mid-
20th century, psychiatric classification was heavily influenced by prominent figures
like Emil Kraepelin, the renowned German nosologist.

The DSM series developed from the American Psychiatric Association’s aim to align
its diagnostic framework with the International Classification of Diseases (ICD)
issued by the World Health Organization. Over time, its evolution has marked
progress toward a more medicalized approach to the classification of psychiatric
disorders.

The evolution of the Diagnostic and Statistical Manual (DSM) can be divided into
three major phases. The first phase includes the development and release of the initial
DSM and its second edition, which laid the groundwork for psychiatric classification.
The second phase marks the release of the DSM-III, considered revolutionary for its
structured, criteria-based approach that shifted the field toward a more standardized
diagnostic system. The third phase spans the post-DSM-III era, including the release
of the DSM-IV and its Text Revision (DSM-IV-TR), which refined previous editions
while maintaining the framework introduced by DSM-III. The current phase is
represented by the DSM-5, the most recent edition.6

Dsm1

By the 1950s, psychiatric diagnosis in the United States relied on five distinct
systems, used in settings like asylums, the military, the Department of Veterans
Affairs (VA), and prisons. Recognizing the need for a unified approach, the
American Psychiatric Association (APA) spearheaded the creation of a
comprehensive diagnostic framework. This effort resulted in the publication of the
first Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952.

The DSM-I drew heavily from the VA’s psychiatric diagnostic system,
incorporating elements from the Statistical Manual for the Use of Hospitals of
Mental Diseases, military psychiatric classifications from World War II, and the
International Classification of Diseases (ICD-6). Drafts were distributed to 520

6
Kawa, S., & Giordano, J. (2012). A brief historicity of the Diagnostic and Statistical Manual of Mental
Disorders: Issues and implications for the future of psychiatric canon and practice. Philosophy Ethics
and Humanities in Medicine, 7(1), 2. https://doi.org/10.1186/1747-5341-7-2
psychiatrists across the U.S. and Canada, with feedback from 241 shaping the final
manual. Disorders were categorized into two main groups: those with identifiable
organic brain causes and those without, labeled as “functional” disorders.
Functional disorders were further divided into psychoses, psychoneuroses, and
personality disorders, with terms like “depressive reaction” and “schizophrenic
reaction” reflecting an assumption that these conditions arose as responses to
stressors.

Although the DSM-I is often considered a psychoanalytic document, this

characterization is debatable. Psychoanalysts constituted a minority on the
committee and rarely used the DSM-I in practice. The manual also integrated
Kraepelinian ideas alongside psychoanalytic concepts, blending diverse
perspectives. Contemporary observers did not see it as exclusively psychoanalytic.
Instead, the DSM-I served as a transitional framework, informed by lessons from
World War II, and sought to balance psychodynamic, biological, and practical
elements in psychiatric diagnosis.7

DSM 2

The Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II),
published in 1968, represented a significant revision of its predecessor, the DSM-I.
This edition sought to harmonize American psychiatric diagnostic practices with the
International Classification of Diseases, Eighth Edition (ICD-8) issued by the World
Health Organization (WHO). Notably, DSM-II allowed for the diagnosis of comorbid
conditions, a departure from the original manual, and expanded its scope by
introducing a section specifically addressing child and adolescent disorders. The
number of diagnostic categories increased from 106 in DSM-I to 182 in DSM-II,
reflecting an effort to incorporate milder and situational conditions alongside severe
psychiatric illnesses.

Despite these modifications, DSM-II largely maintained the psychodynamic

framework of its predecessor. Terms such as “reaction,” which implied maladaptive
responses to stress, were removed, signaling a gradual shift toward a more atheoretical
approach. However, many diagnostic definitions remained concise and theory-laden.
For instance, “depressive neurosis” was characterized as “an excessive reaction of
depression due to an internal conflict or an identifiable event such as the loss of a love
object,” underscoring the psychodynamic emphasis on personality and life
experiences.

7
Surís, A., Holliday, R., & North, C. (2016d). The Evolution of the Classification of Psychiatric Disorders. Behavioral Sciences,
6(1), 5. https://doi.org/10.3390/bs6010005
Grob, G. N. (1991). Origins of DSM-I: a study in appearance and reality. American Journal of Psychiatry, 148(4), 421–431.
https://doi.org/10.1176/ajp.148.4.421
Cooper, R., & Blashfield, R. K. (2016). Re-evaluating DSM-I. Psychological Medicine, 46(3), 449–456.
doi:10.1017/S0033291715002093
Two significant trends were evident in DSM-II. The first involved broadening the
conceptualization of mental illness to include milder conditions, as exemplified by
categories such as “Conditions Without Manifest Psychiatric Disorder” and “Transient
Situational Disturbances.” The second trend suggested a return to Kraepelinian
principles, with an increase in specificity and systematic categorization. This was
reflected in the expansion of diagnostic qualifiers and the recommendation to
diagnose all present disorders, even when one was secondary to another.

While psychodynamic psychiatry remained influential during this period, its

dominance was waning by the late 1960s. Subtle changes in DSM-II hinted at the
discipline’s eventual shift toward an atheoretical and research-driven framework,
which would be more fully realized in subsequent editions. Nevertheless, DSM-II
remained primarily clinician-oriented, reflecting the priorities and practices of its
time.8

DSM 3

During the 1970s, Robert Spitzer, a psychiatrist affiliated with the New York State
Psychiatric Institute, was tasked with leading the development of the Diagnostic and
Statistical Manual of Mental Disorders, Third Edition (DSM-III). Spitzer’s selection
was timely, as he had been working on a National Institute of Mental Health-funded
project to create a set of research-based diagnostic criteria. Collaborating with Eli
Robins and the Feighner criteria team at Washington University, Spitzer adapted and
expanded these criteria into the Research Diagnostic Criteria (RDC), establishing a
structured and reliable framework for psychiatric diagnosis. This effort laid the
groundwork for the operationalization of diagnosis that would define the DSM-III.

The DSM-III introduced a fundamental shift in psychiatric classification by moving

away from psychodynamic explanations and etiological assumptions, adopting a
theoretical and descriptive approach instead. Its diagnostic framework was structured
into a multi-axial system, incorporating exclusion criteria to improve reliability.
Although the term “neurosis” was included as a concession to psychodynamic
practitioners, it was only retained parenthetically and subsequently removed in later
editions. The manual sought to align with the diagnostic framework of the World
Health Organization’s International Classification of Diseases (ICD). However, the
DSM-III’s criteria were ultimately deemed superior, leading to the modification of
ICD-9 to conform to the DSM, contrary to initial intentions.

The publication of DSM-III in 1980 marked a transformative moment in American

psychiatry, signaling a broader effort to re-medicalize the field and anchor it in
8
Horwitz, A. V. (2014). DSM I and DSM II. The Encyclopedia of Clinical Psychology, 1–6.
https://doi.org/10.1002/9781118625392.wbecp012
Surís, A., Holliday, R., & North, C. (2016e). The Evolution of the Classification of Psychiatric
Disorders. Behavioral Sciences, 6(1), 5. https://doi.org/10.3390/bs6010005
Kawa, S., & Giordano, J. (2012b). A brief historicity of the Diagnostic and Statistical Manual of Mental
Disorders: Issues and implications for the future of psychiatric canon and practice. Philosophy Ethics
and Humanities in Medicine, 7(1), 2. https://doi.org/10.1186/1747-5341-7-2
empirical research. This new operationalized approach solidified psychiatry’s position
as a medical specialty, bolstering its scientific credibility. However, the DSM-III was
not without controversy, as its atheoretical stance and rigorous criteria posed
challenges to traditional psychodynamic frameworks.

In 1987, Spitzer oversaw the development of DSM-III-R, a revised edition that further
refined diagnostic criteria based on feedback from practitioners and researchers.
DSM-III-R eliminated the hierarchical diagnostic structure of its predecessor, leading
to increased rates of comorbidity in epidemiological studies. While the original
Feighner criteria aimed to ensure reliable research diagnoses by grouping patients into
homogeneous categories, DSM-III-R revisions emphasized clinical utility,
incorporating practical input from clinicians.

The adoption of systematic diagnostic criteria over time has profoundly influenced
psychiatric practice, shaping reimbursement policies and administrative processes
through its application by insurance companies, managed care organizations, and
government bodies. The development of DSM-III and DSM-III-R reflects a pivotal
period in the history of psychiatric diagnosis, highlighting the evolving interplay
between clinical practice, research, and administrative demands.9

The development of the Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition (DSM-IV) began in 1988 with the appointment of a task force,
which included Allen Frances, a psychoanalyst from New York, as the head of the
revision. Frances had previously worked on the personality disorders section of
DSM-III. Spitzer continued to serve as an advisor. The need for DSM-IV was
prompted by the impending release of the International Classification of Diseases,
Tenth Edition (ICD-10) in 1993, though the DSM-IV itself was not published until
1994. Compared to its predecessor, DSM-IV introduced relatively few significant
changes.

One of the most notable modifications in DSM-IV was the consistent inclusion of
“clinically significant distress or impairment” across diagnostic criteria. In 2000, a
“text revision” edition, DSM-IV-TR, was released. This revision mainly updated
the research literature from 1992 to 1998 and provided additional details in the text
on associated features of disorders, without altering the diagnostic criteria.

DSM-IV, published in 1994, marked the culmination of a six-year process

involving over 1,000 contributors and numerous professional organizations. Much
of the revision focused on reviewing existing literature to establish a more solid
empirical foundation for modifications. The process led to various changes in the
classification of disorders, including additions, deletions, and reorganization, as
well as modifications to the diagnostic criteria and descriptive text.10

9
Surís, A., Holliday, R., & North, C. (2016f). The Evolution of the Classification of Psychiatric
Disorders. Behavioral Sciences, 6(1), 5. https://doi.org/10.3390/bs6010005
10
DSM History. (n.d.). https://www.psychiatry.org/psychiatrists/practice/dsm/about-dsm/history-of-the-
dsm
Dsm 5

Planning for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) commenced in 1999, prior to the release of DSM-IV-TR. David Kupfer, a
neuroscientist from Pittsburgh, was appointed as the chair of the task force, signifying
an emphasis on integrating neuroscientific advancements into psychiatric
classification. The primary objectives of DSM-5 included incorporating findings from
etiological and neurobiological research, addressing public health and clinical
challenges, and enhancing the practical utility of the diagnostic criteria. Additionally,
significant effort was made to align the manual with the upcoming 11th edition of the
International Classification of Diseases (ICD-11).

To achieve these goals, the revision process focused on incorporating dimensional and
cross-cutting measures, as well as developmental and environmental contexts, into
both the diagnostic criteria and accompanying descriptions. The development
involved extensive collaboration, with 13 international conferences conducted as part
of a joint effort among the American Psychiatric Association, the National Institute of
Mental Health, the World Health Organization, and the World Psychiatric
Association. This global collaboration highlighted the importance of creating a
classification system with both scientific rigor and international applicability.

Several notable changes were introduced in DSM-5. For example, Asperger’s disorder
was integrated into the broader category of autism spectrum disorder to reflect a
unified diagnostic framework. Similarly, the term “mental retardation” was replaced
with “intellectual disability” to adopt language that is contemporary and respectful.
The manual also featured improved assessment methodologies and expanded
diagnostic criteria, including the addition of new conditions and the removal or
integration of outdated classifications.

Published in 2013, DSM-5 represented a significant advancement in psychiatric

classification. By incorporating emerging research, aligning with global health
systems, and improving diagnostic utility, DSM-5 established itself as a
comprehensive and evidence-based resource for clinicians and researchers
worldwide.11

DSM–5-TR
The DSM-5-TR development effort started in Spring 2019 and involved more than 200
experts, the majority of whom were involved in the development of DSM-5. These

11
https://courses.lumenlearning.com/atd-herkimer-abnormalpsych/chapter/history-of-
the-dsm/
experts were given the task of conducting literature reviews covering the past nine
years and reviewing the text to identify out-of-date material. Four cross-cutting review
groups (Culture, Sex and Gender, Suicide, and Forensic) reviewed all the chapters,
focusing on material involving their specific expertise. The text was also reviewed by
a Work Group on Ethnoracial Equity and Inclusion to ensure appropriate attention to
risk factors such as racism and discrimination and the use of non-stigmatizing
language. Although the scope of the text revision did not include conceptual changes
to the criteria sets, some necessary clarifications to certain diagnostic criteria were
reviewed and approved by the DSM Steering Committee, as well as the APA
Assembly and Board of Trustees. DSM-5-TR was published in March 2022.

Overview

The purpose and utilization of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) have evolved considerably since its inception. The early editions,
DSM-I and DSM-II, were primarily developed to collect statistical data on the
prevalence of mental disorders, emphasizing public health surveillance and
population-level trends. With the introduction of DSM-III, informed by the Feighner
criteria, the manual shifted its focus to research, aiming to establish valid and reliable
diagnostic standards. This was achieved by creating homogeneous patient groups, thus
enhancing the reliability and validity of research findings.

The revision of DSM-III-R marked another pivotal shift, emphasizing the clinical
utility of diagnostic criteria. This iteration integrated feedback from clinicians to
address practical diagnostic challenges encountered in everyday clinical practice. Over
time, the DSM’s systematic diagnostic criteria have expanded their role, becoming
central to administrative and financial aspects of healthcare. Insurance companies,
managed care organizations, pharmaceutical companies, and government agencies
increasingly rely on these criteria for reimbursement, policy-making, and regulatory
decisions, underscoring their influence beyond clinical and research domains.

Despite its widespread adoption and influence, the DSM has not been without
controversy. Critics argue that it functions as much as a political document as a
scientific one, shaped by consensus and negotiation rather than definitive evidence.
Achieving a universally accepted and reliable classification of psychiatric disorders
remains a challenge. Nevertheless, the DSM has been translated into over 20
languages and is utilized across diverse fields, including clinical practice, research,
policy-making, judicial systems, and insurance frameworks, reflecting its extensive
reach and impact.
The DSM-5, in particular, has redefined the conceptualization of boundaries between
disorders. While some mental disorders exhibit well-defined symptom clusters,
scientific evidence increasingly supports the view that many disorders exist on a
spectrum. Shared symptoms, genetic and environmental risk factors, and potentially
overlapping neural substrates blur the boundaries between disorders, suggesting a
more interconnected understanding of mental health. For example, subsets of anxiety
disorders have been shown to share neural mechanisms, as evidenced by
neuroimaging and animal studies. This spectrum-based approach reflects a significant
shift in psychiatry, recognizing the complexity and fluidity inherent in mental health
diagnoses.

Whether lauded as a reasonable gold standard or critiqued for its limitations, the
DSM’s profound influence on psychiatry, medicine, and broader societal structures
cannot be overstated. As its frameworks continue to shape the field, the ongoing
challenge lies in balancing scientific rigor with practical utility, ensuring that its
impact remains both meaningful and constructive.

“The case formulation for any given patient must involve a careful clinical history and
concise summary of the social, psychological, and biological factors that may have
contributed to developing a given mental disorder. Hence, it is not sufficient to simply
check off the symptoms in the diagnostic criteria to make a mental disorder
diagnosis.”

– (DSM-5, Use of the Manual, page 19)

Comparison between icd and dsm

If we re run the tape of history over and over again, the DSM and ICD would not likely have
the same categories on every iteration.” – Kenneth S. Kendle12

Since the advent of DSM-III, a divergence has become apparent between advocates of
the DSM and those who prefer the ICD. Proponents of the DSM often commend its
structured and detailed framework, which is considered advantageous for research

12
Kendler, K. S. (2016). The nature of psychiatric disorders. World Psychiatry, 15(1), 5–12.
https://doi.org/10.1002/wps.20292
purposes. Conversely, supporters of the ICD value its flexibility, allowing for greater
clinical discretion in diagnosing mental disorders.

The ICD, officially endorsed as the global classification standard by the World Health
Organization, encompasses a section on “Mental and Behavioural Disorders” and is
widely utilized for recording diagnoses in psychiatric care systems globally,
particularly in regions where national health statistics are compiled. In contrast, the
DSM is the primary diagnostic tool in the United States for clinical purposes.
Nonetheless, the DSM’s influence has extended far beyond U.S. borders, largely due
to its perceived superiority for research applications and the widespread belief that it
provides greater diagnostic precision and reliability.

Reliability
The concept of reliability has been a central focus in the development of psychiatric
diagnostic systems, particularly with the introduction of DSM-III. This edition
represented a marked improvement over its predecessors due to its adoption of
operational criteria, which were originally derived from the Feighner criteria
established in 1972. Researchers like Spitzer and colleagues recognized that
psychiatric diagnoses could neither be clinically meaningful nor useful without first
achieving reliability. The incorporation of clear and standardized operational
definitions in DSM-III significantly enhanced the consistency of diagnostic practices.

In psychiatric classification, reliability is a statistical measure that reflects the degree

of agreement among assessors, either when evaluating the same individual at the same
time (interrater reliability) or at different points in time (temporal reliability).

In contrast, the International Classification of Diseases (ICD) adopts a different

approach to reliability. Unlike the DSM, the ICD does not enforce rigid diagnostic
criteria unless independently validated. Instead, it allows clinicians greater discretion
in their diagnostic judgments. While this approach may lead to lower statistical
agreement among practitioners, it does not inherently imply diminished accuracy. The
ICD’s emphasis on clinical judgment acknowledges the importance of professional
expertise and experience, providing space for nuanced decision-making that reflects
the complexities of psychiatric practice.

It is essential to differentiate reliability from validity in this context. Reliability, or the

consistency of diagnostic criteria, does not guarantee that the diagnosis accurately
represents the condition it aims to classify. For instance, perfect reliability could be
achieved within a group that unanimously agrees on an incorrect belief, such as the
Flat Earth Society’s assertion about the Earth’s shape. This agreement, however
consistent, does not validate the claim.

A similar issue emerges in the diagnosis of attention-deficit hyperactivity disorder

(ADHD). DSM-5 defines ADHD as a behavioral pattern causing significant
impairment in social, educational, or occupational settings, with diagnostic criteria
divided into inattention and hyperactivity/impulsivity domains. These criteria outline
specific symptoms, such as difficulty concentrating, organizing tasks, or remaining
seated, with numerical thresholds set for diagnosis. Although clinicians can be trained
to achieve high reliability in diagnosing ADHD, the diagnosis itself may lack validity,
as its broad and heterogeneous symptomatology often overlaps with typical
developmental behaviors, raising concerns about its clinical precision.

While the operational criteria introduced in DSM-III have greatly improved the
reliability of psychiatric diagnoses, achieving a balance between reliability, clinical
flexibility, and diagnostic validity remains a critical challenge. Such a balance is
essential to ensure that psychiatric classification systems remain scientifically robust
while addressing the practical complexities of mental health care.

Validity
Validity, as distinct from reliability, concerns whether a diagnostic system accurately
identifies and classifies the condition it is meant to represent. While operational
criteria in systems like the DSM can enhance reliability, they may inadvertently
compromise validity. This trade-off can lead to situations where a diagnosis adheres
strictly to the criteria but fails to align with the clinical reality.

For instance, under the DSM framework, a patient who meets all the criteria for major
depressive disorder might present symptoms that emerged following a significant life
event, albeit not necessarily a traumatic one. A clinician, interpreting the symptoms in
context, might identify them as a normal adjustment response rather than a clinical
depressive disorder requiring psychological or pharmacological intervention. Despite
this professional judgment, the operational criteria might compel a diagnosis of major
depressive disorder, potentially leading to unnecessary treatment.

This tension between strict diagnostic criteria and clinical judgment is not merely
theoretical. In practice, misdiagnoses based on rigid adherence to criteria can result in
overtreatment. For example, patients whose symptoms reflect situational adjustment
may receive antidepressants when a “wait-and-see” approach, allowing symptoms to
resolve naturally, would have been more appropriate. These instances underscore the
importance of balancing operational criteria with clinical insight to ensure that
diagnostic validity is not sacrificed for the sake of reliability.

Key Differences Between DSM and ICD in Diagnosis and Classification

The DSM and ICD exhibit significant overlap in their diagnostic frameworks,
allowing for a degree of compatibility and conversion between the two systems. Both
classify major psychiatric disorders similarly, yet notable differences exist in the
definitions and naming of individual disorders. These disparities may become more
pronounced with the introduction of ICD-11. This distinction holds practical
implications even in the United States, where clinical practice often relies on the DSM
but hospital diagnostic records must adhere to the ICD system.

One of the key strengths of the DSM is its ability to produce more precise diagnoses,
attributed to its use of operational criteria and the substantial resources devoted to its
development. In contrast, the ICD has traditionally operated with significantly less
funding and resources, resulting in a classification system that, while globally utilized,
often mirrors the advancements made in the DSM. Consequently, the ICD can
sometimes appear as a less detailed counterpart to its American counterpart, striving
to maintain relevance while lacking the extensive refinement seen in the DSM.

Expanding Diagnoses and Pathologizing Normality

The DSM-5 on Boundaries Between Disorders

“Although some mental disorders may have well-defined boundaries around symptom
clusters, scientific evidence now places many, if not most, disorders on a spectrum
with closely related disorders that have shared symptoms, shared genetic and
environmental risk factors, and possibly shared neural substrates (perhaps most
strongly established for a subset of anxiety disorders by neuroimaging and animal
models). In short, we have come to recognize that the boundaries between disorders
are more porous than originally perceived.”– (DSM-5, Introduction, page 5)

The growing number of diagnoses in both the DSM and ICD systems has sparked
concerns, particularly regarding the potential pathologization of normal human
variations. Allen Frances (2013), former chair of the DSM-IV Task Force, has
highlighted the dangers of this trend, emphasizing that an overemphasis on reliability
can lead to the creation of additional diagnostic categories, often turning typical
behaviors into clinical pathologies. When clinical judgment is sidelined in favor of
rigid diagnostic criteria, this tendency is likely to intensify, underscoring the need to
strike a balance between consistent criteria and the clinical subtleties that define
individual cases. The DSM’s compartmentalized approach may sometimes overlook
the broader scholarly perspective necessary to understand pathology, leading to an
overreliance on operational definitions that may not fully capture the complexity of
mental health conditions.

A significant issue with this proliferation of diagnoses is that many are seldom utilized
in practice. Despite this, the number of diagnoses in each DSM revision tends to
increase, resulting in a continually expanding manual. While the DSM is
predominantly used by psychiatrists, there is increasing recognition of its importance
for psychologists and other mental health professionals. In contrast, the ICD has
always aimed for broader applicability, accommodating the needs of a wide range of
mental health practitioners, from specialists in developed nations to those with limited
training in low- and middle-income countries. Its flexibility and simplicity are key to
its goal of being accessible and useful across various healthcare settings, promoting
global adoption.

The focus of the upcoming ICD-11 on clinical utility emphasizes the need for
diagnoses that are both relevant and practical in diverse contexts. A diagnosis can only
be deemed valuable if it is universally applicable, distinguishing the ICD from the
DSM in its broader, more inclusive vision. While both diagnostic systems have
contributed significantly to research on the biological underpinnings of mental
disorders, their reliance on rigid categories has led to a disconnect between clinical
symptoms and biological explanations. For example, depression is not caused by a
single biological system, and symptoms such as insomnia or low motivation overlap
with other disorders, highlighting the necessity of a more integrated understanding of
mental illness. This gap between clinical presentation and neurobiological
mechanisms calls for flexibility in diagnostic systems to more accurately reflect the
complexity of mental health conditions.

Research Domain Criteria

The DSM system continues to play a central role in psychiatric diagnosis, largely due
to the extensive investment and meticulous efforts of the American Psychiatric
Association. Despite its global influence, the DSM has faced criticism for being
overly rigid and, at times, disconnected from the evolving science of mental health. In
response, a new framework, the Research Domain Criteria (RDoC), has emerged,
aiming to integrate neurobiological insights with psychiatric classification (Cuthbert
& Insel, 2013).

The RDoC reimagines mental illnesses as disorders of brain circuits rather than
conditions with identifiable structural lesions, as seen in neurological disorders. These
brain circuit dysfunctions can be investigated using modern tools such as
electrophysiology, functional neuroimaging, and advanced in vivo techniques that
map neural connections. When paired with genetic and clinical neuroscience data, this
approach seeks to develop “biosignatures”—biological markers that enhance the
understanding of mental disorders, refine diagnoses, and guide treatment more
effectively.
While this vision is bold, it is not without its critics. Many question whether the RDoC
framework can truly deliver on its promises, especially given the limited clinical
breakthroughs thus far. However, the progress in understanding mental functioning
over the past two decades cannot be overlooked, offering cautious optimism about the
potential of this approach (Bracken, Thomas & Timimi, 2012; Kleinman, 2012).

Both the DSM and RDoC share a common focus on psychopathology, placing it at the
heart of classification. Yet, key differences highlight their unique perspectives. DSM-
5 mandates the presence of functional impairments for diagnosis, a criterion not
required by ICD-11. Moreover, the systems diverge in their approach to brief
psychotic disorders and the recognition of attenuated psychotic symptoms, reflecting
broader debates in the field.

At its core, the RDoC initiative represents an aspiration to humanize psychiatric

diagnosis by grounding it in the complexities of brain function. While it faces
challenges, it holds promise for a future where mental health care is guided by a
deeper understanding of the brain and its intricate workings, offering hope to
individuals navigating mental health challenges.13

Overview

The DSM and ICD classification systems have each contributed significantly to the
field of psychiatry, offering distinct advantages while also facing notable limitations.
Since 1980, the DSM has garnered significant attention, increasing interest in
nosology and sparking debates on the strengths and weaknesses of psychiatric
classification. It has facilitated substantial research advancements but, paradoxically,
has also impeded progress by legitimizing questionable diagnosis (Markon, 2013)
and fostering redundant inquiries into comorbidities that often reflect overlapping
phenomena rather than distinct disorders.

The ICD, though historically underfunded, has steadily evolved, with improved
descriptions and definitions enhancing its utility. While it has not matched the DSM in
research output, its adaptability and accessibility suggest its increasing prominence
in global psychiatric practice.

Looking forward, it remains unclear whether the DSM, ICD, or the emerging
Research Domain Criteria (RDoC) framework will ultimately dominate diagnostic
practice. Each system has inherent challenges, particularly the absence of
independent, objective measures for many mental disorders—a limitation unlikely to
be resolved for some conditions. Nonetheless, the need for reliable classification
systems in psychiatry is undeniable. These frameworks provide critical tools for

13
Gaebel, W. (2015). ICD-11 and DSM-5 – Similarities and Differences. European Psychiatry, 30,
115. https://doi.org/10.1016/s0924-9338(15)31836-8
understanding, diagnosing, and treating mental illnesses, and their defense is
essential against unfounded criticism. Without them, psychiatric practice would lack
the structure necessary for meaningful clinical and scientific progress.14

The DSM-5 and ICD-11 have significantly contributed to psychiatric research,

enhancing understanding of the global burden of mental health conditions. However,
their focus on diagnostic precision has often limited their relevance from a public
health perspective. These systems emphasize individual diagnoses while frequently
neglecting the societal and environmental factors that play a critical role in mental
health outcomes.

Depression, for example, illustrates the complexity of mental health conditions. It may
arise from environmental stressors requiring systemic societal interventions or from
biological factors that necessitate individual clinical care. A global mental health
classification system would benefit from expanding its focus beyond individual
diagnoses to address broader public health issues such as violence and substance use.
By emphasizing external factors—referred to as “exophenotypes”—attention can be
directed toward the social and environmental determinants of mental illness. Public
health strategies targeting violence and substance use have demonstrated the
effectiveness of prioritizing risk factors and harm-reduction approaches.

Furthermore, societal factors such as income inequality, early childhood adversity,

educational access, and the interconnections between poverty, food insecurity, and
mental health are critical influences on behavioral outcomes. Addressing these factors
is vital for breaking cycles of poverty and poor mental health. A classification system
that prioritizes these broader issues could provide better guidance for interventions,
address underlying causes, and promote equitable well-being across diverse
populations.

By shifting focus toward societal and systemic solutions, mental health care could
become more inclusive, effective, and attuned to the broader public health challenges
shaping mental well-being.

Conclusion

Medical practitioners have long recognized that diseases often manifest as

syndromes—clusters of signs and symptoms that exhibit relatively stable patterns.
Identifying these syndromes holds immense value for medical practice, education, and
research. Patients who share similar clinical presentations are likely to have

Tyrer, P. (2014). A comparison of DSM and ICD classifications of mental disorder. Advances in
14

Psychiatric Treatment, 20(4), 280–285. doi:10.1192/apt.bp.113.011296

comparable prognoses, enabling physicians to infer potential underlying causes
through shared histories and apply effective treatments across cases. The ability to
accurately diagnose and differentiate disorders is fundamental to clinical practice, as
effective treatment depends on correctly identifying the underlying condition. For
instance, distinguishing between pneumonia, pulmonary embolism, congestive heart
failure, or lung cancer—despite overlapping symptoms—is essential for guiding
appropriate interventions.

In psychiatry, as in other fields of medicine, differentiating disorders is equally

critical. Schizophrenia, mood disorders, and substance use disorders are distinct
illnesses with varying prognoses and treatment requirements. The Diagnostic and
Statistical Manual (DSM), published by the American Psychiatric Association, has
become the dominant global reference for diagnosing and categorizing mental
disorders, shaping psychiatric practice not only in the United States but increasingly in
Europe and Asia.

Since the DSM’s inception, psychiatry has undergone significant evolution, and the
fifth edition (DSM-5) has prompted renewed debate about its utility and accuracy.
While some regard it as a progressive refinement of previous editions, reflecting
advances in understanding mental disorders, others argue that it perpetuates
inaccuracies, offering limited improvements. A key conceptual shift in DSM-5 is its
acknowledgment that many mental disorders exist on spectrums, with overlapping
symptoms, genetic and environmental risk factors, and neural mechanisms. As stated
in its introduction, “the boundaries between disorders are more porous than originally
perceived,” particularly for related conditions like anxiety disorders.

This evolving perspective reflects a broader recognition that psychiatric diagnoses are
not rigid entities but complex constructs shaped by biological, psychological, and
social dimensions. While the DSM remains a cornerstone of psychiatric classification,
its limitations underscore the need for continuous refinement and integration of
emerging scientific evidence. By bridging categorical frameworks with dimensional
approaches, psychiatry can better navigate the complexities of mental health,
ultimately enhancing diagnosis, treatment, and patient care.15

15
Surís, A., Holliday, R., & North, C. (2016g). The Evolution of the Classification of Psychiatric
Disorders. Behavioral Sciences, 6(1), 5. https://doi.org/10.3390/bs6010005