Historical Perspectives

Margaret Jordan Halter, PhD, APRN;

Donna Rolin-Kenny, PhD, APRN, PMHCNS-BC;
and Faye Grund, MS, APRN, PMHNP-BC

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22 Copyright © SLACK Incorporated

 Earn
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classifying mental illnesses. Mental

illnesses were not understood, and
ABSTRACT their descriptions were inadequate-
The first major attempts to categorize psychiatric disorders in the ly defined. At a time when naming
United States occurred in the mid-1800s, when census data were conditions was in the rudimentary
stages, descriptions were identified
collected that included “insanity” and “idiocy” of household mem-
based on gross departures from pre-
bers. In Europe, Florence Nightingale promoted the use of non- dictable, logical, and orderly behav-
fatal disease classification for morbidity and treatment in 1860. ioral patterns. These conditions were
By the late 1800s, Kraepelin categorized disorders, and his sixth merely observed, as root causes were
edition of the Compendium der Psychiatrie was widely adopted by not comprehended, nor were any
both Europeans and Americans. In 1952, the American Psychiatric effective treatments devised. Early
attempts to classify mental illnesses
Association published the first edition of the Diagnostic and Sta-
were based on an evolving under-
tistical Manual of Mental Disorders (DSM). Since then, the manual standing of the nature of psychiatric
has been periodically updated, expanded, and edited to reflect disorders.
social and scientific beliefs about the etiology and categorization
of psychiatric illness and care. In this article, we explore the histori- U.S. CENSUS
cal and ongoing development of the DSM and its implications for In the 1840 U.S. Census, respon-
dents were asked to identify a variety
psychiatric nurses.
of demographic data (CensusFinder,
n.d.). One question, “How many idi-
otic or insane Whites?” was used to
determine the prevalence of men-

T
he next edition of the Amer-
ican Psychiatric Associa-
tion’s [APA] Diagnostic and
Statistical Manual of Mental Disorders,
fifth edition (DSM-5), is scheduled
for publication in May 2013. This ar-
ticle is the first of two describing the
development of the DSM. An outline
of the historical perspectives, the
evolution of the classification, and
definition of mental illnesses will be
discussed. Also, contributions of psy-
chiatric nurses in its development are
presented here. The article by Halter,
Rolin-Kenny, and Dzurec (pp. 30-
39) details the changes made in the
DSM-5, highlighting controversial
modifications, and the potential im-
pact of this edition on both the pro-
viders and consumers of psychiatric
services.
CLASSIFYING MENTAL ILLNESSES
The development of a common
language for describing psychiatric
disorders assists in our understand-
ing of global epidemiology and re-
finement of disease statistics. Clas-
sification aids in the replication of
research so that studies may be com-
pared and analyzed, furthering diag-
nostic utility. A common language
also supports interdisciplinary case
collaboration, leading to improved
patient outcomes. It also facilitates
early diagnosis and problem identi-
fication for more immediate, proac-
tive, and effective treatment for in-
dividuals with psychiatric syndromes
(Sanders, 2011).
Historically, countries and indi-
vidual agencies within these coun-
tries had separate approaches to
tal retardation and mental illness of
people residing in public or private
residences. No definitions of these
conditions were provided, presuming
that everyone knew what was meant
by the terms, and this was one of the
earliest widespread attempts at the
categorization of mind-based disabil-
ity. This census even provided a cat-
egorization of insanity as it applied to
non-free individuals by asking about
the number of insane or idiotic slaves
and free Blacks who resided in the
household. A disorder termed drape-
tomania (drapetes, “a runaway [slave]”
+ mania [mania, “madness, frenzy”])
was later used to refer to a mental ill-
ness that caused slaves to flee captiv-
ity (Cartwright, 1851).
Forty years later, the 1880 U.S.
Census included a special form,
Schedule for Insane, to categorize

Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013 23

people who were in asylums or depen-
dent on others for support (Geneal-
ogy Trails, n.d.). The purpose of the
form was to learn more about people
in these situations. It included more
categories of mental illness: mania,
melancholia (depression), monoma-
nia (impulse control, conduct, and
delusional disorders), dementia, and
dipsomania (alcohol craving and
binge drinking). Epilepsy was also in-
cluded as a psychiatric disorder.
KRAEPELINIAN GROUPING OF
MENTAL DISORDERS
The Compendium der Psychiatrie,
an early work by German psychiatrist
Emil Kraepelin (1883), argued that
psychiatric care was as legitimate as
general medical treatment and should
be investigated systematically. In the
sixth edition of the Compendium der
Psychiatrie, Kraepelin (1899) catego-
rized disorders into a notable dichoto-
my with separate etiologies and treat-
ment trajectories. His work was based
on longitudinal studies of clinical
presentations and generational family
histories (Sanders, 2011). Kraepelin
categorizations were quickly adopted
in Europe and America for the purpos-
es of diagnosing psychiatric disorders
and are considered to be the founda-
tion of modern psychiatric classifica-
tion systems (Palm & Möller, 2011).
One Kraepelin category of diag-
noses was exogenous (i.e., originating
outside of the person) and treatable.
This included manic-depressive dis-
orders and melancholia (depression).
The other category was endogenous
(i.e., originating inside a person), or-
ganic, and incurable. Dementia prae-
cox, which means premature dementia
and referred to schizophrenia, was in-
cluded in the latter category. Kraepe-
lin identified three clinical varieties of
this disease: catatonic, characterized
by motor activity disruption (exces-
sively active or inhibited); hebephre-
nic, characterized by inappropriate
emotional reactions and behavior; and
paranoid, characterized by delusions of
grandeur and persecution.
24
INTERNATIONAL CLASSIFICATION
OF DISEASES
While Kraepelin was developing
his own classifications of mental ill-
ness, other health care providers and
governments were searching for ef-
fective ways to classify and organize
medical data. Most focused solely on
recording death/mortality statistics.
At the Fourth International Sta-
tistical Congress in 1860, nursing
research pioneer, Florence Nightin-
The DSM-5 will result
in restructured
assessments,
reformulated
diagnostic criteria,
altered formulas for
the reimbursement
of care, and
therefore changes in
treatment patterns
and strategies.
gale, promoted the use of non-fatal
disease classification for morbidity
and treatment entitled Proposals for
a Uniform Plan of Hospital Statistics
(Gordon, 1998; Nightingale, 1860).
She urgently recommended the use
of a classification of diseases for hos-
pital morbidity statistics. Nightingale
asserted that this would inform treat-
ment options.
A series of international classifica-
tion systems evolved shortly thereaf-
ter. The 40-page Bertillon Classifica-
tion of Causes of Death was developed
in France in the late 1800s. In 1898,
the American Public Health Associ-
ation adopted this system, which was
the precursor to today’s International
Statistical Classification of Diseases
(ICD) (World Health Organization
[WHO], n.d.). The association sug-
gested that the system be updated on
a regular 10-year cycle.
To lay a foundation for the decen-
nial revision process, the First Inter-
national Conference to Revise Bertil-
lon Classification of Causes of Death
followed in 1900 (Moriyama, Loy,
& Robb-Smith, 2011). After that
time, the next three revisions were
relatively minor, and early editions
were fairly short. Little attention was
given to mental illnesses. This lack of
attention may be due to the original
Bertillon text that focused on causes
of death from fatal medical condi-
tions rather than morbidity (i.e., in-
cidence of disease) statistics.
Although most sources credit the
sixth edition as the first ICD to in-
clude mental disorders, it was actu-
ally the fifth edition (Kramer, Sarto-
rius, Jablensky, & Gulbinat, 1979).
In 1938, the ICD contained a section
on diseases of the nervous system and
sense organs. That section included
mental deficiency, dementia praecox,
manic-depressive psychosis, and oth-
er disorders. In another section, alco-
holism was described.
The sixth edition of the ICD was
published in 1948 when the WHO
formed and assumed oversight for the
publication. The new edition would
include morbidity (disease and inju-
ry) in addition to the original focus
on mortality. Thus, the name changed
to the International Statistical Classifi-
cation of Diseases, Injuries and Causes
of Death (ICD). This edition included
a greatly expanded section on men-
tal disorders outlining psychoses and
psychoneuroses (10 categories) and
disorders of character (7 categories),
as well as intelligence (APA, 2012a).
Unfortunately, and despite the fact
that psychiatrists drafted this section
of the text, it was virtually ignored
by the medical community (Kendell,
1975).
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DEVELOPMENT OF THE
DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS
At the same time the ICD was
being developed, psychiatrists were
working to classify mental disorders in
a separate manual. In 1917, the Com-
mittee on Statistics of the American
Medico-Psychological Association
(now the APA) in collaboration with
the National Commission on Men-
tal Hygiene, published the Statistical
Manual for the Use of Institutions for
the Insane. This book contained 22
groups of mental illnesses. The focus
was on severe mental and neurologi-
cal illnesses seen in institutionalized
patients (Tartakovsky, 2011). There
were 10 editions of this manual until
1942.
Military and Veterans Administra-
tion psychiatrists found little use in
the APA’s publication, as most disor-
ders they treated were absent. They
were primarily interested in stress and
anxiety reactions, personality disor-
ders, and somatoform disorders. In
1943, the U.S. Office of the Surgeon
General, Army Services Forces, de-
veloped their own nomenclature, the
Medical 203 classification, which ex-
panded the utility of this text to the
somewhat less acute outpatient condi-
tions of soldiers and veterans. Psychia-
trist and Brigadier General William
C. Menninger led the Group for Ad-
vancement of Psychiatry and heavily
influenced momentum to advance a
common language in the psychiatric
community (Millon, Krueger, & Si-
monsen, 2010).
DSM-I
In the first edition of the DSM
(APA, 1952), the structure and con-
ceptual framework were the same as
the Medical 203, and many passages
of text were identical. Publication of
the DSM-I in 1952 followed the lead
of ICD-6 and added a glossary of clini-
cal descriptions. DSM-I disorders were
viewed as “reactions” of personality,
using Freudian psychoanalytic bases
for etiologies (APA, 2012a). An ex-
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
TABLE 1
SUMMARY OF CHANGES IN THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS (DSM), BY EDITION
Version Year Published
DSM-I 1952
DSM-II 1968
DSM-III 1980
DSM-IV 1994
DSM-IV-TR 2000
Note. TR = text revision.
ample of a diagnostic description in
the DSM-I is “[Dissociative reaction]
represents a type of gross personality
disorganization, the basis of which is
a neurotic disturbance, although the
diffuse dissociation seen in some cases
may occasionally appear psychotic”
(APA, 1952, p. 32).
What made the DSM different
from prior nosology was its expansion
beyond statistical classification into
a document with pragmatic, clinical
utility. The clinical descriptions aided
in establishing reliability in presenta-
tions, but the content remained sub-
jectively consistent with current social
psychological thought and politics.
The DSM-I included 106 disorders
in 130 pages within three broad diag-
nostic categories, including organic
psychoses, psychogenic neuroses (or
reactions responding to psychoanalyt-
ic treatment), and character disorders,
otherwise known as forensic issues
(Millon et al., 2010). The psychotic
disorders included schizophrenic “re-
actions.” Anxiety and depression
were included in the category of psy-
choneurotic disorders. Personality or
character disorders also included ad-
diction (Sanders, 2011).
The APA established a parallel classi-
fication system for psychiatry in the DSM
to what the ICD was issuing, but con-
tinued to pursue a more comprehensive,
utilitarian model for adoption by provid-
ers of clinical psychiatry in America.
Number of
Diagnoses Page Count
106 130
182 134
265 494
297 886
365 943
Continued dissatisfaction with
the diagnostic scope of mental illness
by ICD-6 and ICD-7 resulted in the
WHO commissioning a comprehen-
sive diagnostic review by British psy-
chiatrist Erwin Stengel (APA, 2012a).
He recommended the inclusion of
explicit diagnostic criteria for clini-
cal reliability, a recommendation that
was largely ignored until the develop-
ment of the DSM-III in 1980. Sanders
(2011) asserted that if international
collaboration were as strong in the
mid-1900s as it is now, the United
States would have likely adopted the
ICD-6 and the now influential DSM
would not exist.
DSM-II
The DSM-II was published in 1968
with the aim of its terms coinciding
with those of the ICD-8 (Millon et
al., 2010). The APA’s Nomenclature
and Statistic Committee circulated an
early draft of the DSM-II to 120 psy-
chiatrists for their review and input
(Peele, 2008). The DSM-II covered
182 disorders in 134 pages.
The final version of the second edi-
tion retained the gap between neuro-
sis and psychosis, but the “reactions”
terminology was removed (Millon et
al., 2010). The term reaction was con-
sidered to suggest an environmental
etiology, and the DSM-II developers
could not agree on this notion. There-
fore, a diagnosis such as schizophrenic
25
 nostic criteria on research and empir-
TABLE 2 ical evidence (Feighner et al., 1972).
ABBREVIATED TIMELINE OF THE DSM-5 DEVELOPMENT Another significant change in this
edition was that people were no longer
Time Period American Psychiatric Association (APA) Activity viewed as either mentally healthy or
1999–2007 DSM-5 pre-planning white papers are developed ill. A newer view represented mental
2004–2007 APA, National Institutes of Health, and World Health health and illness as endpoints on a
Organization conduct research-planning conferences continuum, where health and illness
2006–2008 DSM-5 chairs, work group chairs, and members are could take on a variety of values and
appointed and announced fluctuate at different points in time.
This change was controversial, as the
April 2010– Field trial testing for diagnostic categories and cross-
blurring of mental illness and health
April 2012 cutting dimensional measures are implemented
was found by some to be distressing
October 2011– Data from field trials are analyzed (Tartakovsky, 2011). The logic of this
April 2012 continuum eventually received wide-
Spring 2012 Revisions are posted and open to a third public feedback spread acceptance and continues as a
for 2 months and further edits are made contemporary viewpoint where men-
May 18-22, 2013 The DSM-5 will be released during the APA’s 2013 annual tal illnesses are a spectrum of inter-
meeting in San Francisco. secting symptoms and levels of sever-
ity of impairment.
Note. DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, fifth edition. The DSM-III grew to 265 diagno-
Adapted from American Psychiatric Association (2012c). ses and 494 pages. Explicit diagnos-
tic criteria resulted in a more neutral
language in the description of etiology
reaction was changed to schizophre- (Taratovsky, 2011). A famous re- of disorders as compared to previous
nia. A sample of a DSM-II diagnosis search study published by Rosenhan editions (APA, 2012a). The DSM-
follows: in 1973, “Being Sane in Insane Plac- III represented the input of more
Anxiety neurosis is characterized by es,” shocked the nation and likely in- than 1,000 APA members, including
anxious over-concern extending to panic fluenced this shift. In the experiment, workgroups, field trials, and revisions
and frequently associated with somatic eight healthy patients (three psychol- (Peele, 2008). There was little repre-
symptoms. Unlike phobic neurosis, anxi- ogists, a pediatrician, a psychiatrist, sentation from other disciplines in the
ety may occur under any circumstances a painter, and a housewife) briefly development of this edition.
and is not restricted to specific situations faked psychoses—specifically, hear- The process of the DSM-III de-
or objects. This disorder must be distin- ing voices—and were admitted to velopment was coordinated with the
guished from normal apprehension or psychiatric hospitals. After admission development of the ICD-9 in 1975,
fear, which occurs in realistically danger- they behaved normally and denied whereby terms were made consistent
ous situations. (APA, 1968, p. 39) any further symptoms. All eight pseu- between the two taxonomies (APA,
In a 1974 DSM-II revision, the di- dopatients were required to accept a 2012a). The two classifications were
agnosis of homosexuality was replaced psychiatric diagnosis and take psy- used differently; the DSM was mar-
with ego-dystonic homosexuality chotropic medications as a condition keted primarily for clinical utility,
(Peele, 2008). The APA Board of Di- of their release. The average length of whereas the ICD was more suitable for
rectors’ instruction was influenced by stay was 19 days for these symptom- statistical collection and billing. The
growing empirical research from the less actors, and each was discharged U.S. government adopted ICD-9 cod-
1950s through the 1980s, which was with a diagnosis of schizophrenia in ing for records of medical morbidity
less biased, showing a lack of relation- remission. and mortality.
ship between homosexuality and psy- The climate was right for a group A multi-axial psychiatric diagnostic
chopathology or maladjustments. called “Neo-Kraepelinians” who system that generated five dimensions
wanted to reject psychoanalytic (axes) relating to different aspects of
DSM-III language in favor of a scientific ap- disability or disorder was introduced.
The DSM-III was published in 1980 proach. This group advocated for a They included:
and represented a significant move to- system called Feighner criteria that l Axis I: Psychiatric disorders.

ward empiricism in attempt to coun- includes the systematic use of diag- l Axis II: Personality disorders

ter American suspicions and an overt nostic elements, emphasized illness and intellectual disabilities.
distrust of the psychiatric profession course and outcome, and based diag- l Axis III: Medical conditions.

26 Copyright © SLACK Incorporated

 l Axis IV: Environmental and
psychosocial stressors.
l Axis V: A score based on the
Global Assessment of Functioning
Scale.
Prominent diagnostic changes includ-
ed the addition of posttraumatic stress
disorder and the exclusion of neuroses
(Peele, 2008). A DSM-III revision by
the APA in 1987 removed the diagnosis
of ego-dystonic homosexuality. Sexual
disorders not otherwise specified (NOS)
remained and included the specifier of
distress related to sexual orientation.
More than 1 million copies of
the DSM-III were sold to psychiatric
professionals and the general public
alike. Allen Frances (2012), chair of
the DSM-IV Task Force, notes that
the discussion of psychiatric diagno-
sis made a transition from the clinical
area to conversation at cocktail par-
ties. While the psychiatric community
made a shift from Freudian hidden
motivations and dream analysis, so too
did the enlightened reader who began
to consider his own symptoms and
those of others.
DSM-IV
The DSM-IV was published in 1994
and lasted 18 years with some revision.
The DSM-IV included 297 disorders
in 886 pages. National involvement
and consultation with other health
care providers informed its develop-
ment to a greater degree than with
prior editions. In total, it was a 6-year
project and included empirical input
from a variety of professional organi-
zations (APA, 2012a). Again, coordi-
nated efforts were made to minimize
language inconsistencies with the cur-
rent edition of ICD, ICD-10, which
was published in 1992 (APA, 2012a).
Many of the disorders included NOS
titles and comorbidities. This edition
added the requirement of distress or
disability in association with psy-
chological or behavioral syndromes
(APA, 2000). The DSM-IV retained
some Freudian terms such as fetishism.
A major criticism of the DSM-IV
related to pediatric psychiatry. Use of
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
KEYPOINTS
Halter, M.J., Rolin-Kenny, D., & Grund, F. (2013). DSM-5: Historical Perspectives. Journal
of Psychosocial Nursing and Mental Health Services, 51(4), 22-29.
1. A common language for describing psychiatric disorders assists health care
professionals in understanding and communicating information that is
essential to quality patient care.
2. The first edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) was published in 1952. The latest edition (DSM-5) is to be published in
May 2013.
3. Psychiatric nurses participated in the development of the DSM-5 by providing
comments to the draft criteria and by participating in the DSM-5 clinical field
trials.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to the Journal at jpn@healio.com.
the DSM-IV basically required concep- texts of the diagnoses. Relatively few
tualization of children as little adults changes were made to diagnostic cat-
rather than viewing their unique neu- egories and criteria, but some correc-
rodevelopmental issues and potentials tions were made, and categories and
from different categorical and assess- codes were realigned to parallel up-
ment vantages (Rawnsley & Roberts, dates made to ICD-9.
1999). Considering the total percent- Diagnoses and page count
age of life lived for a child, waiting expanded with each version of the
a full year with persistent symptoms original DSM through DSM-IV-TR
before diagnosing may be unneces- (Table 1). Quantities of diagnoses
sarily traumatic. Child psychiatric and pages in the upcoming DSM-5
nurses opined that the DSM-IV lacked were unavailable for this article, but
a comprehensive assessment, an as- according to David Kupfer, co-chair
sessment that should include family of the DSM-5 task force, the number
strengths and resources, understand- of diagnoses will stay approximately
ing of social contexts, and perinatal the same. He notes that the leveling
histories (Rawnsley & Roberts, 1999). off of diagnoses for psychiatry goes
The manual was also published by against the trend for other areas of
the APA as a primary care version medicine that experience annual in-
(DSM-IV-PC) in 1995. This manual creases (Falco, 2012).
supports primary care providers who
may underdiagnose commonly en- DSM-5
countered psychiatric disorders. DSM- The APA has scheduled the release
IV-PC includes a diagnostic algorithm of the DSM-5 for May 2013, 19 years
for a quick, sequential process of as- after the publication of the DSM-IV.
sessment and application of the over- Unlike previous editions, DSM-5 and
all diagnostic criteria. A user-friendly future editions will use Arabic num-
symptom index was also included bers (e.g., DSM-5.1, DSM-5.2), which
(Quinn, 1999). are easier for most people to recognize
The most recent version of the and reflect ongoing updates.
manual (DSM-IV-TR) was published In this edition, the abbreviated
in 2000 as a text revision. Updates term “psychobiological dysfunction”
were made to reflect current research replaces “behavioral, psychological, or
by including updates to background biological dysfunction.” This version
information within the descriptive purports to be more science based,
27
using a greater number of evidence-
based recommendations than previous
editions.
A developmental approach is used
throughout this edition, and the exclu-
sive category of Disorders Usually First
Evident in Infancy, Childhood, and
Adolescence is removed. The overall
list of disorders roughly follows the life
span, and the first category of disorders
is Neurodevelopmental Disorders, a
category of disorders that commonly
occur in infancy and childhood. Each
diagnostic category lists individual
disorders based on child through adult
progression wherever possible.
The DSM-5 developers propose
more dimensional approaches to diag-
nosing psychiatric disorders and take
into consideration common under-
lying characteristics that are shared
between disorders (Sanders, 2011).
With advancing knowledge of under-
lying genetics, there is a spectrum of
intersecting phenotypic presentations,
including clinical diagnoses ranging
from psychosis to mania to depression.
Genetic susceptibilities are found to be
overlapping, which lead to variations
in clinical presentations, as well as co-
morbidities. Increased understanding
should lead to broad-spectrum psycho-
pharmacological treatments (Crad-
dock & Owen, 2005). The timeline of
DSM-5 development is summarized in
Table 2.
PSYCHIATRIC NURSES AND THE
DEVELOPMENT OF THE DSM-5
The APA publicly requested feed-
back on DSM-5 draft diagnostic cat-
egories in the spring of 2010; this
input was considered for necessary
revisions to the manual and is essen-
tial for future buy-in from a variety
of stakeholders. The American Psy-
chiatric Nurses Association (APNA)
responded to this request by solicit-
ing their membership for comments
on DSM-5 draft categories. After re-
ceiving hundreds of suggestions and
comments, APNA summarized them
and in April 2010 provided APA with
seven manuscript pages of comments
28
from a national sample of generalist
and advanced practice psychiatric
nurses. These pages were among the
11,000 comments generated by the
public request for feedback (APA,
2012b).
Subsequently, an APNA mem-
ber notified the Executive Director
of the organization that DSM field
trials were to be conducted without
the input of psychiatric nurses. Ac-
cording to the Institute of Medicine’s
(2010) The Future of Nursing: Lead-
ing Change, Advancing Health, there
should be a full partnership between
nurses and physicians in health care
restructuring. Psychiatric nursing
voices are essential in forming the
health care structure for the individu-
als in their care. In response to the
member’s concern, APNA’s Board of
Directors, its policy group (the Insti-
tute for Mental Health Advocacy),
and the collective membership re-
quested that the APA include psychi-
atric nurses in the DSM-5 field trials.
The APA responded positively with
an invitation for psychiatric nurses to
join in the clinical field trials.
This move was unprecedented,
and 500 advanced practice psychiat-
ric-mental health nurses were invited
to participate in these trials (Halter,
2011). Ultimately, psychiatrists, psy-
chologists, licensed clinical social
workers, advanced practice psychiat-
ric nurses, mental health nurses, li-
censed counselors, and licensed mar-
riage and family therapists were the
professionals who helped shape diag-
nostic criteria and proposed dimen-
sional measures for the new manual
(APA, 2012b).
One of this article’s authors (D.R.-K.)
had the opportunity to participate in
the Routine Clinical Practice Set-
tings Division of the clinical field
trials as an advanced practice psychi-
atric nurse. New diagnoses and diag-
nostic criteria were used in samples of
current and new patients in a com-
munity psychiatric practice. Newly
developed cross-cutting dimensional
measures for specific symptoms pres-
ence and severity, as well as measures
of overall disability, were also put
into practice. The assessment tools
were time consuming. However, the
trade-off of time for more accurate
symptom identification is important.
Also, she found that the global dis-
ability measures individualized the
deficits and helped target care and
resources more pointedly than the
DSM-IV-TR Global Assessment of
Functioning scale.
CONCLUSION
Although physicians have been
the dominant profession in defin-
ing illnesses for more than a century,
Florence Nightingale championed
the classification of health alterations
and generated some of the earliest
classifications of health and disease
statistics. More recently, nurses took
part in the development of the DSM-
IV in terms of task force advisers
and in conducting literature reviews
(Wilson & Skodol, 1994). It is likely
that this participation led the way for
the largest professional group of men-
tal health providers in the United
States to more actively take part in
the development of this new manual.
Through psychiatric nursing’s profes-
sional organization, APNA, psychi-
atric nurses provided input in the
comment section of the DSM-5 and
advanced practice psychiatric nurses
participated in clinical field trials.
The DSM-5 will result in restruc-
tured assessments, reformulated di-
agnostic criteria, altered formulas
for the reimbursement of care, and
therefore changes in treatment pat-
terns and strategies. Recovery for
those with psychiatric disorders will
be better advanced if all care provid-
ers understand changes in assessment,
diagnosis, and treatment that are fa-
cilitated through a common language
of a shared diagnostic system. The in-
creased collaboration in the develop-
ment of the DSM-5 is a good omen
for future interprofessional work that
is needed to improve and transform
mental health care.
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REFERENCES
American Psychiatric Association. (1952). Di-
agnostic and statistical manual of mental dis-
orders (1st ed.). Washington, DC: Author.
American Psychiatric Association. (1968). Di-
agnostic and statistical manual of mental dis-
orders (2nd ed.). Washington, DC: Author.
American Psychiatric Association. (1980). Di-
agnostic and statistical manual of mental dis-
orders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1987). Di-
agnostic and statistical manual of mental dis-
orders (3rd ed., revised). Washington, DC:
Author.
American Psychiatric Association. (1994). Di-
agnostic and statistical manual of mental dis-
orders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (1995). Di-
agnostic and statistical manual of mental dis-
orders (4th ed., primary care). Washington,
DC: Author.
American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental
disorders (4th ed., text. rev.). Washington,
DC: Author.
American Psychiatric Association. (2012a).
DSM: History of the manual. Retrieved from
http://www.psychiatry.org/practice/dsm/
dsm-history-of-the-manual
American Psychiatric Association. (2012b).
The people behind the DSM-5. Retrieved
from http://dsmfacts.org/materials/the-peo-
ple-behind-dsm-5-2
American Psychiatric Association. (2012c).
Timeline. Retrieved from http://www.dsm5.
org/about/Pages/Timeline.aspx
American Public Health Association. (1899).
The Bertillon classification of causes of death:
Recommended for the use of registrars of vital
statistics by the American Public Health As-
sociation and by the Conference of State and
Provincial Boards of Health of North America.
Lansing, MI: Smith.
Cartwright, S.A. (1851, May). Report on the
diseases and physical peculiarities of the
Negro race. The New Orleans Medical and
Surgical Journal, 691-715.
CensusFinder. (n.d.). 1840 census findings.
Retrieved from http://www.censusfinder.
com/1840-census.htm
Craddock, N., & Owen, M.J. (2005). The be-
ginning of the end for the Kraepelinian di-
chotomy. British Journal of Psychiatry, 186,
364-366. doi:10.1192/bjp.186.5.364
Falco, M. (2012, December 3). Psychiatric
association approves changes to diagnos-
tic manual. CNN Health. Retrieved from
http://www.cnn.com/2012/12/02/health/
new-mental-health-diagnoses
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
Feighner, J.P., Robins, E., Guze, S.B., Wood-
ruff, R.A., Jr., Winokur, G., & Munoz, R.
(1972). Diagnostic criteria for use in psy-
chiatric research. Archives of General Psy-
chiatry, 26, 57-63.
Frances, A. (2012, May 11). Diagnosing the
DSM. New York Times. Retrieved from
http://www.nytimes.com/2012/05/12/opin-
ion/break-up-the-psychiatric-monopoly.
html?_r=0
Genealogy Trails. (n.d.). Schedule for insane.
Retrieved from http://genealogytrails.com/
ill/livingston/vital_insane1880.html
Gordon, M. (1998). Nursing nomencla-
ture and classification system develop-
ment. Online Journal of Issues in Nurs-
ing, 3(2). Retrieved from http://www.
nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Vol31998/No2Sept1998/
NomenclatureandClassification.html
Halter, M.J. (2011). Influencing health
care and policy: A professional respon-
sibility. Journal of Psychosocial Nursing
and Mental Health Services, 49(4), 6-7.
doi:10.3928/02793695-20110302-04.
Institute of Medicine. (2010). The future of
nursing: Leading change, advancing health.
Retrieved from http://www.iom.edu/
Reports/2010/The-Future-of-Nursing-
Leading-Change-Advancing-Health.aspx
Kendell, R.E. (1975). The role of diagnosis in
psychiatry. Oxford, UK: Blackwell.
Kraepelin, E. (1883). Compendium per psychiat-
rie. Leipzig, Germany: Abel.
Kraepelin, E. (1899). Compendium per psychiat-
rie (6th ed.). Leipzig, Germany: Abel.
Kramer, M., Sartorius, N., Jablensky, A., &
Gulbinat, A. (1979). The ICD-9 clas-
sification of mental disorders: A review
of its development and contents. Acta
Psychiatrica Scandinavica, 59, 241-262.
doi:10.1111/j.1600-0447.1979.tb06965.x
Millon, T., Krueger, R.F., & Simonsen, E.
(2010). Contemporary directions in psychopa-
thology: Scientific foundations of the DSM-V
and ICD-11. New York: Guilford Press.
Moriyama, I.M., Loy, R.M., & Robb-Smith,
A.H.T. (2011). History of the statistical clas-
sification of diseases and causes of death (Publi-
cation No. PHS 2011-1125). Retrieved from
the Centers for Disease Control and Preven-
tion website: http://www.cdc.gov/nchs/data/
misc/classification_diseases2011.pdf
Nightingale, F. (1860). Hospital statistics (ab-
stract), and Appendix: Proposal for a uni-
form plan of hospital statistics. In Fourth
session of the International Statistical Con-
gress, 1860 (pp. 63-71). London: Her Maj-
esty’s Stationery Office.
Office of the Surgeon General. (1943). Nomen-
clature of psychiatric disorders and reactions.
Washington DC: Author.
Palm, U., & Möller, H.J. (2011). Reception
of Kraepelin’s ideas 1900-1960. Psychiatry
and Clinical Neurosciences, 65, 318-325.
10.1111/j.1440-1819.2011.02226.x
Peele, R. (2008). History and impact of APA’s
leadership in psychiatric diagnosing. Retrieved
from http://www.rogerpeele.com/clinical_
topics/history_of_the_dsm.asp
Quinn, B.P. (1999, April). [Review of the book
Diagnostic and statistical manual of mental
disorders, fourth edition, primary care version,
by American Psychiatric Association]. Pri-
mary Care Companion to the Journal of Clini-
cal Psychiatry, 1, 54-55.
Rawnsley, M.M., & Roberts, M.D. (1999). Re-
sponse to “The DSM and child psychiatric
nursing: A cautionary reflection.” Scholarly
Inquiry for Nursing Practice, 13, 319-325.
Rosenhan, D.L. (1973). On being sane in
insane places. Science, 179, 250-258.
doi:10.1126/science.179.4070.250
Sanders, J.L. (2011). A distinct language and
a historic pendulum: The evolution of the
Diagnostic and statistical manual of mental
disorders. Archives of Psychiatric Nursing, 25,
394-403. doi:10.1016/j.apnu.2010.10.002
Tartakovsky, M. (2011). How the DSM de-
veloped: What you might not know. Re-
trieved from http://psychcentral.com/blog/
archives/2011/07/02/how-the-dsm-devel-
oped-what-you-might-not-know/all/1/
Wilson, H.S., & Skodol, A. (1994). Special re-
port: DSM-IV: Overview and examination
of major changes. Archives of Psychiatric
Nursing, 3, 340-347.
World Health Organization. (n.d.). History of
the development of the ICD. Retrieved from
http://www.who.int/classification/icd/en/
HistoryOfICD.pdf
Dr. Halter is Associate Dean, Ms. Grund is
Interim Dean, Ashland University, Mansfield,
Ohio; and Dr. Rolin-Kenny is Assistant Professor,
University of Texas at Austin, School of Nursing,
Austin, Texas.
Dr. Rolin-Kenny and Ms. Grund have disclosed
no conflicts of interest, financial or otherwise. Dr.
Halter receives travel support from Contemporary
Forums and royalties from Elsevier.
Address correspondence to Margaret Jordan
Halter, PhD, APRN, Associate Dean, Ashland
University, 1020 S. Trimble Road, Mansfield,
OH 44906; e-mail: peggyhalter1@gmail.com.
Received: October 14, 2012
Accepted: February 7, 2013
Posted: March 6, 2013
doi:10.3928/02793695-20130226-03
29
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