The Diagnostic and Statistical Manual of Mental Disorders

The DSM-IV (1994) and the fourth edition text revision (DSM-IV-TR APA, 2000) are written by committees made up of professionals considered experts by many of their colleagues in their respective fields. The conclusions therefore provide a professional consensus or body of conventional wisdom in psychiatry that can at times be useful in clinical practice and in forensics. Many aspects of the DSM-IV are controversial. However, when such an essentially conservative consensus document provides evidence for SSRI-induced adverse reactions related to mania, suicide, and violence, it should alert clinicians to the existence of these clinical phenomena and can provide an avenue for communicating in the courtroom concerning these risks. 

The DSM-IV was published in 1994, several years after the advent of SSRI antidepressants, and makes clear that all antidepressants can 

The DSM-IV makes multiple references to the fact that antidepressants can cause mania or maniclike behavior. It states, for example, Symptoms like those seen in a Manic Episode may be due to the direct effects of antidepressant medication (p. 329). Similarly, it observes, Symptoms like those seen in a Manic Episode may also be precipitated by antidepressant treatment such as medication (p. 331). References to antidepressant-induced mania and mood disorder can also be found elsewhere in the manual as well (e.g., pp. 332 [note at bottom of table], 334, 336, 337, 351, 371, and 372). The DSM-IV-TR contains the same statements. It emphasizes that a diagnosis of mania or bipolar disorder should not be made when the symptoms hypomania or mania first appear while taking a medication that can cause them and usually disappear when the individual is no longer exposed to the substance. Of great clinical importance, it adds, but resolution of symptoms can take weeks or months and may require treatment (p. 191). 

The association between mania and antisocial behavior, including violence, is underscored in the DSM-IV. Aggression is specifically mentioned as a feature of manic behavior. It is noted that antisocial behaviors may accompany the Manic Episode, ethical concerns may be disregarded even by those who are typically very conscientious, the person may become hostile and physically threatening to others and physically assaultive, and the mood may shift rapidly to anger or depression (p. 330). The very next page in the DSM-IV repeats the reminder that symptoms like those seen in a Manic Episode may also be precipitated by antidepressant treatment such as medication (P-331). 

Mania is characterized by increased involvement in goal-directed activities (DSM-IV, p. 328). Therefore the individual does not lack the capacity to plan and carry out inappropriate or destructive actions or to attempt to cover them up once they have been enacted. To the contrary, individuals undergoing mania often feel driven to carry out elaborate plans, however bizarre, violent, or doomed they may be. 

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Individuals with a pattern of chronic use of commonly abused substances should be assessed to determine if they meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for substance dependence (addiction).8 Criteria are not defined for each separate abused substance rather, a pattern of behavior common to the abuse or dependence of all drugs of abuse is established. 

Reprinted from the Diagnostic and Statistical Manual of Mental Disorders, Copyright 2000, American Psychiatric Association, with permission.)... 

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, classifies bipolar disorders as (1) bipolar I, (2) bipolar II, (3) cyclothymic disorder, and (4) bipolar disorder not otherwise specified. Table 69-3 defines mood disorders by type of episode. Table 69-4 describes the evaluation and diagnostic criteria for mood disorders. 

Major depression is characterized by one or more episodes of major depression, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (Table 70-1). Symptoms must have been present nearly every day for at least 2 weeks. Patients with major depressive disorder may have one or more recurrent episodes of major depression during their lifetime. 

EVOLUTION OF CLASSIFICATION IN THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS CURRENT PROBLEMS AND PROPOSED ALTERNATIVES... 

The Diagnostic and Statistical Manual of Mental Disorders (DSM) represents the most widely used psychiatric nosology in the United States. From a historical perspective, it appears that the major changes to the DSM have taken place to solve a few specific problems—particularly, problems with reliability. Over time, the DSM has done well in addressing problems related to reliability, but this evolution has raised many criticisms and has created additional problems. In this chapter, the history of the DSM is reviewed, along with the major criticisms that have been raised about its more recent versions. We also suggest taxometric analysis as one method that will prove useful in addressing many of the limitations of the current system. 

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR American Psychiatric Association, 2000) specifies that the symptoms of substance-related disorders may include tolerance withdrawal loss of control unsuccessful efforts to cut down or quit a great deal of time committed to finding, using, or recovering from using substances impairment in specific areas of one s life and continued use in spite of negative consequences. To meet criteria for dependence, the individual must have three or more of these... 

The clinical presentation of anxiety disorders according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders is siunmarized by R. Lieb. In addition, selected aspects (prevalence, correlates, risk factors and comorbidity) of epidemiological knowledge on anxiety disorders are presented. 

Psychiatric treatment of new illnesses has accelerated since the 1980s. Whereas psychiatry traditionally had been dominated by a psychodynamic perspective on illness, the field has turned its back on that tradition in favor of predominantly biological definitions of mental illness. Critics of this shift focus their attention on the social factors that have led psychiatrists to the prescription pad. One can only express wonderment at the discovery of so many new brain diseases since 1980. The bible of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, or DSM, has now been revised three times since 1953, most recently in 1994. The first two editions classified illnesses in accordance with the psychodynamic model prevalent at the time. Conditions warranting psychiatric treatment were understood as disorders of the mind. Then, in the 1980s, the language of psychotherapeutic disorder abruptly disappeared and was replaced by... 

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for ADHD include symptoms of inattention and hyperactivity or/impulsiv-ity patients can have either combined type, or predominantly inattentive (see below) or predominantly hy-peractive/impulsive types (American Psychiatric Association, 1994). Many of the symptoms of inattention relate to attentional abilities of the PFC—for example, difficulty sustaining attention, difficulty organizing, easily distracted, and forgetful. However, other symptoms described by DSM-FV could result from either PFC or posterior cortical attentional dysfunction— e.g., does not seem to listen, reluctance or difficulty engaging in tasks that require mental effort, poor attention to details. Thus, these symptoms could arise either due to poor attention regulation by the PFC or due to poor attentional allocation by the posterior cortices. Similarly, many of the symptoms of hyperactivity/... 

The terms social phobia or social anxiety disorder refer to a pattern of recurrent fear and apprehension in social situations or scenarios where an individual may be scrutinized. Before modifications in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), identification of social phobia in childhood was limited by having the condition closely aligned to both... 

Although childhood cases are rare (McKenna et ah, 1994), schizophrenia has been identified in children since its earliest descriptions. Despite this, the nosological status of schizophrenia in children was controversial for many years, and the Diagnostic and Statistical Manual of Mental Disorders, 2nd ed. (DSM-II) category childhood schizophrenia included other psychotic disorders in children as well as autistic disorder, limiting the usefulness of early studies. The landmark studies by Kolvin (1971), however, clearly differentiated schizophrenia with onset in childhood from pervasive developmental disorders. 

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