Clinical Diagnosis and Assessment 79
disorders, not just psychological disorders. In fact, until the sixth edition, the ICD
only classifi ed causes of death. With the sixth edition, the editors added diseases,
of which mental disorders were one type. Current versions of the mental disorders
sections of the ICD and the DSM have been revised to overlap substantially. Re-
search on prevalence that uses one classifi cation system is now applicable to the
other system.
The Evolution of DSM
When the original version of the DSM was published in 1952, it was the fi rst manual
to address the needs of clinicians rather than researchers (Beutler & Malik, 2002).
At that time, psychodynamic theory was popular, and the DSM strongly favored
the psychodynamic approach in its classifi cations. For example, it organized mental
illness according to different types of confl icts among the id, ego, superego, and
reality, as well as different patterns of defense mechanisms employed (American
Psychiatric Association, 1952). The second edition of the DSM, published in 1968,
had only minor modifi cations. The fi rst two editions were criticized for problems
with reliability and validity, which arose in part because their classifi cations relied
on psychodynamic theory. Clinicians had to draw many inferences about the spe-
cifi c nature of patients’ problems, including the specifi c unconscious confl icts that
motivated patients’ behavior.
The authors of the third edition (DSM-III), published in 1980, set out to createa classifi cation system that had better reliability and validity. Unlike the previous
editions, DSM-III:
- did not rest on the psychodynamic theory of psychopathology (or on any other
theory); - focused more on what can be observed than on what can be inferred;
- listed explicit criteria for each disorder and began to use available research
results to develop those criteria; and - included a system for clinicians and researchers to record diagnoses as well as
additional information—such as related medical history—that may affect diag-
nosis, prognosis, and treatment.
Some of the criteria in DSM-III were not clear, however, and various inconsis-tencies were identifi ed. So, in 1987, a revised version was published. DSM-III-R
(R for “Revised”) provided more explicit criteria than did previous editions,
which meant that it had greater reliability (Malik & Beutler, 2002). Researchers
in different hospitals could collect information about prevalence, etiological fac-
tors, course, or treatment from patients with a particular disorder and be reason-
ably certain that they all were studying the same disorder. However, this research
revealed certain limitations of DSM-III-R, including continuing problems with va-
lidity (Malik & Beutler, 2002). For instance, criteria were too restrictive for some
disorders; thus, even though some individuals, such as those with preoccupations
of physical illness, were clearly distressed or impaired, their symptoms did not
meet enough of the criteria for a diagnosis (Rief et al., 1996; Wise & Birket-
Smith, 2002).
The Multiaxial System of DSM-IV-TR
The weaknesses of DSM-III-R led to DSM-IV, published in 1994, which speci-
fi ed new disorders and revised the criteria for some of the disorders included
in DSM-III-R. In 2000, the American Psychiatric Association published an
expanded version of DSM-IV that included more current information about
each disorder, such as new information about prevalence, course, issues related
to gender and cultural factors, and comorbidity—the presence of more than one
disorder at the same time in a given patient. This revised edition is called DSM-IV-
TR, where TR stands for “Text Revision.” The list of disorders and almost all of
Comorbidity
The presence of more than one disorder at
the same time in a given patient.