Making sense of historical changes in the Diagnostic and statistical manual of mental disorders: five propositions.

From the first to the current fourth edition, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has grown considerably in size and complexity. The DSM-III (1980) represented a paradigm shift in psychiatric diagnoses and is the main focus of the article's five propositions attempting to make sense of basic historical changes in the manual. The first two propositions concern theoretical changes in the manual; they critically examine the effort to evict unverified etiological assumptions from diagnoses, the adoption of formulations of disorders as discretely constituted, and the role of the multiaxial context in diagnoses. The next two propositions attempt a new development: a set of concepts designating the structural changes in the DSM histories of individual disorders. The fifth proposition examines historical forces supporting the neo-Kraepelinian psychiatrists' efforts to produce the DSM-III. The conclusion brings the propositions together to explain the DSM's growth in size and complexity and to show that the general pattern of the DSM changes are aimed at remedicalizing the profession of psychiatry.