The History of the Psychiatric Diagnostic System Continued

By the 1950s, the concept of "character disorders" had become widely accepted within the psychoanalytic community, and psychoanalytic clinicians were distinguishing character disorders from the more severe forms of mental illnesses that cause people to lose touch with reality (i.e., to become psychotic). But, character disorders were not viewed as legitimate mental illnesses in their own right, at this time. Instead, they were typically understood as weaknesses of character or willfully deviant behavior caused by problems in a person's upbringing. Some of these patients were treated in psychoanalysis (psychotherapy based on Freud's theories) where they typically regressed and got worse. The term "Borderline" dates back to this historical time period, as these character disordered patients were thought to be functioning at the borderline between the psychoses (disorders characterized mainly by suspended reality testing such as Schizophrenia), and the neuroses (disorders characterized mainly by anxiety arising from the conflict among the Id, Ego, and Superego) (Oldham, 2005).

Theories and models of the mental components and fixations of psychosexual development laid the foundation for conceptually understanding "character disorders" and their causes, but these theories were not themselves formal diagnoses. It was not until the 1950s, with the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM), that the character disorders became formally recognized. The original DSM, devised to reduce confusion surrounding psychiatric diagnosis and diagnostic systems prevalent at the time, defined the personality disorders as patterns of behavior that were quite resistant to change, but not connected to a lot of anxiety or personal distress on part of the patient. This first DSM relied heavily on the psychoanalytic tradition and Freud's ideas which were the prevailing view of that time period.

DSM II, published in 1968, (APA, 1968) reflected an attempt to make the American psychiatric classification system compatible with the International Classification of Diseases devised by the World Health Organization. It also reflected an attempt to adopt neutral language that did not endorse specific and controversial theoretical viewpoints (such as Freudian, psychoanalytic theories). In DSM II, personality disorders were described as follows, "This group of disorders is characterized by deeply ingrained, maladaptive patterns of behavior that are perceptibly different in quality from psychotic and neurotic symptoms." (APA, DSM II, 1968, p. 41). Then each disorder was briefly described by a few short sentences. The names of these disorders, and their brief descriptions, bear only a slight resemblance to what we know today as personality disorders.

The third incarnation, DSM III, was published in 1980 (APA, 1980). At this time, the fields of psychology and psychiatry were struggling to establish themselves as scientific fields of study. This new version of the DSM reflected the fact that newer, more contemporary models of mental illness and treatment were emerging. More importantly, these newer models rested upon evidence-based practices: i.e., these models were not based on unproven or un-testable theories, but instead rested upon scientific evidence.

It is important to understand that scientific study cannot proceed without a means for measuring what is being studied. Thus, in order for the scientific study of mental disorders to proceed, these disorders had to be defined in such a way as to make them observable, and therefore measurable. Freud's concepts did not lend themselves to measurement. For instance, one cannot observe, nor measure the Id. Therefore, the DSM III (1980) removed these Freudian concepts which could not be measured, in favor of more easily measurable conceptions of mental disorders that were based upon observable and/or reportable behavior, and cognition (thoughts).

These newer and more contemporary models of mental illness reflected a significant paradigm shift within psychology and psychiatry which was ongoing during the 1970s and 80s; namely the declining influence of psychoanalysis and Freudian theory, and the ascendance of the cognitive-behavioral model within psychology (emphasizing the observable, behavioral manifestations of disorders), and the medical model within psychiatry (cataloging pathological symptoms and their biological causes). As the name suggests, cognitive-behavioral theory was principally concerned with people's thoughts which could easily be reported, and people's behavior which could easily be observed. As such, the cognitive-behavioral theory was perfectly suited to measurement and research, and met the scientific requirements of the day. Treatments for mental conditions took the form of interventions designed to help people learn better and more effective, healthy ways to think and behave in order to relieve their distress.

Psychoanalytic theory's fall from grace occurred because it was a theory that could not be tested or proven using the scientific methods and technologies available at that time. Unfortunately, it merely theorized the causes of mental distress, but these theorized causes were completely invisible (and therefore, not measurable) including: the invisible Id, Ego, and Super-Ego; the invisible conflicts between these invisible mental structures; and the invisible psycho-sexual stages of developments. In contrast, the cognitive-behavioral theory restricted itself to addressing only the observable and measurable causes of distress. Caught in the crossfire between these two influential, psychological theories, one waxing and the other waning, and the rising role of pharmacological treatments within psychiatry, the authors of DSM III attempted to stay out of the conflict by making their document atheoretical. They achieved this by ensuring that their disorder definitions were primarily descriptive. They refrained from endorsing one particular theory accounting for the origin and cause of mental disorders over another.

The goal of DSM III was to outline the diagnostic criteria for as many conditions as possible, and to rely on, and to foster research on mental disorders. The biggest change in DSM III was the introduction of a multi-axial (multi-dimensional) format for making diagnoses, and the placement of personality disorder diagnoses onto a separate axis, distinct from the rest of the major mental disorders and clinical syndromes (such as Major Depression, Schizophrenia, and Bipolar Disorder, to name but a few). The bulk of mental disorders were to be described using the first axis (Axis I), while the personality disorders, and developmental conditions such as mental retardation¹ were to be described on the second axis (Axis II). The goal of this separation of diagnostic dimensions was to enable clinicians to record a person's current state and prevailing difficulties on Axis I while simultaneously describing a person's lifelong and pervasive personality characteristics on Axis II. In other words, Axis I disorders were thought to be transient conditions, while personality disorders and other developmental conditions, described on Axis II, were thought to be permanent conditions. The rationale was that it was necessary to describe these "permanent" conditions on a separate diagnostic dimension in order to highlight them so that they would not otherwise be overshadowed by the more acute Axis I clinical syndromes. The problems associated with the multi-axial system are further explored in another section of this article. 

Prior to DSM III, personality disorders were only vaguely described categories that did not lend themselves to research. However, the publication DSM III (APA, 1980) changed all that. Personality disorders were now recognized as a distinct and separate category of disorders in their own right. As such, research on personality disorders flourished. Researchers developed assessment methods facilitating the systematic study of the personality disorders. This new research resulted in the refinement of the criteria sets for personality disorder diagnoses present in DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000), and ultimately changed the way that personality disorders and their treatment were conceived. By the mid-1990s persons with personality disorders were no longer seen as people with untreatable moral weakness, or willfully bad behavior. Rather, the field has responded to these research efforts and now recognizes that personality disorders are deeply troubling, real and legitimate conditions, that have a large negative impact on people's lives, and in many cases, can be successfully treated.

1 The contemporary term for mental retardation is "intellectual disability" however; the language used in DSM-IV-TR is mental retardation. It is expected that the upcoming DSM-V will adopt the term intellectual disability. Further information about DSM-V is available at http://www.dsm5.org/pages/default.aspx and http://en.wikipedia.org/wiki/DSM-V.