The Conference on “Improvements in Psychiatric Classification and Terminology: A Working Conference to examine critically the Diagnostic Statistical Manual (DSM) III in Midstream” met in St. Louis on June 10 and 11, 1976. Held under the auspices of the American Psychiatric Association through its Task Force on DSM III and the University of Missouri through the Missouri Institute of Psychiatry, the Conference was to develop as much understanding and agreement as possible regarding plans and approaches to DSM III.
Prior to the Conference, the March 1976 Progress Report of the A.P.A. Task Force on DSM III (325 pages) was distributed, along with a companion volume of prepared statements and critiques of the general approach or specific diagnostic categories.
Many more than the 81 invited participants attended, including specialists from the academic, research, and clinical areas of psychiatry; and representatives from the major psychiatric, psychological, psychoanalytic and some non-psychological organizations. There was one representative from the Canadian Psychiatric Association and two British psychiatrists-with special interest in the International Classification of Diseases. Also included were five active members of our Association (Paul Chodoff, Alvin Goldfarb, Otto Kernberg, Jules Masserman, and Alex Kaplan).
Recurrent throughout the Conference was the reminder that the present Progress Report was still in the process of being developed and modified. All interested professionals were encouraged to become better acquainted with the work of the Task Force and scientific input from all sources was solicited. The manual was noted as being in “midstream” with final publication projected for 1978 or 1979 to coincide with the publication of the International Classification of Diseases (ICD) IX.
In its final form, DSM will be a mini-textbook with all of the disorders (the generic term “disorder” being used instead of “disease” or “illness”) described in more extensive detail than in DSM II. Wherever possible, information about each disorder will be supplied in the following areas: course, patient's age at onset, essential clinical features, associated clinical features, degree of incapacity, differential diagnosis, pre-disposing factors, complications, prevalance, sex ratio and familial pattern.
Operational criteria for most of the disorders will indicate both inclusion and exclusion criteria. There will also be a glossary defining all key diagnostic terms. References from the literature will be cited to justify the inclusion of many categories such as Schizophrenia, Affective Organic Mental Disorders, etc. Other categories such as Personality and Sexual Disorders will be included on the basis of tradition with the hope that by defining them with greater precision than was previously done, future validity studies will justify
their inclusion. In general, psychodynamic and psychosocial factors will not be included.
Differences between the neuroses and the psychoses have been dropped as an organizing principle because of the “lack of reliability and validity.” The basic neuroses will be included under Anxiety Disorders. It should be noted that some of these actions were criticized by a number of conference participants.
After the preliminary statements the Conference divided into sub-sections which met separately to discuss six categories of Disorders (Schizophrenia, Personality, Childhood, Mood (Affective), Sexual and Organic Mental). Recorders from each sub-section then reported on the various actions taken in the specific sections. However, no final decisions were made at the Conference. I would like to report here on two of the sections which I attended; on the Sexual Disorders and the Personality Disorders. A more complete review of the meeting has been summarized by the writer and will be available at the Central Office.
The Sexual Disorder category is still in a preliminary stage of development. It has not as yet been referred to a cadre of experts for their study and evaluation. The sexual disorders described are those based mainly on symptoms and individual functioning which lead to feelings of distress with evidence of interpersonal difficulties. The same categories are used for both men and women. The term “Perversion” is not used. The diagnosis of Homosexuality has been omitted (APA referendum) and at this time was replaced by a somewhat vague and value-laden classification—“Sexual Orientation Disorder.” There was much concern expressed over this diagnostic classification in that it was loosely described and unrelated to the classification of the other sexual disorders. Actually, many questions were raised about a number of other sexual disorders and I expect there will be many changes in the final report. Under the leadership of Harold Lief, this sub-section on Sexual Disorders is anxious for input as regards all of the categories in this subheading.
As might be expected, the Personality Disorders category is also a somewhat mixed subheading including some classical non-controversial disorders such as Schizoid, Paranoid, Compulsive, Histrionic (Hysterical) and Anti-social Disorders, along with several other less well-defined disorders such as Narcissistic Personality as well as Dependent Personality, Avoidant Personality and Labile Personality (all new categories replacing other vague classifications in DSM II). There was some discussion as to the category of a Borderline Personality Disorder and, following a suggestion by Otto Kernberg, it was accepted that Borderline personalities should be considered to be a more severe form of all of the personality disorder types. It was recognized that personality disorders shade into behavior disorders and that there are no major markers to distinguish one from the other. While a unifying definition is not possible, it was considered that pervasive and enduring qualities of maladaptive behavior resulting in subjective feelings of distress and evidence of impaired social functioning were essential for a diagnosis of Personality Disorders. These diagnoses, although still not precise, have been studied and quantified by a number of professionals but further input was encouraged.
The question arises as to how our individual members and our Association can best respond to the Task Force's invitation for scientific input. It seems to me that the best plan would be for regional geographic areas to set up study groups of interested professionals to evaluate the more than 500 pages of the initial Progress Report and the volume of critiques as well as the results of the conference which are still to be published and distributed. Since publication of the final report is projected for 1978 or 1979 to coincide with the publication of the I.C.D. IX, there is enough time to present our own scientific values and concerns. To facilitate the setting up of the various study groups, the Association can act as a coordinating body for all of the study groups by collecting copies of the various reports and activities of the study group and making them available to all of our members. Two volumes of the Progress Report and the volume of critiques will be available at the Central Office as well as a more detailed summary of the conference proceedings. Material will also be available from the Task Force.
The Task Force, under the leadership of Robert Spitzer, has accomplished a great deal of work. The problem of classification of Mental Disorders is most complicated and the openness of the Conference left me with the feeling that reasoned scientific suggestions will be seriously considered.
—Alex H. Kaplan