DSM-III is the abbreviation for the Diagnostic & Statistical Manual of the American Psychiatric Association. At the 1978 Fall Meeting the Executive Committee decided to form an ad hoc subcommittee of the Association's Peer Review Committee, also to be called “the DSM-III Committee,” for the explicit purpose of writing a chapter in a companion volume for DSM-III—tentatively called “DSM-III & Treatment Planning,” to be sponsored by the American Psychiatric Association. Presumably this request was made of the Peer Review Committee because we have been occupied for several years with the tasks of organizing a consensus among members of the Association concerning the criteria for prescribing psychoanalytic treatment and for reviewing an ongoing analysis. Dr. Robert Spitzer, Chairman of the APA Task Force that is responsible for the companion volume, asked the Association to prepare a chapter indicating what additional information, beyond the DSM-III diagnosis, is needed to plan psychoanalysis or psychoanalytically-oriented psychotherapy. The members of this ad hoc sub-committee are Sol Altschul, Arnold Cooper, Allen Frances, Gene Gordon, Allan Rosenblatt, Arnold Tobin, and Robert Michels (Consultant).
At the request of Dr. Spitzer, we invited two members of the American Academy of Psychoanalysis: John Schimel and Miltiades Zaphiropoulos. The Chairman of the Committee is William Offenkrantz.
This report will deal with four related but separable issues: (1) the overall progress of DSM-III, (2) the wish by many psychoanalysts for the inclusion of the term “Neurosis” in DSM-III, (3) the question of how a psychodynamically-oriented psychiatrist can use DSM-III for psychodynamic diagnosis, and (4) the companion volume on “DSM-III & Treatment Planning.”
Overall progress. DSM-III was approved by the Assembly of District Branches of the APA on 5/12/79, and by the APA's Council on Research & Development to which its authors (the Task Force on Nomenclature & Statistics) report. It has also been reported on favorably to the APA Board of Trustees by the Board's Ad Hoc Committee (the “Brodie Committee”) on 5/17/79. It will be studied by the APA's Reference Committee, which will make a recommendation to the APA's Board of Trustees for its action on 6/22/79. My opinion is that each of these bodies is likely to approve DSM-III in its present form, and that it may well be distributed by the end of calendar 1979.
The term “Neurosis.” The American Psychoanalytic Association took no formal stand on the desirability of retaining this term in DSM-III. However, many analysts were active in their APA District Branches in seeking its inclusion. They prevailed. Axis I of DSM-III now includes the following paragraph: “NEUROTIC DISORDERS: These are included in Affective, Anxiety, Somatoform, Dissociative, and Psychosexual Disorders. In order to facilitate the identification of categories that in DSM-II were grouped together in the class of Neurosis, the DSM-II terms are included separately in parentheses after the corresponding DSM-III categories.” The neuroses which actually appear in these parentheses are Depressive, Phobic, Anxiety, Obsessive Compulsive, Atypical Anxiety, Hysterical, conversion type, Hysterical, dissociative type, and Depersonalization.
How a dynamic psychiatrist can use DSM-III. Since DSM-III is basically a descriptive, generally atheoretical document, it has been clear that the approximately 70% of psychiatrists who identified themselves as dynamically oriented when they participated in the DSM-III field trials, need something more to use when making a psychodynamic evaluation of their patients.
At its meeting in 12/78, the APA Board of Trustees instructed Dr. Spitzer to include in the Introduction to DSM-III itself, “Comments” about how a dynamic psychiatrist could use the document for psychodynamic diagnosis. However, this had not been passed as a formal resolution: a fact our committee did not discover until March 24th. While the Association's DSM-III Committee was working on its early drafts of the chapter for the Treatment Planning volume, we were unofficially requested by several members of the APA's Board of Trustees to offer Dr. Spitzer assistance by preparing these “Comments” in the form of a “two-page statement” for inclusion in the Introduction to DSM-III. In these two pages, we included 1) the basic premises of psychodynamic pschiatry; 2) one example of the theoretical constructs that are derived from these basic premises, viz. intrapsychic conflict; 3) the additional data needed for a psychodynamic diagnostic formulation and its sources in: (a) presenting symptoms and psychopathology, (b) history, (c) mental status, and (d) quality of interaction between psychiatrist and patient; 4) a case history to illustrate the use of these clinical data to determine the presence or absence of intrapsychic conflict, as a way of demonstrating what is required for a psychodynamic diagnostic formulation.
By request, we submitted this two-page statement to the APA's Executive Committee (of its Board of Trustees) for its meeting on 2/23/79, where it was not discussed. It was also submitted to all the APA Trustees in advance of their meeting 4/22/79, where it was also not discussed, but what did evolve from this meeting was an ad hoc Committee of the APA Board (Chairman, Dr. Brodie) to collate all the various questions that had been raised about DSM-III. This committee made a series of recommendations (including the one about “Neuroses”) and, as indicated above, reported favorably on the resulting changes in DSM-III to the APA Trustees on 5/17/79. Just what will actually appear in the Introduction to DSM-III for dynamic psychiatrists is not clear at present, for the preliminary draft submitted to the APA Trustees on 4/21/79 differs significantly from the document which our DSM-III Committee prepared.
The Psychoanalytic Association's chapter in the companion volume on “DSM-III & Treatment Planning.” We had an early draft prepared in mid-February for our July 1, 1979 deadline. We stopped work temporarily because the Brodie Ad Hoc committee confirmed what we had been hearing for many weeks: the Trustees were not certain how far the APA Board had gone toward implementing the Treatment Planning volume. However, on May 17 the APA Trustees did vote to instruct Dr. Spitzer's Task Force to prepare a draft of the Treatment Planning volume for the meeting of the APA Reference Committee in November 1979. We will now resume our work with the understanding that any chapter we produce will be monitored by the Executive Committee of the American Psychoanalytic Association—and by no other group.
William Offenkrantz
Co-chairman, Committee on Peer Review