What is the DSM?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

What is

What is the DSM?
Photo courtesy of Pixabay.

DSM is short for Diagnostic and Statistical Manual of Mental Disorders.

The DSM, short for Diagnostic and Statistical Manual of Mental Disorders is a book created and published by the APA (American Psychiatric Association) which seeks to codify the classification of mental, emotional or behavioral diagnosis. Currently, the DSM is in its fifth edition (DSM-5.) Each successive edition has seen significant shifts in how we understand and diagnose mental illnesses.

While this volume is published by an American organization it has been widely used throughout the world. A number of reasons for the creation of the DSM have been suggested but a few large reasons stand out as the most important.

The early lists of diseases were about mortality, morbidity, and treatment.

Some of the earliest efforts to categorize diseases had to do with classifying causes of death. Other methods of classification were used on census reports to describe those who were unable to work because of mental retardation or mental illnesses.

It was also useful to doctors to have lists of diseases in order to help direct treatment. That medical model continues to influence mental health treatment. The APA is an organization of those people from a medical specialty who can prescribe medication. The result of reliance on doctors to write the classification system has been medicalization of mental illness. If the main tool you have to treat illness is medications then they get classified by those disorders that will respond to a particular class of medication rather than those that will be best treated by a particular talk therapy.

Your diagnoses should not change with the place you live or who sees you.

One goal in encouraging the universal use of the DSM (and the International Classification of Diseases or ICD, more on the ICD in another post) is to increase the likelihood that when clinicians in various countries diagnose someone with a mental illness they are using the same definitions and criteria.

When you do research it is important to be researching the same disorder.

Standardized criteria, sometimes called strict criteria, are important in researching the treatment of mental disorders. Being sure that everyone in the research study has the same illness improves the chances that a treatment that works once with one group might work again on people with similar symptoms.

The DSM has undergone some huge alterations over the years. Early thinking separated mental illness into neuroses, the problems of living, and psychosis, the loss of contact with reality. Often mental retardation was tossed in with mental illness or vice versa.

Every time the list of mental illnesses has been revised the list has gotten longer. There is still a lot of debate over whether we have all the possible mental health issues listed in the DSM. The result of this uncertainty is a chapter in the back of the DSM-5 called “conditions for further study.” Some of these conditions will eventually get listed as disorders and some will disappear again.

The first or original version of the DSM came out in 1952. It is reported to have been influenced by government efforts to test soldiers during WWII. This was revised into DSM-II in 1968.

DSM-III was introduced in 1980. It introduced a thing called the “multi-axial system.” This was partially a recognition that the boundaries between mental illness, environmental issues, personality disorders and physical illness were not always easy to fix precisely. The multi-axial system survived officially until Oct of 2015 when all were, in theory, required to adopt the new DSM-5. In the DSM-5 there is no longer a 5 axis system though we still look for most of the things that used to be placed on these five axes.

The DSM-III version was revised to be DSM-III-R in 1987 with lots of stuff changed and moved around.

In 1994 the DSM became DSM-IV, followed in 2000 by a minor text revision to become the DSM-4-TR.

The latest DSM revision was released in 2013 as the DSM-5. This version includes the codes for use with both the ICD-9 and the ICD-10. For those clinicians trained over the last 20 years, the DSM-5 was a sort of culture shock as some of the things we thought we knew about mental illness have been redefined. There was and continue to be some professional disagreements about how the DSM-5 classifies certain human problems.

The process of treatment research, especially in the area of brain scans and neuroscience makes it likely that our understanding of the human brain and mental illness will continue to change.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.

See Recommended Books.     More “What is” posts will be found at “What is.”

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

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Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

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How is Hypomania different from Mania or a Manic Episode?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

Hypomanic Episodes.

In a post on Manic Episodes we talked about how episodes, according to the DSM are not diagnoses, they are “building blocks” out of which diagnosis are created. Someone could have either a manic episode or a hypomanic episode. The primary significance is the decision on labeling the condition as Bipolar one or Bipolar two. No Manic or Hypomanic Episode and you will not get the Bipolar label.

The Bipolar Disorder spectrum currently is very confused and confusing. It includes Bipolar I, Bipolar II, proposals for Bipolar III, IV and so on, as well as hypomania, mania, Cyclothymic Disorder, Hyperthymia, Hyperthymic personality disorder and so on. This spectrum is a very divergent group. Disorders involving an elevated mood may be the most Heterogeneous group there is (Van O’s et al. 2007.)

Lumping all these variety’s together may be overlooking the possibility that there are “Types of Bipolar Disorders.”

Hypomania requires a specific time period in which someone has had the symptoms of “elevated, expansive or irritable mood.” The difference is that for full mania the period needs to last for a full week, hypomania need only last for four days.

This creates some problems. What if you have manic-like symptoms for only three days? Do you get left out of the Bipolar spectrum? If someone has serious mania but it only lasts 6 days do they get Bipolar II not Bipolar I?

The effort to separate out conditions by the length of symptom duration may help psychiatrists decide what medication to prescribe but it does not make much difference to the client who has short but intense episodes of manic-like symptoms.

Since some of the changes in Hypomania may be subtle we take the word of others who know you or live with you to make this decision.

Most of the symptoms used to define hypomania are the same as those used to define a manic episode. The primary difference is the duration, four days to six is hypomania and a week or more is mania.

The exception here is that since hypomania is supposed to be a milder or different from mania.

If you have ever had hallucinations or delusions (not caused by drugs) then we skip the hypomania label and go directly to mania.

Here are the hypomania symptoms, then the exclusions. This narrative parallels the DSM but is my less technical, more colorful explanation.

The symptoms list is a lot like the list for Mania. I have italicized some of the differences.

A. For at least 4 days the person has an episode of “elevated, expansive or irritable mood.” Elevated does not mean happy. There are lots of descriptions of these elevated moods and they vary from person to person but the key factor is that these episodes are not like other people and that there are times when this person is not like this. If this episode is really bad we may waive the 4-day rule.

B. Pick 3 or four symptoms from a list of seven.

Each of these symptoms can vary in intensity and it is a judgment call. The result is that diagnosis can vary from clinician to clinician and even from time to time for the same person and the same clinician.

Here are the 7 symptoms needed to make a manic episode.

1. Grandiosity and excessive self-esteem. They can make no mistakes and can’t understand why people question them.

2. Sleep changes. You don’t need to sleep. Someone with Bipolar I can stay up for days and is full of energy. They may only sleep three or four hours a night. And in the morning they are not tired.

This reduced need for sleep may be a little less than in mania but the result is the same. People who are going manic or hypomanic get accused of drug use but if tested they have no drugs in the system or at least no drugs that explain the excess energy.

This is a troubling part of the diagnosis. Research studies (Carver & Johnson 2008) say that a lack of sleep can “induce” mania. So the lack of sleep is both a cause and a symptom of Mania? This sleep mania question needs more research. If the definitive study of this connection has been done so far I have not found it.

Not sleeping and not feeling tired does not mean that the person is rested. The longer this below normal sleep episode goes on the more irritable and delusional the person is likely to get. They may even begin to hallucinate. Only they don’t know they are delusional. They are convinced they are right and other people are dumb to not see how smart they are. If the hallucinations or delusions are noticeable to others we call it mania, not hypomania.

3. They talk a lot.

In hypomania, you may be able to interrupt them but not for long. They have a lot to say. Sometimes they talk too loudly and too emphatically. This is not the same as the way we old people talk when wound up, but that might give you a picture.

4. They feel their thoughts are “racing.”

Too many things to think about. In kids, this looks a lot like ADHD.

5. Lack of focus and easily distracted.

They are in such a hurry they move from topic to topic, project to project and can’t figure out what to do next. Lots of things left half-finished and on to the next one.

6. Increased goal-directed activity.

In mania it is excessive, in hypomania, those around them notice an increase but can’t explain why.

This can be trying to do too much at work, socially, sexually or in most any area of life. This over goal-directed activity can lead to excessive physical motion like a person whose engine is always running.

7. Overdoing pleasurable activities.

Hard to believe that someone could have too much fun but what we are looking for here is not that they have a lot of fun but that they continue to do pleasurable things despite negative consequences. This could also be affected by the assessor’s values judgments.

Examples of excesses are overspending, reckless or dangerous activities, “sexual indiscretions” and so forth. This needs to be more than someone who just likes to do something, like collect something. There is an episodic nature to these activities and most everyone will agree that this person has binges of overdoing things despite them getting in trouble.

This characteristic is highly related to the continued use despite negative consequences we see in substance abuse. As a matter of fact, people with a Bipolar diagnosis are much more likely to also have addiction and alcoholism issues than the general population.

The result?

To be diagnosed with a hypomanic episode you need to have three of the seven symptoms. We want four if you are just irritable but not expansive or elevated in mood. But with hypomania, the symptoms can be milder, more of a judgment call and can be briefer in time duration.

If you or someone you know has symptoms of hypomania please see a professional. This article is not meant to be enough for you to do “do it yourself diagnosis.” There are many effective treatments for Mania, Bipolar Disorder, and related conditions.

BIG QUESTION: What about people who have these symptoms for less than four days? Or those that move in and out of Hypomania very quickly? Are we missing some other type of Bipolar Disorder? Or is that moodiness something else?

Stay tuned for more on Mania, Hypomania, Cyclothymia and Bipolar Disorder and Types of Bipolar Disorder and the things we know and don’t know about all these topics.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.