DSM: A History of Psychiatry's Bible presents a comparatively short and authoritative history of the Diagnostic and Statistical Manual series. Although it is a history of the DSM as a whole, Horwitz's book could have been called The Rise and Legacy of the DSM-III. Previous editions of the manual are framed as the context for the sea change the DSM-III caused, while later editions are discussed in terms of how they altered (or failed to alter) it. Horwitz speeds through the first two DSM editions in a single chapter before embarking on a far more thorough account of the groundbreaking and ambitiously expanded DSM-III. The DSM-III-R and DSM-IV are characterized as continuations of the DSM-III project and treated together. The penultimate chapter recounts how the DSM-5 set out with revolutionary aspirations but ended up differing little from its predecessors. The last chapter, which also serves as a general conclusion, considers the DSM as a socially situated document that reflects the ongoing interaction between psychiatry and the world at large.
In providing an overarching history of the DSM, Horwitz has created an invaluable resource. In his preface, he contrasts his work with earlier books (most notably Hannah Decker's The Making of DSM-III (2013)) that focus on particular editions of the manual, emphasizing that what sets his own text apart is its broad scope. This breadth inevitably comes at some cost. DSM tends towards whistlestop tour rather than in-depth analysis. For readers who already have some familiarity with the DSM series, the conciseness of Horwitz's text is an attractive feature; the pacy discussion gives a compelling sense of the competition and compromise that forged each edition. For readers with less prior knowledge, Horwitz's text may best be read with an open search box on hand.
In Horwitz's telling, the DSM-I and II were psychoanalytically inflected texts of little importance; they provided categories that could be used for record-keeping, but had little broader influence on psychiatric research, clinical practice or culture. Robert Spitzer, working alongside a close-knit group of psychiatric researchers whose primary motive was to develop classifications suited for research, spearheaded the DSM-III revolution. On its publication, it turned out that the DSM-III system furthered the aims of a variety of interest groups, both within and without psychiatry. The scientific-looking categories of the DSM-III made psychiatry appear closely aligned with the rest of medicine, increasing the status of researchers, clinicians and funders. Patients found DSM labels useful for accessing medical care and services, as well as gaining self-understanding. Pharmaceutical companies profited from targeting drugs at DSM disorders. Bureaucracies and insurance companies found DSM codes serviceable for administrative purposes. This confluence of interests helped ensure the stability of the DSM system. Throughout the development of the DSM-III-R and DSM-IV, although individual diagnoses were revised to better fit with new evidence and shifting needs, the classifications fundamentally remained the same. By the start of the twenty-first century, however, some influential psychiatric researchers had begun to lose faith in the DSM-based approach. They feared that the DSM's hundreds of ultra-specific categories might not accurately reflect psychopathology and wondered whether a different, possibly dimensional, system might better serve their needs. The development process for the DSM-5 began with these researchers pushing for a ‘paradigm shift’ that would radically reshape classification. Ultimately, though, the DSM classification had become too useful to its many other users; researchers who pushed for revolution were stymied by working clinicians and advocacy groups who benefited from the status quo.
Horwitz emphasizes that although the DSM series has self-presented as being based on empirical evidence, changes between editions are often better understood as resulting from shifting intra-professional and external interests. These interests have impacted on the various sections of the manual in many different ways. Whereas some diagnoses have been shaped by advocacy groups (PTSD and autism spectrum conditions), others have been more influenced by struggles between psychoanalysts and biologically oriented practitioners (anxiety, depression and personality disorders). Certain sections have been shaped by the development and marketing of psychopharmaceuticals, others by pressures stemming from insurance companies. As Horwitz emphasizes, ‘The distinct trajectories of different conditions across the DSM era means that the manual does not have one common history’ (p. 12).
Overall, Horwitz's history is convincing. The main point we would question is his treatment of the DSM-I and DSM-II. In earlier work, one of us has argued that the DSM-I was less psychoanalytic and more important than Horwitz suggests (Rachel Cooper and Roger Blashfield, Psychological Medicine (2016) 46(3)). We particularly question Horwitz's claim that these earlier editions were little used. To take one user group, one study found that clinical and counselling psychologists employed the DSM-II in the same sorts of ways in which they later employed DSM-III: 91 per cent reported using the DSM-II, with 86 per cent saying that they used it for insurance reimbursement purposes (Lorence Miller, Douglas Bergstrom, Herbert Cross and Joel Grube in Professional Psychology (1981) 12(3)).
Despite this reservation, DSM is an excellent book that will become the go-to text for scholars seeking an account of the DSM series. Like the DSM itself, it straddles multiple needs and adroitly compromises between them. It is one part simple historical narrative, one part jumping-off point for those looking to research further into particular areas, and one part an introduction to the thorny philosophical and political issues that surround the text.
