Can you imagine doctors referring to patients as idiots, morons, or imbeciles? And, doing so not because of disliking their patients but as actual diagnostic labels?

It is difficult to conceive, but just a few decades ago the use of these particular terms was completely acceptable. Each was used to describe individuals with varying degrees of mental retardation (MR).

In my work with some older individuals with developmental disabilities, I have had the opportunity to review medical records from 50-60 years ago. (I know it’s difficult to believe, but some records that old still exist!) It is a surreal experience to see these terms used as casually as “depression” or “diabetes” is used in charts today. Yes, that’s correct, progress notes began with phrases such as, “This 18 year-old female moron,” or “This 22 year-old male imbecile.”

Now, before you jump to conclusions and judge the field of psychiatry as insensitive, disrespectful, or even evil, I want to elaborate. Psychiatry did not choose to use terms that were inherently politically incorrect. These words evolved into pejoratives over many years as they increasingly became used in lay language as colorful ways of insulting people.

It’s interesting that other diagnostic labels for MR have undergone a similar transition. “Cretin” is believed to have come from the word “Christian,” and the term originally meant that those with MR (“Cretins”) were “still Christian,” and therefore should be treated kindly. “Amentia,” “simpleton,” and “feeble-minded” were other such terms. By the 1960′s, the term “retarded” was becoming somewhat derogatory.

Today, the evolution is away from using the term “mental retardation.” The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, TR, (DSM-IV TR), the current diagnostic manual of psychiatry, uses the term “mental retardation” along with the specifiers of mild, moderate, severe, and profound. Many advocates for those with MR are opposed to the continued use of the term because the term “retard” has unquestionably become a major epithet. In fact, there is currently an internet campaign in action to end the use of the “R-word” by raising awareness about how using it is insulting to those with intellectual disabilities.

In the field of intellectual and developmental disabilities, the newer, politically-correct term for mental retardation is “intellectual disability.” One barrier to the quick adoption of this newer term is that the DSM-IV TR still uses the diagnosis of “mental retardation”. Therefore, in order for clinicians to use the diagnostically correct term (politically incorrect or not), “mental retardation” continues to be used.

The next version of the DSM, the DSM-V, is currently being developed. Recent reports indicate that “mental retardation” likely will be replaced with “intellectual disability.”

Reference: Historical Terms for Mental Retardation

The “bible” of psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has had a very interesting, and at times frightening, evolution. Intended to improve reliability and never intended to become a “cookbook,” the DSM has unfortunately been taken quite literally by the insurance industry, the legal system, and others.

The DSM-V is slated for release in May 2012. The original DSM was released in 1952, and the DSM II in 1968. These two early versions nearly went unnoticed and were not widely used clinically. However, the DSM III, and especially the DSM-III R, became much more recognized as providing some degree of standardization of psychiatric diagnosis.

In January 2005, The New Yorker published an article, “The Dictionary of Disorder,” which takes the reader on an interesting journey in the life of psychiatrist Robert Spitzer and his efforts to create the DSM-III and DSM III-R with the goal of improving the reliability of psychiatric diagnosis.

Spitzer assembled groups of data-oriented psychiatrists to complete the task. The problem was that much of the data needed to complete the DSM-III and III-R did not exist. The article accounts some rather improvisatory methods by which new disorders were identified.

While Spitzer’s efforts likely netted an improved diagnostic system for psychiatric disorders, it quickly became clear that much of the DSM-III and DSM-III R was not backed up by science.

The article briefly discusses how the process for creating the DSM-IV and DSM-IV TR (the current version) was improved.

The article was both enlightening and disturbing but definitely worth reading. I’m glad to see the process for listing psychiatric conditions and their respective criteria in the DSM is improving, but I remain skeptical. As the article points out, diagnostic reliability is likely to be poorest in the therapist’s office–the very real-world place where we need reliability!

What are your thoughts about the DSM? Please leave your comments, which you may do anonymously.

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