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Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM; latest edition: DSM-5-TR, published in March 2022 ) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and Australia, while in other countries it may be used in conjunction with other documents. The DSM-5 is considered one of the principal guides of psychiatry, along with the International Classification of Diseases (ICD), Chinese Classification of Mental Disorders (CCMD), and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.

It is used by researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system, and policymakers. Some mental health professionals use the manual to determine and help communicate a patient's diagnosis after an evaluation. Hospitals, clinics, and insurance companies in the United States may require a DSM diagnosis for all patients with mental disorders. Health-care researchers use the DSM to categorize patients for research purposes.

The DSM evolved from systems for collecting census and psychiatric hospital statistics, as well as from a United States Army manual. Revisions since its first publication in 1952 have incrementally added to the total number of mental disorders, while removing those no longer considered to be mental disorders.

Recent editions of the DSM have received praise for standardizing psychiatric diagnosis grounded in empirical evidence, as opposed to the theory-bound nosology (the branch of medical science that deals with the classification of diseases) used in DSM-III. However, it has also generated controversy and criticism, including ongoing questions concerning the reliability and validity of many diagnoses; the use of arbitrary dividing lines between mental illness and "normality"; possible cultural bias; and the medicalization of human distress. The APA itself has published that the inter-rater reliability is low for many disorders in the DSM-5, including major depressive disorder and generalized anxiety disorder.

Distinction from ICD
An alternate, widely used classification publication is the International Classification of Diseases (ICD) is produced by the World Health Organization (WHO). The ICD has a broader scope than the DSM, covering overall health as well as mental health; chapter 5 of the ICD specifically covers mental and behavioral disorders. Moreover, while the DSM is the most popular diagnostic system for mental disorders in the US, the ICD is used more widely in Europe and other parts of the world, giving it a far larger reach than the DSM. An international survey of psychiatrists in sixty-six countries compared the use of the ICD-10 and DSM-IV. It found the former was more often used for clinical diagnosis while the latter was more valued for research. This may be because the DSM tends to put more emphasis on clear diagnostic criteria, while the ICD tends to put more emphasis on clinician judgement and avoiding diagnostic criteria unless they are independently validated. That is, the ICD descriptions of psychiatric disorders tend to be more qualitative information, such as general descriptions of what various disorders tend to look like. The DSM focuses more on quantitative and operationalized criteria; e.g. to be diagnosed with X disorder, one must fulfill 5 of 9 criteria for at least 6 months.

The DSM-IV-TR (4th ed.) contains specific codes allowing comparisons between the DSM and the ICD manuals, which may not systematically match because revisions are not simultaneously coordinated. Though recent editions of the DSM and ICD have become more similar due to collaborative agreements, each one contains information absent from the other. For instance, the two manuals contain overlapping but substantially different lists of recognized culture-bound syndromes. The ICD also tends to focus more on primary-care and low and middle-income countries, as opposed to the DSM's focus on secondary psychiatric care in high-income countries.

Census Office, AMA and ISI (1840–1911)
The initial impetus for developing a classification of mental disorders in the United States was the need to collect statistical information. The first official attempt was the 1840 census, which used a single category: "idiocy/insanity". Three years later, the American Statistical Association made an official protest to the U.S. House of Representatives, stating that "the most glaring and remarkable errors are found in the statements respecting nosology, prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation", pointing out that in many towns African Americans were all marked as insane, and calling the statistics essentially useless.

The Association of Medical Superintendents of American Institutions for the Insane ("The Superintendents' Association") was formed in 1844.

In 1860, during the international statistical congress held in London, Florence Nightingale made a proposal that was to result in the development of the first international model of systematic collection of hospital data.

In 1872, the American Medical Association (AMA) published its Nomenclature of Diseases, which included various "Disorders of the Intellect". Its use was short-lived however.

Edward Jarvis and later Francis Amasa Walker helped expand the census, from two volumes in 1870 to twenty-five volumes in 1880.

In 1888, the Census Office published Frederick H. Wines' 582-page volume called Report on the Defective, Dependent, and Delinquent Classes of the Population of the United States, As Returned at the Tenth Census (June 1, 1880). Wines used seven categories of mental illness, which were also adopted by the Superintendents: dementia, dipsomania (uncontrollable craving for alcohol), epilepsy, mania, melancholia, monomania, and paresis.

In 1892, the Superintendents' Association expanded its membership to include other mental health workers, and renamed to the American Medico-Psychological Association (AMPA).

In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at a congress of the International Statistical Institute (ISI) in Chicago. (The ISI had commissioned him to create it in 1891). A number of countries adopted the ISI's system. In 1898, the American Public Health Association (APHA) recommended that United States registrars also adopt the system.

In 1900, an ISI conference in Paris reformed the Bertillion Classification, and created the International List of Causes of Death (ILCD)''. '' Another conference would be held every ten years, and a new edition of the ILCD would be released. Five were ultimately issued. Non-fatal conditions were not included.

In 1903, New York's Bellevue Hospital published "The Bellevue Hospital nomenclature of diseases and conditions", which included a section on "Diseases of the Mind". Revisions were released in 1909 and 1911. It was produced with the assistance of the AMA and Bureau of the Census.

APA Statistical Manual (1917) and AMA Standard (1933)
In 1917, together with the National Commission on Mental Hygiene (now Mental Health America), the American Medico-Psychological Association developed a new guide for mental hospitals called the Statistical Manual for the Use of Institutions for the Insane. This guide included twenty-two diagnoses. It would be revised several times by the Association, and by the tenth edition in 1942, was titled Statistical Manual for the Use of Hospitals of Mental Diseases.

In 1921, the AMPA became the present American Psychiatric Association (APA).

The first edition of the DSM notes in its foreword: "In the late twenties, each large teaching center employed a system of its own origination, no one of which met more than the immediate needs of the local institution."

In 1933, the AMA's general medical guide the Standard Classified Nomenclature of Disease, (referred to as the Standard), was released. Along with the New York Academy of Medicine, the APA provided the psychiatric nomenclature subsection. It became well adopted in the US within two years. A major revision of the Statistical Manual was made in 1934, to bring it in line with the new Standard. A number of revisions of the Standard were produced, with the last in 1961.

Medical 203 (1945)
World War II saw the large-scale involvement of U.S. psychiatrists in the selection, processing, assessment, and treatment of soldiers. This moved the focus away from mental institutions and traditional clinical perspectives. The U.S. armed forces initially used the Standard, but found it lacked appropriate categories for many common conditions that troubled troops. The United States Navy made some minor revisions but "the Army established a much more sweeping revision, abandoning the basic outline of the Standard and attempting to express present-day concepts of mental disturbance."

Under the direction of James Forrestal, a committee headed by psychiatrist Brigadier General William C. Menninger, with the assistance of the Mental Hospital Service, developed a new classification scheme in 1944 and 1945.

Issued in War Department Technical Bulletin, Medical, 203 (TB MED 203); Nomenclature and Method of Recording Diagnoses was released shortly after the war in October 1945 under the auspices of the Office of the Surgeon General. It was reprinted in the Journal of Clinical Psychology for civilian use in July 1946 with the new title Nomenclature of Psychiatric Disorders and Reactions. This system came to be known as "Medical 203".

This nomenclature eventually was adopted by all the armed forces, and "assorted modifications of the Armed Forces nomenclature [were] introduced into many clinics and hospitals by psychiatrists returning from military duty." The Veterans Administration also adopted a slightly modified version of the standard in 1947.

The further developed Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions was released in 1949.

ICD-6 (1948)
In 1948, the newly formed World Health Organization took over the maintenance of the ILCD. They greatly expanded it, included non-fatal conditions for the first time, and renamed it the International Statistical Classification of Diseases (ICD). The foreword to the DSM-I states the ICD-6 "categorized mental disorders in rubrics similar to those of the Armed Forces nomenclature."

DSM-I (1952)
The APA Committee on Nomenclature and Statistics was empowered to develop a version of Medical 203 specifically for use in the United States, to standardize the diverse and confused usage of different documents. In 1950, the APA committee undertook a review and consultation. It circulated an adaptation of Medical 203, the Standard's nomenclature, and the VA system's modifications of the Standard to approximately 10% of APA members. 46% of members replied, with 93% approving the changes. After some further revisions, the Diagnostic and Statistical Manual of Mental Disorders was approved in 1951 and published in 1952. The structure and conceptual framework were the same as in Medical 203, and many passages of text were identical. The manual was 130 pages long and listed 106 mental disorders. These included several categories of "personality disturbance", generally distinguished from "neurosis" (nervousness, egodystonic).

The foreword to this edition describes itself as being a continuation of the ''Statistical Manual for the Use of Hospitals of Mental Diseases. '' Each item was given an ICD-6 equivalent code, where applicable. The DSM-I centers on three classes of symptoms: psychotic, neurotic, and behavioral. Within each class of mental disorder, classifying information is provided to differentiate conditions with similar symptoms. Under each broad class of disorder (e.g. "Psychoneurotic Disorders" or "Personality Disorders"), all possible diagnoses are listed, generally from least to most severe. The 1952 DSM version also includes sections detailing how to record patients' disorders along with their demographic details. The form includes information like a patient's area of residence, admission status, discharge date/condition, and severity of disorder. See Figure 1. for the form that psychiatrists were asked to utilize for recording preliminary diagnostic information.

Furthermore, the APA listed homosexuality in the DSM as a sociopathic personality disturbance. Homosexuality: A Psychoanalytic Study of Male Homosexuals, a large-scale 1962 study of homosexuality by Irving Bieber and other authors, was used to justify inclusion of the disorder as a supposed pathological hidden fear of the opposite sex caused by traumatic parent–child relationships. This view was influential in the medical profession. In 1956, however, the psychologist Evelyn Hooker performed a study comparing the happiness and well-adjusted nature of self-identified homosexual men with heterosexual men and found no difference. Her study stunned the medical community and made her a heroine to many gay men and lesbians, but homosexuality remained in the DSM until May 1974.

DSM-II (1968)
In the 1960s, there were many challenges to the concept of mental illness itself. These challenges came from psychiatrists like Thomas Szasz, who argued mental illness was a myth used to disguise moral conflicts; from sociologists such as Erving Goffman, who said mental illness was another example of how society labels and controls non-conformists; from behavioural psychologists who challenged psychiatry's fundamental reliance on unobservable phenomena; and from gay rights activists who criticised the APA's listing of homosexuality as a mental disorder.

The APA was closely involved in the next significant revision of the mental disorder section of the ICD (version 8 in 1968). It decided to go ahead with a revision of the DSM, which was published in 1968. DSM-II was similar to DSM-I, listed 182 disorders, and was 134 pages long. The term "reaction" was dropped, but the term "neurosis" was retained. Both the DSM-I and the DSM-II reflected the predominant psychodynamic psychiatry, although both manuals also included biological perspectives and concepts from Kraepelin's system of classification. Symptoms were not specified in detail for specific disorders. Many were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems that were rooted in a distinction between neurosis and psychosis (roughly, anxiety/depression broadly in touch with reality, as opposed to hallucinations or delusions disconnected from reality). Sociological and biological knowledge was incorporated, under a model that did not emphasize a clear boundary between normality and abnormality. The idea that personality disorders did not involve emotional distress was discarded.

A study published in Science in 1973, the Rosenhan experiment, received much publicity and was viewed as an attack on the efficacy of psychiatric diagnosis. An influential 1974 paper by Robert Spitzer and Joseph L. Fleiss demonstrated that the second edition of the DSM (DSM-II) was an unreliable diagnostic tool. Spitzer and Fleiss found that different practitioners using the DSM-II rarely agreed when diagnosing patients with similar problems. In reviewing previous studies of eighteen major diagnostic categories, Spitzer and Fleiss concluded that "there are no diagnostic categories for which reliability is uniformly high. Reliability appears to be only satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism. The level of reliability is no better than fair for psychosis and schizophrenia and is poor for the remaining categories".

Seventh printing of the DSM-II (1974)
As described by Ronald Bayer, a psychiatrist and gay rights activist, specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. In 1971, gay rights activist Frank Kameny worked with the Gay Liberation Front collective to demonstrate at the APA's convention. At the 1971 conference, Kameny grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you."

This gay activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations as gay activists.

Taking into account data from researchers such as Alfred Kinsey and Evelyn Hooker, the seventh printing of the DSM-II, in 1974, no longer listed homosexuality as a category of disorder. After a vote by the APA trustees in 1973, and confirmed by the wider APA membership in 1974, the diagnosis was replaced with the category of "sexual orientation disturbance".

DSM-III (1980)
The emergence of DSM III represented a "quantum leap" in terms of the scale and reach of the manual. In 1974, the decision to revise the DSM was made, and psychiatrist Robert Spitzer was selected as chair of the task force. The initial impetus was to make the DSM nomenclature consistent with that of the International Classification of Diseases (ICD). The revision took on a far wider mandate under the influence and control of Spitzer and his chosen committee members. One added goal was to improve the uniformity and validity of psychiatric diagnosis in the wake of a number of critiques, including the famous Rosenhan experiment. There was also felt a need to standardize diagnostic practices within the United States and with other countries, after research showed that psychiatric diagnoses differed between Europe and the United States. The establishment of consistent criteria was an attempt to facilitate the pharmaceutical regulatory process.

The criteria adopted for many of the mental disorders were influenced by the Research Diagnostic Criteria (RDC) and Feighner Criteria, which had just been developed by a group of research-orientated psychiatrists based primarily at Washington University School of Medicine and the New York State Psychiatric Institute. However, the influence of clinical psychiatrists, themselves often working with psychoanalytic ideas, were still strong. Other criteria, and potential new categories of disorder, were established by debate, argument and consensus during meetings of the committee chaired by Spitzer. A key aim was to base categorization on colloquial English (which would be easier to use by federal administrative offices), rather than by assumption of cause, although its categorical approach still assumed each particular pattern of symptoms in a category reflected a particular underlying pathology (an approach described as "neo-Kraepelinian"). The psychodynamic view was marginalised, although still influential, in favor of a regulatory or legislative model that emphasised observable symptoms. A new "multiaxial" system attempted to yield a picture more amenable to a statistical population census, rather than a simple diagnosis. Spitzer argued "mental disorders are a subset of medical disorders", but the task force decided on this statement for the DSM: "Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome." Personality disorders were placed on axis II along with "mental retardation".

The first draft of DSM-III was ready within a year. It introduced many new categories of disorder, while deleting or changing others. A number of unpublished documents discussing and justifying the changes have recently come to light. Field trials sponsored by the U.S. National Institute of Mental Health (NIMH) were conducted between 1977 and 1979 to test the reliability of the new diagnoses. A controversy emerged regarding deletion of the concept of neurosis, a mainstream of psychoanalytic theory and therapy but seen as vague and unscientific by the DSM task force. Faced with enormous political opposition, DSM-III was in serious danger of not being approved by the APA Board of Trustees unless "neurosis" was included in some form; a political compromise reinserted the term in parentheses after the word "disorder" in some cases. Additionally, the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance". The gender identity disorder in children (GIDC) diagnosis was introduced in the DSM-III; prior to the DSM-III's publication in 1980, there was no diagnostic criteria for gender dysphoria.

Finally published in 1980, DSM-III listed 265 diagnostic categories and was 494 pages long. It rapidly came into widespread international use and has been termed a revolution, or transformation, in psychiatry.

When DSM-III was published, the developers made extensive claims about the reliability of the radically new diagnostic system they had devised, which relied on data from special field trials. However, according to a 1994 article by Stuart A. Kirk:

"Twenty years after the reliability problem became the central focus of DSM-III, there is still not a single multi-site study showing that DSM (any version) is routinely used with high reliably by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version. There are important methodological problems that limit the generalizability of most reliability studies. Each reliability study is constrained by the training and supervision of the interviewers, their motivation and commitment to diagnostic accuracy, their prior skill, the homogeneity of the clinical setting in regard to patient mix and base rates, and the methodological rigor achieved by the investigator ..."

DSM-III-R (1987)
In 1987, DSM-III-R was published as a revision of the DSM-III, under the direction of Spitzer. Categories were renamed and reorganized, with significant changes in criteria. Six categories were deleted while others were added. Controversial diagnoses, such as Premenstrual Dysphoric Disorder and Masochistic Personality Disorder, were considered and discarded. (Premenstrual Dysphoric Disorder was later reincorporated in the DSM-5, published in 2013). "Ego-dystonic homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which could include "persistent and marked distress about one's sexual orientation." Altogether, the DSM-III-R contained 292 diagnoses and was 567 pages long. Further efforts were made for the diagnoses to be purely descriptive, although the introductory text stated for at least some disorders, "particularly the Personality Disorders, the criteria require much more inference on the part of the observer"[page xxiii].

DSM-IV (1994)
In 1994, DSM-IV was published, listing 410 disorders in 886 pages. The task force was chaired by Allen Frances and was overseen by a steering committee of twenty-seven people, including four psychologists. The steering committee created thirteen work groups of five to sixteen members, each work group having about twenty advisers in addition. The work groups conducted a three-step process: first, each group conducted an extensive literature review of their diagnoses; then, they requested data from researchers, conducting analyses to determine which criteria required change, with instructions to be conservative; finally, they conducted multi-center field trials relating diagnoses to clinical practice. A major change from previous versions was the inclusion of a clinical-significance criterion to almost half of all the categories, which required symptoms causing "clinically significant distress or impairment in social, occupational, or other important areas of functioning". Some personality-disorder diagnoses were deleted or moved to the appendix.

DSM-IV Definitions
The DSM-IV characterizes a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significant increased risk of suffering death, pain, disability, or an important loss of freedom". It also notes that "although this manual provides a classification of mental disorders it must be admitted that no definition adequately specifies precise boundaries for the concept of 'mental disorder."

DSM-IV Categorization
The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries" but isolated, low-grade, and non-criterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers are sometimes used: for example, to specify mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning", although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias due to their egosyntonic nature. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

DSM-IV multi-axial system
The DSM-IV was organized into a five-part axial system. Axis I provided information about clinical disorders, or any mental condition other than personality disorders and what was referred to in DSM editions prior to DSM-V as "mental retardation". Those were both covered on Axis II. Axis III covered medical conditions that could impact a person's disorder or treatment of a disorder and Axis IV covered psychosocial and environmental factors affecting the person. Axis V was the GAF, or global assessment of functioning, which was basically a numerical score between 0 and 100 that measured how much a person's psychological symptoms impacted their daily life.

DSM-IV Sourcebooks
The DSM-IV does not specifically cite its sources, but there are four volumes of "sourcebooks" intended to be APA's documentation of the guideline development process and supporting evidence, including literature reviews, data analyses, and field trials. The sourcebooks have been said to provide important insights into the character and quality of the decisions that led to the production of DSM-IV, and the scientific credibility of contemporary psychiatric classification.

DSM-IV-TR (2000)
A text revision of DSM-IV, titled DSM-IV-TR, was published in 2000. The diagnostic categories were unchanged as were the diagnostic criteria for all but nine diagnoses. The majority of the text was unchanged; however, the text of two disorders, pervasive developmental disorder not otherwise specified and Asperger's disorder, had significant and/or multiple changes made. The definition of pervasive developmental disorder not otherwise specified was changed back to what it was in DSM-III-R and the text for Asperger's disorder was practically entirely rewritten. Most other changes were to the associated features sections of diagnoses that contained additional information such as lab findings, demographic information, prevalence, and course. Also, some diagnostic codes were changed to maintain consistency with ICD-9-CM.

DSM-5 (2013)
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM-5, was approved by the Board of Trustees of the APA on December 1, 2012. Published on May 18, 2013, the DSM-5 contains extensively revised diagnoses and, in some cases, broadens diagnostic definitions while narrowing definitions in other cases. The DSM-5 is the first major edition of the manual in 20 years. DSM-5, and the abbreviations for all previous editions, are registered trademarks owned by the American Psychiatric Association.

A significant change in the fifth edition is the deletion of the subtypes of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual. The deletion of the subsets of autistic spectrum disorder – namely, Asperger's syndrome, classic autism, Rett syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified – was also implemented, with specifiers regarding intensity: mild, moderate, and severe.

Severity is based on social communication impairments and restricted, repetitive patterns of behavior, with three levels:

 * 1) requiring support
 * 2) requiring substantial support
 * 3) requiring very substantial support

During the revision process, the APA website periodically listed several sections of the DSM-5 for review and discussion.

Future revisions and updates
Beginning with the fifth edition, the APA communicated that they intend to add subsequent revisions more often, to keep up with research in the field. It is notable that DSM-5 uses Arabic rather than Roman numerals. Beginning with DSM-5, the APA will use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2) and whole numbers for new editions (e.g., DSM-5, DSM-6), similar to the scheme used for software versioning.

The National Board of Medical Examiners (NBME), which is responsible for creating and publishing board exams for medical students around the United States, conforms to the use of DSM-5 criteria.

DSM-5-TR (2022)
A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and ICD-10-CM codes. The diagnostic criteria for avoidant/restrictive food intake disorder was changed, along with adding entries for prolonged grief disorder, unspecified mood disorder and stimulant-induced mild neurocognitive disorder. Prolonged grief disorder, which had been present in the ICD-11, had criteria agreed upon by consensus in a one day in-person workshop sponsored by the APA. A 2022 study found that higher rates of diagnosis of prolonged grief disorder in the ICD-11 could be explained by the DSM-5-TR criteria requiring symptoms persist for 12 months, and the ICD-11 requiring only 6 months.

Three review groups for sex and gender, culture and suicide, along with an "ethnoracial equity and inclusion work group" were involved in the creation of the DSM-5-TR which led to additional sections for each mental disorder discussing sex and gender, racial and cultural variations, and adding diagnostic codes for specifying levels of suicidality and nonsuicidal self-injury for mental disorders.

Other changed mental disorders included:
 * Autism spectrum disorder
 * Bipolar I disorder, Bipolar II disorder, and related bipolar disorders
 * Obsessive–compulsive personality disorder in the alternative DSM-5 model for personality disorders
 * Depressive episodes with short-duration hypomania
 * Intellectual developmental disorder
 * Delusional disorder
 * Disruptive mood dysregulation disorder
 * Brief psychotic disorder

DSM Library
The APA have supplemented the DSM with supporting works, collectively forming the "DSM Library." As of 2022, the other books in the library are "DSM-5 Handbook of Differential Diagnosis", "DSM-5 Clinical Cases", "DSM-5 Handbook on the Cultural Formulation Interview" and "Guía De Consulta De Los Criterios Diagnósticos Del DSM-5".

Criticisms
Many criticisms have been leveled against the DSM and its usefulness as a diagnostic manual.

Reliability and validity
The revisions of the DSM from the 3rd Edition forward have been mainly concerned with diagnostic reliability – the degree to which different diagnosticians agree on a diagnosis. Henrik Walter argued that psychiatry as a science can only advance if diagnosis is reliable. If clinicians and researchers frequently disagree about the diagnosis of a patient, then research into the causes and effective treatments of those disorders cannot advance. Hence, diagnostic reliability was a major concern of DSM-III. When the diagnostic reliability problem was thought to be solved, subsequent editions of the DSM were concerned mainly with "tweaking" the diagnostic criteria. Neither the issue of reliability or validity was settled.

In 2013, shortly before the publication of DSM-5, the director of the National Institute of Mental Health (NIMH), Thomas R. Insel, declared that the agency would no longer fund research projects that relied exclusively on DSM diagnostic criteria, due to its lack of validity. Insel questioned the validity of the DSM classification scheme because "diagnoses are based on a consensus about clusters of clinical symptoms" as opposed to "collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response."

Field trials of DSM-5 brought the debate of reliability back into the limelight, as the diagnoses of some disorders showed poor reliability. For example, a diagnosis of major depressive disorder, a common mental illness, had a poor reliability kappa statistic of 0.28, indicating that clinicians frequently disagreed on diagnosing this disorder in the same patients. The most reliable diagnosis was major neurocognitive disorder, with a kappa of 0.78.

Diagnosis based on superficial symptoms
By design, the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect these disorders based on statistical or clinical patterns. As such, it has been compared to a naturalist's field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however, is not specific to the DSM, but rather reflects a general lack of pathophysiological understanding of psychiatric disorders. Proponents argue this absence of explanatory classification is necessary, but it presents a problem for researchers as it results in the grouping of individuals who may have little in common except superficial criteria. As DSM-III chief architect Robert Spitzer and DSM-IV editor Michael First outlined in 2005, "little progress has been made toward understanding the pathophysiological processes and cause of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology."

While there is generally a lack of consensus on underlying causation for most psychiatric disorders, some proponents of specific psychopathological paradigms have faulted the DSM for failing to incorporate evidence from other disciplines. For instance, evolutionary psychology distinguishes between genuine cognitive malfunctions and malfunctions due to psychological adaptations (that is learned behaviors may be adaptive in one context but maladaptive in another). However, this distinction is one that is challenged within general psychology.

There is also criticism of the strong operationalist viewpoint of the DSM. The DSM relies on operational definitions, which means that intuitive concepts like depression are defined by specific measurable criteria (observable behavior, specific timelines). Some have argued that instead of replacing metaphysical terms like "desire" or "purpose" the DSM chose to legitimize them by giving them operational definitions. However, this may have served only to provide a "reassurance fetish" for mainstream methodological practice, rather than representing a substantial and meaningful alteration of mainstream psychiatric practice.

A central problem with the use of superficial symptoms is that psychiatry deals with the phenomena of consciousness, which adds much more complexity than the somatic symptoms and signs used by most of medicine. A 2013 review published in the European Archives of Psychiatry and Clinical Neuroscience gives the example of the problem of superficial characterization of psychiatric signs and symptoms. If a patient says they "feel depressed, sad, or down" there are actually a wide variety of underlying experiences they could be referencing: "not only depressed mood but also, for instance, irritation, anger, loss of meaning, varieties of fatigue, ambivalence, ruminations of different kinds, hyper-reflectivity, thought pressure, psychological anxiety, varieties of depersonalization, and even voices with negative content, and so forth." This criticism is especially pertinent to the structured interview, as simple "yes or no" questions may not be specific enough to truly confirm or deny the diagnostic criterion at issue. That is, whether a patient says yes or no will rely on their own understanding of the meaning of the various words in the question as well as their own interpretation of their experience. There is thus danger in being overconfident in the face value of the answers. The authors of the 2013 review give an example: A patient who was being administered the Structured Clinical Interview for the DSM-IV Axis I Disorders denied thought insertion, but during a "conversational, phenomenological interview", a semi-structured interview tailored to the patient, the same patient admitted to experiencing thought insertion, along with a delusional elaboration. The authors suggested 2 reasons for this discrepancy: either the patient did not "recognize his own experience in the rather blunt, implicitly either/or formulation of the structured-interview question", or the experience did not "fully articulate itself" until the patient started talking about his experiences.

Economic causes
The DSM-5 has been criticized for overlooking capitalism’s interconnectivity with pathology. One example is the development and treatment of diagnoses: around 69% of psychiatrists involved in the development of the DSM-5 were reported to have financial ties to the pharmaceutical industry. These ties situate many care services within the medical-industrial complex, a framework that prioritizes profit instead of the care of individuals. Lane found the medical-industrial complex intertwined with setting the parameters to diagnose conditions such as social anxiety disorder. Other authors have supported similar findings. Kincaid and Sullivan estimate that the cost of the industry surrounding diagnosis will rise to around six trillion dollars by 2030.

Scholars differ in the extent of capitalism's influence on diagnosis. Davies supports the social model of disability in explaining that diagnosis at present relies on considering conditions a consequence of a “broken brain.” His wider logic on mental illness in response to societal issues problematizes diagnosis as a tool of the medical-industrial complex. His previous book, Cracked, demonstrates the market interactions within the medical-industrial complex, as diagnosis becomes a source for monetization.

Others find that the dependency of patients on their psychiatric care providers makes the industry vulnerable to economic exploitation under capitalism. These individuals argue that diagnosis is manipulated, but not caused, by capitalistic forces. Academics have critiqued the directness of the association between the medical model, capitalism, and diagnosis, but generally agree that characteristics of the capitalist system contribute to poor mental health.

Institutional causes
Diagnoses of mental conditions have been used to obscure institutional practices of discrimination. Late nineteenth-century diagnoses of white women with hysteria, for instance, were said to be caused by “overcivilization,” shaped by racially discriminatory Social Darwinism. Similarly, American physician Samuel Cartwright coined "drapetomania" in 1851 as a mental condition which "caused" slaves to escape captivity. In the present day, Brinkmann finds that “contemporary diagnostic cultures,” whereby humans assess their conditions through a psychiatric lens, can “risk losing sight of the larger historical and social forces that affect [their] lives.” Contemporary diagnostic cultures help explain how diagnosis reflect larger historical biases.

Critics have argued that the DSM-5's criteria pathologize a wide range of people with distress or impairment. Chapman et al. discuss the implications for obscuring distress in the incarceration and confinement of "intellectually disabled" populations; they argue that "differentiation based on psychiatric and intellectual disability" is arbitrarily set and altered based on capitalism's needs for "mobile and free workers." Metzl demonstrates that the shifting diagnostic parameters of schizophrenia became a method for institutionalizing Black men during the Civil Rights Movement. In sum, those who have experienced “domination” or “exploitation” based on an identity trait are more likely to be pathologized through diagnosis.

Overdiagnosis
Allen Frances, an outspoken critic of DSM-5, states that "normality is an endangered species," because of "fad diagnoses" and an "epidemic" of over-diagnosing, and suggests that the "DSM-5 threatens to provoke several more [epidemics]." Some researchers state that changes in diagnostic criteria, following each published version of the DSM, reduce thresholds for a diagnosis, which results in increases in prevalence rates for ADHD and autism spectrum disorder. Bruchmüller, et al. (2012) suggest that as a factor that may lead to overdiagnosis are situations when the clinical judgment of the diagnostician regarding a diagnosis (ADHD) is affected by heuristics.

Dividing lines
Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed. Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations. The DSM does include a step ("Axis IV") for outlining "Psychosocial and environmental factors contributing to the disorder" once someone is diagnosed with that particular disorder.

Because an individual's degree of impairment is often not correlated with symptom counts and can stem from various individual and social factors, the DSM's standard of distress or disability can often produce false positives. On the other hand, individuals who do not meet symptom counts may nevertheless experience comparable distress or disability in their life.

Cultural bias
Psychiatrists have argued that published diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and so understate the scientific importance of social-psychological variables. Advocating a more culturally sensitive approach to psychology, critics such as Carl Bell and Marcello Maviglia contend that researchers and service-providers often discount the cultural and ethnic diversity of individuals. In addition, current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook. Although these guidelines have been widely implemented, opponents argue that even when a diagnostic criterion-set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy. Cross-cultural psychiatrist Arthur Kleinman contends that Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is to Kleinman revelatory of an underlying assumption that Western cultural phenomena are universal. Other cross-cultural critics largely share Kleinman's negative view toward the culture-bound syndrome, common responses included both disappointment over the large number of documented non-Western mental disorders still left out, and frustration that even those included were often misinterpreted or misrepresented.

Mainstream psychiatrists have also been dissatisfied with these new culture-bound diagnoses, although not for the same reasons. Robert Spitzer, a lead architect of DSM-III, has held the opinion that the addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support. Spitzer also posits that the new culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved. In general, the mainstream psychiatric opinion remains that if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations. One result of this dissatisfaction was the development of the Azibo Nosology by Daudi Ajani Ya Azibo as an alternative to the DSM in treating patients of the African diaspora.

Historically, the DSM tended to avoid issues involving religion; the DSM-5 relaxed this attitude somewhat.

Medicalization and financial conflicts of interest
There was extensive analysis and comment on DSM-IV (published in 1994) in the years leading up to the 2013 publication of DSM-5. It was alleged that the way the categories of DSM-IV were structured, as well as the substantial expansion of the number of categories within it, represented increasing medicalization of human nature, very possibly attributable to disease mongering by psychiatrists and pharmaceutical companies, the power and influence of the latter having grown dramatically in recent decades. In 2005, then APA President Steven Sharfstein released a statement in which he conceded that psychiatrists had "allowed the biopsychosocial model to become the bio-bio-bio model". It was reported that of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had financial relationships with the pharmaceutical industry during the period 1989–2004, raising the prospect of a direct conflict of interest. The same article concluded that the connections between panel members and the drug companies were particularly strong involving those diagnoses where drugs are the first line of treatment, such as schizophrenia and mood disorders, where 100% of the panel members had financial ties with the pharmaceutical industry.

William Glasser referred to DSM-IV as having "phony diagnostic categories", arguing that "it was developed to help psychiatrists – to help them make money". A 2012 article in The New York Times commented sharply that DSM-IV (then in its 18th year), through copyrights held closely by the APA, had earned the Association over $100 million.

However, although the number of identified diagnoses had increased by more than 300% (from 106 in DSM-I to 365 in DSM-IV-TR), psychiatrists such as Zimmerman and Spitzer argued that this almost entirely represented greater specification of the forms of pathology, thereby allowing better grouping of similar patients.

Potential harm of labels
A core function of the DSM is the categorization of people's experiences into diagnoses based on symptoms. However, there is disagreement about the use of diagnoses as labels. Some individuals are relieved to find they have a recognized condition that they can apply a name to, and this has led to many people self-diagnosing. Others, however, question the accuracy of diagnosis, or feel they have been given a label that invites social stigma and discrimination (the terms "mentalism" and "sanism" have been used to describe such discriminatory treatment).

Diagnoses can become internalized and affect an individual's self-identity, and some psychotherapists have found that the healing process can be inhibited and symptoms can worsen as a result. Some members of the psychiatric survivors movement (more broadly the consumer/survivor/ex-patient movement) actively campaign against their diagnoses, or the assumed implications, or against the DSM system in general. Additionally, it has been noted that the DSM often uses definitions and terminology that are inconsistent with a recovery model, and such content can erroneously imply excess psychopathology (e.g. multiple "comorbid" diagnoses) or chronicity.

Critiques of DSM-5
Psychiatrist Allen Frances has been critical of proposed revisions to the DSM–5. In a 2012 New York Times editorial, Frances warned that if this DSM version is issued unamended by the APA, "it will medicalize normality and result in a glut of unnecessary and harmful drug prescription."

In a December 2012, blog post on Psychology Today, Frances provides his "list of DSM 5's ten most potentially harmful changes:"
 * Disruptive Mood Dysregulation Disorder, for temper tantrums
 * Major Depressive Disorder, includes normal grief
 * Minor Neurocognitive Disorder, for normal forgetfulness in old age
 * Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
 * Binge Eating Disorder, for excessive eating
 * Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of school services
 * First-time drug users will be lumped in with addicts
 * Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
 * Generalized Anxiety Disorder, includes everyday worries
 * Post-traumatic stress disorder, changes "opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings."

A group of 25 psychiatrists and researchers, among whom were Frances and Thomas Szasz, have published debates on what they see as the six most essential questions in psychiatric diagnosis:
 * Are they more like theoretical constructs or more like diseases?
 * How to reach an agreed definition?
 * Should the DSM-5 take a cautious or conservative approach?
 * What is the role of practical rather than scientific considerations?
 * How should it be used by clinicians or researchers?
 * Is an entirely different diagnostic system required?

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Over 15,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other APA divisions have endorsed the petition. Robbins has noted that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.

Cultural responses to the DSM
There are several works written in recent years by scholars of the disabled community that specifically critique the cultural impact of the DSM V. These pieces criticize the DSM V from different cultural perspectives, integrating the experiences of disabled people identifying as crip, feminists, Asian Americans, Black Americans and other marginalized viewpoints.

DSM CRIP
DSM CRIP is a collection of essays by various authors that explore the critiques of the DSM V from feminist and crip perspectives. These essays tackle the critiques of the DSM using specific diagnoses  such as gender dysphoria, transvestic disorder, complex somatic symptom disorder, hypoactive sexual desire disorder, schizophrenia and autism. These are used as case studies to tackle the topics of the potential harm of labels, overmedicalization, overdiagnosis, pathologizing normality and various other critiques informed by the feminist and crip lens.

Open in Emergency
Open in Emergency is a multimedia collaborative project of the Asian American Literary Review that takes the lens of an Asian American Experience and redefines wellness in terms of care instead of focusing on diagnosis, unlike the original DSM V. This included mock versions of DSM diagnoses such as gender dysphoria, social anxiety disorder and cannabis use disorder that mean to recharacterize the disorders under the lens of wellness and care. The project was said to contextualize mental disorders with their relationship to structures of power like patriarchy, colonialism and violence (here).

The Protest Psychosis: How Schizophrenia became a Black disease
The Protest Psychosis: How Schizophrenia became a Black disease is a critically acclaimed book that was written to analyze the history of schizophrenia and how perceptions of the condition have changed. In this book, Metzl shows how the condition of schizophrenia was experienced against the backdrop of the Civil Rights Movement. This book was recognized by the Disability Studies Quarterly academic journal as an excellent analysis of schizophrenia’s link to black history.


text:
Talk:Diagnostic and Statistical Manual of Mental Disorders

DSM Copyright
Here is a collection of historical information relating to the DSM Copyright:

December 2005 http://en.wikipedia.org/wiki/Wikipedia:Administrators%27_noticeboard/IncidentArchive57#DSM-IV-TR_Copyright_question

March 2010 http://en.wikipedia.org/wiki/Talk:Narcissistic_personality_disorder#Copyright_problems_with_diagnostic_criteria

DSM-5-TR
If someone can add a bit about DSM-5-TR, while being mindful of the APA's copyright, here are a couple of articles that will help:

Appelbaum PS, Leibenluft E, Kendler KS. Iterative Revision of the DSM: An Interim Report From the DSM-5 Steering Committee. Psychiatr Serv. 2021 Nov 1;72(11):1348-1349. doi: 10.1176/appi.ps.202100013. Epub 2021 Apr 22. PMID: 33882702.

First MB, Yousif LH, Clarke DE, Wang PS, Gogtay N, Appelbaum PS. DSM-5-TR: overview of what's new and what's changed. World Psychiatry. 2022 Jun;21(2):218-219. doi: 10.1002/wps.20989. PMID: 35524596; PMCID: PMC9077590.

Mark D Worthen PsyD (talk) [he/him] 04:13, 9 July 2022 (UTC)

 * I've had a go expanding the DSM-5-TR section. Thanks for the references :) Darcyisverycute (talk) 05:54, 10 July 2022 (UTC)

There is a curiosity that the article says "Beginning with DSM-5, the APA will use decimals to identify incremental updates (e.g., DSM-5.1, DSM-5.2)" immediately followed by "A revision of DSM-5, titled DSM-5-TR, was published in March 2022, updating diagnostic criteria and ICD-10-CM codes."2A00:23C6:148A:9B01:691F:F623:CF1E:F7D3 (talk) 11:37, 17 March 2023 (UTC)

I know at the moment I've do got ATLEAST 12 mental health issues maybe more. And I've been without a Dr. Mental health conditions now almost a yr now
I'm HAVEING ALOT OF issues mental health and behavioral health and RITE before my drs husband show very uncommon professional conduct an took it on his self to take away all 12 mental health meds that I ONCES had been on an TAKEING ATLEAST I was getting thru even my really bad times and it all were controlled then it's not even doing me no differant now days like it ONCES WAS working now if I was to get all of my meds back I do know that I won't be HAVEING all of my day to day issues near as badly as I'm HAVEING to try to make it daily cold turkey without no help 50.96.164.89 (talk) 08:13, 3 March 2023 (UTC)

 * Well said I agree 49.197.107.32 (talk) 13:53, 7 July 2023 (UTC)

Wiki Education assignment: Writing 101-The Archive
— Assignment last updated by Docscharn (talk) 21:59, 5 April 2023 (UTC)

Editing This Page For a Class!
Hi all! Hope you are well. I'm messaging here because I'll likely be making some edits over the next two months on this page as a part of a class assignment. Particularly, I plan to add to or clarify text from the Critique subsections "Obscuring the Root Causes of Psychological Distress" & "Overdiagnosis." I'll be mainly staying out of the way of the larger stuff, so I hope I can contribute to the knowledge base in smaller, more subtle ways. I want to thank you in advance for your suggestions... I appreciate your patience while I figure out Wikipedia :) Klrgmclass (talk) 02:42, 29 February 2024 (UTC)

Wiki Education assignment: Race, Gender, and Medicine
— Assignment last updated by Liliput000 (talk) 00:08, 12 April 2024 (UTC)

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/


text:
Dar es Salaam

Dar es Salaam (from دَار السَّلَام) is the largest city and financial hub of Tanzania. It is also the capital of the Dar es Salaam Region. With a population of over five million people, Dar es Salaam is the largest city in East Africa and the sixth-largest in Africa. Located on the Swahili coast, Dar es Salaam is an important economic center and one of the fastest-growing cities in the world.

The town was founded by Majid bin Said, the first Sultan of Zanzibar, in 1865 or 1866. It was the main administrative and commercial center of German East Africa, Tanganyika, and Tanzania. The decision was made in 1974 to move the capital to Dodoma which was officially completed in 1996.

Dar es Salaam is Tanzania's most prominent city for arts, fashion, media, film, television, and finance. It is the capital of the co-extensive Dar es Salaam Region, one of Tanzania's 31 administrative regions, and consists of five districts: Kinondoni in the north; Ilala in the centre; Ubungo and Temeke in the south; and Kigamboni in the east across the Kurasini estuary.

History
In the 19th century, Mzizima (Swahili for "healthy town") was a coastal fishing village on the periphery of Indian Ocean trade routes. In 1865 or 1866, Sultan Majid bin Said of Zanzibar began building a new city very close to Mzizima and named it Dar es Salaam. The name is commonly translated from Arabic as "abode (home) of peace", from dar ("house"), and es salaam ("of peace"). Dar es Salaam fell into decline after Majid's death in 1870, but was revived in 1887 when the German East Africa Company established a station there. The town's growth was facilitated by its role as the administrative and commercial centre of German East Africa and industrial expansion following the construction of the Central Railway Line in the early 1900s.

In the East African campaign of World War I, British and Empire forces captured German East Africa. The Royal Navy bombarded the city with the monitor HMS Mersey (1914) on 21 July 1916 and battleship HMS Vengeance (1899) on 21 August. The German colonial authorities surrendered the city on 3 September. German East Africa became the British Tanganyika Territory.

Dar es Salaam remained the administrative and commercial centre. Under British indirect rule, European areas such as Oyster Bay and African areas (e.g., Kariakoo and Ilala) developed separately from the city centre. The city's population also included a large number of workers from British India, many of whom came to take advantage of trade and commercial opportunities. After World War II, Dar es Salaam experienced a period of rapid growth.

Political developments, including the formation and growth of the Tanganyika African National Union, led to Tanganyika's independence from colonial rule in December 1961. Dar es Salaam continued to serve as its capital, even when Tanganyika and the People's Republic of Zanzibar merged to form Tanzania in 1964. In 1973, provisions were made to relocate the capital to Dodoma, a more centrally located city in the interior. The relocation process to Dodoma was completed, although Dar es Salaam continued to be the location of most government offices.

In 1967, the Tanzanian government declared the ujamaa policy, which made Tanzania lean towards socialism. The move hampered the potential growth of the city as the government encouraged people not to move into cities and instead remain in Ujamaa socialist villages. By the 1980s, the policy failed to combat the increasing poverty and hunger that Tanzania faced, and had delayed necessary development. This situation led to the liberalization policy of the 1980s that essentially ended socialism and silenced its proponents within Tanzania's government through political repression.

Until the late 1990s, Dar es Salaam was not regarded in the same echelon as Africa's leading cities like Cairo, Nairobi, Johannesburg, Lagos, or Addis Ababa. During the 2000s, businesses opened and prospered; growth expanded in the construction sector, with new multi-storey buildings, bridges and roads; Tanzanian banks headquartered in the city became better regulated; and the Dar es Salaam Stock Exchange expanded. The port is prominent for entrepot trade with landlocked countries like Rwanda, Burundi, Zambia, and the eastern portion of the Democratic Republic of the Congo. The city's skyline features tall buildings, among them the 35-storey PSPF Tower (finished in 2015) and the Tanzania Ports Authority (TPA) Tower, the tallest in the country (completed in 2016).

A number of historical buildings and elements of urban planning, such as parts of the harbour and streets going back to colonial times, still exist. The Old Boma, one of the city's oldest buildings, was built in 1866-67 by Majid bin Said, sultan of Zanzibar, and enlarged under German rule. The Botanical Gardens now are close to the National Museum of Tanzania. The present-day State House goes back to Majid bin Said, and were the seat of the German and later the British colonial governments. Along with the Azania Front Lutheran Church, built between 1899 and 1902, and the Roman Catholic St. Joseph's Cathedral, constructed around the same period, Ocean Road Hospital also belongs to a number of early historical buildings in Dar es Salaam.

Geography
Dar es Salaam is located at 6°48' S, 39°17' E (−6.8000, 39.2833), on a natural harbour on the coast of East Africa, with sandy beaches in some areas.

Districts of Dar es Salaam region
Dar es Salaam Region is divided into five administrative districts, four of which are governed by municipal councils that are affiliated with the city's suburbs or wards. The regional commissioner is Aboubakar Kunenge.

Kinondoni
Kinondoni is the most populated of the districts. It houses half of the city's population and several high-income suburbs.

 * Masaki, Oyster Bay and Ada Estate are the high-income suburbs located along the central beach. During the Colonial Era, they were the major European suburbs of the city. Diplomats and expatriates currently reside in these areas. Oyster Bay Beach (also known as Coco Beach) is the only white sandy beach east of Kinondoni.
 * Mikocheni and Regent Estate are also suburbs within the district. These are high and middle-income areas with Mikocheni B enjoying a higher population density than Mikocheni A and Regent Estate. According to the 2012 census, the Mikocheni ward had a population of 32,947.
 * Msasani is a peninsula to the northeast of the city center and home to expatriates from the United Kingdom and other western countries. It contains a mixture of traditional shops and western-oriented resorts and stores including the redevelopment of the former Msani Slipway shipyard by architect Antoni Folkers
 * Mbezi Beach is the beachfront suburb located along the northern Dar es Salaam Beach. It contains several tourist hotels, residences and a kite-surfing area by Upepo Avenue.
 * Sinza, Kijitonyama, Magomeni, Kinondoni and Mwenge are more ethnically mixed than the areas above and are located west of Dar es Salaam's Central Business District.

Ilala
The administrative district of Ilala contains almost all government offices, ministries, and the Central Business District. It is the transportation hub of the city, as the Julius Nyerere International Airport, Central Railway Station and Tazara Railway Station are all within the district's boundaries. The residential areas are mainly middle- to high-income, among them:
 * Upanga and Kisutu have the highest concentration of Asian communities within Dar es Salaam, with residents of Indian and Arabic descent. These areas contain colonial houses and mansions built in Indian, Arabic and European styles. Upanga is divided into Upanga East and Upanga West.
 * Kariakoo is the shopping district of the city: shops, bazaars, and merchants sell products from foodstuffs to hardware. The Kariakoo Market contains the only underground section of the city. It is the major supply point of the food consumed by all Dar es Salaam residents.
 * Tabata, Segerea and Ukonga are located slightly farther west from the city center.
 * Ilala, among the middle-income suburbs very near to the city center, is marked by the Askari Monument and suffers from gang activity.

Temeke
Temeke is the main industrial district of the city, where manufacturing (both heavy and light industry) is located. To the east is the Port of Dar es Salaam, the largest port in the country. Temeke is believed to have the largest concentration of low-income residents due to industry. It is home to military and police officers as well as port officials.
 * Kurasini, located on the harbour, contains Dar es Salaam Port, the Police College, the Mgulani Police Barracks and the Dar es Salaam International Trade Fair grounds. The main residents are police officers and port officials.
 * Chang'ombe is one of the few higher-income areas in Temeke. It has maintained this status due to the presence of African high colonial officers and some industry owners from the Colonial Era. Chang'ombe houses the Dar es Salaam University College of Education, the National Stadium and Uhuru Stadium.
 * Temeke, Mtoni, Tandika, Kijichi, and Mbagala are middle to low-income suburbs, of which the last is the largest suburb in the entire district.

Ubungo
The Ubungo terminal serves as a transportation link to most large Dar es Salaam urban nodes. The narrow-gauge commuter rail runs from there to the city centre, with ten level crossings along the route.

This district is characterised with a lot of potential social and economic centres such as industries i.e. Urafiki textile industry, bus station and vatious institutes and universities such as National Institute of Transport(NIT)

Kigamboni
Kigamboni (also known as South Beach), a beachfront suburb on a peninsula, is home to an economically diverse population. Access to the suburb is mainly by ferry, although the Kigamboni Bridge provides an alternative.

Climate
Dar es Salaam experiences tropical climatic conditions, typified by hot and humid weather throughout much of the year due to its proximity to the equator and the warm Indian Ocean. It has a tropical savanna climate (Köppen: Aw/As). Annual rainfall is approximately 1150 mm, and in a normal year there are two rainy seasons: the "long rains" in April and May, and the "short rains" in November and December.

Climate change
A 2019 paper published in PLOS One estimated that under Representative Concentration Pathway 4.5, a "moderate" scenario of climate change where global warming reaches ~2.5-3 C-change by 2100, the climate of Dar es Salaam in the year 2050 would most closely resemble the current climate of Barquisimeto in Venezuela. The annual temperature and temperatures of the warmest month would increase by 1.3 C-change, while the temperature of the coldest month would go down by 0.1 C-change. According to Climate Action Tracker, the current warming trajectory appears consistent with 2.7 C-change, which closely matches RCP 4.5.

Moreover, according to the 2022 IPCC Sixth Assessment Report, Dar es Salaam is one of 12 major African cities (Abidjan, Alexandria, Algiers, Cape Town, Casablanca, Dakar, Dar es Salaam, Durban, Lagos, Lomé, Luanda and Maputo) which would be the most severely affected by the future sea level rise. It estimates that they would collectively sustain cumulative damages of US$65 billion under RCP 4.5 and US$86.5 billion for the high-emission scenario RCP 8.5 by the year 2050. Additionally, RCP 8.5 combined with the hypothetical impact from marine ice sheet instability at high levels of warming would involve up to US$137.5 billion in damages, while the additional accounting for the "low-probability, high-damage events" may increase aggregate risks to US$187 billion for the "moderate" RCP4.5, US$206 billion for RCP8.5 and US$397 billion under the high-end ice sheet instability scenario. Since sea level rise would continue for about 10,000 years under every scenario of climate change, future costs of sea level rise would only increase, especially without adaptation measures.

Government

In his 1979 journal A Modern History of Tanganyika, historian John Iliffe wrote, "In 1949 the town became a municipality...[with] four honourable nominated Town Councillors who elected a Mayor." According to Associational Life in African Cities: Popular Responses to the Urban Crisis, published in 2001: "Until June 1996, Dar es Salaam was managed by the Dar es Salaam City Council...the highest policy-making body in the city." As of 2017, Paul Makonda serves as the commissioner of Dar es Salaam Region.

Demographics
Dar es Salaam is the most populous city in Tanzania and the fifth most populous in Africa. In 2020, the population was estimated to be 6.4 million.

When the 2012 national census was taken, the city had a population of 4,364,541, about ten percent of the country's total. The average private household size was 3.9 persons compared to the national average of 4.7. Less than half of the city's residents were married, with a rate lower than any other region in the country. The literacy rate in the city was 96%, while the national average was 78%. Between the 2002 and 2012 censuses, the city's 5.6% average annual growth rate was the highest in the country.

More than three-quarters of the city's population live in informal settlements. In 2018, Dar es Salaam scored 0.631 (medium category) on the Human Development Index (HDI). The city's HDI has increased every year since 1992, and it ranked higher than any other region in the country except for one.

Dar es Salaam is the second-fastest-growing city in the world and could have a population as high as 13.4 million by 2035. The population was estimated at 20,000 in 1900, 93,000 in 1957 and 273,000 in 1967.

Economy and infrastructure
Dar es Salaam is Tanzania's most important city for both business and government. The city contains high concentrations of trade and other services and manufacturing compared to other parts of the country, which has about 65 percent of its population in rural areas. Downtown includes small businesses, many of which are run by traders and proprietors whose families originated in the Middle East and the Indian subcontinent—areas of the world with which the settlements of the Tanzanian coast have had long-standing trading relations.

The Dar es Salaam Central Business District is the largest in Tanzania and comprises the Kisutu, Kivukoni, Upanga and Kariakoo areas. The downtown area is located in the Ilala district. Kivukoni is home to the Tanzania Central Bank, The Bank of Tanzania, the Dar es Salaam Stock Exchange and the city's important Magogoni fish market. With businesses and offices, Kisutu is the location of Dar es Salaam central railway station, the PSPF Towers, and the TPA Tower.

Dar es Salaam is undergoing major construction and development. The 35-storey PSPF Twin Towers are the second tallest building in the city and the country. The city has major infrastructural challenges, including an outdated transport system and occasional power rationing.

Financial services
The Dar es Salaam Stock Exchange (DSE) is the country's first stock market. The headquarters of the Natural Gas Revenue Fund is also here.

Retail
Dar es Salaam hosts the Mlimani City shopping mall, the City Mall in the Kisutu area, Quality Center Mall, GSM Pugu Shopping Mall, GSM Msasani Mall, and Dar Free Market Mall.

Transportation

On a natural harbour on the Indian Ocean, Dar es Salaam is one of the hubs of the Tanzanian transportation system, as the main railways and several highways originate in or near the city to provide convenient transportation for commuters.

Local public transport
Public minibus share taxis (dala dala) are the most common form of transport in Dar es Salaam and are often found at the major bus terminals of Makumbusho, Ubungo and other areas of the city. However, since the introduction of the motorcycle transit business known as "bodaboda", most people prefer it, allowing them to get into the city faster as compared with the minibuses, which encounter heavy traffic. Other types of transport include motorcycles and bajaj (auto rickshaws).

Bus
The government has been introducing a metro bus system, Dar es Salaam bus rapid transit (mwendo kasi in Kiswahili). The metro buses are managed by UDA-RT, a partnership between Usafiri Dar es Salaam (UDA) and the government.

The bus rapid-transit system Phase 1 has been completed by UDA-RT and began operation on 10 May 2016. The first section runs between Kimara in the northwest to Kivukoni on the northern headland of the harbour. Phase 1 was funded by the World Bank, African Development Bank and the Tanzanian government.

Metro
Dar es Salaam will have a metro system, currently undergoing a feasibility study conducted by Mota-Engil and Dar Rapid Transit Agency.

Port
The Port of Dar es Salaam is Tanzania's busiest, handling 90% of the country's cargo. It is located in the Kurasini administrative ward of Temeke District southeast of the city's central business district. Due to a huge influx of cargo and the slow pace of expansion, a new cargo port 60 km northwest of Dar es Salaam is proposed at Bagamoyo.

Ferry
MV Kigamboni ferries run between southeast of Kivukoni and northwest of Kigamboni in Dar es Salaam.

Dar es Salaam commuter rail
Travel to urban and suburban parts of the city is provided by the Dar es Salaam commuter rail.

Intra-city railway
Tanzania Railways operates the Central Line from Dar es Salaam west to Kigoma.

International railway
The city also hosts the head office of Tanzania–Zambia Railways Authority (TAZARA) built in the late 1960s to early 1970s. The main terminal is located west of Dar es Salaam's central business district in north Yombo Vituka along the Nelson Mandela Road. The TAZARA Railway connects Dar es Salaam to Zambia.

SGR
Tanzania Standard Gauge Railway is a new railway station currently under construction. It will link the country to Rwanda, Uganda, Burundi and Congo.

Airport
The Julius Nyerere International Airport is the principal airport serving the country, with three operating terminals. Terminal Three is located at Kipawa in Ilala Municipality. The airport is located west of Dar es Salaam's central business district.

Art
The Tingatinga painting style originates from Dar es Salaam. The Nyumba ya sanaa ("House of Art") is a cultural centre, workshop and retail outlet dedicated to Tanzanian art, showcasing and promoting Tanzanian craftsmanship. Prominent Tanzanian sculptor George Lilanga has donated some of his works to the centre, including decorations of the building's main entrance.

Music
The music scene in Dar es Salaam is divided among several styles. The longest-standing style is live dance music (muziki wa dansi) played by bands such as DDC Mlimani Park Orchestra and Malaika Musical Band. Taarab, which was traditionally popular in Zanzibar has also found a niche. However, it remains small compared both to dance music and "Bongo Flava", a broad category representing the Tanzanian take on hip hop and rhythm and blues that has quickly become the most popular locally produced music. The rap music scene is also present. Traditional music, which locally refers to tribal music, is still performed, but typically only on family-oriented occasions such as weddings.

In the 1970s, the Ministry of National Youth Culture aimed to create a national culture stressing the importance of music. Dar es Salaam became the music center in Tanzania, with the local radio showcasing new bands and dominating the music and cultural scene. With this ujamaa (family) mentality governing culture and music, a unified people's culture was created, leading to the rise of hip hop culture. Throughout the years, the radio in Dar es Salaam has played a major role in the dissemination of music, because many people do not have television; cassettes are more common than CDs.

Tourism
Dar es Salaam has two of the five museums that make up the National Museum of Tanzania consortium, namely the National Museum proper and the Makumbusho Cultural Centre & Village Museum. The National Museum is dedicated to the history of Tanzania; most notably, it exhibits some of the bones of Paranthropus boisei that were among the findings of Louis Leakey at Olduvai. In 2016, there was a breakthrough discovery in Northern Tanzania by a scientist, from the University of Dar es Salaam, of footprints thought to be of a hominid that predates Homo sapiens. The Makumbusho Cultural Centre & Village Museum, located in the outskirts of the city on the road to Bagamoyo, showcases traditional huts from 16 different Tanzanian ethnic groups. There are also examples of traditional cultivation, as well as daily traditional music and dance shows. Close to the National Museum are also the botanical gardens, with tropical plants and trees.

There are beaches on the Msasani peninsula north of Dar es Salaam and in Kigamboni to the south. Bongoyo Island can be reached by boat from the Msasani Slipway.

Places of worship

The city is home to several churches and mosques. The churches in the city belong to various denominations; for example, Roman Catholic Archdiocese of Dar es Salaam (Catholic Church), Anglican Church of Tanzania (Anglican Communion), Evangelical Lutheran Church in Tanzania (Lutheran World Federation), Baptist Convention of Tanzania (Baptist World Alliance), Ilala Seventh Day Adventist Church and Assemblies of God. There is a Hindu temple like Shree Shankarashram temple, Shree Sanatan Dharma Sabha temple, Swaminarayan temple. Muslims make up 70% of the population in Dar es Salaam.

Stadium
Dar es Salaam is the sports center of Tanzania and hosts the second-largest stadium in East and Central Africa, the National Stadium, which can accommodate up to 60,000 people.

Association football
The Tanzanian National Stadium hosts football clubs based in Dar es Salaam: Young Africans and Simba. It also hosts other Tanzanian football clubs and international matches. A new stadium in Dodoma with a much larger capacity has been proposed by the government as a donation from Morocco.

Apart from the National Stadium, the city is home to two other stadiums: the Uhuru Stadium, the Karume Memorial Stadium and Chamazi Stadium. The Uhuru Stadium is used mainly for local tournaments and political gatherings, whilst the Karume Memorial Stadium is situated west of Kurasini and home to the Tanzania Football Federation. Azam Complex Chamazi is owned by Azam Football Club.

Golf
The Gymkhana Golf Courses located northwest of the Kivukoni area (between the city centre overlooking the shores of the Indian Ocean in the east and Barack Obama Drive), also have tennis courts, squash courts, and a fitness club. Outside of the metropolitan districts is Lugalo Military Golf Course located in the Lugalo Military Barracks.

Acrobatics
Founded in 2003, Mama Africa is a school known for training some of Africa's professional acrobats.

Boxing
Boxing is a popular sport in Tanzania and Dar es Salaam hosts numerous boxing galas organised throughout the year. Tanzanian professional boxer Francis Checka is the current World Boxing Federation (WBF) Super Middleweight Champion.

Newspapers
Newspapers in Dar es Salaam are often sold by vendors weaving through stationary traffic at road intersections. English-language newspapers, with online versions, include The Citizen and The Guardian. Swahili dailies Tanzania Daima and Mwananchi are also available. Business Times is the only financial and economic newspaper in the city; it was established in 1988 and became the first private newspaper in Tanzania. Business Times owns Majira, another Swahili newspaper.

Television stations
Dar es Salaam is home to ITV, Sibuka, Channel Ten Television Station (formerly Dar es Salaam Television [DTV]) and Azam TV, a subscription-based service from the Azam group of companies.

Television station Ayo TV is based in Ubungo, Dar es Salaam, as is the Tanzania Broadcasting Corporation.

Internet access
Installation of the trans-Indian Ocean backbone cable (SEACOM) in 2009 has, in theory, made Internet access much more readily available in Dar es Salaam in particular and in East Africa in general. However, roll-out to end-users is currently slow. Telephone-line coverage provided by the Tanzania Telecommunications Company Limited is limited, prices are high, and long contracts are required for purchase of bandwidth for small Internet service providers. The expressed aim of the SEACOM cable is to enable East Africa to develop economically through increased online trading.

Internet cafés are found in the city centre, and free Wi-Fi hotspots are available in various government and nongovernment institutions as well as public transport.

Mobile-telephone access to the Internet via 3G and 3.75G is still relatively expensive, though 4G is making its way through major cities and towns with plans to go nationwide in the advanced stages.

Radio
Dar es Salaam's first radio station began operation in the early 1950s with "little more equipment than a microphone and a blanket hung over a wall..." This project was overseen by Edward Twining.

Environment
Since the 1990s, Dar es Salaam has experienced heavy and frequent flooding due to intense rainfall. The city is especially vulnerable to flooding, due to its lowland coastal orientation and the fact that the Msimbazi River flows through the city. The situation has worsened over the years, both due to climate change and the expansion of city pavement, which increases surface runoff.

In 2019, flooding displaced 1,215 households. Between 2017 and 2018, the city experienced seven floods. The World Bank estimates that exposure to floods has impacted about 2 million people, or 39% of the population in Dar es Salaam. Flooding incidents destroy bridges and roads, disrupt transportation, increase risk of diseases such as cholera and skin infection, and are a barrier to reducing poverty.

Education
Dar es Salaam has the highest concentration of educational opportunities in Tanzania and the city is home to several institutions of higher learning.

Universities

 * The University of Dar es Salaam is the oldest and second largest public university in Tanzania after the University of Dodoma. It is located in the western part of the city in north-east Ubungo, and occupies 1,625 acre on Observation Hill, 13 km from the city centre. The university has 16,400 undergraduate and 2,700 postgraduate students.
 * Ardhi University (ARU) was established on 1 July 1996 after transforming the former University College of Lands and Architectural Studies (UCLAS), which was then a Constituent College of the University of Dar es Salaam. Historically, Ardhi University, dates back to 1956 when it started as Surveying Training School offering land surveying technician certificate courses at the present location of Mgulani Salvation Army Camp in Dar es Salaam. In 1958, the school was moved to the present location on Observation Hill. At present, there are over 80 PhD holders who have graduated from over 25 universities worldwide. The university comprises four schools, one institute and several centres, and offers undergraduate and postgraduate studies with postgraduate, bachelor's, master's and PhD degrees in various disciplines.
 * The Muhimbili University of Health and Allied Sciences consists of Muhimbili Campus and Mloganzila Campus. Muhimbili Campus is situated in Upanga, Ilala Municipality, along United Nations Road. Mloganzila Campus occupies 3,800 acre and is located 3 km off the Dar es Salaam-Morogoro highway, 25 km from Dar es Salaam.
 * The Open University of Tanzania is a full-fledged, accredited public institution of higher learning, featuring programmes leading to certificates, diplomas, undergraduate and postgraduate qualifications. Since it was founded, the university has enrolled students from Malawi, Uganda, Kenya, Namibia, Hungary, Burundi, Libya, Ethiopia, Rwanda, Saudi Arabia, Lesotho, Botswana and most of Tanzania., total enrollment was 44,099, the majority of which was Tanzanian.
 * Hubert Kairuki Memorial University is a private institution located on plot No. 322 Regent Estate in the Mikocheni area, about 7 km from Dar es Salaam's city centre, off Ali Hassan Mwinyi and Old Bagamoyo Roads.
 * International Medical and Technological University is a privately owned institute of higher education.
 * Kampala International University began operations in 2009. The University Centre is situated on 60 acre of land in the Gongo la Mboto area, Ilala District, 7 km from Mwalimu Julius Nyerere International Airport along Pugu Road.

Notable people

 * Sir David Frank Adjaye (born 1966), London-based architect born in Dar es Salaam
 * C.A. "Peter" Bransgrove (1914–1966), architect in Dar es Salaam from 1947 to 1966
 * Joaquim Chissano (born 1939), the second President of Mozambique, from 1986 to 2005; headed the FRELIMO headquarters in Dar es Salaam
 * Kanyama Chiume (1929–2007), a leading nationalist in the struggle for Malawi's independence in the 1950s and 1960s and Minister
 * Roald Dahl (1916–1990) a British novelist, short-story writer and poet; he lived in Dar es Salaam from 1934 to 1939
 * Jane Goodall (born 1934), scientist and primatologist
 * Gertrud von Hassel (1908-1999) a German teacher and painter
 * Marin Hinkle (born 1966), actress, Two and a Half Men TV show
 * Rayah Kitule (born 1984), author and magazine editor
 * Rachel Luttrell (born 1971), actress, Stargate Atlantis, born in Dar es Salaam
 * Nairn McEwan (1941–2018), rugby union player and second national coach, born in Dar es Salaam.
 * Bibi Titi Mohammed (1926–2000), politician and chair of the women's branch of TANU
 * Yoweri Museveni (born 1944), president of Uganda since 1986
 * Godfrey Mwakikagile (born 1949), prominent Tanzanian author, Africanist scholar and journalist
 * Juma Mwapachu (born 1942), Tanzanian diplomat, lawyer and author of books on African politics and economics; served as secretary-general of the East African Community (EAC)
 * Herieth Paul (born 1995), fashion model
 * Walter Rodney (1942–1980) Guyanese historian, political activist; author of How Europe Underdeveloped Africa
 * Justinian Rweyemamu (1942–1982), Tanzanian economist, author and professor of economics at the University of Dar es Salaam; worked at the United Nations; economic adviser to Tanzania's first president, Julius Nyerere
 * Mbwana Samatta (born 1992), footballer, 2015 CAF African Player of the Year; 68 caps for Tanzania
 * Issa G. Shivji (born 1946), Tanzanian scholar, and expert on constitutional law and development issues
 * Ally Sykes (1926–2013), politician and leading figure in Tanzania's independence movement
 * Hasheem Thabeet (born 1987), basketball player in the US
 * Paul von Lettow-Vorbeck (1870–1964), commander of the German East Africa Army

International relations
Dar es Salaam is sister cities with:
 * 🇩🇪 Hamburg, Germany
 * 🇮🇳 Mumbai, India
 * 🇹🇷 Samsun, Turkey
 * Changzhou, Jiangsu, China
 * Sari, Iran

title: Dar es Salaam