How Everyone Became Depressed

The rise and fall of the nervous breakdown

The Backlash Against the New DSM-5

DSM-5, launched in May 2013, has been the object of blowtorch treatment.

The backlash has begun. DSM-5, scarcely launched in May 2013 at the annual meeting of the American Psychiatric Association, has been the object of blowtorch treatment in the current Acta Psychiatric Scandinavica, which, despite its regional-sounding title, is one of the premier psychiatry journals of the world.

Jose De Leon, a psychiatrist of Spanish origin at the University of Kentucky, confidently – and I think correctly – writes, “The DSM-5 is a dead end for the historical process initiated in 1980 with the publication of the DSM-3.”

There are a lot of reasons why one might consider DSM-5 a dead end. One is its perpetuation of such diagnoses as “schizophrenia” and “bipolar disorder” that do not in fact correspond to natural disease entities. I have blogged about this before and recently wrote an article on the history of the DSM series that emphasizes this point. (Shorter, 2013)

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Dr De Leon, however, has another point in mind. Such has been the hegemony of the APA’s Diagnostic and Statistical Manual that it has crushed the national traditions of diagnosis once so lively in France and Germany in particular.

Let me background this a bit. The Germans were the world masters of psychiatric diagnosis in the late nineteenth and early twentieth centuries, when the great nosological systems were laid down. (Nosology is the scientific classification of disease.) Emil Kraepelin, professor of psychiatry first in Heidelberg then in Munich, created a system in his series of textbooks in the years 1893 to 1915 that lays the basis of much modern psychiatric science. Kurt Schneider, who became the professor in Heidelberg after the end of the Nazi terror in 1945, is another of these historic German names to reckon with. Likewise Karl Jaspers, who in 1913 wrote the classic General Psychopathology. These were all world-beating figures.

After the Second World War, the Germans came up with all kinds of fine distinctions among the psychotic illnesses. Karl Leonhard, who had the chair of psychiatry at the famous Charité Hospital in Berlin, devised a system with literally dozens of differentiations involving “systematic” and “unsystematic” psychoses. (Die Aufteilung der Psychosen, 1957). Outside of a small band of disciplines, all this possibly quite valid knowledge has been forgotten in Germany and elsewhere today, pushed off the table by the DSM.

Across the Rhine, the French were busy with their own system, almost all the elements of which have slid unjustly from memory. The French pushed back against Kraepelin’s idea that patients with major psychotic illnesses went relentlessly downhill into terminal “dementia.” (Kraepelin called this progressive deterioration “dementia praecox”: it became “schizophrenia” under the pens of others)

Pas du tout! was the French response. There are a slew of illnesses, French scholars maintained, that may involve chronic hallucinations and delusions but no deterioration of the personality (which is the essence in these patients of so-called “dementia”: people are not demented but suffer from “avolitional syndromes”: an inability to get one’s act together, plus deadened moods). The French diagnosis “chronic delirium with a systematically progressive course” (délire chronique à progression systématique) has a lot to recommend it. Totally off the DSM radar, and now vanishing from French psychiatry too.

That we have let a document as flawed as DSM crowd all these potentially valid systems and concepts off the shelf is a shocking testimonial to the power of fashion over science. DSM has been driven internationally by the prestige of US psychiatry, which in turn is powered by money from the federal government (National Institute of Mental Health) and from the pharmaceutical industry, in the form of financial support for clinical trials: the trials are conducted for DSM-style diseases, and many are scientifically valueless.

De Leon’s bugbear is the US fascination with “neuroscience,” which has contributed so little to clinical psychiatry. No one, of course, is against science. But there are other moments in clinical illness aside from brain biology, and neuroscience will be incapable of nailing them. De Leon rebukes the US for being “intoxicated on neuroscience and European psychiatry mimics those intoxicated moves.”

There’s more to come on this front. Stay tuned!

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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