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Trouble at the Heart of Psychiatry’s Revised Rule Book

The views expressed are those of the author and are not necessarily those of Scientific American.


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By Edward Shorter*

Part 3 in a series

One might liken the latest draft of psychiatry’s new diagnostic manual, the DSM-5, to a bowl of spaghetti. Hanging over the side are the marginal diagnoses of psychiatry, such as attention deficit hyperactivity disorder and autism, important for certain subpopulations but not central to the discipline.

At the center of the spaghetti bowl are the diagnoses at the heart of psychiatry: major depression, schizophrenia, bipolar disorder.

Courtesy of Shot_by_Cam via Wikimedia Commons.

There has been enormous commentary in the media and in professional journals about proposed changes in the strands hanging over the side, such as lumping different forms of autism together in an autism spectrum diagnosis. (For more on these changes, see “Psychiatry’s ‘Bible’ Gets an Overhaul,” by Ferris Jabr, Scientific American Mind, May/June 2012.) Indeed, the number of dangling strands has increased so greatly that some observers, such as Allen Frances, the editor of the current manual, the DSM-IV, have very correctly commented on the increasing medicalization of areas of life previously considered normal: the draft DSM-5 does seem to be expanding the scope of what is considered a psychiatric disorder.

But that is not the main problem.

Few observers have called attention to difficulties at the center of the spaghetti bowl. The main difficulty is that the principal diagnoses of psychiatry are artifacts. Let’s consider them one by one.

Major depression

Major depression was created in 1980 by DSM-III editor Robert Spitzer as an effort to bridge disagreements between psychoanalysts, when they ruled the roost in the American Psychiatric Association, and the rest of the profession, which was becoming increasingly oriented towards biology. As a political construct, major depression included the two forms of depressive illness that previously had been considered as different from each other as measles and tuberculosis: melancholic illness and nonmelancholia. Melancholia, a grave form of depression involving slowed thought and movement, a complete joylessness in life and lack of hope for the future, had always been considered a separate illness. By 1980 the term melancholia had gone out of style and had been replaced by endogenous depression.

Depressed man

Courtesy of Hendrike via Wikimedia Commons.

The other form of depressive illness that psychiatry had always recognized as separate was an ill-defined aggregation of symptoms of mood, anxiety, fatigue, somatic complaints – and a tendency to obsess about it all – that had been called on occasion neurasthenia, neurotic depression, reactive depression and other terms indicating real illness but not melancholic disease.

So the first artifact the DSM series created was lumping these two forms of depressive illness together. In fact, they are so disparate that the depression term itself should be abandoned. It is now shopworn with use and has approximately the same scientific value as other discarded psychiatric diagnoses such as hysteria and madness.

In 1996 Gordon Parker, professor of psychiatry at the University of New South Wales, proposed melancholia and nonmelancholia as the main mood diagnoses, and his proposals have gained much traction, though not, alas among the disease designers of DSM-5.

Schizophrenia

The second artifact at the heart of DSM is schizophrenia. A term coined in 1908 by Zurich psychiatry professor Eugen Bleuler, schizophrenia is nothing more than a synonym for chronic psychosis. (The Massachusetts General Hospital’s psychiatric Manual, for example, has replaced the once-obligatory chapter on schizophrenia with one on “Psychotic Patients.”) There is no natural disease entity called schizophrenia: it has no typical, or pathognomonic, symptom, no predictable response to treatment, no reliable prognosis. Chronic psychosis is really a common final pathway for several disparate forms of psychotic illness that should not be lumped together.

sculpture of person in psychic pain

Courtesy of mRio via Flickr.

One such form, baptized hebephrenia in 1871 by German psychiatrist Ewald Hecker, is really core schizophrenia, meaning chronic psychosis that begins in adolescence with social withdrawal, proceeds to a psychotic break, and then involves restitution to a relatively low level of function (but neither does it lead to a vegetative existence on the terrible “back wards”). Hebephrenics can hold undemanding jobs as porters or laborers; they can marry. Their illness trajectories may, or may not, include later episodes of psychosis. But they never return to their prepsychotic levels of functioning.  This enfeeblement is very different from other forms of chronic psychosis, and lumping them all together commits the same error as lumping together melancholia and nonmelancholia.

Bipolar disorder

The third fatal flaw at the center of the bowl of spaghetti is bipolar disorder, a diagnosis that assumes that the depression of unipolar disorder (otherwise known as major depression) is different from bipolar depression. But they’re really the same. The response of bipolar and unipolar depression to electroconvulsive therapy, for example, is identical. In fact, it makes little sense to classify depressions by polarity. There may be a difference, in the sense that bipolar depression is often melancholic, and major depression is highly diverse, but there are no natural disease entities called “bipolar depression” and “unipolar depression.” And the entire concept of bipolar disorder has been a gift to the pharmaceutical industry, which has been able to re-position anticonvulsant drugs to counter the terrible bipolar menace. Being considered “bipolar” has not, however, been a gift to patients with mood disorders, who end up being diagnosed and treated inappropriately.

Does it really matter which diagnoses get into this wretched manual, stuffed as it is with artifacts of every manner?

Yes, it does. It matters, for example, to drug discovery and development. There has been almost no progress in psychopharmacology for the last thirty years: among drugs for “depression,” none has been shown superior to the first of the tricyclic antidepressant medications, imipramine, that reached the American market as Tofranil in 1959. Among antipsychotics (with the possible exception of clozapine, an effective but dangerous agent), none is superior to the first antipsychotic ever launched, chlorpromazine, marketed as Thorazine in the United States in 1955.

Why this lack of progress? You can’t develop drugs for diseases that don’t exist. And in U. S. psychiatry today the principal diagnoses are comparable to a handful of smoke. Will DSM-5 fix this? Don’t count on it.

*Edward Shorter is an historian of psychiatry at the University of Toronto

Tomorrow: I reflect on why mixed depression/anxiety could be real, despite concerns that almost everyone might have it.

Yesterday: Ferris Jabr explained why science has so far played only a bit part in the creation of the new DSM.

 

Further Reading

Melancholia: A Disorder of Movement and Mood. Gordon Parker and Dusan Hadzi-Pavlovic, Cambridge University Press, 1996.

Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Edward Shorter, Oxford University Press, 2009.

Opening Pandora’s Box: The 19 Worst Suggestions for DSM-5. Allen Frances Psychiatric Times, Feb. 11, 2010.

Endocrine Psychiatry: Solving the Riddle of Melancholia. Edward Shorter and Max Fink, Oxford University Press, 2010.

The Failure of the Schizophrenia Concept and the Argument for Its Replacement By Hebephrenia: applying the medical model for disease recognition (Editorial). Michael Alan Taylor et al. Acta psychiatrica scandinavica 122, pages 173–183, 2010.

 

 

Ingrid Wickelgren About the Author: Ingrid Wickelgren is an editor at Scientific American Mind, but this is her personal blog at which, at random intervals, she shares the latest reports, hearsay and speculation on the mind, brain and behavior. Follow on Twitter @iwickelgren.

The views expressed are those of the author and are not necessarily those of Scientific American.





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Comments 11 Comments

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  1. 1. jtdwyer 10:57 am 05/9/2012

    As a lay person, this appears to me to be an excellent and insightful analysis – good luck with it!

    Link to this
  2. 2. Danny Haszard 12:32 pm 05/9/2012

    Schizophrenia affects 1 percent of the world population yet I found that Zyprexa sales were far exceeded that range.
    A patient victim speaks.

    The saga of the schizophrenia drugs is one of incredible profit.Eli Lilly made $65 BILLION on Zyprexa franchise.
    Described as *the most successful drug in the history of neuroscience* the drugs at $12 pill are used by states to medicate deinstitutionalized mental patients to keep them out of the $500-$1,000 day hospitals (*Viva Zyprexa* Lilly sales rep slogan).

    There is a whole underclass block of our society,including children in foster care that are the market for these drugs,but have little voice of protest if harmed by them.
    I am an exception,I got diabetes from Zyprexa as an off-label treatment for PTSD and I am not a mentally challenged victim so I post.
    –Daniel Haszard

    Link to this
  3. 3. Tumorhead 1:30 pm 05/9/2012

    As someone struggling with depression and mood disorders since puberty, it’s shocking to me that I’ve never before heard of the distinction between melancholic and nonmelancholic depression! Now that I know what to look for, the literature makes it apparent, but it’s never a part of the normal psychiatric discussions.

    This is a very disturbing oversight!

    Link to this
  4. 4. Heidi Lindborg 2:21 pm 05/9/2012

    The DSM should be thrown out and Psychiatry abolished.
    There are known illnesses which cause all these symptoms and if they were treated, there would be no need for the distinction of “mental” illness from the rest of medicine.

    -Streptococcal Autoimmunity produces obsession and mania. The underlying strep infection causes depression.
    - Food allergies produce obesity, sleep disorders and depression.
    - And Herpes Virus- the one that causes cold sores- is known to cause psychosis and dementia. It is the Leading Candidate for the cause of Alzheimer’s Disease.

    If doctors properly addressed these three medical pathologies- Psychiatry would be irrelevant.

    All this talk of revising the DSM is merely perpetuating Codified Malpractice.
    THROW IT OUT.

    Link to this
  5. 5. kebil 9:00 pm 05/9/2012

    Yes Heidi, the world of mental illness is as simple as you say. How would you treat streptococcal autoimmunity? I guess we could just shut down the immune system, or maybe a bone marrow transplant. Autoimmunity continues after strep is cleared, which is why it is commonly called poststreptococcal autoimmunity. And why is the rate of depression so vastly greater than the rate of autoimmunity? The course of these diseases do not resemble each other.

    And it is true that virtually all patients with psychosis or dementia test positive for one of the many herpes virus’s (60 to 80% for HSV 1 alone), correlation is not causation.

    I don’t understand people who like to bash psychiatry. To me, they sound like they are belittling the problems of the mentally ill, and denying that there is any efficacy in any of the treatments for mental illness. I am not that naive to think that the pharmaceutical industry is not financially motivated, and I realize that there salespeople push drug therapies for illness’s without evidence of benefit. It is true that therapies other than psychopharmacology are tragically underutilized, but that is scant reason to believe that three individual illness’s, all involving infection and immunity, are responsible for all the wide variety of mental disease.

    Link to this
  6. 6. emizruc1 9:34 pm 05/9/2012

    I find these two articles both disturbing and amusing. In 1953,as a graduate student in sociology at Yale, I wrote a paper based on “The Manual…” in which I tried to sort out the concept of DEPENDENCE(“Behavioral Concomitants of the Concept of Dependency.”)There were so many divergent behaviors subsumed in this category,that it was obvious that any effort to articulate a distinctive behavior pattern would be a waste of time. The confusion and ineptitude on display–as described by these two authors–in the efforts to make scientific claims for meaningless measures suggests that, in spite of my colleague Ed Shorter’s very sophisticated knowledge of the seemingly complex conditions, contemporary psychiatric researchers have squandered almost 60 years of effort. Ephraim H. Mizruchi, Ph.D. Syracuse U.

    Link to this
  7. 7. windhill 10:35 pm 05/9/2012

    I worked as an psychiatric orderly at a hospital in Victoria, Texas in the late 1960′s. At the time, a treatment called “insulin shock therapy” was in vogue. The treatment protocol went like this- the patient was literally tied to the bed, and insulin was administered, the purpose of which was to produce profound hypoglycemia to induce a seizure. After this occured, glucose would be administered to reverse the process. After the “patient” regained consciousness, he or she would walk the halls literally like zombie and have no recollection of the morming’s events. One of my jobs was to mix up a concoction of sugar and orange juice and make sure the patient drank a big glass at least three times per shift. This was to prevent further(unwanted) episodes of hypoglycemia during the day. The patients gained massive amounts of weight from the “therapy” which would occur daily for six weeks. The treatment caused profound memory loss, which was supposed to make people “forget” their psychosis, depression or whatever they suffered from. Insulin shock therapy is no longer performed, as it tended to cause irreversable brain damage, which one might suspect. I remember the psychiatrist making his rounds in the morning, breezing through the wards, scratching the word” stable” in the chart while ordering around the nursing staff like a rooster in a henhouse. I also remember thinking that this person did not really have a clue as to what happened to his “patients” the rest of the day.
    During my tenure I also witnessed electroshock treatment, although lobotomy was on it’s way out- I did meet several patients who had one, however , and the threat of such was quickly given to anyone who was less than cooperative. I learned that very quickly.
    Psychiatry’s role a societal psychic policemen rather than physicians who treat and heal those of us who are sick is horribly frightening. Perhaps a book to give them some direction is not a bad thing…….

    Link to this
  8. 8. rgcorrgk 4:25 am 05/10/2012

    Ingrid Wickelgren, you have given some information here that is both very important and largely unknown. Thank you!
    To understanding the “nut” business, as the old story goes, “follow the money”. There is,and always has been, a lot of slop in what is considered deranged. Of course, “the increasing medicalization … of normal” is the trend, with money the impetus. As the march down the socialist road continues the gap widens between the receivers and the payers, adding yet more waste, incompetence and confusion to the mental health picture (another large dose of politically driven bureaucratic medicine, administer from on high, through sweeping inflexible edicts, will only magnify and ossify errors – adding yet more cover for gaming the system).

    Richard Carlson

    Link to this
  9. 9. windhill 8:56 am 05/10/2012

    I worked as an psychiatric orderly at a hospital in Victoria, Texas in the late 1960′s. At the time, a treatment called “insulin shock therapy” was in vogue. The treatment protocol went like this- the patient was literally tied to the bed, and insulin was administered, the purpose of which was to produce profound hypoglycemia to induce a seizure. After this occured, glucose would be administered to reverse the process. After the “patient” regained consciousness, he or she would walk the halls literally like zombie and have no recollection of the morming’s events. One of my jobs was to mix up a concoction of sugar and orange juice and make sure the patient drank a big glass at least three times per shift. This was to prevent further(unwanted) episodes of hypoglycemia during the day. The patients gained massive amounts of weight from the “therapy” which would occur daily for six weeks. The treatment caused profound memory loss, which was supposed to make people “forget” their psychosis, depression or whatever they suffered from. Insulin shock therapy is no longer performed, as it tended to cause irreversable brain damage, which one might suspect. I remember the psychiatrist making his rounds in the morning, breezing through the wards, scratching the word” stable” in the chart while ordering around the nursing staff like a rooster in a henhouse. I also remember thinking that this person did not really have a clue as to what happened to his “patients” the rest of the day.
    During my tenure I also witnessed electroshock treatment, although lobotomy was on it’s way out- I did meet several patients who had one, however , and the threat of such was quickly given to anyone who was less than cooperative. I learned that very quickly.
    Psychiatry’s role a societal psychic policemen rather than physicians who treat and heal those of us who are sick is horribly frightening. Perhaps a book to give them some direction is not a bad thing…….

    Link to this
  10. 10. marclevesque 9:15 am 05/10/2012

    “One such form, baptized hebephrenia in 1871 by German psychiatrist Ewald Hecker, is really core schizophrenia … But they never return to their prepsychotic levels of functioning”

    Just to add that relatively recent large scale research shows better courses are possible: not only social recovery but also complete recovery (WHO, 1979; Sartorius et al., 1987; Shepherd et al., 1989). Though there is disagreement on the criteria that define and separate those two outcomes.

    Link to this
  11. 11. cacummings 3:07 pm 05/11/2012

    Melancholia may be an actual category of illness (i.e., can’t be ranged on a continuum like anxiety, for example) but you could just as well call the other form of depression “insomnia”!

    Link to this

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