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.
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 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 By 1980 the term melancholia had gone out of style and had been replaced by endogenous depression.
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.
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.
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.
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.
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.