Posts Tagged ‘ DSM-5 ’

New book by Edward Shorter: “What Psychiatry Left Out of the DSM-5” (2015)

Historian of psychiatry Edward Shorter, author of numerous books including A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (1997); Before Prozac. The Troubled History of Mood Disorders in Psychiatry (2009) and How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (2013), has published a new book:

What Psychiatry Left Out of the DSM-5

Historically-Based Mental Disorders and the DSM: What Psychiatry Left Out covers the diagnoses that the Diagnostic and Statistical Manual of Mental Disorders (DSM) failed to include, along with diagnoses that should not have been included, but were. Psychiatry as a field is over two centuries old and over that time has gathered great wisdom about mental illnesses. Today, much of that knowledge has been ignored and we have diagnoses such as “schizophrenia” and “bipolar disorder” that do not correspond to the diseases found in nature; we have also left out disease labels that on a historical basis may be real. Edward Shorter proposes a history-driven alternative to the DSM.

For more information, click here.

To access the author’s interview on H-Madness, click here.

A humorous take on DSM-V

DSM-5 video performed to Stayin’ Alive by Professor Stephen Stahl and produced by the Neuroscience Education Institute

Book Review – Richard Noll, American Madness: The Rise and Fall of Dementia Praecox (Harvard 2011)

By Jesse Ballenger

As indicated by the controversies swirling around the proposed revisions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders due to be published next year, psychiatry is probably more concerned with the categorization of diseases under its purview than any other medical specialty. Yet solid knowledge of the causes and precise pathological mechanisms that might define mental illness remains more elusive than with any other sort of human affliction. In this richly detailed book, Richard Noll explores the historical predicament of psychiatry through the efforts of America’s early twentieth century psychiatric elite to integrate their field with the main currents of an emergent scientific medicine by creating a scientific classification of mental illness.

In the second half of the nineteenth century, culminating in the emergence of germ theory and the microbiological turn, medicine as a whole increasingly oriented itself around a concept of disease specificity. Disease was no longer thought of as a general process manifesting itself uniquely in each individual, but as a specific entity with distinctive signs, symptoms, cellular pathology, and a typical course and outcome. Medicine increasingly emphasized the rational investigation of biological mechanisms or physiological abnormalities in the laboratory or on the autopsy table.

By contrast, American alienism – the term used through the early twentieth century to describe the branch of medicine devoted to disorders of the mind – seemed left behind to grapple with the protean, inscrutable and seemingly intractable nature of insanity in increasingly overcrowded, understaffed and physically decaying asylums and state hospitals. Noll argues that by adopting and adapting the European concepts of dementia praecox to the American context, leading American psychiatrists transformed their field into a branch of modern medicine.

Historians of American psychiatry, pulled toward the historiographical black hole of conflicts between partisans of Freudian psychoanalysis and the bio-pharmacological turn of the past few decades, have paid far too little attention to the influence of German psychiatrist Emil Kraepelin in the first four decades of the twentieth century. Noll’s book goes a long way toward remedying that. He devotes an excellent chapter to describing how Kraepelin revolutionized psychiatry by replacing a static view of insanity as a single entity that could express itself in a number of characteristic forms in particular patients – melancholia, mania and finally terminal dementia – with the idea that mental disorders could be sorted into distinct categories based on a rigorous, quantitative study of how clinical symptoms manifested over time. This work established two main categories – manic-depressive inanity and dementia praecox – distinguished primarily on the basis of the deteriorating course and bleak prognosis of the latter. Manic depressives improved between acute episodes, and sometimes recovered completely. Patients with dementia praecox very seldom did.

Most of the remainder of the book explores how American psychiatrists like Adolph Meyer introduced and adapted Kraepelin’s methods and concepts into American psychiatry. From a series of increasingly influential positions – first as head of pathology at the Worcester Hospital in Massachusetts, then director of the New York Pathological Institute, and finally professor of psychiatry and head of the Phipps Psychiatric Clinic at Johns Hopkins, Meyer trained nearly every psychiatrist who rose to a senior administrative position in American asylums in the first half of the twentieth century.

Meyer learned Kraepelin’s methods and nosological system during a six week visit to his clinic in Heidelberg in 1896 just as the revolutionary fifth edition of Kraepelin’s textbook was published, and returned to the United States a confirmed Kraepelinian. He was enthusiastic about Kraepelin’s methods and concepts not only because they provided a scientific basis for psychiatric research, but because they provided a rationale for asylum doctors to take a more active interest in the patients who crowded their wards. Thanks to the influence of Meyer and a few other elite psychiatrists like August Hoch and E.E. Southard, dementia praecox, which did not exist in American psychiatry in 1895, became in the space of a decade the mental disorder most widely written about in American medical journals and most frequently diagnosed in American psychiatric institutions.

Although Noll’s book mostly focuses on the thought-world of elite psychiatrists, he recognizes that most American alienists practiced in a much different world in which limitations in their training, and the lack of resources and clinical demands of the institutions they worked in, made it very difficult for them to follow the psychiatric literature published in English, let alone read Kraepelin’s original work in German. Noll argues that in their hands, Kraepelin’s classification scheme became something of a diagnostic blunt instrument – with mixed results for patients. To the good, Kraepelin’s emphasis on clinical observation restored interest in patients and their symptoms, and Noll thinks it likely that some patients benefitted simply from the increased attention. Moreover, since the major categories of mental disorder were distinguished by prognosis, giving patients a diagnosis allowed alienists to say something about the future to patients and their families, and a diagnosis of manic-depressive insanity gave grounds for some hope of recovery. To the bad, Noll argues that the rising prominence of dementia praecox facilitated continued neglect. The dire prognosis of dementia praecox, which Noll estimates to have been the diagnosis for between one quarter to one half of institutionalized patients during this period, justified non-treatment or mistreatment.

Noll shows that American psychiatrists began to stretch the concept of dementia praecox almost from the moment it entered American psychiatry in 1896. In part, this reflected the relative isolation of workaday asylum alienists described above. But even elite American psychiatrists were dissatisfied with several ambiguous aspects of Kraepelin’s concept, and by 1904 Noll finds prominent neurologists and psychiatrists complaining that the term was so malleable that it could be applied to any young person with a serious mental disturbance. The imprecision with which psychiatrists used the term dementia praecox became an embarrassment to the profession when it was mocked in the sensational murder trial of Henry Kendall Thaw in 1907. As widely reported in newspapers around the world, numerous prominent alienists testified as expert witnesses for both sides in the trial and offered conflicting diagnoses, and the strange new term dementia praecox that many had used was lampooned in the closing statement of the defense attorney as “dementia Americana.”

In addition to the slipperiness of diagnosing dementia praecox, many leading psychiatrists, including Meyer, were frustrated that it implied nothing about the cause of mental illness. Kraepelin had rejected the “brain psychiatry” that developed in Germany in the 1860s and ‘70s because he thought its focus on finding the cause of mental illness in specific brain pathology was reductionist and premature. He thought that the first priority of a scientific psychiatry had to be using rigorous clinical observation to establish disease concepts that corresponded to natural disease entities. Kraepelin assumed that dementia praecox had a biological basis, probably in systemic autointoxication, but thought psychiatry should resist etiological speculation in favor of classification based on clinical observation.

Leading American psychiatrists could not easily abide such restraint. In the first two decades of the twentieth century, dozens of articles appeared in the psychiatric literature trying to establish a specific neuropathology for dementia praecox, or compiling laboratory data of various bodily functions of praecox patients to try and identify evidence of autointoxication or “endocrinopathy.”  Despite initial enthusiasm, none of these studies shed much light on the causes of madness, but Noll argues they did serve to demonstrate that psychiatry shared the sort of methods and concerns that characterized modern medicine as a whole. They also encouraged some unfortunate adventures in therapeutics. Convinced that the cause of dementia praecox was autointoxication, Bayard Taylor Holmes, a Chicago surgeon whose son was stricken with the disorder, developed a surgical treatment that involved removing part of the appendix and maintaining an open appendicostomy to allow for frequent direct irrigation of the bowel to remove the infectious material that he believed was the cause of mental derangement. Holmes’s first patient – his son – died of complications following the treatment, but he claimed modest success in the more than twenty patients he and his associates operated on. Others, most notably Henry Cotton at the Trenton State Hospital, developed similar surgical treatments that generated initial excitement, but ultimately failed to produce meaningful results. Hundreds of patients suffered the painful and often fatal consequences of the therapeutic optimism fostered by biological theories of dementia praecox.

Meanwhile, many other American psychiatrists, led by Meyer, grew scornful of narrow laboratory approaches to psychiatry and began to approach dementia praecox as a psychodynamic disorder whose origins could be found in a pre-morbid personality type marked by psychosocial introversion, disorganized habits, and maladaptive psychological reactions to the biological, social and emotional challenges of life. The search for psychogenic causes of dementia praecox led Meyer and his followers to pay increasing attention to the peculiarities of individual patients, thus moving them away from mainstream medicine’s concept of diseases as discrete entities that could be isolated from the particularities of individual patients. By the late 1920s, most psychiatrists intent on finding the psychogenic roots of insanity began to use the term schizophrenia rather than dementia praecox. Noll argues that this represents more than a simple change in nomenclature, as is often suggested, but a fundamentally different approach to psychiatry that emphasized psychological reactions as holding both the key to diagnosis and a potential means of treatment. The concept of schizophrenia proved especially attractive to more doctrinaire followers of Freudian psychoanalysis who became the dominant force in American psychiatry in the 1940s.

In an epilogue, Noll makes explicit the critique of eclecticism in American psychiatry implicit throughout the book. During the period in question, psychiatric elites like Adolf Meyer embraced ambiguity, making room under Meyer’s capacious notion of “psychobiology” for conflicting theories and practices, ranging from psychosurgery to psychoanalysis. Noll acknowledges that Meyer’s eclecticism was in part at least a “pragmatic response to clinical perplexities” that “imposed a fragile peace on rivals in the service of “the greater goal of restoring maladjusted individuals to society” (276). Though Meyer and even more the early psychoanalysts were committed to a psychogenic approach, they understood that biological research and somatic treatments were essential for the prestige of the profession.

But Noll argues that this eclecticism kept alive a tendency to emphasize the peculiar expression of disease in each individual rather than identifying the general characteristics that other branches of medicine used to demarcate specific disease entities, and ultimately marginalized laboratory research and statistical methods, and inhibited psychiatry’s integration into the increasingly powerful and prestigious modern medicine. The enforcement of doctrinaire psychoanalysis in the 1940s and ‘50s was an attempt to solve the problem by constructing a rigorous theory of psychogenic disease that could rival the explanatory and therapeutic power of biomedicine. But psychoanalysis was plagued by ambiguity and paradox and ultimately failed. From the 1960s on, progress in biomedical research into brain chemistry, psychopharmacology and genetics provided the basis for the rationalization of psychiatry that culminated in the triumphant return of Kraepelinian psychiatry as embodied in the DSM-III of 1980.

Many historians will take issue with some or all of Noll’s critique. I tend to take the clinical perplexities psychiatry has always faced more seriously than Noll, and find grounds for skepticism whenever psychiatric theories of any stripe have arrogantly asserted that the fundamental ambiguity of mental disorder has finally been vanquished by science. But the great strength of this book is that it invites intellectual engagement. Noll does not allow his own interpretive commitments to overwhelm the narrative; his representation of the world of American psychiatry during this critical period is so rich and nuanced that readers are able to develop alternative interpretations even as they consider his. In other words, it generates much more light than heat and should be widely read by historians, neuroscientists, clinicians, social scientists and educated general readers interested in understanding medicine’s efforts to come to terms with mental illness. Given the issues at play in the upcoming revision of the DSM, a work of mature, responsible historical scholarship is a timely and valuable contribution to the broad discussion we need to be having about what is at stake in psychiatric classification.

 

Jesse Ballenger is an associate professor in the Science, Technology, and Society program at Penn State University. He is the author of, among other works, Self, Senility and Alzheimer’s Disease in Modern America: A History (Johns Hopkins University Press 2006).

 

Hans Pols: “Treating Mental Illness Before It Strikes”

As we have mentioned before, H-Madness publishes an essay every month for the online magazine Psychiatric Times.  We know, however, that many H-Madness readers do not subscribe to the magazine (although, it is free).  In order to be sure that you don’t miss any of the pieces there, we will be making a point of posting those essays and reviews here on H-Madness as well.  What follows is a commentary posted last month at Psychiatric Times, written by co-editor of H-Madness, Hans Pols.

Treating Mental Illness Before it Strikes

by Hans Pols

Hans Pols is senior lecturer at the Unit for History and Philosophy of Science at the University of Sydney. He is interested in the history of psychiatry and the mental hygiene movement in North America and Europe, psychiatric war syndromes, and colonial psychiatry, in particular in the Dutch East Indies.

Psychotic episodes are devastating for the individuals who have them, their friends, and families. Wouldn’t it be wonderful if individuals could receive treatment before the first psychotic episode strikes, so that it could be avoided altogether? After all, an ounce of prevention is better than a pound of cure. Unfortunately, in psychiatry, we are a long way from achieving primary prevention—there is no vaccine for psychosis, nor have clear genetic markers for severe and persistent forms of mental illness been identified. Throughout the twentieth century, psychiatrists have therefore focused their attention on the early detection of signs and symptoms of mental ill health, assuming that early treatment will stop conditions from becoming worse. However, the ideal of secondary prevention can only be realized if these early signs and symptoms, or a “pre-psychotic syndrome” can be identified successfully. During the twentieth century, psychiatrists have defined many of these “pre-mental illness syndromes”; unfortunately, it has not always been demonstrated that they indeed constitute the early phases of severe and persistent forms of mental illness.

In June 2011, a number of Australian newspapers reported that a high-profile medical trial targeting psychosis in young adults would not go ahead. It was to be conducted by Prof. Patrick McGorry, who had been Australian of the year (an honorary and mostly symbolic title bestowed by the Australian government on an unusually deserving citizen advocating worthy causes). In the proposed trial, youths as young as 15 would receive Seroquel when they were first diagnosed, not with psychosis but with attenuated psychosis syndrome (previously called psychosis risk syndrome). Treating young adults with this syndrome would nip the danger in the bud—their potential psychosis would be treated before it even arose. The trial was to have been sponsored by the drug’s manufacturer, AstraZenaca, which, like many pharmaceutical companies, was probably eager to test its medication on a younger age group to expand the market for its medications. What could be wrong with such a commendable initiative?

Attenuated psychosis syndrome is proposed for inclusion in DSM-V and has attracted an unusual amount of discussion (and dissent). In particular, its relation to psychosis is unclear. Emeritus professor Allan Frances, who chaired the task force which produced DSM-IV, is a fierce critic of the concept. According to him, there is hardly any evidence that attenuated psychosis syndrome, if left untreated, will ultimately develop into a full-blown psychosis (current estimates state that this will happen in merely 10 to 20% of cases). The number of “false positives” is therefore staggering. According to him, treating a group of individuals of whom 90% would never become psychotic appears to be a waste of resources and a rather risky proposition.

McGorry’s proposed trial was widely criticized by psychiatrists world-wide, raising a number of significant ethical problems. First, there is the high number of false positives who would receive medication for a condition they would never develop if left untreated. The trial would not target incipient psychosis but probably address more or less unrelated conditions. This leads to the second ethical problem: a great number of young people would therefore be put on a medication they do not need. This would not matter so much if only aspirin or vitamin tablets were tested. Unfortunately, Seroquel has many highly undesirable side-effects including extreme weight gain and diabetes. One should only prescribe it when it is absolutely necessary.

Last April, AstraZeneca settled a lawsuit by the U.S. government after allegations it paid kickbacks to doctors while promoting the drug for unapproved uses by children, the elderly, veterans and prisoners for $525 million (New York Times, July 28, 2011). It has also settled, for $647 million, product liability cases for misleading patients about the risks of diabetes and weight gain associated with the use of the drug. Total expenses in legal fees associated with Seroquel are now $1.9 billion, which constitutes less than five months of Seroquel sales. Not a great medication to prescribe to individuals who do not need it.

McGorry’s proposed research has attracted (unfavorable) media attention (in Australia); I highlight it here not because it is exceptional or unusual in any way, but instead because it illustrates ways of thinking that have been part and parcel of twentieth century psychiatry. The most important of these is the ideal of secondary prevention in psychiatry: it is imperative to treat psychiatric conditions when they first appear and when they are not as serious as they could become if left untreated. This prevents them from becoming worse and less responsive to treatment. This strategy is of course commendable when there is a proven link between these less serious conditions and more serious ones. In most cases, it has been assumed that such a link exists; it has hardly ever been demonstrated.

The emphasis on prevention is not unique to psychiatry but characterizes developments in several (if not all) medical specialties. In days long since gone, one would see a dentist when one’s toothache became unbearable—today, dentists fill cavities and polish our teeth so that we will never end up in this situation. They also whiten and straighten our teeth although this prevents neither toothaches nor tooth decay. Today, the demands we make of physicians (and dentists) far exceed those of average patients a hundred years ago. Today, physicians do a lot more than treating serious illness—and we expect them to do that.

Most historians of psychiatry have discerned two themes in the history of twentieth century psychiatry. First, there has been a broadening of the definition of what constitutes mental ill-health. A wide range of conditions in between mental health and severe and persistent forms of mental illness have been identified and investigated. The formerly almost absolute distinction between mental health and mental illness has been replaced by a wide spectrum of conditions, which has led to the blurring of the distinction between the normal and the abnormal. Second, conditions on this spectrum have increasingly become the target of psychiatric intervention; psychiatrists now treat a variety conditions less serious than severe and persistent forms of mental illness but definitely in need of treatment. During the twentieth century, prevention has been the most important argument to hold both themes together: treating less serious psychiatric conditions prevents these from becoming worse—because it has been assumed these conditions will inevitably become more serious over time. It was well into the twentieth century before any effective medical treatments for severe and persistent forms of mental illness were developed. Mental hospitals were severely overcrowded while little could be done for their inmates. Therapeutic nihilism reigned. Any type of intervention that promised to prevent mental illness from developing or becoming worse was therefore worth considering.

The blurring of the distinction between normal and abnormal is generally associated with Sigmund Freud: according to psychoanalysis, nobody is entirely normal, although some individuals are better in keeping their unconscious desires in check than others, thereby maintaining an appearance of mental health and normality. Despite differences in appearance, we are all to a certain extent mad. Views like these open up unexpected vistas for psychiatric attention: behind the everyday veils of normality, happiness, and adjustment hides psychopathology, lust, and perversion. Nevertheless, the blurring of the distinctions between the normal and the abnormal is not unique to psychoanalysis. The historian of psychiatry Elizabeth Lunbeck has analyzed (in The Psychiatric Persuasion, 1994) how, in the 1910s, American psychiatrists proposed psychopathy as a category to designate forms of psychopathology that had previously been unrecognized because they had been able to pass as normal. No longer would mental illness, as insanity, be limited to insane asylums, where it could be contained successfully. On the contrary, the widespread presence of psychopaths everywhere, hiding under the veil of normality, threatened the social fabric of American society. These views made psychiatric intervention even more compelling: not only would it remove sick individuals from public life, it could also protect the social order.

In my own work on the history of the mental hygiene movement, similar themes appear. In the 1920s, mental hygienists launched a major project on the treatment of juvenile delinquency to prevent children from developing life-long criminal careers. The concept of adjustment as an essential marker of mental health, central to the philosophy of mental hygiene, brought a great range of human behavior under the purview of psychiatry. Instead of treating maladjustment in adults (for example, adults with mental illness), mental hygienists argued that treating maladjustment in children (for example, children with enuresis or temper tantrums) would prevent serious forms of mental illness arising later in life. By labeling all forms of undesirable behavior as maladjustment, it became self-evident to expect relatively innocent forms of maladjustment to become serious forms of maladjustment later on. Rather than punishing delinquency, the therapeutic treatment of children with “pre-delinquent syndrome” could be expected to bear fruit. Unfortunately, the central assumptions of this approach were never put to the test, and would most certainly not hold up when investigated properly. Led by their convictions, psychiatrists and mental hygienists were not bothered by this. They focused on lesser complaints, while neglecting the plight of the mentally ill in increasingly overcrowded mental hospitals (leaving them to somatic psychiatrists who experimented with insulin therapy, metrazol shock therapy, ECT, and lobotomy).

The mistaken impression could arise that the two themes in the history of psychiatry identified thus far (blurring the distinction between normal and abnormal, and targeting less serious states for psychiatric intervention) were a characteristic of psychoanalysis or other psychiatric approaches focusing on mental and behavioral factors. It would be too easy to dismiss them because, with psychiatry becoming increasingly biological and scientific, such trends have been reversed today. Nothing could be farther from the truth, however. During the last twenty years or so, we see these trends developed in an unprecedented way in psychopharmacological psychiatry. In the 1950s, only individuals with severe and persistent forms of mental illness received medication such as Thorazine. Today, fidgety and distracted kids as well as shy adults are portrayed as individuals who could benefit from psychopharmacology. Increasingly, a wider range of psychiatric medications are prescribed to young children, with the idea that early intervention will prevent problems from getting worse. It is this mind-set, now more than a century old, that made McGorry’s research project appear innovative and cutting edge.

McGorry has introduced a slight modification to his study, which will now go ahead. Instead of Seroquel, he will now test the efficacy of fish oil.

Multidisciplinary Perspectives on the Revision of the DSM

The journal Personality and Mental Health features a special issue entitled “The Revision of DSM – Intended and Unintended Consequences:  Multidisciplinary Perspectives“.  Sociological, epistemological, legal, and ethical aspects of the DSM-5 are among the themes discussed.  In looking ahead, the papers invariably look to the past at earlier developments in psychiatric nosology.  Andrea Fossati, for instance, discusses the history of personality disorders in Europe during the 19th and 20th centuries:

ABSTRACT.  A recent focus in Western European research on personality disorders (PDs) has been an attempt to generate an integrative perspective or at least a common framework that could be used by researchers with different theoretical orientation to exchange and integrate their findings. This article discusses 19th and 20th century Western European perspectives on PDs, which led to their conceptualization as separate entities. In particular, we focus on the contribution of three approaches: the psychiatric approach, the dynamic contribution and the individual difference perspective. European tradition suggests revising current PD classification systems to produce PD diagnoses that are close to clinical reality but also grounded in data from scientific studies and characterized by a high degree of transtheoretical acceptance. Copyright © 2011 John Wiley & Sons, Ltd.

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