H-Madness is delighted to present a new piece by Prof. Dr. Edward Shorter, PhD FRSC, the Jason A Hannah Professor of the History of Medicine and Professor of Psychiatry, Faculty of Medicine, University of Toronto. Prof. Dr. Shorter has published widely on the history of psychiatry. His books include the classic A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (Wiley, 1997) and, most recently, How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (Oxford,  2013). Here he explores the issue of psychiatric nosology, especially in view of the recent publication of the DSM-V.

An Alternative, History-Based, Nosology for Psychiatry

For their comments on earlier versions, the author would like to thank Tom Bolwig, Bernard Carroll, Max Fink, Gordon Parker, Robert Rubin, Michael Alan Taylor, and Lee Wachtel.

Current efforts to produce a classification of disease have not turned out well.  The fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) was released to general dismay in May 2013.  The current DSM, though vastly influenced by history, pays little attention to it, either in the form of attributing significance to patients’ own histories or in acknowledging the historical diagnostic traditions of psychiatry.

Yet it is possible to take history as our guide in drawing up classifications of diseases.  Here is an analogy: In Traditional Chinese Medicine a sifting process lasting thousands of years has taken place to winnow out effective medications from the ineffective ones lost in the mists of time.  Similarly in psychiatry, a winnowing process of mere tens and hundreds of years has distilled a good deal of the collective wisdom of the profession.  It is, in other words, possible to think about historical diagnoses as having the potential of cutting nature closer to the joints than do current diagnostic systems, drawn up on the basis of whim, fad, and consensus.[1]

There are, in disease classifications, lumpers and splitters. The DSM has taken splitting over the side of the cliff.  Philippe Pinel (1801) was the first lumper. The present effort at classification also is a lumping nosology that tries to discern diseases on the basis of biology and historical integrity. It is not meant to be absolutely inclusive of all psychiatric disorders but to convey some notion of how the main ones should be classified in a way that corresponds better than the present system to natural disease entities. In the absence of definitive biological verifications of many disorders, we have as our guide to “nature” the diagnostic traditions of a century and a half of scientific psychiatry, incubated in Germany and France, and brought today to great blossom in the transatlantic community.

Subsequent versions will need to come to grips with the addictions and the adult dementias.  Personality disorders have not been included.

An Alternative, History-Based, Nosology

 ADULT

I. Acute brief psychosis

II. Neuropsychiatric presentations (eg frontal and temporal dysrhythmia syndromes, Parkinsons, etc.)

III. Chronic psychosis: flat affect with avolition:

(a)—chronic psychosis:  hebephrenia

(b)—chronic psychosis: early progression to personality disintegration

IV. Chronic psychosis: Kraepelin’s disease.  (melancholic syndrome with or without mania; biological markers: DST, cortisol, sleep markers)  This includes such entities as vascular depression.   On a lifetime basis, one should rather think of “para-melancholia,” in which patients are at continuous risk of psychotic complications.

V. Chronic psychosis:  paranoia, meaning well-systematized delusional disorder, without  hallucinations, without disintegration of the personality.

VI. Catatonia.  It may also complicate any of these diseases (biological marker: immediate response to lorazepam)

VII. Non-melancholic, non-psychotic depressive and nervous illnesses

(a) mixed depression-anxiety  (Non-melancholic, non-atypical depression, often accompanied by anxious symptoms)

(b) atypical depression  (Note that this is distinct from the depression of what used to be called “bipolar disorder” and corresponds to the depressive disease described by William Sargant and Donald Klein.)

(c) OCD

(d) phobias

(e) paroxystic anxiety (“panic attacks”) (biological marker: various

panicogens)

VIII. Delirium

IX.  Breakdowns in the mind-body relationship

  X. CHILD

As adult, except for:

—Intellectual disability/learning disabilities

—Autism/catatonia with or without psychosis

—Hyperactivity syndromes (biological marker: abnormal EEG)

—The childhood anxiety disorders, including separation anxiety

Notes

II.  Neuropsychiatric presentations are not in DSM but should be.  There is widespread agreement among clinicians that epilepsy, for example, has its own psychiatric pathology.[2]   One senior American psychopathologist, Michael Alan Taylor, argues that psychiatry has erred seriously in omitting neuropsychiatric indications from the nosology[3], and this should be corrected.  We make an early start here with epilepsy and Parkinsons..

III.  This form of chronic psychosis splits the former “schizophrenia” into chronic psychotic disorders that partially remit, and those that do not.

(NB: positive symptoms may well be present, but they are not essential for the diagnosis of  chronic psychosis.)

“Schizophrenia” has been given here an overdue burial and replaced with several different forms of chronic psychosis that demolish the former firewall between psychosis and affect.  While abolishing the firewall, this nosology does restore the dividing line between “psychosis” and “neurosis,” although the latter term is shunned in favor of “nervous,” or the more modern-sounding but clunkier “non-melancholic, non-atypical depression. “

On the separation of hebephrenia from other forms of chronic psychosis:  hebephrenia does not carry a disastrous prognosis, even though there is no restitutio ad integrum.[4]   Hebephrenia is further distinguished by its onset in adolescence.[5]   In DSM-3 the hebephrenic subtype became the “disorganized type”; it was filled with catatonic symptoms, and was relentlessly progressive, none of which is true of Hecker’s original “hebephrenia.”   The DSM description also perpetuated the myth of the patients being “silly.”  Even though the subtypes have vanished from DSM-5, a disaggregation of “schizophrenia” is long overdue, and this represents a first step.

The term “personality disintegration” is used in the sense of W. Mayer-Gross et al (1954) in preference to the term “dementia.”[6]

IV.  On Kraepelin’s disease, meaning  “melancholic syndrome with or without mania,” this nosology basically restores the unity of Kraepelin’s “manic depressive illness” that he first formulated in the 6^th edition of his textbook in 1899, bringing together all the various depressions, of whatever polarity, together with the manias, whether they occurred in the same illness episode or not.  This nosology follows the current of not considering mania and hypomania as separate illnesses[7]; nor are they part of “bipolar disorder,” as the DSM series presents it, because this version of affairs ignores bipolar disorder.

This nosology tackles head-on the issue of the “Kraepelinian dichotomy,” the firewall that Emil Kraepelin constructed between dementia praecox and manic-depressive illness in 1899.[8]  A fundamental issue in the classification of melancholia is whether it belongs under the psychoses or the non-psychoses.  The recent nosological tendency has been to consider psychotic melancholia (psychotic depression) as a rather anomalous subform of  melancholic disease, which, in general, does not involve delusions or hallucinations.[9]  In my view, this issue needs to be re-thought.  The lower boundary of “psychosis” needs to be pushed downward, beneath formal and systematized delusions, to include fixed ideas and highly eccentric notions. It is true that most melancholic patients do not have systematized delusions or hallucinations.  Still, in the words of Tom Bolwig, “They suffer from unjustified feelings of guilt, they don’t accept being ill, and they are unresponsive to all attempts at psychotherapy.  Isn’t that a deficiency in their reality testing, and thus a forme fruste of psychosis?” [10]

On a lifetime basis, psychosis may well be more common in melancholia than has been thought to date (a common assessment is 30 percent – yet the authors Michael Alan Taylor and Max Fink stipulate that an additional number of patients with forme fruste fixed ideas and delusive suspicions should be added on.[11]).  The percent of melancholics who on a lifetime basis may at some point or another be, or have been, psychotic is among the most difficult statistics to nail in the literature, because, as soon as a depressive patient becomes psychotic, the diagnosis is changed to “schizophrenia,” or “schizoaffective disorder.”  It is true that DSM accepts the category “psychotic depression,” but it is quite underused.    (There is also an ascertainment problem.  As one observer pointed out in 1970:  “It is well known that the more we like a patient, the less likely we are to place him on the psychotic end of the psychiatric spectrum.”[12] )

Many European authors considered melancholia basically a psychotic disorder.  As Wilhelm Griesinger noted in the influential second edition of his textbook in 1861, “The core of [the psychic depressive conditions] consists of the pathological prevalence of a distressing, depressive, negative affect.  . . . Corresponding to the mood there then appear false ideas and judgments that have no external basis, true delusions, distressing and painful in content.” [13]   Such authoritative statements continue into the present-day literature as well:  At a conference in 1991 Joseph Zubin  reflected, “Many outstanding diagnosticians first decide whether the patient before them has a psychosis, and then, after that decision is made, go on to determine whether it is schizophrenia or manic-depressive. . . .  Is it possible that what is the basic feature of the illness is psychosis, and that it takes the direction of either manic-depressive psychosis or schizophrenia depending on other factors . . . ?”[14]

In an effort to straddle this as yet unclarified issue of lifetime prevalence of psychosis in melancholic illness, the term “para” has been added to the lifetime version.

On the classification of melancholia, the disorder classically has been said to occur in two versions: (1) anxious, agitated (Angstmelancholie), and (2) stuporous (melancholic stupor).  There is no evidence that these represent separate diseases but are, rather, separate presentations.  There is a body of literature suggesting that psychotic anxiety exists as a separate diagnosis.[15][16]

In the spirit of Kraepelin, mania has been abolished as a separate disease and so there is no “bipolar disorder.”   It makes little sense to classify depressions on the basis of polarity, as the depression of bipolar disorder seems to be melancholic in nature, and identical to the melancholic version of unipolar depression (“major depression”).[17]  DSM-5 now accepts that bipolar and unipolar depression are identical, and calls both “major depression.”

“Major depression,” as well, has not found a place in this nosology on the grounds that it is highly heterogeneous, mixing together melancholic and non-melancholic illness.[18]

On the basis of etiology, there are many “depressions,” such as vascular depression, alcoholic depression, the depression of Parkinson’s, and so forth.  Yet it is unclear that any of these depressions have a distinctive psychopathology not included under either melancholia or non-psychotic nervous disease.  As science elaborates the existence of other distinctive depressions, these should be added to the nosology.   Bernard Carroll has raised a thoughtful objection to letting psychopathology drive the nosology:  “Aren’t you getting it backwards?  Our nosology requires distinctive disorders with distinctive etiologies.  The form of psychopathology is just one plank in the platform, not the main thing.”[19]  One can only respond that this view is indeed correct.  And if we were certain of the distinctive etiologies, we would, of course, let them drive the nosology.  But since we are not quite there yet, driving the nosology with psychopathology is a pis aller.

VII.  The classification of what used to be called “nervous disease” has bedeviled psychiatry for a century and a half, ranging through “nerves,” to “psychoneurosis,” to the current avalanche of micro-diagnoses.  The present nosology tries to lessen reliance on the term “depression,” which has been badly stretched out of shape by overuse.  It has also seemed judicious to revive the classic term “nervous disease,” as has ben recently suggested.[20]  The present version of the nosology seeks a compromise with the use of both terms, depression and nerves.

VII (a) Mixed depression-anxiety has been called “cothymia” by Peter Tyrer.[21]  It was the commonest form of depressive illness (with the exception of the psychoanalytic term “depressive neurosis”) in the decades before the appearance of DSM-3 in 1980, which sundered depression and anxiety.

VII (c-e)  There is no special line in the nosology for adult anxiety, or any of the DSM “anxiety disorders,”  several of which have now been shifted to the nervous category.

On removing OCD from the “anxiety disorders” as classified in DSM-4:  the present nosology argues that OCD be made a “nervous” disease, which simply means a non-psychotic, non-melancholic disorder the proper classification of which will have to await further research.  Patients with OCD do not display the classic somatic symptoms of anxiety, such as racing pulse, dizziness, sweating and tremor, nor the fear and dread of a panic attack.   Rather, the obsessive patient is uneasy and apprehensive about his or her symptoms, while fully recognizing that they are unjustified and unrealistic.

On the omission of PTSD from the nosology:  Traumatic neurosis was first described in the late 19^th century, and belongs among the classic “nervous complaints.”  Patients who have experienced severe trauma, in wartime or otherwise, may indeed become symptomatic, but that their symptoms (“the full diagnostic criteria” in DSM terms) first occur after some unspecified duration — which is the essence of “post” — is not at all clear.  The whole diagnosis resulted from a systematic campaign of the Vietnam veterans in the late 1970s, and as a political construct PTSD has little place in a scientific classification of disease.

IX.  Breakdowns in the mind-body relationship:  There needs to be a category for what used to be called “hysteria,” “conversion disorder,” and so forth, symptoms that present in a medical way but are caused by the action of the mind.

Similarly, the personality disorders have been omitted from the nosology as they are considered a holdover from psychoanalysis and may well be abolished in ICD-11.

X.  The classification of childhood disorders poses a special conundrum, because “pure” anxiety without depression is commoner in children than in adults.   Children with “pure” depression more often present as angry.  In the adult section these issues are classified under “mixed depression-anxiety.”

It is now considered possible that hyperactivity has a biological EEG test. [22] This revives Charles Bradley’s original 1938 view of the EEG in hyperactivity.[23]