With Kraepelin's textbook as its major war engine, German psychiatry went on to capture the world of classification. Yet, even after Kraepelin's death in , by no means did this great European tradition come to an end. Careful psychopathological observation was its hallmark, and the academic psychiatrists made a great virtue of fine differentiation.
There is a certain misunderstanding in the literature about the nature of European influences on American psychiatry, 16 one that overlooks the radical discontinuity that occurred between the s, when European influences were strong, and the s, when, aside from Sigmund Freud's psychoanalysis, they had virtually vanished. However, the drafters of DSM-III , in , despised psychoanalysis, were unilingual and unicultural to the core, and had little insight into distant European influences, except for those of Kraepelin, whom they understood only dimly at best.
With the later editions of DSM , it was time for American exceptionalism. This is how it began. The large section on psychoneuroses came, of course, from the psychoanalysts; the rest owed much to the Old World.
These publications were not germinal in the making of DSM. The immediate origins of DSM lay not in the statistical classification for the mental hospitals, but in a nosology directed by psychoanalyst William Menninger, who, during World War II, was a brigadier-general and the head of psychiatry in the Office of the Surgeon General. The military nosology appeared in October as the Technical Medical Bulletin number of the United States Army, and it was thereafter referred to as Medical The repressed impulse, giving rise to the anxiety, may be either discharged or deflected into various symptomatic expressions such as fugue, amnesia, etc.
As stated, with the exception of the Kraepelinian psychotectonics, most of the Central European writing on nosology never came to American attention. It essentially became forgotten. Why is this? For one thing, the events of World War II and the Holocaust tended to discredit German as the international language of science. In some quarters, the verysound of the German language was heard with dismay.
The world's scientific center of gravity was shifting from Berlin, Munich, and Vienna to New York and quite particularly to Bethesda, Maryland, where a generous Congress was investing huge amounts of federal money in research at the National Institutes of Health NIH , one of which was the National Institute of Mental Health sometimes independent of the NIH, sometimes not.
Ugo Cerletti, by now an emeritus professor of psychiatry in Rome and the originator of electroconvulsive therapy, told an English-speaking audience in the mids reading laboriously from a manuscript text heavy with diction directions :.
And therefore it was necessary for me to learn them well. In these sixty years, scientific research in English-speaking countries has taken so formidable a jump forward, that English has become the international language, and I am reduced to presenting myself to you, not speaking English, but rather to clumsily reading to you.
Excuse me. During these years, Freud's psychoanalysis, which had no use for hoary German diagnostic traditions, vaulted to the fore. Psychoneurosis was the main diagnosis in psychoanalysis, its fundament anxiety.
Catatonia became a subtype of schizophrenia; this was, admittedly, something Kraepelin had initiated, yet much German psychiatric opinion opposed the downgrading of this important diagnosis to a subtype of something else.
Under the influence of psychoanalysis, US psychiatry began to lose interest in the systematic study of psychopathology that had distinguished the German school.
In Meyer's thought, patients had to be understood in their own terms, a notion that, however laudable in its humanitarian objectives, ruled out the quantitative scientific method. The psychoanalytic period began to be rung out with the introduction of effective new pharmaceutical agents. Is it, therefore, any wonder that the American disease-designers, as they sat down to compose their own nosology, were largely cut off from the rich continental traditions of learning? In , unhappy about the confusing diagnostic systems currently in play, the APA asked its Committee on Statistics to take in hand the preparation of an official nosology that would preclude all others.
George Raines, head of neuropsychiatry at the Navy Department Bureau of Medicine—later director of psychiatry at the Georgetown University Medical Center—was evidently seconded to assist in the effort. What accounted for this widespread duplication is unclear because only one of the seven members of the statistics committee—Moses Frohlich—was an analyst, and Raines' own interests were on the neurological side of things.
By , DSM-I had gone through fifteen printings. Increasingly unmoored from psychoanalysis and its main diagnosis of psychoneurosis, psychiatry was clearly in need of diagnostic guidance. The second edition, in , led by Ernest Gruenberg, was justified on the grounds that American diagnosis should be brought into line with the forthcoming eighth edition of the World Health Organization's International Classification of Diseases.
By the late s, the great swing from psychoanalysis to biology was in full course. The success of the new psychopharmacology had demonstrated that the brain was involved in illness after all and that biological perspectives were the field's future.
We will attempt [in this book] to utilize categorizations that have an explicit validity. That is, class membership will convey information beyond the gross symptomatology of the patient. Diagnosis will have specified prognostic and treatment response correlates. The expected event was a looming new edition of the International Classification of Diseases, agreed upon by the World Health Organization in ; an American edition followed in Audiences of psychiatrists in the eastern US and several parts of the United Kingdom were shown videotapes of diagnostic interviews with three American and five English patients, and asked to make diagnoses.
A few minor tucks were really what they had in mind. They asked Robert Spitzer, a biometrician at Columbia University, to direct the task force. Spitzer had played a leadership role in DSM-II and was the obvious candidate for the job this story has been told in detail elsewhere and I shall not repeat it again here Appointing Spitzer was, from the viewpoint of the APA, a huge mistake, because Spitzer took as his remit the construction of an entirely new nosology.
The idea of founding a nosological system on consensus rather than on clinical experience, as in the Kraepelinian system, was rather startling. The path to DSM-III , in , led via St Louis, Missouri, where a nosologically inclined department of psychiatry, led by Eli Robins and Samuel Guze, had been toying for some years with the concept of operational criteria, or diagnostic criteria, in nosology.
What we want that paragraph to include are the key items that research will have shown important for classifying that person. Led by resident John Feighner, and then joined by the staff, in , the St Louis group proposed specific criteria required for a diagnosis.
On a parallel track, Spitzer at Columbia University had been collaborating with Guze and Robins in working out some early ideas about diagnosis. Virtually none of the other features of Leonhard's nosology was taken up internationally, but bipolar disorder was enough! It is not the place of this review to comment on the validity of these innovations. One does have to cut Spitzer and the members of his task force some slack, considering that they were working with a nosological tabula rasa.
Psychoanalysis had carved a sharp discontinuity into the historical flow of diagnoses, and the task force members do not even seem to have been aware, at least based on their correspondence preserved in the archives of the APA, that previous efforts existed before psychoanalysis swept the board. That there should be any criteria, aside from the psychiatrist's own possibly idiosyncratic views, was a major change.
One, it began the end of psychoanalysis as the intellectual core of the field. What psychopharmacology had begun, DSM-III finished off; the analysts were shown the exit sign from the field, or at least from its commanding heights. Having a nosology composed of specific diseases with diagnostic criteria for each dates, in medicine, back to the days of Edinburgh's William Cullen in the late 18th century and has always been the standard of the field: diagnoses that are clinically well defined, verified with physical findings and laboratory data, and validated with specific responses to treatment.
Although each edition trimmed at the edges of its predecessor, there were no fundamental changes in the architectonics of the diagnoses or the content of the operational criteria.
The ever greater size of the volumes— DSM-IV had pages, DSM-5 had —began to create the impression of a diagnostic sausage machine that was somehow cranking out of control. Paul Chodoff, speaking from the perspective of 60 years of practice, said in As new diagnoses proliferate in each successive DSM I feel concern about a burgeoning furor diagnosticus—offering a name and number for every untoward feeling or behavior in a way that trivializes the human condition by denying its inescapable, somber, and even tragic elements.
Chodoff, a psychoanalyst, may be pardoned a bit of nostalgia. However, this feeling of unease became increasingly palpable. The promise, in , seemed enormous. Today, the field contemplates DSM-5 with apprehension. Have we overdone this? Has depression become the tail that wags the classificatory dog?
This trend of subdivision and reclassification was most pronounced, however, for the categories previously classified as "neuroses". The single category "Phobic Neurosis" was divided into five classes of "Phobic Disorders ", and the single category "Depressive Neurosis" was substituted by four categories of "Major Depression" [ 20 ]. One of the amendments that was of greatest impact was the permanent removal of the category "Homosexuality" from the DSM-II. The change was originally made upon the publication of the seventh printing of the DSM-II in , following a vote by the American Psychiatric Association earlier that year [ 14 ].
The decision was provocative if not controversial within camps of both advocacy and antagonism: in the former because it was contended and in retrospect rightly so that the earlier classifications of homosexuality-as-disorder were largely shaped by politically and socio-culturally contingent notions of deviance, rather than scientific corroboration [ 13 ], and in the latter because it was claimed that the change was based on consensus between figures representing "expert opinion" and Gay Rights' lobbying efforts.
Specifically, elaborate and more explicitly defined operational criteria for inclusion and exclusion were formulated for each disorder. These included standards for differential diagnosis of several categories of disorder that share similar characteristics, and the minimum duration of signs and symptoms required for a clinical diagnosis to be made. Another unique feature of the DSM-III was the adoption of a "multi-axial system" of diagnosis to account for patients' multi-factorial presentation and multi-dimensional experience of mental illness, and to facilitate a more comprehensive depiction of the patient's condition [ 21 ].
While not compared to inter-rater agreement s on earlier nosologies, the DSM-III classification system was reported to have relatively good diagnostic reliability [ 11 , 22 ]. Taken together, the multiple amendments introduced to the DSM-III demonstrate a shift in the conceptualization of mental disorders from psychological "states" to discrete, operationally defined disease categories, and a return to a descriptive, symptom-based classification.
The APA's executive officer Melvin Sabshin heralded it as the victory of "science over ideology" [ 23 ], and Gerald Klerman, a leading psychiatrist at the time of the DSM-III 's inception, termed its development a "fateful turning point in the history of the American psychiatric profession" [ 24 ].
As early as , Klerman asserted that " In fact, as Young has stated, "American medical schools and residency programs routinely expected students and physicians to pass examinations based on DSM-III criteria. In an appraisal of the DSM-III a mere six years after its publication, Klerman noted a number of repercussions within several schools of thought in psychiatric research and clinical practice.
Klerman claimed that the DSM-III had provided a formal common language that facilitated communication between multiple mental health professionals. While contending that the DSM-III had not become "the final consensus" with which to unify divergent perspectives regarding psychopathology, he acknowledged the "increasing acceptance of this diagnostic framework as the basis for teaching and research" [ 13 ].
Even proponents of the psychodynamic tradition, some of DSM-II 's major critics, gained a greater appreciation for the manual's classification system, while hoping for the addition of another "Axis" that would be more aligned with psychodynamic theory in the next edition of the DSM-III an aspiration which, while explicitly suggested to the DSM-III 's Task Force and tentatively agreed upon by Spitzer and colleagues, never actually materialized [ 13 ].
Indeed, while a torrent of criticism met the publication of the DSM-III , the "revolution" it fostered was quick and its effects durable, and psychiatrists who wished to retain their roles and credibility in the field soon had to conform to its newly introduced, government-sanctioned nosology of mental disorders [ 14 ]. The delineation of operationally defined diagnostic categories for mental disorders incurred a surge in epidemiological morbidity studies.
Furthermore, while the DSM-III classification system did not explicitly link diagnostic categories to any particular treatment options, the symptom-based, somatically-oriented nature of the classification scheme was particularly compatible with biological therapies customized to discretely constructed disease entities.
For any medication to be approved by the FDA, a drug needs to be proven effective in the treatment of a specific disease [ 14 ]. The clear demarcation of standardized, purportedly more reliable psychopathological diagnostic categories thus provided researchers, and pharmaceutical companies, an incentive to launch randomized controlled trials RCT to test newly developed psychopharmacological agents in the treatment of specific DSM-III disorders [ 14 ].
In the years following the publication of the DSM-III , billions of dollars were allocated by the government and pharmaceutical companies for psychopharmacological research [ 27 ]. Insurance providers equally welcomed the arrival of the new nosology, and adopted the DSM-III and its subsequent editions as the standard diagnostic categorization upon which to base reimbursement of therapeutic modalities particularly, psychopharmacologic interventions [ 14 ].
The trend toward enhanced specificity of operational criteria has likewise become more pronounced throughout successive editions of the DSM , and information regarding prevalence, age- and sex -differential characteristics, and co-morbidity with other disorders has been added and regularly updated since the DSM-III-R.
The significant increase in epidemiological studies based upon DSM criteria following the publication of the DSM-III has allowed for the incorporation of empirical data into the classification of several disorders [ 18 , 29 - 32 ].
Additions to the DSM s have also included information gathered from studies of the pathophysiology of mental disorders, and most recently have included data obtained from and based upon neuroimaging studies. The trend toward increased subdivisions of disorders that was originally initiated in the DSM-III has been evident in all subsequent editions of the manual. Other major amendments included the incorporation of a section dealing with "Culture-bound Syndromes" in the DSM-IV and DSM-IV-TR , thereby acknowledging cultural variability in the ways that mental health and illness are expressed and construed [ 30 , 31 ].
Rogler has attempted to interpret the increasing size and complexity of the DSM since its first edition until the DSM-IV , and has identified five major changes in its evolution; these are: 1 a theoretical shift in the conceptualization of mental disorders from a bio-psychosocial model to a research-oriented, medical model; 2 development of the multi-axial diagnostic system that facilitated a rise in biomedical findings based upon the five axes and the relation s between them; 3 the inclusion of new disorders and expansion of previously defined disorders; 4 a "lateral" reorganization of disorders into discrete, broad categories that entailed merging a number of disorders and eliminating others; and 5 a neo-Kraepelinian paradigm shift that was first evidenced in the DSM-III , that reinforced the descriptive, somatic orientation that then became the norm in all subsequent DSM s [ 33 ].
Indeed, this last point is important, as Rogler's analysis highlighted the iterative dominance of the medical model since the DSM-III - and, in parallel, the growth of this model in throughout almost all of psychiatric practice, education, and training. At present, field trials of the DSM-V are underway, and the objectives outlined in " A Research Agenda for DSM-V " are largely concordant with the trends observed throughout the manual's evolution.
Of particular interest is the continuing emphasis on the at least implicit incorporation of biological data into the classification of disorders in the DSM , with the intended elaboration of findings from studies in behavioral genetics and neuroimaging in the disorder classifications in the DSM-V. However, the Manual does not explicitly specify what and how neurogenetic, neuroimaging, and neurochemical data can or should be employed in establishing differential diagnoses of mental disorders.
Moreover, the possibility of employing these largely experimental neuroscientific and neurotechnological methods for diagnostic purposes is not without contention and has become the focus of considerable neuroethical debate see [ 34 ] for overview. The history of the DSM series may certainly be viewed as an attempt to integrate scientific progress to the categorization of psychopathology, thereby reflecting an increased epistemological capital, and compelling psychiatric diagnoses to be better aligned with the medical model.
Yet, while elaboration of a standardized nosology for mental disorders may have afforded a major impetus for research on psychopathology, it has also generated particular problems, abuses and possibly unforeseen consequences in the manner in which psychiatric disturbances are understood, diagnosed, and treated [ 35 ]. Perhaps one of the most striking corollaries of the symptom-based, somatically-oriented descriptive approach fostered by the DSM-III is the increase in psychopharmacological interventions, applied to conditions ranging from the severest of mental disorders to much milder DSM categories that had previously been treated with psychotherapeutic and behavioral approaches.
Research in the neurochemistry and pharmacology of specifically defined psychopathological conditions has enabled the pharmaceutical industry to develop drugs targeting biological markers associated with such conditions.
While this has led to the relatively successful treatment of a number of neuropsychiatric conditions e. As well, the potential for misusing the pharmaceutical approach has been decried by several critics [ 36 - 39 ], and the phenomenon of "disease mongering" has been noted in the marketing of various drugs e.
Similarly, the medicalization of cognition, emotion, and behavior has also generated discourse- if not controversy- about the interpretation of subjective variables, such as what constitutes "normal" or "optimal" function within the context and expectations of society and culture [ 40 ]. In this light, the broadening categorization of mental disorders, both in terms of what constitutes "un-health", and who may be a target of psychopharmacological intervention including young children , has paralleled the increase in the number of individuals considered to possess a mental illness [ 41 ].
The perplexing conclusion drawn from a recent National Comorbidity Survey for mental disorders in the United States asserts that: " Interventions aimed at prevention or early treatment need to focus on youth" [ 42 ], and this prompts a renewed interest in questions of what constitutes treatment, enablement, or enhancement- and what metrics, guidelines, and policies need to be established to clarify such criteria [ 40 , 43 ]. Problematic issues arising in psychiatry, arguably reflecting the large-scale adoption of the DSM , may be linked to the difficulties of formulating a standardized nosology of psychopathology.
Charles Rosenberg has posited that the formulation of standardized and clearly delineated diagnostic classifications, based on the conceptualization of dysfunctions as discrete disease entities, serves to legitimize existence of named and defined disease s , and can obscure the 'constructedness' of the categories themselves [ 44 ].
It may be worth pondering the extent to which such a phenomenon could be particularly problematic with regard to a number of behavioral and emotional conditions that might be mere extensions of normal behavior or simple "eccentricities" that would then construed as medical diseases. The "pathologization of deviance" and the "medicalization of social ills" are potential effects of psychiatric diagnoses and treatment trends. While such categorizations may arise from, and be directed toward benevolent intentions, caution is required to insure against socio-political usurpation of these diagnoses, and repetition of historical instances of bastardization of medicine by capricious agenda [ 45 - 49 ].
The history of the DSM has been characterized by a shift in the conceptualization of mental health and illness, reflecting an attempt to adhere to the ontological claims and canon of "biomedicine" and sustain psychiatry's medical identity.
The evolution of the DSM illustrates that what is considered to be "medical" and "scientific" is often not an immutable standard, but rather, may be variable across time and culture, and in this way contingent upon changes in dominant schools of thought.
The elaboration of a standardized nosology of mental disorders has had diverse impact s on the manner in which psychopathology is conceived, on the definition of who constitutes a psychiatric patient, and how cognitions, emotions, and behaviors are regarded and treated.
The act of diagnosis in and of itself validates the very disease it names and defines [ 44 , 50 ]. As such, current classifications of mental disorders must be understood, at least to some extent, as "constructed concepts" that are amenable to modification, as evidenced by the various transmutations within the DSM throughout its successive editions, rather than incontestable facts.
The development of the DSM has evidenced values and assumptions reflective of the Zeitgeist of each edition.
As noted by John Sadler, " In other words, values lend structure to the field of attention, predefining background and foreground, and clustering disparate items into groups. Consequently, descriptive statements about psychopathology issue from presupposed value stances that conceal their own deeper sources, compatibilities, and incompatibilities" [ 51 ].
While such values and assumptions may be neither inherently "good" nor "bad", and may be enmeshed within scientific pursuits of all types [ 52 ], awareness of their existence and of their contribution to the shaping of what is regarded as scientific knowledge is imperative.
Even if we were to presume that scientific knowledge were wholly objective and free of any values or bias whatsoever, it is nonetheless critical to recognize that new information adds to, and may subordinate, older knowledge in an iterative, self-corrective process.
Thus, adherence to a doctrinal stance must be flexible to adapt to new insights and revision, lest it become anachronistic and dogmatic. While the changes to the DSM are based upon scientific strides and humanitarian intent, it's important to measure such claims by the purported objectives to improve diagnosis and treatment in accordance with both psychiatry's professed medical identity, and the new dimensions of the discipline and its practice that are enabled by neuroscience, neurotechnology, genetics, the social sciences, and the humanities.
If, and how such claims are realized by the DSM-V remain questions for contemporary users of this new edition - and scholars, researchers and practitioners of psychiatry, the aforementioned fields, and ultimately patients and the public to address and decide. Clearly, both the DSM and psychiatry will remain a work-in-progress, and we must be ready and responsible for the potential benefits - and possible problems - that such progress may foster.
This work was supported by the J. Fulbright Foundation, William H. The authors thank Daniel Howlader for his assistance on this manuscript. National Center for Biotechnology Information , U. Philos Ethics Humanit Med. Published online Jan Developers of DSM—IV and the 10th edition of the ICD worked closely to coordinate their efforts, resulting in increased congruence between the two systems and fewer meaningless differences in wording.
ICD—10 was published in DSM—III introduced a number of important innovations, including explicit diagnostic criteria, a multiaxial diagnostic assessment system, and an approach that attempted to be neutral with respect to the causes of mental disorders. This effort was aided by extensive work on constructing and validating the diagnostic criteria and developing psychiatric interviews for research and clinical uses.
ICD—9 did not include diagnostic criteria or a multiaxial system largely because the primary function of this international system was to outline categories for the collection of basic health statistics.
In contrast, DSM—III was developed with the additional goal of providing precise definitions of mental disorders for clinicians and researchers. A much broader classification system was later developed by the U. Army and modified by the Veterans Administration to better incorporate the outpatient presentations of World War II servicemen and veterans e.
ICD—6 was heavily influenced by the Veterans Administration classification and included 10 categories for psychoses and psychoneuroses and seven categories for disorders of character, behavior, and intelligence. DSM contained a glossary of descriptions of the diagnostic categories and was the first official manual of mental disorders to focus on clinical use. In part because of the lack of widespread acceptance of the mental—disorder listings contained in ICD—6 and ICD—7 , WHO sponsored a comprehensive review of diagnostic issues, conducted by the British psychiatrist Erwin Stengel.
0コメント