After 1950

In the decades following World War ∏, psychiatry as a medical profession experienced tremendous expan­sion. In the United States the advent of community mental health centers and third-party payments swdlled the ranks of noninstitutional practitioners.

At the same time, dramatic developments occurred in somatically oriented treatment and research. The introduction in the mid-1950s of the major tranquiliz­ers, such as chlorpromazine, revolutionized hospital care. By dampening hallucinations and other florid psychotic symptoms, the new drugs quieted ward life and encouraged new “open-door” hospital policies. Also, they accelerated the process of deinstitutionali­zation, helping many patients to achieve a level of functioning consistent with some form of extramural existence. Tranquilizers were soon followed by other classes of psychoactive drugs, such as antidepres­sants and the use of lithium in the treatment of manic-depression. The growing importance of psy­chopharmacology spurred neurophysiological re­search, leading to suggestive models of neurotrans­mitter deficiencies as the mediating cause of severe mental disorders.

One of the striking developments of the postwar years in the conceptualization of mental disorders has been the influence of the social sciences, espe­cially sociology and anthropology. Once behavior is understood to reflect the matrix of psychological, social, and cultural forces that mold an individual, it is a natural progression to assume that abnormal or impaired behavior is likewise shaped and should be investigated with these additional tools. Again, the literature is much too large to provide other than a bare outline. Sociologists have reported on such in­fluences as social class, role conflicts, social control, life stress, social integration, family interactions, institutional milieu, and even the very act of psychi­atric labeling in determining patterns of mental dis­order. Anthropologists have brought the power of cross-cultural study to the problem of mental illness, showing that what was assumed to be biologically fixed often was in fact “culture bound,” a local prod­uct, specific to place and time. Within any major U.S. city are subpopulations who Conceptualize- and experience - disease in incommensurate ways. Moreover, if a diagnosis of mental illness reflects a judgment as to adaptive functioning, mental disor­ders can no longer be held to be natural, universally true categories of illness, for what is adaptive in one local culture is maladaptive in another. These stud­ies of health and healing have also brought to light the manifold ways in which concepts of disease and therapeutic rituals enter into the complex web of power relations we call society.

Psychiatric conditions, which touch on our most intimate concerns and relationships, are especially rich cultural resources and have embedded meanings and structures not easily seen - and often denied by the professional culture of scientific medicine.

ClassiGcation in the 1980s

In 1980, the third version of the DSM was released, signaling a new departure in psychiatric nomencla­ture. Responding to calls for a diagnostic system that might elevate psychiatry’s status as a scientific disci­pline, the DSM task force pared down medical classifi­cation to its most basic elements, the description of known phenomena, usefully arranged. Without ques­tion, the most stable and powerful nosologies are those based on proven etiology. For example, identifi­cation of the culpable spirochete made it possible to distinguish paresis from senility. Because debate still surrounds the true cause of any mental disorder, the DSM argues that it is premature for psychiatry to construct etiologically based systems. At present, we find that phobic disorders can have Pavlovian, Freud­ian, or somatic explanations. In disagreeing about theory and treatment, however, clinicians neverthe­less can reach a consensus on the identification of a disorder.

The stated goal of the DSM-III is simply to provide a set of criteria and procedures by which all camps of psychiatrists might speak a common diagnostic lan­guage. In the interest of ensuring interrater reliabil­ity, disorders were to be defined unambiguously and based on checklists of easily verified data. The diag­nostic categories were themselves to be constructed in the form of statistically significant clusters of symptoms, derived from extensive field trials and empirical reports. Without etiology, psychiatric ail­ments can be referred to only as syndromes or disor­ders, not specific diseases. Indeed, it is expected that elements from several different disorders might ap­pear in any one individual. The authors of DSM-ΠI argue that the quest for scientific purity has not, however, negated all clinical utility. Tightly defined and empirically tested descriptions of syndromes do allow practitioners to predict a patient’s course and outcome, and they provide some guidance in treat­ment choice.

As of 1980 the DSM outlined the following catego­ries: disorders of childhood or infancy (hyperactivity, anorexia, retardation, autism); known organic cause (diseases of old age, drug-induced); disorders of schizophrenia (disorganized, catatonia, paranoid, un­differentiated); paranoid disorders (without schizo­phrenic signs); affective disorders (bipolar, major depressive); anxiety disorders (phobias, obsessive­compulsive); somatoform (conversion disorder, hypo­chondriasis); dissociative (fugue states, amnesia, multiple personality); and personality disorders. Per­haps the most controversial change in the new ap­proach was the elimination of the category of psycho­neuroses. In the “atheoretical” approach, disorders were grouped according to symptoms, not underlying psychic mechanism. Neurotic disorders thus resolve into various forms of anxiety states. Also removed was the heading of psychosis, which had included the major affective disorders; experience showed that many patients labeled psychotic did not have psy­chotic features. Involutional melancholia was col­lapsed into ordinary depression, because no evidence surfaced to show that it was unique.

It is, of course, far too early to make informed judgments about the consequences of the new DSM. However, some trends can be discerned. First, DSM-III clearly marks a loss of professional author­ity by psychoanalysis, one that will worsen. Much of the need for teaching Freudian theory to the mass of workers within the allied mental health professions - most of whom would never practice true psychoanalysis - was based on the need to ex­plain the psychiatric diagnostic system.

Second, a more subtle and unpredictable effect of DSM-ΠI concerns its diminution of the value of clini­cal judgment. On one hand, its “atheoretical” empha­sis shifts power into the hands of the statistical re­searcher and away from the clinician. DSM-IΠ sets in place procedures for the continued revision of diagnostic categories, whose organization may soon reflect more of what seems “statistically significant” than the realities of clinical practice. On the other hand, the symptom-based nosology also harkens back to the eighteenth century, when patients’ sub­jective assessments of their problems set the pace of medical practice. In DSM-III homosexuality was eliminated from the rolls of mental disorders - except when it is considered bothersome by the pa­tient. Squeezed between deference to patients’ self­rating scales and statistical priorities, the clinician has less room to form independent diagnoses.