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WHAT PSYCHIATRY LEFT OUT OF
THE DSM-5
What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today 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 gath-
ered great wisdom about mental illnesses. Today, much of that knowledge has
been ignored and we have diagnoses such as “schizophrenia” and “bipolar dis-
order” 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.
Edward Shorter is Professor of the History of Medicine and Professor of Psy-
chiatry at the University of Toronto, Canada. He has written a number of
books, including A History of Psychiatry, which has been translated into many
languages. Professor Shorter is considered among the leading historians of psy-
chiatry in the world.
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WHAT PSYCHIATRY
LEFT OUT OF THE
DSM-5
Historical Mental Disorders
Today
Edward Shorter
First published 2015
by Routledge
711 Third Avenue, New York, NY 10017
and by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 Taylor & Francis
The right of Edward Shorter to be identified as author of this work has
been asserted by him in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilized in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without
permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and
explanation without intent to infringe.
Library of Congress Cataloging in Publication Data
Shorter, Edward, author.
What psychiatry left out of the DSM-5 : historical mental disorders today
/ Edward Shorter.
p. ; cm.
Includes bibliographical references.
I. Title.
[DNLM: 1. Diagnostic and statistical manual of mental disorders.
2. Mental Disorders–classification. 3. Mental Disorders–diagnosis.
4. Psychiatry–history. WM 15]
RC455.2.C4
616.89'075–dc23 2014035919
ISBN: 978-1-138-83090-5 (hbk)
ISBN: 978-1-138-83089-9 (pbk)
ISBN: 978-1-315-73699-0 (ebk)
Typeset in Bembo
by Wearset Ltd, Boldon, Tyne and Wear
CONTENTS
Preface viii
Acknowledgments xi
List of Abbreviations xii
Full References to Sources Briefly Cited in the Notes xiii
1 Introduction 1
2 Disease Designing 10
3 Delirious Mania 26
4 Malignant Catatonia 48
5 Bipolar Craziness 68
6 Adolescent Insanity 99
7 Firewall 130
8 Stages 147
9 An Alternative, History-Based, Nosology 160
10 Conclusion 179
Index 181
PREFACE
This book is about the psychiatric diagnoses that have a lot of historic validity,
with the wisdom of decades and centuries behind them, and should have been
included in today’s listing – but weren’t. It’s also about a few diagnoses that
shouldn’t have been included – but were. I’m a historian, not a clinician. I don’t
diagnose individual patients. Yet I know some of the diagnoses that should be
circling in clinicians’ minds – but aren’t. The book’s premise is that one can
search the medical literature of the past for wisdom. The psychiatry of the past
has something to teach the present, an accumulated payload of knowledge and
thoughtfulness that should remain vibrant.
But in fact this storehouse of good judgment is often lost. It’s not true in
psychiatry that each piece of new knowledge is a building block on a wall that
gets higher and higher. Indeed, the opposite seems to happen: Every now and
then, psychiatry systematically undergoes a total knowledge wipeout. All the
accumulated knowledge of the past is scrapped: The triumph of Freudianism in
the 1920s effectively wiped out all the accumulated knowledge of a century of
earlier biological psychiatry. And the death of psychoanalysis today has effect-
ively wiped out most of the previously accumulated wisdom about psychother-
apy – which really does work. So psychiatry is continually reinventing itself,
and often getting it wrong. As one of the old hands of French psychiatry,
Philippe Chaslin at the Salpêtrière hospice, observed in 1912, “Progress does
not consist, as people seem all too frequently to believe, in making a blank slate
of the past, but in enriching it with the present and preparing for the future.”1
Here is indeed where a knowledge of history comes in. Clinical psychiatry
has effectively forgotten a century of accrued wisdom about diagnosis, and the
task force that put together the famous third edition of the Diagnostic and Statis-
tical Manual (DSM) in 1980 was essentially winging it. But here’s the thing: Let’s
Preface ix
go back and see what actually did work, in diagnostic terms, and has now been
forgotten. This could bring a payoff for patients, who will get diagnoses that
correspond more exactly to disease entities that exist in nature. And there could
be a payoff for drug development; there have been no new drugs for mood dis-
orders in psychiatry in the past thirty years! If someone says, “Hey, the dia-
gnoses you guys have are largely rubbish. No wonder none of your trials work
out. You aren’t cutting nature at the joints” – there could be a turning of the
page.
This book is about lots of conditions that people today have never really
heard of: an explosive form of violence – actually quite common – called deliri-
ous mania; forms of catatonia that can end fatally; dementing illnesses that begin
in adolescence and that are pieces of the larger “schizophrenia” package. There
are also other diagnoses, once quite familiar, that today have vanished from the
scene. But this book is also about diagnoses totally familiar today that perhaps
should become . . . somewhat less so, such as “bipolar disorder” and “schizo-
phrenia.” What all these valid and invalid diagnoses have in common is a history
of past reality, or unreality. Clinicians over the decades have believed implicitly
in some, yet scorned others that today we cherish. Do we cherish them wisely?
Patients, after all, don’t come in with diagnoses stamped on their foreheads. Are
we seeing straight?
I know people are going to say, “OK, Mr. Smarty Pants, if you’re so clever,
what should the correct classification of diseases be?” And so at the end I’ve
included an alternative, history-driven, version of the nosology. It may not be
perfect, but it’s a big improvement on what we’ve got.
There is one omission: Readers will find relatively little here about depres-
sion, aside from the chapter on “bipolar disorder,” even though the current
classification of mood disorders is vastly lacking. The reason for the omission is
simple: I wrote another whole book on the epidemic of “depression” that cur-
rently afflicts us and its origins.2 The argument of the book was that there basi-
cally are two kinds of depressions: melancholic; and the vast garden-variety
sweep of dysphoria, anxiety, obsessive-compulsive thinking, and somatic com-
plaints that used to be called “psychoneurosis,” and before that, “nerves.” We
also revisit the subject here in the little nosology, or classification of diseases,
that is Chapter 9. The whole subject of melancholia is hugely important,
because melancholic patients are much at risk of killing themselves; and even if
they survive, they lead lives of bitter misery until a spontaneous recovery even-
tuates. The subject is the more poignant because, of all patients in psychiatry, it
is these who can be relieved most swiftly and effectively, with a class of antide-
pressant drugs called “tricyclics,” and with convulsive therapy. I hope that
readers interested in depression will accept a historian’s referral to a previous
book of his.
Gimlet-eyed clinicians of today may object that the stories in this book are
just that, stories, and that what is required to convince clinical scientists is hard
x Preface
numbers. I’ve nothing against hard numbers, and the “medical model” discussed
below as the ultimate desideratum of research in nosology depends upon hard
numbers. Yet none of the main diagnoses of psychiatry today arose as a result of
hard numbers! Schizophrenia, depression, obsessive-compulsive disorder,
anxiety disorder: none owed their birth to quantitation. They came from atten-
tive physicians’ observations of their patients and the differences among them –
from anecdotes, in other words. Yet what permitted these anecdotes to pass into
science was a stream of convergence of these observations over the years. The
stream of convergence settled slowly into collective agreement that, yes, schizo-
phrenia was a disease of its own, different from melancholia, and that there were
two kinds of depression, and that obsessive-compulsive disorder was an illness
sui generis, and so forth. So let’s not knock stories, as long as they aren’t a substi-
tute for numbers (but no numbers were really available before the Second
World War: psychiatry was all impressions). It is satisfying to the historically
minded that these diagnoses, rightly or wrongly, are the main intellectual
content of the field today. Let’s take a closer look at them.
Edward Shorter
Fall 2014
NOTES
1 Philippe Chaslin, Eléments de sémiologie et clinique mentales (Paris: Asselin, 1912), vii.
2 Edward Shorter, How Everyone Became Depressed: The Rise and Fall of the Nervous Break-
down (New York: Oxford University Press, 2013).
ACKNOWLEDGMENTS
I want to acknowledge a small group of friends in real life, as well as email com-
panions, who have accompanied this manuscript in hard-hitting commentaries.
They include Tom Bolwig, Bernard Carroll, Max Fink, David Healy, Gordon
Parker, Robert Rubin, Michael Alan Taylor, and Lee Wachtel. To say the least,
they are not all in agreement with the book’s contents, but without their aid,
the contents might have been quite different. I should also like to thank Susan
Bélanger, who has been the chief operating officer of countless research pro-
jects, including this one, and Esther Atkinson, a crackerjack research assistant
and PhD candidate who soon will be an independent scholar on her own
account. Daniela Cancilla has been helpful on the electronic side of things.
I am grateful to Associated Medical Services (AMS), the Canadian Institutes
of Health Research, and the Social Sciences Research Council of Canada for
supporting portions of this work.
George Zimmar at Routledge has been wonderful to work with, as an editor
– and as a colleague!
ABBREVIATIONS
ADHD attention deficit hyperactivity disorder
AGP Archives of General Psychiatry
AJP American Journal of Psychiatry
AMP Annales Médico-Psychologiques
AZP Allgemeine Zeitschrift für Psychiatrie
BMJ British Medical Journal
BJP British Journal of Psychiatry
CMD common mental disorders
DSM Diagnostic and Statistical Manual of Mental Disorders
(various editions)
DST dexamethasone suppression test
ECT electroconvulsive therapy
EEG electroencephalograph
JAMA Journal of the American Medical Association
JNMD Journal of Nervous and Mental Diseases
MAOI monoamine oxidase inhibitor
NEJM New England Journal of Medicine
NIMH National Institute of Mental Health (United States)
NMS neuroleptic malignant syndrome
OCD obsessive-compulsive disorder
PET positron emission tomography
PTSD post-traumatic stress disorder
RDC Research Diagnostic Criteria
TSS toxic serotonin syndrome
FULL REFERENCES TO SOURCES
BRIEFLY CITED IN THE NOTES
Complete citations to the various editions of Emil Kraepelin’s textbook cited in
this book are as follows:
4th ed. Psychiatrie: Ein kurzes Lehrbuch für Studirende und Aerzte (Leipzig: Abel, 1893).
5th ed. Psychiatrie: Ein Lehrbuch für Studirende und Aerzte (Leipzig: Barth, 1896).
6th ed. Psychiatrie: Ein Lehrbuch für Studirende und Aerzte (Leipzig: Barth, 1899), 2 vols.
7th ed. Psychiatrie: Ein Lehrbuch für Studierende und Aerzte (Leipzig: Barth, 1903), 2 vols.
8th ed. Psychiatrie: Ein Lehrbuch für Studierende und Aerzte (Leipzig: Barth, 1909–15), 5
vols.
The various editions of the DSM series are as follows:
DSM-1 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Dis-
orders (Washington, DC: APA, 1952).
DSM-2 American Psychiatric Association, DSM-II, Diagnostic and Statistical Manual of
Mental Disorders, 2nd ed. (Washington, DC: APA, 1968).
DSM-3 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Dis-
orders, 3rd ed. (Washington, DC: APA, 1980).
DSM-3-R American Psychiatric Association, DSM-III-R, Diagnostic and Statistical Manual
of Mental Disorders, 3rd ed. rev. (Washington, DC: APA, 1987).
DSM-4 American Psychiatric Association, DSM-IV, Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. (Washington, DC: APA, 1994).
DSM-4-TR American Psychiatric Association, DSM-IV-TR, Diagnostic and Statistical
Manual of Mental Disorders, 4th ed, text revision (Washington, DC: APA, 2000).
DSM-5 American Psychiatric Association, DSM-5, Diagnostic and Statistical Manual of
Mental Disorders, 5th ed. (Arlington, VA: APA, 2013).
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1
INTRODUCTION
I sent an earlier draft of this book to Mickey Taylor, Dr Michael Alan Taylor,
at the University of Michigan. “What psychiatry left out,” I said, was the
subject.
He responded, “The brain.”
I said I wanted to have a chapter on “neuropsychiatric syndromes,” thinking
of diseases such as epilepsy and Parkinson’s, that have many psychiatric manifes-
tations but are not in the official disease classification.
He replied, “Here’s the fundamental problem. It’s all neuropsychiatric. The
rest is flummery, personality trait deviations, the worried well, etc.”
As for the value of the official DSM classification, he said, “Put it in a shit
solvent and all that’s left is the binding.”1
Wow.
This book is about a number of diagnoses most people have never heard of.
There’s a good reason for that. They’re not in the official manual of psychiatry,
the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Associ-
ation. But that doesn’t mean that they don’t exist.
Although they are real diseases that are found in nature and that patients
have, no drug company has ever advertised remedies for them. This is how psy-
chiatrists often find out about currently accepted diagnoses – through drug ads
and pharma detailing – and no sales rep has ever touted “delirious mania” or
“adolescent insanity.” So, the field has let them fall off the edge of the earth.
There is a great deal of unhappiness with the current system of psychiatric
diagnosis because it does not “cut nature at the joints,” as the saying goes. It
does not delineate real psychiatric disorders as they exist in the mind and brain;
rather, it proposes diagnoses that have emerged as compromises from commit-
tees. This is not the way we do science. And science is at stake here. For the
2 Introduction
new imaging technologies such as positron emission tomography (PET) scan-
ning to bear clinical fruit, accurate descriptions of “phenotypes” are needed –
those characteristics of a disease presumably caused by genetics. Psychiatric
historian German Berrios at Cambridge University writes, “For years, all
involved in this [research] business have assumed that the psychiatric object of
inquiry is real, recognizable, unitary and stable (like stones, daffodils or horses).”2
But what if the psychopathological descriptions currently available are contami-
nated with spillover from other categories, mix stones and tin cans together, and
generally do not correspond to the underlying object one is trying to study?
Under those circumstances, the research findings from the costly PET scanners
will be of limited value. Yet that is exactly the situation we are facing today,
and investigators are aware of the problem: The National Institute of Mental
Health has just ruled out the latest DSM as a guide to psychopathology.3
So, we need more reliable descriptions of psychiatric diseases. In this book
I’m not going to propose an alternative schema, for the most part. Well, I do
tack one on at the end. But that’s not why I wrote the book. I wrote it in
order to show what we can learn about diagnosis from history. The psychiat-
ric literature of the past is rich in diagnoses that today simply no longer exist.
Because they’re bad diagnoses? No. What has typically happened over the past
two hundred years is the slow emergence of a concept as a gradual, evolution-
ary exercise in collective wisdom: People see something in their patients that
hadn’t occurred to them before; they write about it; others start seeing the
same thing – for example, that some patients seem to be driven by a kind of
furious rage – and slowly the concept emerges. But what comes out of this
collective filtering is often a powerful notion, because lots of thoughtful
people have endorsed it.
The problem is that psychiatry has been so unstable as a field that wisdom is
often forgotten. Unlike other medical specialties, psychiatry has been subject to
sudden convulsions in which some faddish idea takes over, dominates the radar,
and then is tossed aside by another faddish idea. But this tossing aside often
obliterates much of what we’ve learned from the past as the field sets out again
from ground zero. This tossing aside happened notably with the rise of psycho-
analysis in the 1920s, as virtually everything the field previously knew was oblit-
erated, and it happened again in the 1970s, as the previous psychotherapeutic
wisdom was wiped out and “neurotransmitters” took over.
In the 1970s, as a task force of the American Psychiatric Association set out
to produce a new classification of illnesses, its members were indeed at ground
zero. They dumped all of the psychoanalytic diagnoses, such as “depressive
neurosis,” and created a number of what were essentially neologisms for diseases
that they basically put together in the kind of horse-trading that characterizes
any committee: Out of this process came such new concepts as “major depres-
sion” and “bipolar disorder,” the brainchild in 1957 of an obscure German pro-
fessor, that found a home in DSM-3 in 1980.
