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Psychology and Psychiatry

Psychiatric Diagnosis: From Psychosis To The "psychopathology Of Everyday Life"

The years following World War II were a time of unprecedented growth in the scope of psychiatry in the United States. In a transformation that reflected an increase in outpatient psychiatry rather than a decrease in state hospital treatment, the percentage of psychiatrists working in outpatient settings, a slim minority before the war, grew to more than half by 1947 and to an astounding 83 percent by 1957. Accompanying this shift was a similarly dramatic expansion in the kinds of ills that led patients to seek psychiatric care, inside or outside of the state hospital system. Psychiatrists began caring for an entirely new type of patient, one who suffered from "psychoneurotic" ills instead of severe mental illness.

Diagnostic expansion.

Throughout the twentieth century, psychiatrists divided psychiatric illness into two main classes: "organic" and "functional." They classified organic illnesses as those in which there was an obvious cause (e.g., intoxication) or brain lesion (e.g., dementia), whereas the functional disorders, those most commonly associated with the practice of psychiatry, had no ascertainable biological cause. Toward the end of the twentieth century, psychiatrists increasingly criticized this division between functional and organic, arguing that all psychiatric illness is, at its root, biological. In 1994, the distinction was entirely dropped from the fourth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual (DSM). However those disorders with known organic causes tend to fall under the domain of neurology, while psychiatry continues to tend primarily to disorders that fall under the traditionally functional category. These disorders are subdivided into two categories—psychotic disorders and nonpsychotic disorders—that are then further divided into specific diagnoses.

In 1952 the APA published the first edition of the DSM (DSM-I), replacing the collection of diagnoses endorsed by the APA in 1933. DSM-I was heavily influenced by psychoanalytic theory and by Adolf Meyer's emphasis on individual failures of adaptation to biological or psychosocial stresses as the cause of psychiatric illness. The diagnoses enumerated in DSM-I indicate a major enlargement in the ways in which nonpsychotic illness could be experienced and named.

This change reflected not a simple recategorization of existing patients, but rather a redrawing of the line between "dis-eased" and "normal" distress that resulted in the creation of entirely new patients. The years following the war witnessed a staggering increase in the number of patients seeking psychiatric care for their troubles in everyday living, either by voluntarily admitting themselves to state psychiatric hospitals or by hiring the services of a psychotherapist. This explosion of psychiatric concerns and practice is owed in large part to two related phenomena: the psychiatric profession's reaction to World War II, and the increasing dominance of psychoanalytic theory and practice.

World War II was the single most important factor in propelling psychodynamic psychiatry to the forefront of American psychiatry. Most fundamentally, the war reinforced the belief "that environmental stress contributed to mental maladjustment and that purposeful human interventions could alter psychological outcomes" (Grob, p. 427). Of the 18 million men screened for induction, nearly 2 million were deemed unfit for military service because of severe emotional difficulties. Despite flaws in the screening process (especially its cursory nature and the broad criteria used for rejection), this huge rejection rate highlighted the ubiquity of psychiatric disorder in the community.

The war provided a means for addressing this new concern by greatly increasing the number of physicians with experience treating psychiatric disorders. Between 1941 and 1945, the number of Army Medical Corps physicians working in psychiatry increased from 35 to 2,400. Psychoanalytic theory and therapy figured centrally in much of the training they received, and many of these physicians went on to practice psychiatry as well as psychoanalysis after the war. Moreover successfully treating wartime neuropsychiatric casualties with psychosocial interventions strengthened psychiatrists' convictions in the efficacy of psychotherapy based in psychodynamic principles.

The proportion of psychiatrists following psychodynamic tenets rose to a third by the late 1950s, and to half by the early 1970s. Psychoanalysis and psychodynamics dominated the curriculum of medical schools and residency programs, as well as the orientation of many academic departments, through the mid-1960s. The 1968 publication of the second edition of the DSM (DSM-II) reflected this. Like DSM-I, DSM-II presented a psychosocial view of psychiatric illness. Psychiatric illnesses were reactions to stresses of everyday living, not discrete disease entities that could easily be demarcated from one another or even from normal behavior or experience. From this perspective, naming a disease was of much less consequence than understanding the underlying psychic conflicts and reactions that gave rise to symptoms.

Diagnoses as disease entities.

Diagnosis, relegated to the periphery of psychiatric concerns from the 1950s through 1970s, has since taken center stage. DSM-III (1980) and DSM-IV (1994), as well as DSM-V (planned for release in 2011), reflect American psychiatry's embrace of a biomedical model of disease, complete with discrete illness categories that are distinct both from one another and from that which qualifies as "normal." Unlike DSM-I and DSM-II, the subsequent revisions have been major undertakings of central scientific importance to the field. Whereas DSM-II had consisted of a paltry 119 pages, DSM-III was 494 pages long and listed 265 distinct subdisorders—a number that would grow to nearly 400 with the publication of DSM-IV. Many disorders came to exist for the very first time when they made their appearance in print, the end product of six years' effort and of endless debate and compromise within committees assigned to each major disease category.

Unlike previous editions, DSM-III was intended to actively guide psychiatrists in assessing and diagnosing patients. The need for such a guide arose largely from psychiatry's place within larger contexts. The whole of medicine had experienced a cultural shift, one that was characterized by reliance on standardized knowledge rather than clinical expertise; statistical knowledge based on groups rather than individuals; and an increasingly reductionistic view of disease in which biology was paramount. This shift occurred within psychiatry as well: The availability of pharmacological treatments for psychiatric disorders, combined with a desire to remain part of an increasingly scientifically rigorous medical realm, led psychiatry to trade psychoanalytic theory for a new biopsychiatry that largely rejected a disease model rooted in individual biographies, psychological conflict, and psychosocial stressors. Shifting fiscal realities also contributed to psychiatry's need for greater diagnostic certainty and accountability for outcomes, as the percentage of outpatient psychiatric care paid by third-party payers (either private or public) in the United States rose from almost zero in the 1950s to nearly a quarter in the 1960s, and continued to rise steadily in the 1970s. The antipsychiatry movement of the 1960s, which critically viewed psychiatry's diagnostic categories as labels constructed by society in order to silence social deviance, created additional pressure on the discipline to define its targets in biological terms.

The diagnostic manual that grew out of this transition from psychodynamics to biopsychiatry was explicitly "atheorietical" with regard to etiology, but most of the diagnostic categories enumerated in the DSM-III were underpinned by an implicit assumption that biology and not psychological conflict was their primary cause. Symbolic of this was the excision of the word "reaction" from many diagnoses: thus a patient who would have been diagnosed with a "psychotic depressive reaction" prior to 1980 was now diagnosed with "major depression with psychotic features." Each diagnosis was thought of not only as stemming from a unique biological cause, but also as being made up of a unique (and determinant) set of symptoms—a marked departure from the psychodynamic view of disease, in which a given set of symptoms, depending as they did on the individual's life history and beliefs, could result from any number of underlying conflicts. DSM-III and DSM-IV have been heavily criticized for their approach to diagnosis, in which the presence of a minimum number of symptoms from a list determines the presence or absence of the disorder in question. However this approach is perhaps the best that can be expected from a field in which symptoms are generally thought to be direct reflections of an underlying disease of presumed, but as yet unknown, biological cause. As a means by which to increase diagnostic consensus, facilitate research into the efficacy of disease-specific cures, and justify insurance reimbursement, DSM-III and DSM-IV have been largely successful, and the DSM remains the dominant system of psychiatric classification in the United States and most other countries.

Implications.

While psychoanalytic treatments have largely fallen from grace, psychoanalytic theory and language continue to influence American psychiatry and culture. Since the late-twentieth century, American psychiatry has traded this language for the language of biology and brain, but the expanded definition of psychiatric illness—one that includes problems formerly seen as inevitable parts of life—remains. Intriguingly while these problems originally were recast as psychiatric illnesses by virtue of their psychosocial etiology, beginning in the late twentieth century their status as disorders has them readily subject to purely biological interpretations and cures.

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