Ernest M. Gruenberg, M.D., Dr. P.H.
Chairman, Committee on Nomenclature and Statistics
American Psychiatric Association
This second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) reflects the growth of the concept that the people of all nations live in one world. With the increasing success of the World Health Organization in promoting its uniform International Classification of Diseases, already used in many countries, the time came for psychiatrists of the United States to collaborate in preparing and using the new Eighth Revision of that classification (ICD-8) as approved by the WHO in 1966, to become effective in 1968. The rapid integration of psychiatry with the rest of medicine also helped create a need to have psychiatric nomenclature and classifications closely integrated with those of other medical practitioners. In the United States such classification has for some years followed closely the International Classification of Diseases.
As stated in the forward, the manifest reason for the DSM II revision was to bring the American classification of mental disorders in line with the ICD-8 [International Classification of Disease, 8th Edition]. But there were subtle changes other than simply revising the numbering system. Notice that Manic-Depressive Reactions have returned to Manic-Depressive Illness reflecting some distance from Adolph Meyer’s notion of "reactions." On the other hand, Psychotic Depressive Reaction maintains the "reaction" moniker. Also note that Psychotic Depressive Reaction specifically states that it is "attributable to some experience." The distinction between this category and Depressive Neurosis rests solely on "whether the reaction impairs reality testing or functional adequacy enough to be considered a psychosis." It is no longer the "fuzzy" category of depression – something like Depressive Neurosis with Psychosis.
In the DSM II, the "fuzzy category" was Other Major Affective Disorder.They mention "’mixed’ manic-depressive illness, in which manic and depressive symptoms appear almost simultaneously." But it was also used for Severe Depressions that had no apparent precipitants. And although some cases did not have manifestly psychotic symptoms, I recall being told that the magnitude of the depressive ideas were not reality based so they "counted" – what were later called mood congruent delusions. Felt a bit like fudging to me, but there was no severe, non-precipitated, non-psychotic category of depression.
Notice also that the write-up for Neurosis and Depressive Neurosis are psychodynamic, but not particularly psychoanalytic. They mention "unconsciously," defense mechanisms, and "internal conflict," but not the explicit Freudian interpretations prominent in the original DSM. This was the era of Psychodynamic Psychotherapy in Psychiatry, but also the period when Aaron Beck was beginning to develop Cognitive Behavior Therapy.
| DSM II [1968]
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III. PSYCHOSES NOT ATTRIBUTED TO PHYSICAL CONDITIONS LISTED PREVIOUSLY [295—298]
296 Major affective disorders…
This group of psychoses is characterized by a single disorder of mood, either extreme depression or elation, that dominates the mental life of the patient and is responsible for whatever loss of contact he has with his environment. The onset of the mood does not seem to be related directly to a precipitating life experience and therefore is distinguishable from Psychotic depressive reaction and Depressive neurosis…
296.0 Involutional melancholia
This is a disorder occurring in the involutional period and characterized by worry, anxiety, agitation, and severe insomnia. Feelings of guilt and somatic preoccupations are frequently present and may be of delusional proportions. This disorder is distinguishable from Manicdepressive illness by the absence of previous episodes; it is distinguished from Schizophrenia in that impaired reality testing is due to a disorder of mood; and it is distinguished from Psychotic depressive reaction in that the depression is not due to some life experience. Opinion is divided as to whether this psychosis can be distinguished from the other affective disorders. It is, therefore, recommended that involutional patients not be given this diagnosis unless all other affective disorders have been ruled out…
Manic-depressive illnesses…
These disorders are marked by severe mood swings and a tendency to remission and recurrence. Patients may be given this diagnosis in the absence of a previous history of affective psychosis if there is no obvious precipitating event. This disorder is divided into three major subtypes: manic type, depressed type, and circular type.
296.1 Manic-depressive illness, manic type…
This disorder consists exclusively of manic episodes. These episodes are characterized by excessive elation, irritability, talkativeness, flight of ideas, and accelerated speech and motor activity. Brief periods of depression sometimes occur, but they are never true depressive episodes.
296.2 Manic-depressive illness, depressed type…
This disorder consists exclusively of depressive episodes. These episodes are characterized by severely depressed mood and by mental and motor retardation progressing occasionally to stupor. Uneasiness, apprehension, perplexity and agitation may also be present. When illusions, hallucinations, and delusions [usually of guilt or of hypochondriacal or paranoid ideas] occur, they are attributable to the dominant mood disorder. Because it is a primary mood disorder, this psychosis differs from the Psychotic depressive reaction, which is more easily attributable to precipitating stress. Cases incompletely labelled as "psychotic depression" should be classified here rather than under Psychotic depressive reaction.
296.3 Manic-depressive illness, circular type…
This disorder is distinguished by at least one attack of both a depressive episode and a manic episode. This phenomenon makes clear why manic and depressed types are combined into a single category. [In DSM-I these cases were diagnosed under "Manic depressive reaction, other."] The current episode should be specified and coded as one of the following:
296.33 Manic-depressive illness, circular type, manic
296.34 Manic-depressive illness, circular type, depressed
296.8 Other major affective disorder…
Major affective disorders for which a more specific diagnosis has not been made are included here. It is also for "mixed" manic-depressive illness, in which manic and depressive symptoms appear almost simultaneously. It does not include Psychotic depressive reaction or Depressive neurosis…
298.0 Psychotic depressive reaction…
This psychosis is distinguished by a depressive mood attributable to some experience. Ordinarily the individual has no history of repeated depressions or cyclothymic mood swings. The differentiation between this condition and Depressive neurosis depends on whether the reaction impairs reality testing or functional adequacy enough to be considered a psychosis…
IV. NEUROSES [300]
300 Neuroses
Anxiety is the chief characteristic of the neuroses. It may be felt and expressed directly, or it may be controlled unconsciously and automatically by conversion, displacement and various other psychological mechanisms. Generally, these mechanisms produce symptoms experienced as subjective distress from which the patient desires relief. The neuroses, as contrasted to the psychoses, manifest neither gross distortion or misinterpretation of external reality, nor gross personality disorganization. A possible exception to this is hysterical neurosis, which some believe may occasionally be accompanied by hallucinations and other symptoms encountered in psychoses. Traditionally, neurotic patients, however severely handicapped by their symptoms, are not classified as psychotic because they are aware that their mental functioning is disturbed.
300.4 Depressive neurosis
This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession. It is to be distinguished from Involutional melancholia and Manic-depressive illness. Reactive depressions or Depressive reactions are to be classified here.
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The era of psychopharmacology had begun in the time between the DSM and the DSM II – the Antipsychotics in the early 1950s followed by the Tricyclic Antidepressants toward the end of the decade. The Community Mental Health Movement was is full swing as were the dramatic social changes of the late "sixties." In contrast to everything else, the changes in the DSMs were minimal.
Such clarity and simplicity. I long for a return to simpler times…. But i suspect DSM-V will need a Talmudic scholar to decipher….