Psychiatry as a distinct medical specialty in the United States came into being at the turn of the last century, heavily influenced by the thinking of a number of Europeans:
Prior to Kraepelin, the psychotic disorders were classified by symptoms, and there were too many syndromes to be useful. Kraepelin began to look at these symptom complexes, the life histories, the family histories, and the course of the illnesses and came up with a classification of the psychoses he called "clinical" [as opposed to "symptomatic"]. He defined two distinct disorders: Manic-Depressive Illness and Dementia Praecox. He noted a genetic component to each, and thought both would ultimately turn out to have a biological basis.
A colleague of Kraepelin, they co-discovered the brain pathology in pre-senile dementia. Their discovery heavily influenced Kraepelin’s belief in the biologic "cause" of Manic-Depression and Dementia Praecox.
A Swiss Psychiatrist, Bleuler, coined the term Schizophrenia highlighting the schism between thought and emotion and broadened the clinical description and subtyping of Schizophrenia. He demonstrated a wide variety if presentations and courses of illness that replaced the inevitable dire prognosis of Kraepelin’s description.
Freud’s addition had to do with the contribution of the Mind rather than the Brain to the symptoms of mental disorders. His evolving models of development and psychic conflict heavily influenced 20th century psychiatry, first as a perceived solution then later as a perceived problem.
Meyer was a Swiss Neurologist who came to the U.S. in 1892 [influenced by all of the above]. He focused on collecting detailed histories from his patients and insisted that they be understood in the context of their histories. He called his way of thinking psychobiology [the biopsychosocial model], and thought of mental disorders as adaptations he called "reactions." His thinking heavily influenced the earliest Diagnostic and Statistical Manual.
Statistical Classification and Nomenclature
Classification is fundamental to the quantitative study of any phenomenon. It is recognized as the basis of all scientific generalization and is therefore an essential clement in statistical methodology. Uniform definitions and uniform systems of classification arc prerequisites in the advancement of scientific knowledge. In the study of illness and death, therefore, a standard classification of disease and injury for statistical purposes is essential.
Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death
Volume 1. World Health Organization. [Geneva, Switzerland, 1948]
In the late 1920s, there was a move to create a standard nomenclature for diseases that came to fruition in 1932 as the Standard Nomenclature of Disease, including mental disorders. But with the coming of World War Two, there were massive changes made periodically by the Army and Navy [independently] to fit their needs, so by the end of the War, the classification was in disarray. The reorganization that ensued resulted in the Diagnostic and Statistical Manual [1952] that we now refer to as the DSM I. At the time, the systems for diagnosis and statistical coding had diverged, so the name, Diagnostic and Statistical Manual, testifies to the efforts to unify these two systems. The overall framework followed the thinking of Adolph Meyer who had been influential in the creation of the Standard Nomenclature of Disease:-
those in which there is disturbance of mental function resulting from, or precipitated by, a primary impairment of the function of the brain, generally due to diffuse impairment of brain tissue.
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those which are the result of a more general difficulty in adaptation of the individual, and in which any associated brain function disturbance is secondary to the psychiatric disorder.
This diagnostic scheme employs the term "disorder" generically to designate a group of related psychiatric syndromes. Insofar as is possible, each group is further divided into more specific psychiatric conditions termed "reactions." The code numbers are assigned in accordance with the overall plan of the Standard Nomenclature of Diseases and Operations, a system fully explained in that publication. All mental disorders are divided into two major groups:
Although the classification follows the thinking of Adolph Meyer, the Psychoanalytic influence is apparent in the section on the Psychoneuroses. This scheme is essentially unchanged from the version of the earlier Standard Nomenclature of Diseases included in the DSM Manual:
| DSM [1952] – DEPRESSION
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PSYCHOTIC DISORDERS
These disorders are characterized by a varying degree of personality disintegration and failure to test and evaluate correctly external reality in various spheres. In addition, individuals with such disorders fail in their ability to relate themselves effectively to other people or to their own work.
000-796 Involutional psychotic reaction
In this category may be included psychotic reactions characterized most commonly by depression occurring in the involutional period, without previous history of manic depressive reaction, and usually in individuals of compulsive personality type. The reaction tends to have a prolonged course and may be manifested by worry, intractable insomnia, guilt, anxiety, agitation, delusional ideas, and somatic concerns. Some cases are characterized chiefly by depression and others chiefly by paranoid ideas. Often there are somatic preoccupations to a delusional degree. Differentiation may be most difficult from other psychotic reactions with onset in the involutional period; reactions will not be included in this category merely because of their occurrence in this age group.
000-xlO AFFECTIVE REACTIONS
These psychotic reactions are characterized by a primary, severe, disorder of mood, with resultant disturbance of thought and behavior, in consonance with the affect.
000-xll—000-xl3 Manic depressive reactions
These groups comprise the psychotic reactions which fundamentally are marked by severe mood swings, and a tendency to remission and recurrence. Various accessory symptoms such as illusions, delusions, and hallucinations may be added to the fundamental affective alteration. Manic depressive reaction is synonymous with the term manic depressive psychosis. The reaction will be further classified into the appropriate one of the following types: manic, depressed, or other.
000-xll Manic depressive reaction, manic type
This group is characterized by elation or irritability, with overtalkativeness, flight of ideas, and increased motor activity. Transitory, often momentary, episodes of depression may occur, but will not change the classification from the manic type of reaction.
000-xl2 Manic depressive reaction, depressed type
Here will be classified those cases with outstanding depression of mood and with mental and motor retardation and inhibition; in some cases there is much uneasiness and apprehension. Perplexity, stupor or agitation may be prominent symptoms, and may be added to the diagnosis as manifestations.
000-xl3 Manic depressive reaction, other
Here will be classified only those cases with marked mixtures of the cardinal manifestations of the above two phases (mixed type), or those cases where continuous alternation of the two phases occur (circular type). Other specified varieties of manic depressive reaction (manic stupor or unproductive mania) will also be included here.
000-xl4 Psychotic depressive reaction
These patients are severely depressed and manifest evidence of gross misinterpretation of reality, including, at times, delusions and hallucinations. This reaction differs from the manic depressive reaction, depressed type, principally in (1) absence of history of repeated depressions or of marked cyclothymic mood swings, (2) frequent presence of environmental precipitating factors. This diagnostic category will be used when a "reactive depression" is of such quality as to place it in the group of psychoses (see 000-x06 Depressive reaction).
PSYCHONEUROTIC DISORDERS
The chief characteristic of these disorders is "anxiety" which may be directly felt and expressed or which may be unconsciously and automatically controlled by the utilization of various psychological defense mechanisms (depression, conversion, displacement, etc.). In contrast to those with psychoses, patients with psychoneurotic disorders do not exhibit gross distortion or falsification of external reality (delusions, hallucinations, illusions) and they do not present gross disorganization of the personality. Longitudinal (lifelong) studies of individuals with such disorders usually present evidence of periodic or constant maladjustment of varying degree from early life. Special stress may bring about acute symptomatic expression of such disorders. "Anxiety" in psychoneurotic disorders is a danger signal felt and perceived by the conscious portion of the personality. It is produced by a threat from within the personality (e.g., by supercharged repressed emotions, including such aggressive impulses as hostility and resentment), with or without stimulation from such external situations as loss of love, loss of prestige, or threat of injury. The various ways in which the patient attempts to handle this anxiety results in the various types of reactions listed below.
000-x06 Depressive reaction
The anxiety in this reaction is allayed, and hence partially relieved, by depression and self-depreciation. The reaction is precipitated by a current situation, frequently by some loss sustained by the patient, and is often associated with a feeling of guilt for past failures or deeds. The degree of the reaction in such cases is dependent upon the intensity of the patient’s ambivalent feeling toward his loss (love, possession) as well as upon the realistic circumstances of the loss. The term is synonymous with "reactive depression" and is to be differentiated from the corresponding psychotic reaction. In this differentiation, points to be considered are (1) life history of patient, with special reference to mood swings (suggestive of psychotic reaction), to the personality structure (neurotic or cyclothymic) and to precipitating environmental factors and (2) absence of malignant symptoms (hypochondriacal preoccupation, agitation, delusions, particularly somatic, hallucinations, severe guilt feelings, intractable insomnia, suicidal ruminations, severe psychomotor retardation, profound retardation of thought, stupor).
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In spite of the use of Adolph Meyer’s term, Reactions, the category of Manic-Depressive Illness remains much as it had been described by Emil Kraepelin at the turn of the century. The Psychoneuroses were thoroughly psychoanalytic. In the case of the Depressive Reaction, they followed the explanation in Sigmund Freud’s 1917 Essay, Mourning and Melancholia.
The overly inclusive category was Psychotic Depressive Reaction which encompassed severe depressions which were not part of a Manic-Depressive course of illness [yet] and Depressive Reactions to life events that were severe and had psychotic features. There was really no category for severe depression without psychosis. Notice that in this category, there may or may not have been a precipitating cause. This was the "fuzzy" depression category in this system…
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