1 Boring Old Man

^{It fell to Kraepelin to systematically apply the medical model to the diagnosis of psychopathology, attempting a classification of mental illnesses that went beyond presenting symptoms (Havens, 1965; Shorter, 1997). But in this respect, Kraepelin’s program largely failed. Beginning in the fifth edition (1896) of his Textbook, and culminating in the seventh and penultimate edition (the second edition to be translated into English), Kraepelin acknowledged that classification in terms of pathological anatomy was impossible, given the present state of medical knowledge. His second choice, classification by etiology, also failed: Kraepelin freely admitted that most of the etiologies given in his text were speculative and tentative. In an attempt to avoid classification by symptoms, Kraepelin fell back on classification by course and prognosis: what made the manic-depressive psychoses alike, and different from the dementias, was not so much the difference between affective and cognitive symptoms, but rather that manic-depressive patients tended to improve while demented patients tended to deteriorate. By focusing on the course of illness, in the absence of definitive knowledge of pathology or etiology, Kraepelin hoped to put the psychiatric nosology on a firmer scientific basis.}

But I don’t miss the point that our diagnostic criteria needed to be revised and disconnected from anyone’s specific theories. My complaint is that the revision, rather than being "neo-Kraepelinian," was more like the classification by symptom list Kraepelin set out to revise than the one he ended up with. It looks to me to be "pre-Kraepelinian." Kreapelin moved from syndromes defined by symptoms to conditions defined by symptoms, course, and prognosis. Many of his conditions were analogous to medical diseases of unknown etiology. He and colleague Alois Alzheimer discovered a case of early onset dementia where they could, in fact, see the brain pathology – now known as pre-senile dementia or Alzheimer’s disease. Other conditions had both defined brain pathology and known etiology – eg Tertiary Syphilis.

Kraepelin had unified a number of symptom syndromes under the heading Dementia Praecox based on their deteriorating course [which he got wrong], but the inclusion has stood the test of time as Schizophrenia. He unified Mania and Depression under the condition Manic-Depressive Illness also based on course and prognosis. In both cases, the new conditions were clarifying. In revising the DSM, Robert Spitzer and later Allen Frances unified the various depressive syndromes under Major Depressive Disorder [M.D.D.]. Rather than clarifying, they obscured things that seemed clearer before: clinical depressions that were related to personality disorders [or life itself], and syndromes like melacholia or depressions of psychotic proportions which many believe to be unique biological conditions. The only things unifying their category are symptom overlaps. This is not a Kraepelinian category by course, prognosis, or treatment response. In reaching their goal of expunging the category, Depressive Neurosis, they also undid productive work on clarifying certain depressive syndromes. I’d personally call M.D.D. "anti-Kraepelinian."

In other areas, the same phenomenon seemed to repeat. In their ardor to deconstruct the Neuroses, they created derivative disorders that were defined by symptom lists without the supporting prognostic or longitudinal data to reach the threshold of a condition. Worse, successive revisions added little refinement. In fact the number of diagnostic categories grew rather than condensed. The fact that the DSM-III was so awkward was understandable. They were trying something new and determined to eliminate diagnoses that implied psychological causation. But the hoped for clarifications with usage just haven’t materialized. Progressive committees have added new categories rather than iterate the categories based on careful observation – "Kraepelinian" observation. So the DSM is first and foremost "not psychoanalytic," but not a whole lot more than that.

I’ve been repeatedly reassured that the DSM-III was not devised under the influence of the pharmaceutical industry [which remains hard for me to believe]. But that influence has certainly been felt in the revisions. The listing of Disorders implies discrete entities and the constant discussion of  "neuroscience and genetics and the tried and true diagnostic techniques of biological medicine" implies biological causation – which translates to biological treatment. So for twenty-five year, our literature has been filled with biological research sure enough, but the research has clarified neither nosology nor etiology, remaining primarily focused on drug trials that are short on rationale.