The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness

11 Order out of Chaos? The Evolution of Psychiatric Nosology

C H A P T E R 1 1 Order out of Chaos? The Evolution of Psychiatric Nosology Studies of invalid constructs will probably generate invalid results, however sophisticated the methodology used might have been. —HERMANN VAN PRAAG, 1999 1. In the eighteenth century, there was only one mental illness: insanity. The diagnosis of insanity meant roughly what clinicians currently mean by the word psychosis or what is referred to colloquially by “crazy.” Insanity denoted that patients had somehow lost touch with reality, often with delusions or hallucinations or with severe melancholia or states of elation. Although these symptomatic states were described, and had been for ages dating back to the Greeks, physicians who treated these patients did not consider them to represent different diseases or diagnoses. The general condition of insanity was applied to all. Physicians who specialized in these patients were largely identified by their work in the mental asylum, usually in rural areas. Another group, as the nineteenth century progressed, was physicians who worked in cities and towns, treating patients in their homes, in the physician’s office, or in a hospital clinic. As a classic example of the mental asylum physicians, sometimes called “alienists,” one could cite Philippe Pinel, the Frenchman who is known for taking shackles off asylum patients after the French Revolution in the 1790s. Pinel introduced “moral therapy,” the concept that insanity was a disease and that patients needed to be assisted in their recovery, not through shackles or medicines , but through calm, pleasant surroundings and understanding care. Pinel belonged to the Hippocratic school of treatment, which viewed medical therapy as the handmaiden to nature. Nature caused illnesses, and nature cured ill- nesses; the physician’s job was to not hinder, and perhaps help, nature in the process. This was a very different view from the interventionist school in medicine , which focused on treatments (medicines, bleeding, tinctures of this and that) for symptoms. An American revolutionary, Dr. Benjamin Rush, one of the signers of the Declaration of Independence, is often seen as a proponent of the anti-Hippocratic view in psychiatry (Ghaemi 2002). (Ironically, Rush is viewed as the founder of American psychiatry, and his figure is on the seal of the American Psychiatric Association.) Although figures such as Rush and Pinel, both of whom wrote texts on insanity, could disagree on how to treat mental illness, they agreed on the diagnostic schema: one diagnosis—insanity. This simple nosology, one illness of insanity, held sway in the United States and most of Europe throughout most of the nineteenth century. The exception was mainly in France, where Pinel’s successors engaged in a fervent effort to split the concept of insanity into its different components, viewed as bona fide medical diagnoses. As the disease model in medicine spread quickly in the late nineteenth century (influenced by the discovery of the bacterium and the rise of Darwinian materialism), the German schools of psychiatry unified the French “splitting” approach and the one-illness “lumping” approach. Emil Kraepelin was the key unifier, with his schema of two major mental illnesses, dementia praecox (soon relabeled schizophrenia by Eugen Bleuler) and manicdepressive illness (also labeled affective illness by Bleuler). Some opposed Kraepelin ’s splitting of insanity in two, and these critics upheld a “one psychosis” (Einheit psychosen) model, also called the continuum model (current proponents include Timothy Crow). Aubrey Lewis describes this period: [The German psychiatrist] Hoche pointed out that Kraepelin had relegated melancholia from . . . a disease to a clinical picture and that it no longer mattered whether there was mania or melancholia, occurrence once in life, or many times, at irregular or at regular intervals, whether late or early, with predominance of these symptoms or those—it was still manic-depressive insanity. This standpoint Hoche attacked on theoretical and practical grounds, and proceeded to his general thesis—that clinically distinguishable diseases do not exist. . . . The influence of these views . . . was great, and Kraepelin himself in 1920 made considerable concessions. (1967, 92) As early as 1906, when Kraepelin was gaining steam internationally, Adolf Meyer (1948) was opposed to Kraepelin’s approach: The Evolution of Psychiatric Nosology 149 The superstition about the value of a diagnosis of a disease prompts many to believe that a diagnosis once made puts them into a position to solve the queries about the case not with the facts presented by it and naturally considered in the light...