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The DSM-5 was published in May 2013. Its publication has been associated with increasing controversy about some specific diagnoses but is not a ‘paradigm shift’. Furthermore, US psychiatric leaders want to ‘sell us’ the belief that the future integration of neuroscience with psychiatric diagnosis will ‘cure and prevent’ mental illness [1]. In 100 years, these words will seem as laughable as similar statements Kraepelin made when he was marketing his Research Institute [2].

This author proposes that the DSM-5 is a dead end for the historical process initiated in 1980 with the publication of the DSM-III, which was an important step in the history of psychiatric vocabulary. Psychiatric terminology has two interrelated levels (symptom and diagnosis levels). The description of psychiatric symptoms and signs is usually called descriptive psychopathology. Nosology is the scientific discipline of classifying medical disorders.

This article proposes that the DSM-III put European psychiatry to sleep; it now must wake up and establish a 21st century language of psychiatry (descriptive psychopathology and psychiatric nosology) to advance its scientific development and practical utility.

Descriptive psychopathology

  1. Top of page
  2. Descriptive psychopathology
  3. Development of DSM-III and later editions in the United States
  4. The devastating consequences of the DSM-III for European psychiatry
  5. An epistemology of psychiatry?
  6. References

The fundamentals of descriptive psychopathology, which allowed the development of psychiatry as a medical discipline, were initially developed in France, then spread to Germany during the 19th century and peaked in the 20th century.

In 1912 France, Chaslin, after 25 years of work, published a 956-page book on psychiatric symptoms including 350 clinical cases. In 1914, he published a superb article stressing the weakness and lack of accuracy of psychiatric terminology, but it included the unrealistic comment that his textbook would make psychiatry a ‘well-studied science’ with a ‘well-made language’ [3]. The absence of translation of this book underscores two factors ignored by the current leadership of US psychiatry: i) the crucial importance of ‘historical contingencies’ in understanding the weakness of nosological psychiatric systems and ii) the difficulty of fulfilling the fantasy that psychiatry can become a science [4].

In 1913, at the University of Heidelberg, a 30-year-old German psychiatrist (who later became a philosopher) published the first edition of a book called General Psychopathology. The first English translation was published in 1963, had 900 pages and reflected the 7th German edition. Jaspers wrote this book during his psychiatric training because he thought that the discipline of psychiatry was crying out for a systematic clarification of current thinking, which this author believes is even more true in the 21st century. Not an easy-to-read book, General Psychopathology contains two essential interrelated ideas: i) psychiatric disorders are heterogeneous (some are medical illnesses, some are variations of normality and others are in the middle, such as schizophrenia and severe mood disorders).Therefore, ii) psychiatry is a hybrid scientific discipline that must combine the methods of both natural and social sciences. They provide, respectively, an explanation of illness that follows the medical model and an understanding of those psychiatric abnormalities that are variations of human life. The idea that psychiatric disorders are heterogeneous entities had no influence on the DSM-III or the DSM-5.

Development of DSM-III and later editions in the United States

  1. Top of page
  2. Descriptive psychopathology
  3. Development of DSM-III and later editions in the United States
  4. The devastating consequences of the DSM-III for European psychiatry
  5. An epistemology of psychiatry?
  6. References

The complex historical influences leading to the DSM-III include [4] i) the scientific methodological problems with psychoanalysis; ii) the predominance of psychoanalytic thinking in the United States which led to the limited clinical diagnostic expertise of the average US psychiatrist before the DSM-III; iii) the neo-Kraepelinian revolution which fought psychoanalytic dominance and led to the DSM-III; and iv) the unfortunate consequences of the DSM-III and later versions, which have not really led to improved diagnostic skills or greater knowledge of descriptive psychopathology among US psychiatrists. Furthermore, something went wrong in the neo-Kraepelinian revolution. In 1972 with Feighner's criteria, there were 15 ‘valid’ psychiatric disorders; in 1978 with the Research Diagnostic Criteria, there were 25, and in 1980 with the DSM-III, there were 265 [5]. Thus, neo-Krapelinians were originally concerned with validity, while the DSM-III focused on ‘diagnostic democracy’ (agreement among ‘experts’) and interrater reliability [5].

The devastating consequences of the DSM-III for European psychiatry

  1. Top of page
  2. Descriptive psychopathology
  3. Development of DSM-III and later editions in the United States
  4. The devastating consequences of the DSM-III for European psychiatry
  5. An epistemology of psychiatry?
  6. References

DSM-III devastated European psychiatry by destroying the national textbooks, which increased consistency but eliminated creative European thinking and the Association for Methodology and Documentation in Psychiatry (AMDP) system [6], the most reasonable attempt to reach diagnostic agreement, which started with symptoms/signs (first level) versus disorders (second level). To get real agreement in psychiatric language, agreement on the definitions of symptoms and signs is needed first, followed by agreement on disorders using these commonly held definitions.

The French and the Germans finally combined their efforts in developing a manual that would enable all European psychiatrists to use the same definitions of psychiatric signs and symptoms. The final AMDP version was translated into 12 languages including English in 1982 [6]. The AMDP system consists of three forms for recording prior psychiatric history and two comprehensive rating scales for current psychiatric and somatic symptoms. This examination takes no longer than a clinical interview, but interest in it disappeared almost completely by the 1980s.

An epistemology of psychiatry?

  1. Top of page
  2. Descriptive psychopathology
  3. Development of DSM-III and later editions in the United States
  4. The devastating consequences of the DSM-III for European psychiatry
  5. An epistemology of psychiatry?
  6. References

Cambridge University's German E. Berrios is an expert in the history of psychiatry. Berrios's main contribution to the future of psychiatry is his focus on the hybridity of psychiatric symptoms [7, 8], at a time when US psychiatry is intoxicated on neuroscience and European psychiatry mimics those intoxicated moves. At the beginning of the 20th century, Jaspers warned us of the precarious methodological position of psychiatry between the natural and social sciences. Almost no one paid attention to this bad methodological news for 100 years until Berrios reminded us that psychiatry deals with hybrid objects with different levels of difficulty of study using the traditional scientific methods employed in medicine [7, 8].

Epistemology can be defined as the science that studies the origins and legitimacy of knowledge [8]. Berrios proposes that the studies of epistemology and the history of psychiatry go hand in hand, using the same methods. He says not only that psychiatric disorders are very heterogeneous, as Jaspers proposed, but that psychiatric symptoms are also heterogeneous. When the psychiatric symptoms are closely related to brain signals, such as those in patients with ‘neurological’ disorders, a neuroscience approach and methods such as brain imaging make sense because the presence of a brain disorder explains these symptoms. Conversely, when psychiatric symptoms are related to ‘semantics’ (communication between human beings), a neuroscience approach and methods such as brain imaging make no methodological sense, because these symptoms can only be understood, in the sense of Jaspers, and not explained by brain disturbances. These relatively simple concepts are bad news for psychiatric researchers. Berrios also describes the difficulty of developing new elements in psychiatric language, such as new symptoms, because experienced clinicians reinterpret them using known psychiatric symptoms defined according to 19th century language.

Jaspers was ignored when he proposed that psychiatric disorders are heterogeneous and some should be studied with social science methodology. Berrios may also be ignored when he emphasizes that psychiatric symptoms/signs are heterogeneous and some of them are in ‘semantic space’ (a concept entering the cognitive sciences) and cannot be ‘explained’, in Jaspers's sense, by neuroscience. Berrios is proposing that 21st century European psychiatrists must develop a 21st century language for descriptive psychopathology to build a new psychiatric nosology.

References

  1. Top of page
  2. Descriptive psychopathology
  3. Development of DSM-III and later editions in the United States
  4. The devastating consequences of the DSM-III for European psychiatry
  5. An epistemology of psychiatry?
  6. References