Saturday, 22.07.2017

Thomas A. Ban: Psychiatry for Neuropsychopharmacologists. 2. From Kraepelin’s manic-depressive psychosis to Leonhard’s phasic and cycloid psychoses

Carlos Morra’s comment

The Diagnostic and Statistical Manuals of the American Psychiatric Association

I noted that in your review, you made no reference to the Diagnostic and Statistical Manuals (DSM) of the American Psychiatric Association (APA). Is there any reason for this?  

The first DSM (DSM-I) was published in 1952. In DSM-I, Kraepelin’s (1913) “manic-depressive psychosis” (MDP) was referred to as “manic-depressive reaction” (MDR) and classified under “affective reactions”. DSM-I recognized three types of   MDR, “manic”, “depressive”, and “others”, which included “mixed type”, “circular type”, “manic stupor” and “unproductive mania”.

The second, DSM-II was published in 1968. In DSM-II, Kraepelin’s MDP became “manic-depressive illness” (MDI) and was classified under “affective psychoses”. DSM-II recognized three types of MDI (“manic”, “depressive and “"circular”) with three subtypes in the third (“circular, manic,” “circular, depressive,” and “circular, circular”.

            The third, DSM- III, was published in 1980. In DSM-III, Kraepelin’s MDP became “bipolar disorder” (BD) and was classified under “affective disorders”.  DSM-III recognized four types of BD: “manic”, “depressed”, “mixed” and “atypical”.

            In 1987, DSM-III was revised with the introduction of an additional “type”, “non-otherwise specified” (NOS) and a new diagnostic concept, “bipolar II disorder”. While, so far, to qualify for BD, the presence of at least one “manic” and “major depressive” episodes were required, to qualify for “bipolar II disorder”, one “major depressive” and one “hypomanic” episode sufficed.  

            In DSM-IV, published in 1994, the distinction between “bipolar I disorder” with a requirement of at least one “manic” and one “major depressive” episode and “bipolar II disorder” was consolidated.

In 2000, the text of DSM-IV was revised (DSM-IV-TR) without any change related to BD.    

            In 2013, DSM- 5, the last DSM so far, was published. In addition to changes to diagnostic criteria, in DSM-5, “mixed episodes” are no longer recognized as a distinct type of BD.

            Since the publication of its Third Edition, in 1980, the DSMs of the APA have had a major impact on psychiatric practice, education and research. With their well-defined diagnostic criteria, they facilitated reliable communication about psychiatric disorders. Irrespective of reliability, your review underlines the common clinical experience of the pharmacological  heterogeneity within the DSM diagnoses relevant to Kraepelin’s (1913) MDP and it seems your position is that by using diagnoses derived by Leonhard’s (1957) nosology this heterogeneity could be reduced. Would this mean that in spite of the great impact these classifications have had in the past decades, they have not provided psychiatric populations with greater predictive validity than we could identify 50 years ago with advanced (differentiated) psychiatric nosology?

References:

American Psychiatric Association. Diagnostic and Statistical Manual. First Edition (DSM-I). Washington: American Psychiatric Association; 1952.

American Psychiatric Association. Diagnostic and Statistical Manual. Second Edition  (DSM-II). Washington: American Psychiatric Association; 1968.

American Psychiatric Association. Diagnostic and Statistical Manual. Third Edition  (DSM-III). Washington: American Psychiatric Association; 1980.

American Psychiatric Association. Diagnostic and Statistical Manual. Third Edition-Revised  (DSM-III-R). Washington: American Psychiatric Association; 1987.

American Psychiatric Association. Diagnostic and Statistical Manual. Fourth Edition (DSM-IV). Washington: American Psychiatric Association; 1994.

American Psychiatric Association. Diagnostic and Statistical Manual. Fourth Edition-Text Revised (DSM-IV-TR). Washington: American Psychiatric Association; 2000.

American Psychiatric Association. Diagnostic and Statistical Manual. Fifth Edition (DSM 5). Washington: American Psychiatric Association; 2013.

Kraepelin E. Psychiatrie. Ein Lehrbuch für Studierende und Ärzte. III. Klinische Psychiatrie. 8. Auflage. Leipzig: Barth; 1913.

Leonhard K. Aufteilung der endogenen Psychosen. Berlin:  Akademie Verlag; 1957.

 

Carlos Morra

April 28, 2016