Edward Shorter: What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today

New York: Routledge, Taylor & Francis Group, 2015 (188 pages)

Reviewed by Edward Shorter

INFORMATION ON CONTENTS: There are diagnoses that should have been included in the DSM but weren’t and diagnoses that should not have been included but were.  This book is about both and concludes with a historian’s register of what belongs in a proper psychiatric nosology.

         What should have been included (but didn’t have a chance of getting in!): delirious mania, adolescent insanity and “stage theory” (the Guislain-Zeller-Griesinger concept of psychiatric illness as progressing through stages, a concept that Kraepelin rejected).  Stage theory is a notion that psychiatry today is entirely unfamiliar with, but that doesn’t mean that it doesn’t exist.

        What shouldn’t have been included (but was!): bipolar disorder, the Kraepelinian firewall between mood disorders and madness, and schizophrenia.  Kraepelin emerges here as the formative figure in modern psychiatry, simultaneously leading the field astray and imparting wisdom.  Kraepelin’s notion of “manic-depressive insanity” hit the nail right on the head:  mood disorders as a giant fluid basin where one has as little hope of drawing fine distinctions as of drawing lines in a bucket of water.  Kraepelin’s “firewall” was his historic blunder: asserting that mood disorders and psychosis are such different entities that on the whole they never overlap (he did recognize psychotic depression). The pharmaceutical industry has been glad to reinforce this distinction with separate classes of “antidepressants” and “antipsychotics.”  In DSM-5 today there are, of course, separate chapters for “schizophrenia” and “major depression” — and a separate chapter for “bipolar disorder,” which Kraepelin would have found gobsmacking.

AUTHOR’S STATEMENT:  There was so much resistance in the field to the concepts in  What Psychiatry Left Out that it was not reviewed in a single psychiatry journal.  I am not arguing that the book’s merits make such an omission unpardonable but that the field today is so totally committed to schizophrenia, bipolar disorder and major depression as its principal diagnoses that alternative formulations are simply not seen as within the realm of possibility.

        My sense is that there is a growing discontent within the field about diagnosis.  So many clinicians say, “The DSM does not describe my patients.”  The whole rickety structure, conceived by Robert Spitzer and his Task Force in 1980, is ready for a fundamental reworking.  The APA, a professional guild and not a scientific organization, has shown that it is not up to the task.  There should be no “DSM-6.”  Instead, a root-and-branch reworking of the nosology should be entrusted to a proper scientific organization, such as NIMH or the Karolinska Institute. 

January 30, 2020