But the Manual’s greatest impact is on the lives of tens of millions of men and women who long for relief from the anguish of mental disorder, since first and foremost, the book precisely defines every known mental illness. It is these detailed definitions that empower the DSM’s unparalleled medical influence over society.
So how did we get here? How did we go from the psychoanalytical definitions of schizophrenogenic mothers and unconscious neuroses to DSM diagnoses ranging from Schizoaffective Disorder, Depressive Type (code 295.70) to Trichotillomania, hair-pulling disorder (code 312.39)? And how can we be confident that our twenty-first-century definitions of mental illness are any better than those inspired by Freud? As we shall see, the stories of psychoanalysis and the DSM ran parallel for almost a century before colliding in a tectonic battle for the very soul of psychiatry, a battle waged over the definition of mental illness.
We can trace the primordial origins of the Bible of Psychiatry back to 1840, the first year that the American Census Bureau collected official data on mental illness. The United States was barely fifty years old. Mesmer was not long dead, Freud was not yet born, and virtually every American psychiatrist was an alienist. The United States was obsessed with the statistical enumeration of its citizens through a Constitution-mandated once-a-decade census. The 1830 Census counted disabilities for the first time, though limiting the definition of disability to deafness and blindness. The 1840 Census added a new disability—mental illness—which was tabulated by means of a single checkbox labeled “insane and idiotic.”
All the myriad mental and developmental disorders were lumped together within this broad category, and no instructions were provided to the U.S. Marshals tasked with collecting census data for determining whether a citizen should have her “insane and idiotic” box checked off. Based on the prevailing ideas at the time, the census makers probably considered “insanity” to be any mental disturbance severe enough to warrant institutionalization, encompassing what we would now consider schizophrenia, bipolar disorder, depression, and dementia. Similarly, “idiocy” likely referred to any reduced level of intellectual function, which today we would subdivide into Down syndrome, autism, Fragile X syndrome, cretinism, and other conditions. But without any clear guidance, each marshal ended up with his own idiosyncratic notion of what constituted a mental disability—notions that were often influenced by outright racism.
“The most glaring and remarkable errors are found in the Census statements respecting the prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation,” the American Statistical Association informed the House of Representatives in 1843, in perhaps the earliest example of a civil protest against excessive labeling of mental illness. “In many towns, all the colored population are stated to be insane; in very many others, two-thirds, one-third, one-fourth or one-tenth of this ill-starred race are reported to be thus afflicted. Moreover, the errors of the census are just as certain in regard to insanity among the whites.” Even more troubling was the fact that the results of this census were used to defend slavery: Since the reported rates of insanity and idiocy among African Americans in the Northern states were much higher than in the Southern states, advocates of slavery argued that slavery had mental health benefits.
Amazingly, the same elementary separation of mental conditions into insanity and idiocy remains to this day in our modern institutions. As I write this, every state has a separate administrative infrastructure for mental illness and for developmental disability, despite the fact that each of these conditions affects similar brain structures and mental functions. This somewhat arbitrary division reflects historic and cultural influences on our perception of these conditions rather than any scientifically justified reality. A similarly artificial categorization has resulted in services for substance-use disorders often being administered by a separate government agency and infrastructure, even though addiction disorders are treated by medical science no differently than any other illness.
By the twentieth century, the census had begun to focus attention on gathering statistics on inmates in mental institutions, since it was believed that most of the mentally ill could be found there. But every institution had its own system for categorizing patients, so statistics on mental illness remained highly inconsistent and deeply subjective. In response to this cacophony of classification systems, in 1917 the American Medico-Psychological Association (the forerunner of the American Psychiatric Association) charged its Committee on Statistics with establishing a uniform system for collecting and reporting data from all the mental institutions of America.
The committee, which was comprised of practicing alienists rather than researchers or theorists, relied on their clinical consensus to categorize mental illness into twenty-two “groups,” such as “psychosis with brain tumor,” “psychosis from syphilis,” and “psychosis from senility.” The resulting system was published as a slender volume titled The Statistical Manual for the Use of Institutions for the Insane, though psychiatrists quickly took to calling it the Standard.
For the next three decades, the Standard became the most widely used compendium of mental illnesses in the United States, though its sole purpose was to gather statistics on patients in asylums; the Standard was not intended (or used) for the diagnosis of outpatients in psychiatrists’ offices. The Standard was the direct forerunner to the Diagnostic and Statistical Manual of Mental Illness, which would eventually lift the phrase “Statistical Manual” from the Standard, a phrase that had in turn been borrowed from the language of nineteenth-century census-taking.
Despite the existence of the Standard, in the early twentieth century there was nothing approaching consensus on the basic categories of mental illness. Each large psychiatric teaching center employed its own diagnostic system that fulfilled its local needs; psychoses were defined differently in New York than in Chicago or San Francisco. This resulted in a polyglot of names, symptoms, and purported causes for disorders that thwarted professional communication, scholarly research, and the collection of accurate medical data.
Things took a different course on the other side of the Atlantic. Until the latter part of the nineteenth century, there was disarray in European classification of mental illness just as there was in American psychiatry. Then, out of this chaos arose a classifier par excellence, a German psychiatrist who imposed rigorous order upon psychiatric diagnosis on the Continent. His influence over the world’s conception and diagnosis of mental illness would eventually rival—and then surpass—that of Sigmund Freud.
He Decorates Himself in a Wonderful Way
Emil Kraepelin was born in Germany in 1856—the same year as Freud, and just a few hundred miles from Freud’s birthplace. (So many pivotal figures in psychiatry came from German-speaking countries—Franz Mesmer, Wilhelm Griesinger, Sigmund Freud, Emil Kraepelin, Julius Wagner-Jauregg, Manfred Sakel, Eric Kandel—that psychiatry could justifiably be called “the German discipline.”) Kraepelin trained in medical school under Paul Fleischig, a famed neuropathologist, and Wilhelm Wundt, the founder of experimental psychology. Under the tutelage of these two empiricists, Kraepelin developed a lifelong appreciation for the value of research and hard evidence.
After becoming a professor of psychiatry in modern-day Estonia, Kraepelin became appalled by the spider’s nest of diagnostic terminology and struggled to find some sensible way to bring consistency and order to the classification of mental illness. One of the most vexing problems was the fact that many disorders that seemed distinct often shared some of the same symptoms. For example, anxiety manifested as a prominent symptom of depression and hysteria, while delusions were present in psychosis, mania, and severe forms of depression. Such overlap led many psychiatrists to braid depression and hysteria together as a single disorder, or endorse a single definition that encompassed both psychosis and mania.
Kraepelin was confident that observable symptoms were essential to discriminating mental illnesses, but he didn’t think sym
ptoms were enough. (To do so would be akin to grouping all illnesses associated with fever under a single diagnosis.) Consequently, he sought some other criteria that could help distinguish disorders, and by tracking the progress of his patients for their entire lives he found one. Kraepelin decided to organize illnesses not just by symptoms alone but also according to the course of each illness. For example, some psychoses waxed and waned and eventually lifted for no discernible reason, while other psychoses grew worse and worse until afflicted patients became incapable of caring for themselves. In 1883, Kraepelin assembled a draft of his ad hoc classification system in a small book entitled Compendium der Psychiatrie.
Emil Kraepelin, the founder of the modern system of psychiatric diagnosis. (©National Library of Medicine/Science Source)
In his compendium, Kraepelin divided the psychoses into three groups based upon their life histories: dementia praecox, manic-depressive insanity, and paranoia. Dementia praecox most closely resembled what we would today call schizophrenia, though Kraepelin limited this diagnosis to patients whose intellectual capacity steadily deteriorated over time. Manic-depressive insanity maps onto the modern conception of bipolar disorder. Kraepelin’s classification scheme was immediately marked by controversy because dementia praecox and manic-depressive illness had usually been considered manifestations of the same underlying disorder, though Kraepelin justified the distinction by pointing out that manic-depressive illness was episodic rather than continuous, like dementia praecox.
Despite the initial resistance to Kraepelin’s novel proposal, his classification system was eventually accepted by the majority of European psychiatrists, and by the 1890s it had become the first common language used by European psychiatrists of all theoretical bents to discuss the psychoses. To help explain his classification system, Kraepelin wrote portraits of prototypical cases for each diagnosis, derived from his own experiences with patients. These vivid portraits became a pedagogical device that influenced generations of European psychiatrists and are as compelling today as when he wrote them more than a century ago. His detailed accounts of dementia praecox and manic-depressive illness even persuaded many psychiatrists that the two conditions were distinct. Here is an excerpt from his description of dementia praecox:
The patients see mice, ants, the hound of hell, scythes, and axes. They hear cocks crowing, shooting, birds chirping, spirits knockings, bees humming, murmurings, screaming, scolding, voices from the cellar. The voices say: “That man must be beheaded, hanged,” “Swine, wicked wretch, you will be done for.” The patient is the greatest sinner, has denied God, God has forsaken him, he is eternally lost, he is going to hell. The patient notices that he is looked at in a peculiar way, laughed at, scoffed at, that people are jeering at him. People spy on him; Jews, anarchists, spiritualists, persecute him; they poison the atmosphere with toxic powder, the beer with prussic acid.
And of manic-depressive psychosis:
The patient is a stranger to fatigue, his activity goes on day and night; ideas flow to him. The patient changes his furniture, visits distant acquaintances. Politics, the universal language, aeronautics, the women’s question, public affairs of all kinds and their need for improvement, gives him employment. He has 16,000 picture post-cards of his little village printed. He cannot be silent for long. The patient boasts about his prospects of marriage, gives himself out as a count, speaks of inheritances which he may expect, has visiting cards printed with a crown on them. He can take the place of many a professor or diplomatist. The patient sings, chatters, dances, romps about, does gymnastics, beats time, claps his hands, scolds, threatens, throws everything down on the floor, undresses, decorates himself in a wonderful way.
Over the following decade, Kraepelin’s hastily written compendium swelled into a wildly popular textbook. New editions came out with increasing frequency, each larger than the last. By the 1930s, a majority of European psychiatrists had embraced Kraepelin’s classifications. Across the Atlantic, by contrast, it was a very different story. While a minority of American alienists had adopted his system of diagnosis in the early decades of the twentieth century, by the end of World War II his influence on American psychiatry had been almost completely wiped out by the rise of the Freudians, at precisely the same time that Freudian influence in Europe was being expunged by the Nazis.
Infinite Neuroses
According to psychoanalytical doctrine, since mental illness emanated from a person’s unique unconscious conflicts, it was infinitely variable and could not be neatly packed into diagnostic boxes. Each case must be treated (and diagnosed) on its own merits. Kraepelin, on the contrary, drew a sharp boundary between mental health and mental illness. This bright dividing line, along with his system of classifying disorders based on their symptoms and time-course of the illness, ran entirely counter to the psychoanalytic conception of mental disease, which held that a person’s mental state lay on a continuum between psychopathology and sanity; everyone possessed some degree of mental dysfunction, said the Freudians.
Freud himself acknowledged general patterns of dysfunctional behavior—like hysteria, obsessiveness, phobias, anxiety, depression—but he believed they were all mutable manifestations of neuroses that grew out of emotional stresses occurring at specific stages of development. For example, a psychoanalytic diagnosis of Abigail Abercrombie might account for her spells of anxiety by connecting them to the way she reacted to her parents’ strict Lutheran upbringing, combined with her decision to leave home at an early age to work rather than marry. A Kraepelinian diagnosis would characterize Abbey as suffering from an anxiety disorder based upon her symptoms of intense fear and discomfort accompanied by heart palpitations, sweating, and dizziness, symptoms that occurred together in regular episodes. (Wilhelm Reich’s diagnostic method presents yet another contrast: He claimed that the physical constriction of Abbey’s body impeded the free flow of her orgones, which caused her anxiety.) These are strikingly different interpretations.
Psychoanalysts believed that attending too much to a patient’s specific symptoms could be a distraction, leading the psychiatrist away from the true nature of a disorder. The proper role for the psychoanalyst was to look beyond mere behaviors, symptomatic or otherwise, to unearth the hidden emotional dynamics and historical narrative of a patient’s life. Given this profound discordance in the basic conceptualization of mental illness within Freud’s and Kraepelin’s systems, you may not be surprised to learn that Emil Kraepelin was openly derisive of psychoanalysis:
We meet everywhere the characteristic features of Freudian investigation, the representation of arbitrary assumptions and conjectures as assured facts, which are used without hesitation for the building up of new castles in the air towering ever higher, and the tendency to generalization beyond all measure from a single observation. As I am more accustomed to walking upon the surer foundations of direct experience, my Philistine conscience of natural science stumbles at every step upon objections, uncertainties, and doubts, while Freud’s disciples’ soaring tower of imagination carries them over without difficulty.
To complicate matters further, practitioners in each individual school of psychoanalysis had their own categories and definitions of unconscious conflicts. Strict Freudians emphasized the central role of sexual conflicts. Adlerians identified aggression as the key source of conflict. The school of ego psychology combined these approaches, focusing on both sexual and aggressive drives. Jungians, meanwhile, sought to identify the clash of psychic archetypes within a person’s unconscious.
Other psychoanalysts simply invented their own diagnoses out of whole cloth. Helene Deutsch, a renowned Austrian émigré, created the “as if personality” to describe people “who seem normal enough because they substituted pseudo-emotional contacts for real connections to other people; they behave ‘as if’ they had feelings and relations with other people rather than superficial pseudo-relations.” Paul Hoch and Phillip Polatin proposed “pseudoneurotic schizophrenia” to describe people who
invested their relationships with too little—or perhaps too much—emotional attachment. It is chilling to think that patients diagnosed with pseudoneurotic schizophrenia were once referred to the psychosurgery clinic here at Columbia University, where Hoch worked.
Freud contributed his fair share of psychopathological creations, such as the anal-retentive personality disorder: “an anal-erotic character style characterized by orderliness, parsimony, and obstinacy.” Someone who excessively consumed food, alcohol, or drugs was labeled an oral-dependent personality by Freud, who argued that such patients had been deprived of oral nourishment as infants (namely, breast-feeding). Freud characterized other neurotic conflicts as Oedipal complexes (a man unconsciously wanting to kill his father and have sex with his mother), Electra complexes (a woman unconsciously wanting to kill her mother and have sex with her father), castration anxiety (a boy fearing losing his penis as punishment for his sexual attraction to his mother), or penis envy (a woman unconsciously longing for the power and status afforded by a penis).
The most notorious psychoanalytic diagnosis was undoubtedly homosexuality. In an era when society considered homosexuality both immoral and illegal, psychiatry labeled it a mental disorder as well. Ironically, Freud himself did not believe that homosexuality was a mental illness, and was supportive of homosexual acquaintances in letters and personal interactions. But from the 1940s to the 1970s, the leading psychoanalytical view of homosexuality held that it developed in the first two years of life due to a controlling mother who prevented her son from separating from her, and a weak or rejecting father who did not serve as a role model for his son or support his efforts to escape from the mother.
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