Descriptive Psychopathology: The Signs and Symptoms of ...

44 Section 1: Present, past, and futureas schizophrenic were found to be misdiagnosed and to in fact have manicdepressiveillness. However, it was not until after 1970 when lithium carbonatebecame widely available and marketed as a mood stabilizer did psychiatrists in theUSA re-consider the existence of manic depression. 136The failure to recognize mania and severe depression became untenablefollowing the publication of cross-national studies that compared diagnosticpractice in the USA and Europe. Psychiatrists in the USA failed to recognizemania, psychotic depression, and personality disorder, commonly interpretingsuch conditions as schizophrenia. 137 One irony is the first reported psychiatricpatient successfully treated with chlorpromazine in 1952. The 57-year-old mandiagnosed as schizophrenic, was hospitalized for “making improvised politicalspeeches in cafés, becoming involved in fights with strangers”, and for severaldays “walking around the street with a pot of flowers on his head preaching hislove of liberty”. 138 Many clinicians today would recognize him as manic. Had themost famous anti-schizophrenia medication been first given to chronically illpsychotic patients rather than to a handful of treatment-responsive manics, thepharmacotherapy era might have been substantially delayed. 139Biometricians formulate classification: the triumphof the splittersIn response to the inadequate classifications, alternative operationally defineddiagnostic criteria were proposed. 140 Their success encouraged the AmericanPsychiatric Association (APA) to reformulate the DSM in the late 1970s. 141The effort joined the departments of psychiatry at the Washington Universityin St Louis and at Columbia University’s Psychiatric Institute. The former offeredthe Feighner criteria as a model of a few syndromes with reasonable validation.The latter, under the direction of the biometrics division of the institute offereda system that was centered on the computer-based diagnostic program, DIAGNO,and its related assessment instrument the SADS. The latter’s overly simplifiedapproach to psychopathology prevailed and defined the format of the DSM-III. 142The DSM-III proposal quickly became a political document fashioned toappeal to the widest audience to insure approval by the APA membership.Lacking a consensus theory of psychiatric illness, the formulation of the DSMcategories was left to consensus among the members of each committee. Differentcommittees relied on different sources, idiosyncratic personal clinical experiences,and different psychological and pharmacologic notions. For some disorders, aKraepelinian template can be recognized (e.g. the schizophrenia criteria); forothers a psychological formulation is apparent (e.g. dissociative disorders). Thecommittees also represented diverse constituencies, and the final proposal was