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What Psychiatry Left Out of the DSM-5Review - What Psychiatry Left Out of the DSM-5
Historical Mental Disorders Today
by Edward Shorter
Routledge, 2015
Review by Lloyd A. Wells
Nov 24th 2015 (Volume 19, Issue 48)

This is a remarkable short book, which I highly recommend.

          The theme of the book is that some historic (but not current) concepts of psychiatric disease, not included in the current nosology, may be more rigorous phenotypes than those in the official nosology,  and deserve reconsideration, especially in view of the author's perception -- shared by a great many -- that DSM-5 disorders are composed of highly heterogeneous populations which lead to non-specific research findings and eventually less than stellar therapeutic results.

          Shorter examines some forgotten or partly forgotten, discarded diagnoses.  But these were major diagnoses and not curiosities such as the nineteenth century syndrome of "jumping Frenchmen".  And they are not diagnoses of questionable current relevance:  they once comprised major paradigms for psychiatry and they continue to exist though they are not diagnosable per se.  They are syndromes which could play some role in current and future paradigms in psychiatry.

          Shorter sets the ground for this argument in his introduction and then goes on to a thoughtful chapter on "disease designing", essentially the description and defining of new disorders leading up (or down) to the DSM system and its current DSM-5.  He presents an excellent overview of initial diagnoses from the eighteenth and nineteenth centuries, leading up to Kraepelin, the central figure in nosology and in this book.

          He then discusses "delirious mania", a syndrome of psychosis and rage, described over many centuries (up to the present) and under many different names:  homicidal mania, murderous monomania, maniacal rage, manie sans delire, furious mania, Bell's mania and many others.  They were often variants of catatonia but in modern nosologies have tended to be viewed as types of personality disorder or intermittent explosive disorder, a syndrome which seems silly to me.  These syndromes persist and are caught poorly in contemporary psychiatry, though many of them likely represent excited catatonia.

          The next chapter discusses malignant catatonia, from which people die.  Shorter traces accounts of this syndrome to the early nineteenth century, again with many names for it, including "typho-mania" because of clinical similarities to typhus.  Under the influence of Kraepelin, catatonia lost its "independence" as a syndrome and was classified as a type of schizophrenia, and the understanding that it could be a lethal syndrome was largely lost.  With the resurgence of knowledge of this syndrome in recent decades, it has become highly treatable with biological treatments.

          The next chapter is interesting and sure to be controversial, as demonstrated by its title, "bipolar craziness".  The historic tradition for centuries was to link mania and depression as one syndrome, and the belief was that severe depression could have manic components.  Shorter provides many examples of this reasoning as well as case reports, with a good discussion of Falret and Baillarger's concept of "circular insanity", which is often abruptly dismissed.  He then considers the concepts of cyclothymia and manic-depressive illness.  The account of the development of the concept of bipolar disorder from all these antecedents is cogent and accurate.  But Shorter clearly has a bias, as one can see from his language:  he asserts, for example, that bipolar disorder "burrowed its way" into psychiatry.

          He goes on to an account of "adolescent insanity", an early variant of dementia praecox and then schizophrenia.  He examines good- and bad-prognosis adolescent insanity and argues for a good-prognosis category for schizophrenia.  He discerns differences between Bleuler and Kraepelin regarding this syndrome and notes some of Bleuler's fuzzy thinking on the topic.

          The next chapter, "Firewall", is about the impact of Kraepelin's demarcation of psychosis (schizophrenia) and affective illness.  In fact, Kraepelin tended to change his mind about this from time to time, but there is a clear belief that "never the twain shall meet" (except, for many psychiatrists , in the murky waters of "schizoaffective disorder" -- and Shorter actually delineates this syndrome well with a few pages in several chapters).  Shorter provides study after study indicating the falsity of this firewall, with some excellent quotations, up to modern times.

          I view the next chapter, about "stages" as the most important in the book.  Shorter asserts, "We think of the current disease picture as the illness" -- in other words, we diagnose based on a clinical picture at a given moment in time.  "...The old asylum doctors saw their patients' current disease picture changing, transitioning from stage to stage."  He names this phenomenon "stage theory", perhaps not the best name.  Stage theory in the nineteenth century had different but parallel lines in France and Germany and was especially advocated by such luminaries as Falret and Magnan.

          But has it really been forgotten, as Shorter asserts?  Almost all psychiatrists pay lip service, at least, to it, and, I believe, most try to apply it.  A great part of the problem is that the sickest patients tend to have very spotty outpatient care, so that a single psychiatrist does not follow them through "stages", though almost all attempt to read the patient's previous history and think about possible stages.

          I recall a child I saw at age three, the most hyperactive child I have ever seen.  At about age nine, he demonstrated severe anxiety in addition to his hyperactivity.  In early adolescence, these symptoms continued, along with some vaguely paranoid thinking.  In later adolescence, he became a very heavy drug abuser.  In his early twenties, he began to have severe psychotic episodes.  Today, in his mid-thirties, he is unfortunately classically schizophrenic.

          This is a wonderful example of "stage theory", and it also poses problems, because the vast majority of children with severe ADHD and severe anxiety symptoms do not go on to develop schizophrenia, and it would be unconscionable not to treat them for the symptoms they do have.

          Shorter concludes with a proposal for a history-based nosology, with ten categories:

          Acute brief psychosis

          Neuropsychiatric presentations

          Chronic psychosis

          Kraepelin's disease


          Stage theory


          Subpsychotic mood and anxiety disorders

          This effort at a historically based nosology is surprisingly good, dealing with major psychiatric syndromes.  It is not without its problems, with a great deal of overlap among Kraepelin Syndrome, chronic psychosis, stage theory (a theory, not a diagnosis) and catatonia, but it is a good effort.  I think that Shorter, like NIMH, is waiting for more biomarkers to delineate true psychiatric disease.

          This book has many wonderful components.  One of its most delightful aspects is the huge number of quotations and vignettes from historic psychiatrists, some of whom are not well known today.  Another excellent aspect of the book is its focus on Kraepelin.  Shorter has a deep and clear understanding of the amazing and central role Kraepelin played in the history and development of psychiatry.  Another positive is the book's emphasis is entirely on very serious disorders of the past, not the myriad of fascinating and obscure syndromes such as the "jumping Frenchmen" of the nineteenth century (which certainly deserve another book).  And there are wonderful comments, just dropped in:  "Unfortunately, he (Kahlbaum) coined his own neologisms for almost everything, making his work not highly accessible."  Or again, "This complete inability of US psychiatrists to reach out and touch the past is interesting; the traditional diagnostic bridges to these kinds of issues having been destroyed by psychoanalysis."  What a profound, evocative statement, and how true!  Or, finally, in a comment after a lengthy passage by Kraepelin, "Hard to know what is going on in this mixed bag aside from Kraepelin's own anti-female prejudices."

          There are some negatives as well.  The book is very easy to read, which is pleasant, and the style is breezy and colloquial, sometimes overly so:  "Further downgrading was to come.  The star of the future was something called 'intermittent explosive disorder', which, although it sounded fierce, was really just bursts of anger."  While this is fun to read, it is not quite accurate.  There are other inaccuracies as well, many related to issues of diagnosis and almost all of them trivial.  Shorter is, however, a bit naïve about the standard of evidence for some of the biomarkers he discusses.  The chapter on bipolar disorder seems honestly biased.  What Shorter has written is accurate, but it is not the whole story on this intricate situation (nor can it be in a book of less than two hundred pages).

          Because of the brevity of the book, Shorter had to leave out quite a bit.  He does an excellent job of delineating differences among French, German, British and American psychiatry in the late nineteenth and early twentieth centuries, but there were many fascinating international conferences during this period, and he could have focused on them more.  The retarding influence of Adolf Meyer on diagnosis, especially in the United States, may deserve more discussion.

          But the book's merits far outweigh its minor problems.  In addition to the fascination of the history, the book is pragmatic.  In the chapter on adolescent psychosis, for example, there are wonderful quotes from Karl Jaspers (on "incomprehensibility"),Schneider, and Rumke.  When a junior resident asked recently about differences on interview between a psychotically depressed patient and a schizophrenic patient, I referred her to the quote from Jaspers.

          I strongly recommend this excellent book.  Its minor deficiencies pale in comparison to its strengths.  Any reader will learn a great deal about the best of psychiatry's past and that past's contribution to psychiatry's future.  Well done, Dr. Shorter!


© 2015 Lloyd A. Wells


          Lloyd A. Wells, Emeritus Consultant (Psychiatry),  Mayo Clinic



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