Edward Shorter is one of the greatest historians of health care alive today, and maybe the most gifted writer on the topic. In this seminal book, Shorter manages not only to bridge the gap between scholar and clinician, but also to make a convincing case that psychiatrists have a lot to learn from the history of their own field. Ian Dowbiggin, PhD, FRSC, History Department, University of Prince Edward Island, Canada Every scientific field grinds to a halt from time to time and psychiatry is cur- rently stuck in a cul- de-sac. This is when forgotten or inconvenient observa- tions from the past can provide the best way forward. In What Psychiatry Left Out of the DSM- 5, Edward Shorter gives us a series of cornerstones that will have to be included in any new building if it is to stand. This book offers food for thought and is a great read. David Healy, author of Pharmageddon; Professor of Psychiatry, Bangor University, UK Arguing that recent DSM “knowledge destruction engine” classification systems have been catastrophic for psychiatry, Edward Shorter’s polemic is written with a brio- fired challenge. If psychiatry has lost the plot in classify- ing psychiatric diseases, why not have a model provided by a historian? His “remembrance and respect of things past” model builds on the wisdom of the consensual experiences clinicians accumulated over the centuries. Here, Shorter demonstrates his masterful and profound capacity to intertwine chart- ing the history of psychiatric classification with critical appraisal. This is a book to be read by all who wish to understand psychiatry’s historical territory and consider a stimulating and provocative alternative road map. Gordon Parker, PhD, Scientia Professor of Psychiatry, University of New South Wales, Australia This new book from Dr. Shorter is an engaging romp through the history of psychiatric labeling over several centuries. Shorter once again proves he is an accomplished master of the European traditions that migrated to the United States, where they metamorphosed to, well, something else. He has deeply researched the origins of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DSM-5). The accounts of horse- trading in the DSM committees are at times hilarious. One is reminded of the saying that a camel is a horse designed by a commit- tee! Throughout, there is a principled emphasis on clinical science rather than consensus, a respect for the wisdom of the past, and a grasp of all the threads that should contribute to a scientific classification of mental maladies – from clinical description to pathophysiology. The style is provocative, even cheeky in places, and this book is certain to spark useful dialogues for years to come. Bernard J. Carroll, MBBS, PhD, FRCPsych, FRANZCP, Professor and Chairman Emeritus, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA Edward Shorter is the most knowledgeable, prolific, and venturesome his- torian of psychiatry writing in the English language today. What Psychiatry Left Out of the DSM-5 is a bold example of what he does best, namely, bring an immense reservoir of historical knowledge, acquired from a lifetime of reading in several languages, to bear on our understanding of the present-day mental health world. Western psychiatrists and psychologists – including architects of the vaunted DSM – ignore psychiatry’s deep, remarkable past at their own peril, Shorter shows convincingly. This is a brilliant and timely polemic book. Mark S. Micale, University of Illinois at Urbana-Champaign, USA WHAT PSYCHIATRY LEFT OUT OF THE DSM- 5 What Psychiatry Left Out of the DSM- 5: Historical Mental Disorders Today covers the diagnoses that the Diagnostic and Statistical Manual of Mental Disorders (DSM) failed to include, along with diagnoses that should not have been included, but were. Psychiatry as a field is over two centuries old and over that time has gath- ered great wisdom about mental illnesses. Today, much of that knowledge has been ignored and we have diagnoses such as “schizophrenia” and “bipolar dis- order” that do not correspond to the diseases found in nature; we have also left out disease labels that on a historical basis may be real. Edward Shorter proposes a history- driven alternative to the DSM. Edward Shorter is Professor of the History of Medicine and Professor of Psy- chiatry at the University of Toronto, Canada. He has written a number of books, including A History of Psychiatry, which has been translated into many languages. Professor Shorter is considered among the leading historians of psy- chiatry in the world. This page intentionally left blank WHAT PSYCHIATRY LEFT OUT OF THE DSM- 5 Historical Mental Disorders Today Edward Shorter First published 2015 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Routledge is an imprint of the Taylor & Francis Group, an informa business © 2015 Taylor & Francis The right of Edward Shorter to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging in Publication Data Shorter, Edward, author. What psychiatry left out of the DSM-5 : historical mental disorders today / Edward Shorter. p. ; cm. Includes bibliographical references. I. Title. [DNLM: 1. Diagnostic and statistical manual of mental disorders. 2. Mental Disorders–classification. 3. Mental Disorders–diagnosis. 4. Psychiatry–history. WM 15] RC455.2.C4 616.89'075–dc23 2014035919 ISBN: 978-1-138-83090-5 (hbk) ISBN: 978-1-138-83089-9 (pbk) ISBN: 978-1-315-73699-0 (ebk) Typeset in Bembo by Wearset Ltd, Boldon, Tyne and Wear CONTENTS Preface viii Acknowledgments xi List of Abbreviations xii Full References to Sources Briefly Cited in the Notes xiii 1 Introduction 1 2 Disease Designing 10 3 Delirious Mania 26 4 Malignant Catatonia 48 5 Bipolar Craziness 68 6 Adolescent Insanity 99 7 Firewall 130 8 Stages 147 9 An Alternative, History- Based, Nosology 160 10 Conclusion 179 Index 181 PREFACE This book is about the psychiatric diagnoses that have a lot of historic validity, with the wisdom of decades and centuries behind them, and should have been included in today’s listing – but weren’t. It’s also about a few diagnoses that shouldn’t have been included – but were. I’m a historian, not a clinician. I don’t diagnose individual patients. Yet I know some of the diagnoses that should be circling in clinicians’ minds – but aren’t. The book’s premise is that one can search the medical literature of the past for wisdom. The psychiatry of the past has something to teach the present, an accumulated payload of knowledge and thoughtfulness that should remain vibrant. But in fact this storehouse of good judgment is often lost. It’s not true in psychiatry that each piece of new knowledge is a building block on a wall that gets higher and higher. Indeed, the opposite seems to happen: Every now and then, psychiatry systematically undergoes a total knowledge wipeout. All the accumulated knowledge of the past is scrapped: The triumph of Freudianism in the 1920s effectively wiped out all the accumulated knowledge of a century of earlier biological psychiatry. And the death of psychoanalysis today has effect- ively wiped out most of the previously accumulated wisdom about psychother- apy – which really does work. So psychiatry is continually reinventing itself, and often getting it wrong. As one of the old hands of French psychiatry, Philippe Chaslin at the Salpêtrière hospice, observed in 1912, “Progress does not consist, as people seem all too frequently to believe, in making a blank slate of the past, but in enriching it with the present and preparing for the future.”1 Here is indeed where a knowledge of history comes in. Clinical psychiatry has effectively forgotten a century of accrued wisdom about diagnosis, and the task force that put together the famous third edition of the Diagnostic and Statis- tical Manual (DSM) in 1980 was essentially winging it. But here’s the thing: Let’s Preface ix go back and see what actually did work, in diagnostic terms, and has now been forgotten. This could bring a payoff for patients, who will get diagnoses that correspond more exactly to disease entities that exist in nature. And there could be a payoff for drug development; there have been no new drugs for mood dis- orders in psychiatry in the past thirty years! If someone says, “Hey, the dia- gnoses you guys have are largely rubbish. No wonder none of your trials work out. You aren’t cutting nature at the joints” – there could be a turning of the page. This book is about lots of conditions that people today have never really heard of: an explosive form of violence – actually quite common – called deliri- ous mania; forms of catatonia that can end fatally; dementing illnesses that begin in adolescence and that are pieces of the larger “schizophrenia” package. There are also other diagnoses, once quite familiar, that today have vanished from the scene. But this book is also about diagnoses totally familiar today that perhaps should become . somewhat less so, such as “bipolar disorder” and “schizo- phrenia.” What all these valid and invalid diagnoses have in common is a history of past reality, or unreality.