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Special Articles

Origins of DSM-I: A Study in Appearance and Reality

Gerald N. Grob, Ph.D.

The author traces the history of psychiatric nosology in the United States from its origins
in the early nineteenth century to the introduction of DSM-I in 1 952. Until World War I,
psychiatrists were not interested in systematic classification, although they were concerned
with diagnosis. The first official nosology, adopted in 1 91 8, reflected the need to collect
mental hospital data. The federal Bureau of the Census had a role in the development of this
nosology in that it required such data. The publication of DSM-I marked an internal trans-
f ormation that mirrored the growing dominance ofpsychodynamic and psychoanalytic psy-
chiatry and the relative weakness of the biological tradition. This transformation occurred
largely as a result of the lessons learned by psychiatrists during World War II. The author’s
basic argument is that nosology reflected not only psychiatric ideology but also other, ex-
ternal determinants at any given point in time.
(Am J Psychiatry 1991; 148:421-431)

I modern medicine, as in modern society, classifi- turn, the analysis of the relationships among different
cation systems play a crucial role, for without such classes of data could lead to greater knowledge and
systems the collection and analysis of data are all but understanding, whether of the social and physical envi-
impossible. Two symbols perhaps best represent the ronment or of human behavioral patterns.
centrality of taxonomy: the census and the computer. Classification systems are neither inherently self-ev-
In its origins, the census was but a limited undertaking ident nor given. On the contrary, they emerge from the
designed for certain specific purposes: to facilitate the crucible of human experience; change and variability,
collection of taxes, to measure the strength of the na- not immutability, are characteristic. Indeed, the ways
tion-state, or to allocate political representation. In the in which data are organized at various times reflect
nineteenth century, however, a radically new concept specific historical circumstances. Empirical data, after
emerged, namely, that the census could define and de- all, can be presented and analyzed in endless varieties
scribe reality in statistical terms. Similarly, the com- of ways.
puter was given legitimacy by the appealing claim that The development of psychiatric nosology is a case in
it was both possible and desirable to group data of all point. Although nosological debates dealing with men-
varieties into logical and self-evident categories. In tal disorders were (and are) phrased in scientific and
medical language, they were shaped by a variety of
factors: the social origins and ideological, political,
and moral commitments of psychiatrists; their desire
Presented at the 143rd annual meeting of the American Psychiatric for status and legitimacy; the characteristics of their
Association, New York, May 12-17, 1990. Received April 13,
patients; the nature and location of their practices; and
1990; revision received July 30, 1990; accepted Aug. 27, 1990.
From the Institute for Health, Health Care Policy, and Aging Re- the broader social and intellectual currents prevalent at
search, Rutgers University. Address reprint requests to Dr. Grob, a given time. Nowhere are these generalizations better
Institute for Health, Health Care Policy, and Aging Research, Rut- illustrated than in the developments that culminated in
gers University, 30 College Ave., New Brunswick, NJ 08903.
the publication of the first edition of the Diagnostic
Supported by NIMH grant MH-39030 and a fellowship from the
National Endowment for the Humanities. and Statistical Manual: Mental Diseases (DSM-I) in
Copyright © 1991 American Psychiatric Association. 1952.

Am J Psychiatry 148:4, April 1991 421


NOSOLOGY VERSUS DIAGNOSIS Nor were Brigham’s views unique. Samuel B. Wood-
ward (4), Superintendent of the Worcester State Luna-
Psychiatrists in nineteenth-century America were for tic Hospital and first President of the Association of
the most part uninterested in elaborate nosologies that Medical Superintendents of American Institutions for
systematized mental illnesses in formal and overly rigid the Insane (now APA), had observed earlier that insan-
ways. Like other physicians, they conceived of disease ity was a “unit, indefinable . . . easily recognized . ..
in individual rather than general terms. Health was a [but] not always easily classified.” Indeed, he believed
consequence of a symbiotic relationship or balance that therapy was independent of any nosological sys-
among nature, society, and the individual (1, 2). Dis- tern but, rather, had to reflect the unique circumstances
ease, by way of contrast, represented an imbalance presented by each individual case (4-8).
that followed the violation of certain natural laws that To suggest that American psychiatrists were not per-
governed human behavior. To be sure, mental illnesses suaded that a systematic nosology was crucial to their
were indistinguishable from other physical illnesses practice is not to imply that they were unconcerned
and occurred when false impressions were conveyed to with diagnosis. On the contrary, they recognized the
the mind because the brain or other sensory organs importance of classification and even engaged in fierce
had been impaired. Nevertheless, psychiatrists also be- debates over the validity of such specific categories as
lieved that mental illnesses were precipitated by a corn- moral insanity (9) (a condition in which there was a
bination of psychological and environmental etiologi- morbid perversion of the emotions but little or no im-
cal factors that were mediated by the constitution or pairment of the thought process or the intellect) and
predisposition of the individual. Thus, insanity often the relationship of broad psychiatric categories associ-
followed violation of the natural laws that governed ated with homicidal insanity (10). However, they also
human behavior and was linked as well with immo- were acutely aware of the formidable barriers that
rality, improper living conditions, or other stresses that blocked the development of all-encompassing systems.
upset the natural balance. Hence, their nosologies tended to be general and fluid,
The holistic concept of insanity for American psy- and judgments about individual patients represented
chiatrists represented bothof faith and a start-
an act pragmatic choices that had few practical conse-
ing assumption. Except for a few cases in which au- quences. In 1838, in his classic treatise on the medical
topsies revealed the presence of a brain tumor or other jurisprudence of insanity, for example, isaac Ray (11)
physical abnormality, the ‘link between organ and be- followed J.E.D. Esquirol’s classifications and divided
havior remained shrouded in mystery. Given their in- insanity into two broad groups. The first-idiocy and
ability to demonstrate a relationship between anatorn- imbecility-included individuals with congenital de-
ical changes and behavior, psychiatrists identified fects. The second encompassed those in whom lesions
mental disorders by observing external signs and had impaired the functioning of the mind and included
symptoms. In this respect they were no different from mania (either intellectual or affective) and dementia.
other physicians. Prior to the conceptual changes that Ray, as a matter of fact, denied that any classification
began to transform medical thought in the late nine- could be “rigorously correct, for such divisions have
teenth century (symbolized by the specific germ theory not been made by nature and cannot be observed in
of disease), most practitioners defined pathological practice.” Diseases, he added, “are naturally associ-
states in terms of external and visible signs (such as ated into some general groups only; but if these be
fever). To infer pathology by focusing on signs admit- ascertained and brought into view, the great end of
tedly created serious intellectual and scientific prob- classification is accomplished.”
lems; the preoccupation with differentiating among If psychiatrists recognized that nosology was not
various fevers was but one striking example. Although critical to clinical practice, they were cognizant of its
disagreeing on the diagnosis of signs and symptoms, role in the collection of statistical data. After 1800, a
few physicians questioned this approach, if only be- number of currents had given rise to a type of social
cause other alternatives were largely lacking. Similarly, inquiry whose methodological distinctiveness was a
nineteenth-century psychiatrists accepted disease as a commitment to quantitative research. Underlying the
given; the inability of patients to function, combined application of quantification was the assumption that
with severe behavioral symptoms, was sufficient evi- such a methodology could illuminate and explain so-
dence of the presence of pathology. cial phenomena. Nineteenth-century American psychi-
Classification systems based on symptoms created atrists were deeply committed to the collection and
grave and perhaps insoluble problems, thus reinforcing analysis of such data. In their eyes, statistical inquiry
psychiatrists’ lack of interest, if not hostility, toward could shed light on recovery rates, uncover the laws
nosology. What kind of classification system could governing health and disease, serve the ends of policy
possibly encompass the innumerable and protean advocacy, and enhance the legitimacy of both their
forms of abnormal behavior? No system of classifica- specialty and their hospitals (12).
tion, conceded Amariah Brigham in 1843 (3), ap- The collection of statistical data, of course, required
peared to be of “much practical utility”; all categories categories. Most of the categories used by nineteenth-
based on symptoms “must be defective, and perhaps century psychiatrists, however, dealt with the demo-
none can be devised in which all cases are arranged.” graphic characteristics of patients as well as admission

422 Am J Psychiatry 148:4, April 1991


and discharge rates; nosology occupied a distinctly sanity, observed Walter Channing (17), involved an
subordinate position. At the International Congress of internal relationship between the individual and the
Alienists in 1867 (13), for example, a commission environment that remained a mystery. Given the im-
dealing with psychiatric statistics recommended a mense complexities in understanding the inner life his-
broad system that involved only seven categories of tory of a person, he emphasized external predisposing
insanity (simple, epileptic, paralytic, senile dementia, causes. Mental illnesses followed several conditions:
organic dementia, idiocy, and cretinism). The focus of the harmful effects of the increasing demands of mod-
their report, nevertheless, was on demographic rather em civilization, the migration from abroad of individ-
than nosological variables. When the document was uals already well on the road to degeneracy, and the
brought before the Association of Medical Superinten- role of such factors as marriage and occupation. Nor
dents of American Institutions for the Insane in 1869 were Channing’s etiological theories unique; virtually
(14), the focus remained unchanged. Some years later, every psychiatrist focused on external elements. The
Clark Bell (President of the New York Medico-Legal list seemed endless: addiction to alcohol, drugs, and
Society and a delegate to the International Congress on tobacco; sexual excesses; improper nutrition; made-
Psychiatry and Neurology in 1885) asked a group of quate housing; misdirected education; uterine and
psychiatrists to prepare an American nosology. In re- ovarian diseases; and moral or psychological causes
sponse, a small group (15, pp. 372-377) simply fol- such as domestic difficulties, grief, anxiety, adverse cir-
lowed their British brethren and identified only eight cumstances, business failure, financial difficulties, sud-
categories (mania, melancholia, monomania, demen- den fright, worry, and mental overwork (18-21).
tia, general paralysis of the insane, epilepsy, toxic in- For much of the nineteenth century mental illnesses
sanity, and congenital mental deficiency); they rejected were loosely classified on the basis of symptoms with
only moral insanity. unprovable etiology or content. Toward the close of
The intellectual and scientific constraints that inhib- the century, however, interest in psychiatric nosology
ited the development of psychiatric nosology persisted reawakened. Psychiatrists began to shift their attention
for much of the nineteenth century. When, toward the to the course and outcome of mental illnesses. Emil
close of his long career, the venerable Pliny Earle was Kraepelin (22) in particular singled out groups of signs
approached by Bell in 1886 about the possibility of as evidencing specific disease entities such as dementia
developing a universally accepted classification of praecox and, later, manic-depressive psychosis. Study-
mental diseases, Earle (16) responded in somewhat ing thousands of patients at his clinic in Heidelberg,
negative terms. “In the present state of our knowl- Kraepelin identified the disease entity in terms of its
edge,” he wrote, “no classification of insanity can be eventual outcome. Dealing with a large mass of data,
erected upon a pathological basis, for the simple rea- he sorted out everything that individuals had in corn-
son that, with but slight exceptions, the pathology of mon, omitting what he regarded as purely personal
the disease is unknown. Hence, for the most ap-
. . . data. In this respect he diverted attention away from
parent, the most clearly defined, and the best under- the unique circumstances of individuals toward more
stood foundation for a nosological scheme for insan- general and presumably universal disease entities. In so
ity, we are forced to fall back upon the symptoms of doing, he was simply emulating a distinct trend in
the disease-the apparent mental condition, as judged medical thinking in general.
from the outward manifestations.” The oldest, sim- The Kraepelinian emphasis on classification was not
plest, and most practical classification systems (mania, immediately accepted; nosological uncertainty per-
monomania, dementia, and idiocy), therefore, were sisted. In 1894 the Committee on Statistical Tables
still of considerable value. (23) reported that many members regretted the fact
Recognition of the difficulties that blocked the for- that the American Medico-Psychological Association
mutation of a nosology of insanity did not in any way (now APA) lacked a nosology that “would place its
inhibit etiological discussions. To be sure, psychiatrists members upon common ground.” Six years later,
were aware of their inability to demonstrate meaning- Henry J. Berkley (24), Clinical Professor of Psychiatry
hit relationships between causal elements and the pres- at Johns Hopkins, noted that a classification based on
ence of particular behavioral signs or symptoms. Yet clinical symptoms was unsatisfactory “because the in-
the social and cultural roles of medicine required that dications of one form of disease frequently overlap
all physicians-psychiatrists and others-provide those of another.” Similarly, an etiological nosology
some explanation of disease processes. This was as was defective “inasmuch as the fundamental causation
true for the early part of the nineteenth century as it is frequently unknown and unascertainable.” Berkley
was for the closing decades, when a new ideal of sci- fell back on a classification based on morbid anatomy,
entific medicine (symbolized by the introduction of an- “for when the pathology of a disease has been once
tisepsis in the 1870s and pathogenic specificity in the recognized, the course can be predicted with some cer-
1880s) was taking shape. tainty, and the treatment instituted rests upon a solid
Nineteenth-century psychiatric etiological concepts foundation.” In another textbook published in 1905,
reflected broad social perceptions and prevailing cul- Stewart Paton (25) conceded that classification in psy-
tural norms. Consequently, etiological discussions chiatry and medicine differed; the former did not deal
tended to be protean and nonspecific in character. In- with “definite disease entities, such as typhoid fever or

Am J Psychiatry 148:4, April 1991 423


pneumonia,” where a demonstrable causal link was fare. Wines had been appointed as secretary of the
present. Nor had psychiatrists been able to establish a Illinois Board of State Commissioners of Public Char-
connection between lesions and behavior. The only ra- ities in 1869 and subsequently became prominent in
tional method, Paton suggested, was one that took into the National Conference of Charities and Corrections.
consideration “all the possible facts bearing upon the His stature was such that his views on the care and
case.” His preferred nosology was a system that di- treatment of a variety of dependent groups, including
vided diseases into the “defect psychoses-idiocy, im- the mentally ill, the mentally retarded, and imprisoned
becility, and other degrees of mental debility,” psycho- criminals, received national attention.
ses due to autointoxication (admittedly unproven), Wines’s S81-page volume was published in 1888 Un-
and the groups of manic-depressive insanity and de- der the title Report on the Defective, Dependent, and
mentia praecox. The growing preoccupation with clas- Delinquent Classes . . . as Returned at the Tenth Cen-
sification led Charles G. Hill (26) in his presidential sus (June 1, 1 880) (29). That Wines regarded the cen-
address before the American Medico-Psychological sus as an instrument of policy was indisputable. In his
Association in 1907 to observe that there was little eyes the organization of modern society was intimately
room for addition “unless we add ‘the classifying ma- related to the increase in dependency, a development
nia of medical authors.’” he viewed with considerable misgivings. “There is a
morphology of evil which requires to be studied,” he
wrote. “For the information of legislatures it is impor-
SOCIAL SCIENCES AND THE FEDERAL CENSUS tant that the whole extent of the evil to be contended
against shall be known, and that it shall be accessible
The impetus to create a psychiatric nosology came in a single report, in order that they may make ade-
largely from outside of psychiatry or medicine. By the quate provision for its care or alleviation” (p. x).
end of the nineteenth century a number of new social Wines’s analysis went beyond mere aggregation of
science disciplines had come into existence. Many of data pertaining to insanity; he began to speculate on
the individuals associated with these new disciplines the relationship between mental illness and such van-
were concerned not only with developing a scientific ables as sex, nativity, race, geographical residence, age,
understanding of individual and social behavior but and marital status.
also with applying this understanding to a series of Wines was cognizant that psychiatrists had been Un-
pressing social problems that seemed to threaten the able to agree on a satisfactory nosology. He called
very fabric of society. attention to the fact that existing nosologies repre-
In its quest for empirical data, social science drew sented a melange of etiology, symptomatology, and
upon the tradition of statistical analysis that had description. Some classifications were “based upon
emerged during the first half of the nineteenth century. symptoms” and some upon “physical causes”; others
Ultimately, a general consensus developed around the were “a mixture of the two”; and still others took into
indispensable utility of the federal census. To those account “the complications of insanity.” After consult-
hoping to interpret individual and collective behavior ing with a series of alienists, Wines decided to identify
in scientific terms, the census was not merely an un- seven forms of insanity: mania, melancholia, monoma-
dertaking designed to collect data. On the contrary, nia, paresis (general paralysis of the insane), dementia,
the census represented a radical faith that quantitative dipsomania, and epilepsy (29, p. xli). A decade later,
research, when merged with administrative rationality, Dr. John Shaw Billings (30), the physician who created
could replace politics. Statistical knowledge could what is today the National Library of Medicine, served
thus serve as the foundation for social policy and end as president of the American Public Health Associa-
the pernicious bickering over theory, principles, and tion, and prepared the eleventh census volume dealing
politics. with dependency, which followed Wines’s classifica-
As early as the 1830s, concern with morbidity, mor- tion but subdivided mania and melancholia into acute
tality, and dependency had stimulated efforts to gather and chronic.
statistical data that could presumably illuminate their After 1900, the Bureau of the Census expanded its
causes and thus assist in the development of appropri- coverage of dependent groups in general and the men-
ate policies. The federal census of 1 840, for example, tally ill in particular. In 1904 and 1910 it conducted
attempted to enumerate the insane, but with little suc- two special censuses dealing with the institutionalized
cess. The obstacles confronting the collection of aggre- insane. The first focused attention on the ethnic and
gate data were formidable, and administrative mecha- racial characteristics of the institutionalized mentally
nisms were weak or nonexistent (27, 28). The major ill and did not use any psychiatric nosological catego-
turning point came with the tenth census in 1880. The nies because of the absence of a standard classification.
scope of this census was evident in its size; it ran to 25 The census officials’ preoccupation with race and eth-
volumes plus a three-volume compendium (compared nicity was related to the growing fear that the alleged
with two volumes in 1870). More importantly, depen- racial superiority of the native-born population, whose
dency was the subject of an entirely separate volume families were originally from Western and Northern
prepared under the supervision of Frederick H. Wines, Europe, was being threatened by large-scale immigra-
who was already a significant figure in American wel- tion of presumably inferior groups from Eastern and

424 Am J Psychiatry 148:4, April 1991


Southern Europe. Eugenical concepts, which posited a demographic data dealing with the institutionalized
relationship between race and culture, enjoyed consid- mentally ill would be useful to public officials respon-
erable popularity at the turn of the century. A number sible for administering large hospital systems. Preoc-
of states passed laws regulating marriage for eugenical cupation with public policy, however, reinforced the
purposes, mandating the segregation of the feeble- lack of attention given to the imprecise nature of di-
minded and providing for the involuntary sterilization agnostic categories-an oversight that contradicted
of some of the retarded and mentally ill (31-33). Al- generally accepted epidemiologic principles.
though the data collected in 1904 provided relatively Psychiatrists initially manifested relatively little in-
little support for the validity of eugenical concepts, it terest in the activities of the Bureau of the Census. This
was evident that the categories used by the Bureau of began to change as concern regarding mental hygiene
the Census (34) reflected some of the concerns about and prevention mounted. When Dr. Thomas W.
the relationship between race and immigration on the Salmon became medical director of the recently
one hand and social problems and dependency on the founded National Committee for Mental Hygiene in
other. 1912, it was clear that the preoccupation with mental
The special census of 1910 was even broader in hygiene transcended concern with the problems of the
scope than its predecessor 6 years before and reflected institutionalized insane. Indeed, Salmon had a new and
a growing sophistication in the analysis of statistical radical vision of the role of psychiatry. In the past, he
data. Once again the focus was on the role of demo- observed in 1917 (36), the isolation of patients in men-
graphic characteristics and the relationship between tal hospitals had also isolated psychiatrists. A new
insanity and social factors. With the exception of some kind of psychiatry, on the other hand, would reach
brief data on the admission of patients with alcoholic beyond hospital confines and play a crucial part “in
psychosis and paresis (two fairly well-recognized cat- the great movements for social betterment.” He urged
egories) and death rates of those suffering from mental his colleagues to undertake research, to help shape
disorders, the census again all but ignored psychiatric public policy, to lay the foundations of mental hy-
nosology. That the compilation reflected the growing giene, to supervise the care of the retarded, to promote
importance of the social sciences was evident. Respon- eugenical practices, to control alcoholism, to manage
sibility for its preparation lay with Joseph A. Hill (35), abnormal children, to define the treatment of crimi-
who had received his doctorate in Germany and taught nals, and to play crucial roles in the prevention of
political economy at Harvard before joining the Bu- crime, prostitution, and dependency.
reau of the Census in 1898. Hill offered little comfort Even if not universally accepted by the specialty,
to those fearful of the new immigration. The claim that such broad goals helped to move psychiatrists into the
insanity was increasing rapidly, he wrote, was dubi- community and involve themselves in a broad range of
ous. A variety of determinants shaped the statistics of problems not related specifically to the needs of se-
insanity: the growing practice of institutionalizing the verely mentally ill individuals traditionally found in
insane, the increasing average length of life, new diag- hospitals. Out of these experiences came a new psy-
nostic methods in psychiatry leading to the detection chiatric interest in statistics and epidemiology. As early
of mental factors in physical illness, the establishment as 1908 the Bureau of the Census had asked the Amer-
of dispensaries, provision for “voluntary” and emer- ican Medico-Psychological Association to appoint a
gency commitment, and better modes of transporta- Committee on Nomenclature of Diseases to facilitate
tion (such as automobiles) that made it possible to the collection of data (37). In subsequent years the
bring individuals in poor physical condition to mental interest of census officials in a standard psychiatric no-
hospitals. By correcting for the age distribution of the sology grew even stronger. The Association finally cre-
entire native and foreign-born population, Hill also ated a Committee on Statistics in 1913. Its members
demonstrated that the allegation that immigrants had quickly affirmed the need to develop a uniform system
higher rates of mental illnesses was in error. “The age to gather data on mental diseases and mental hospitals.
difference,” he wrote, “probably goes further than any In 1917 (38) they reported that the lack of uniformity
other factor toward explaining the contrast between “makes it absolutely impossible at the present time to
the native white and the foreign-born in respect to the collect comparative statistics concerning mental dis-
proportionate numbers admitted to hospitals for the eases in different states and countries, and extremely
insane.” Other differences between the two groups difficult to secure comparative data relative to move-
might also be accounted for by sex distribution or res- ment of patients, administration, and cost of mainte-
idence in urban or rural areas. nance and additions.” Such data, if collected in a uni-
form and systematic manner, “would serve as the basis
for constructive work in raising the standard of care of
STATISTICS AND EPIDEMIOLOGY the insane, as a guide for preventive effort, and as an
aid to the progress of psychiatry.” They added, “The
The growing involvement of the Bureau of the Cen- present condition with respect to the classification of
sus with the statistics of mental illnesses was indicative mental diseases is chaotic. This condition of affairs
of the concern outside of psychiatry with policy impli- discredits the science of psychiatry and reflects unfa-
cations and future trends. The presumption was that vorably upon our Association.”

Am J Psychiatry 148:4, April 1991 425


Cognizant that the Bureau of the Census would con- ditions might in the future be regarded as symptoms if
tinue to expand its data-gathering activities, the mem- the etiology of the disease were discovered. Neverthe-
bers of the Committee on Statistics urged their col- less, the collection of statistical data required a formal
leagues to prepare a uniform nomenclature of mental nomenclature. Three years after the publication of its
diseases. The Association, with the cooperation of the own nosology, the Bureau of the Census began its an-
National Committee for Mental Hygiene, issued the nual collection of the statistics of the institutionalized
first standardized psychiatric nosology, Statistical mentally ill population (40), which was continued af-
Manual for the Use of Institutions for the Insane (39) ter World War II by the National Institute of Mental
in 1918. This manual divided mental disorders into 22 Health (NIMH).
principal groups. One of these represented undiag- The adoption of a uniform psychiatric nosology was
nosed psychoses, one represented patients without psy- not without controversy. The major opponent was
choses, and the remaining 20 categories rested for the Adolf Meyer. Meyer’s genetic-dynamic psychiatry at-
most part on the belief that mental disorders had a tempted to integrate the life experiences of the individ-
biological foundation. These categories were traumatic ual with physiological and biological data. Training
psychoses, senile psychoses, psychoses with cerebral several generations of American psychiatrists at Johns
arteriosclerosis, general paralysis, psychoses with cere- Hopkins between 1910 and 1941, Meyer had never
bral syphilis, psychoses with Huntington’s chorea, psy- been fond of Kraepelinian nosological psychiatry,
choses with brain tumor, psychoses with other brain or given his belief that the life history of the individual
nervous diseases, alcoholic psychoses, psychoses due
was the most important element in the etiology of
to drugs and other exogenous toxins, psychoses with mental disorders. He therefore refused to be identified
pellagra, psychoses with other somatic diseases, man-
with the nosology that was prepared by the Committee
ic-depressive psychoses, involution melancholia, de-
on Statistics, of which he was a member. The differ-
mentia praecox (subsequently schizophrenia), para-
ence, he wrote to E.E. Southard (42, 43), is “that I
noia or paranoid conditions, epileptic psychoses,
have no use for the essentially ‘one person, one disease’
psychoneuroses and neuroses, psychoses with consti-
view; that I prefer to speak of an individual presenting
tutional psychopathic inferiority, and psychoses with
certain facts that we can do something with in the way
mental deficiency.
of definite demonstration, and, if possible, in the way
That American psychiatrists preferred a somatic no-
of some prediction of a type of lesion, and along the
sology was hardly surprising. In 1918 the overwhelm-
lines of attack in the way of some therapeutic activity,
ing majority of those who were identified with psychi-
atry were employed in mental hospitals; the number in and also along the lines of prognosis. Whether a per-
noninstitutional settings was negligible. In public hos- son has a dozen such facts or only one, is to be a matter
pitals psychiatrists dealt with patients with severe of demonstration and not of legislation” (42). Meyer
physical impairments. In 1922, for example, 33.4% of told Samuel T. Orton (44, 45) that “statistics will be
all first admissions represented psychoses of known most valuable if they do not attempt to solve all the
somatic origins; by 1940 the figure had risen to problems of administration and psychiatry and sociol-
42.4%. (The data for this paragraph are taken from ogy under one confused effort of a one-word diagnosis
the U.S. Bureau of the Census annual compilations of marking the individual . . . . The statistics published
hospital statistics from 1926 to 1946. The first volume annually as they are now are a dead loss to the States
was published in 1926 [40].) If we assume that a sub- that pay for them, and an annual ceremony misdirect-
stantial proportion of individuals in the functional cat- ing the interests of the staff.” Orton (46) was equally
egories also suffered from conditions with a somatic critical. The Association’s
classification, he insisted,
origin-an assumption that may be warranted from was deficient on three counts. First, it was “too narrow
present-day data-it is evident that mental hospitals pro- in that it excludes all disorders of the nervous system,
vided care for a patient population with severe physical which do not produce . . . psychoses.” Second, it was
as well as mental problems. The fact that the somatic “illogical” because the categories were based in part
group had a higher death rate than the group with func- on etiology, in part on pathology, and in part on
tional psychoses suggests that the diagnoses were not purely clinical data. Third, it was “inconsistent.”
inaccurate. In 1940 the somatic group accounted for Despite such criticisms, the Statistical Manual be-
19,357 deaths (61.6%) out of a total of 31,417. The came the definitive nosology of the interwar years and
somatic nosology adopted in 1918, therefore, mirrored went through no fewer than ten editions between 1918
in part the nature of psychiatric practice. and 1942. The first seven editions incorporated minor
From the point of view of the Bureau of the Census, changes; the latter three included more extensive mod-
the adoption of a formal classification system was of ifications. The tenth edition (47) continued to empha-
major importance. Indeed, in 1920 the Bureau pub- size the biological basis of most mental disorders but
lished its own nomenclature of diseases (41), which made provision for the psychoneuroses (hysteria, corn-
relied on the Statistical Manual (39) in defining psy- pulsive states, neurasthenia, hypochondriasis, reac-
chiatric categories. It conceded its inability to draw a tive depression, anxiety state, anorexia nervosa, and
clear line between symptoms and diseases and admit- mixed psychoneuroses) and primary behavior disor-
ted that many terms used to describe pathological con- ders (adult maladjustment and primary behavior dis-

426 Am J Psychiatry 1 48:4, April 1991


orders in children). As late as 1940, the somatic view- and activism, which was carried back into civilian life
point continued to shape psychiatric nosology. after the war (49-52). “Our experiences with therapy
Paradoxically, the classification system incorporated in war neuroses have left us with an optimistic atti-
in the Statistical Manual was only of marginal concern tude,” Roy R. Grinker and John P. Spiegel (53) re-
to psychiatrists and their patients. Its categories were ported in a chapter for a manual of military psychiatry.
quite general, for the goal was to facilitate the collec- “The lessons we have learned in the combat zone can
tion of institutional data rather than to provide defin- well be applied in rehabilitation at home.”
itive diagnoses that in turn were related to specific World War II had other effects as well. In 1941, the
therapies. Psychiatric therapies between the two World status of psychiatrists in military as well as civilian life
Wars, as a matter of fact, were for the most part eclec- was marginal. Only 35 members of the Army Medical
tic and nonspecific; diagnosis was of only marginal Corps were assigned to neuropsychiatric sections in
significance. hospitals. During the war, psychiatrists slowly in-
creased their presence and importance. At the begin-
fling of 1944 the specialty was raised to the level of a
AFTER WORLD WAR II: PSYCHODYNAMICS AND division within the Office of the Surgeon General and
SOCIAL ACTIVISM placed on an equal organizational level with medicine
and surgery. William C. Menninger, who directed the
World War II marked a major watershed in the his- division, was the first psychiatrist to be elevated to the
tory of the care and treatment of the mentally ill in the rank of brigadier general. By the end of the war about
United States. Many psychiatrists who served in the 2,400 physicians had been assigned to psychiatry, al-
military came to some novel conclusions. They found though perhaps less than a third had previous training
that neuropsychiatric disorders were a more serious in the specialty (54, 55). In 1940, by way of compar-
problem than had previously been recognized, that en- ison, APA had a total membership of only 2,29S. The
vironmental stress associated with combat contributed war, in other words, brought into psychiatry hundreds
to mental maladjustment, and that early and purpose- of physicians who might otherwise have selected dif-
ful treatment in noninstitutional settings produced fa- ferent medical specialties. Their wartime experiences
vorable outcomes. These beliefs became the basis for in successfully treating neurotic symptoms in noninsti-
claims after 1 945 that early identification of symptoms tutional settings (and allegedly preventing the onset of
and treatment in community settings could prevent the more serious psychotic symptoms) reinforced the
onset of more serious mental illnesses and thus obviate growing importance of a psychodynamic and psycho-
the need for prolonged institutionalization. The war analytic model that ultimately became the basis for the
reshaped psychiatry by attracting into the specialty a postwar transformation of the specialty. More than
substantial number of younger physicians whose out- anything else, the war helped to unify the belief that
look, molded by their wartime experiences, was based environmental stress contributed to mental maladjust-
on psychodynamic and psychoanalytic concepts. After ment and that purposeful human interventions could
1945 many of these psychiatrists assumed leadership alter psychological outcomes.
positions within the specialty, fought to reorganize In the postwar era, the traditional preoccupation
APA (48), and attempted to forge new policies that with the severely mentally ill in public mental hospitals
broke with the traditional consensus on the need for slowly gave way to a concern with the psychological
prolonged hospitalization of mentally ill individuals. problems of a far larger and more diverse population
To be sure, the foundation of psychodynamic and as well as social problems generally. Persuaded that
psychoanalytic psychiatry had its origins in the early there was a continuum from mental health to mental
part of the twentieth century. Nevertheless, its triumph illness, psychiatrists increasingly shifted their activities
within the specialty had to await the transforming ex- away from the psychoses toward the other end of the
periences of World War II. During that conflict, psy- spectrum in the hope that early treatment of functional
chiatrists made major contributions in developing sim- but troubled individuals would ultimately diminish the
ple but effective means of dealing with large numbers incidence of the more serious mental illnesses.
of neuropsychiatric casualties. They found that sup- Nowhere was the changing outlook of American
portive forms of psychotherapy, when combined with psychiatry better revealed than in the formation of the
rest, sleep, and food, produced almost instantaneous Group for the Advancement of Psychiatry (GAP) in
results. Treatment in a local setting also ensured that 1946. GAP represented a group of “young Turks” de-
soldiers were not separated for any length of time from termined to reshape APA. Two years before the for-
their units and established social relationships. Over- mation of GAP, the APA Council had authorized its
all, about 60% of the soldiers who became neuropsy- president to appoint a Special Committee on Reorga-
chiatric casualties were returned to duty within 2-S nization to recommend the employment of a medical
days. The highest success rates were found in forward director for APA and to study the organization’s struc-
combat units; the lowest at rear-echelon hospitals. ture (56-58). Fearful that the heterogeneity of the As-
More than any other element, the success in returning sociation might preclude decisive action, William C.
to active duty servicemen who experienced psycholog- Menninger and a group of colleagues met at the APA
ical problems renewed a spirit of therapeutic optimism meetings in May 1946 to found GAP. There was gen-

Am J Psychiatry 148:4, April 1991 427


eral agreement that GAP would operate as a pressure nomenclature ill-adapted for 90% of their patients.
group within APA to overcome the apathy of its lead- Minor personality disturbances-many of which were
ers and, in particular, its “incapacity to function.” The of importance only because they occurred within a mil-
new organization was based on the presumption that itary context-were placed in the “psychopathic per-
psychiatry’s responsibilities and functions transcended sonality” category. The “psychoneurotic” label was
institutional care and treatment of the mentally ill (59- given to men who had developed symptoms because of
61). “I do feel,” Menninger (60) told a colleague in the stress of combat. There was virtually no recogni-
early 1947, “that American psychiatry needs renova- tion of psychosomatic disorders. Indeed, by the end of
tion in the sense of consideration of social problems the war the Army and Navy had adopted their own
and social needs.” classifications, which subsequently became the basis
Indeed, the early reports of GAP (issued in final form for revisions of the International Statistical Classifica-
as published documents) reveal a willingness to engage tion (DSM-I, pp. v-viii).
in a debate on broad social and political issues that The nosological confusion, proliferation of nomen-
bore little direct relationship to the problems of the clatures, and shift toward psychodynamic and psycho-
institutionalized mentally ill. A draft report on the so- analytic concepts led the APA Committee on Nomen-
cial responsibility of psychiatry (62) urged that psychi- clature and Statistics in 1948 to postpone further
atric insights be used in the service of social action changes in its manual and solicit instead suggestions
(defined as “a conscious and deliberate wish to change for change (67). By 1950 it had prepared mimeo-
society”). Preventive psychiatry, therefore, had to graphed copies of a revised psychiatric nosology,
move “out of the hospitals and clinics and into the which was widely circulated to various individuals and
community” (63). Although GAP’s social activism and organizations; a completed version was presented to
emphasis on a psychodynamic social psychiatry the APA Council in 1950 for its approval (DSM-I, pp.
quickly aroused hostility within the specialty, in a vii-x). In 1952 APA formally published DSM-I (68).
short time the ideological orientation of GAP pre- DSM-I reflected the intellectual, cultural, and social
vailed, and its views were shared by the majority of forces that had transformed psychiatry during and af-
APA members. ter World War II. It divided mental disorders into two
In emphasizing the need to focus on nonpsychotic major groupings. The first represented cases in which
but presumably troubled individuals, psychodynamic the disturbed mental function resulted from or was
psychiatrists tended to blur nosological categories. The precipitated by a primary impairment of brain func-
changing character of the specialty was reflected in its tion. Such brain syndromes were associated with a Va-
terminology. Traditionally, diagnoses were expressed riety of somatic conditions-infection; drug, poison,
in the language of pathology; the presumption was or alcoholic intoxication; trauma; circulatory or met-
that changes in behavior, which admittedly might be abolic disturbances; intercranial neoplasms; multiple
related to environmental factors, had a biological sclerosis; and Huntington’s chorea or other diseases of
foundation. Postwar psychiatrists, by way of compar- hereditary origin. The second category encompassed
ison, did not necessarily reject traditional formula- disorders resulting from a more general inability of the
tions. Their interest in the nature of personality (nor- individual to adjust, in which brain function distur-
mal as well as abnormal), the role of childhood and the bance was secondary to the psychiatric illness. DSM-I
influence of parenthood, and the ability of the organ- (pp. 9-43) divided this group into psychotic and psy-
ism to adjust to the environment in ways that were choneurotic disorders. The former included manic-de-
both effective and satisfying, however, led them to use pressive and paranoid reactions as well as schizophre-
a quite different terminology. Their new language em- nia. The latter, in turn, was composed of anxiety,
phasized the need to assist unhappy and neurotic in- dissociative, conversion, phobic, obsessive-compul-
dividuals, presumably through different psychothera- sive, and depressive disorders as well as a variety of
pies. In emphasizing their ability to deal with such personality disorders that included emotional instabil-
varied concerns as parent-child relationships, mar- ity, compulsiveness, antisocial behavior, sexual devia-
riage, emotional maturity, and occupational roles, the tion, alcoholism, drug addiction, stress, and various
specialty appealed to a broad public eager for assis- reactions associated with different age categories.
tance in dealing with the problems of ordinary life The prominence of psychodynamic and psychoana-
(64-66). lytic concepts in DSM-I mirrored fundamental changes
within psychiatry. The pressure for change, as a matter
of fact, was generated largely by analytically oriented
THE NEW PSYCHIATRIC NOSOLOGY psychiatrists who had few ties with public mental hos-
pitals; most of them were in medical schools, clinics,
Nowhere was the change in the nature of postwar and private practice. By 1956, for example, only about
psychiatry better illustrated than in the effort to create 17% of the 10,000 or so members of APA were em-
a new psychiatric nosology. During the 1940s, discon- ployed in hospitals, compared with more than two-
tent mounted with the classification system prepared thirds in 1940. (Data for 1956 are based on a 10%
more than two decades earlier. Military and Veterans subgroup [N943] of the 10,000 members of APA,
Administration psychiatrists found themselves using a according to the Biographical Directory for 1957

428 Am J Psychiatry 148:4, April 1991


[69].) The clientele of psychiatrists not affiliated with in the specialty, the Board announced, had to include
public mental hospitals tended to come from (to use clinical work with psychoneurotic and psychotic pa-
DSM-I categories) the ranks of the psychoneurotic, tients (75, 76). Clinical experience had to be integrated
many of whom seemed to benefit from psychotherapy. “with the study of the basic psychiatric sciences, mcd-
Psychodynamic psychiatrists also were more commit- ical and social psychology, psychopathology, psycho-
ted to social activism, a commitment mirrored in the therapy, and the physiological therapies” (75). Psychi-
activities of GAP. atrists had to be taught to collaborate with social
The growing dominance of psychodynamic and psy- workers, clinical psychologists, courts, and other so-
choanalytic concepts was reflected in changes in mcd- cial agencies. Finally, residents had to be exposed to
ical and postgraduate education. After 1945 the num- neurology to enable them “to recognize and to evalu-
ber of psychodynamic and psychoanalytic psychiatrists ate the evidences of organic neurological disease” (75).
affiliated with medical schools increased rapidly. The In 1 95 1 and 1 952 APA and the Association of
result was predictable: more and more psychiatry was American Medical Colleges sponsored two important
taught in all 4 years, thus serving as a means of intro- conferences. The first (77) dealt with psychiatry in
ducing and recruiting young medical students to the medical education and the second (75) with residency
specialty. At the same time, psychiatric teaching influ- training. Both were dominated by the psychodynamic
enced other departments. NIMH grants, in turn, sub- perspective. Anxious to alter the marginal role of the
sidized both undergraduate and residency training (70, specialty, the participants at the first conference urged
71), and the number of psychiatric residencies cx- that all medical students be exposed to psychiatric in-
panded rapidly. In 1946 there were 155 residency pro- sights in each of the 4 years. The basic aim was “to
grams; a decade later the total reached 294. The num- equip the student with a reasonably adequate knowl-
ber of actual residencies in this period leaped from 758 edge of the facts of human nature” (77). More specif-
to 2,983. The rising prestige and attractiveness of psy- ically, all medical students had to have the ability “to
chiatry was accompanied by a dramatic increase in the diagnose correctly the condition of patients who are
proportion of medical school graduates selecting the emotionally disturbed and who may be expressing
specialty, which in 1954 peaked at 12.5% (72, 73). their distress in physical, psychological or social symp-
Even more important than the increase in actual toms. This ability implies . . . a reasonable understand-
numbers was the shift in orientation that marked un- ing of the zones of healthy and sick behavior in our
dergraduate and graduate (i.e., residency) training. A society and, more particularly, the ability to differen-
1942 report on psychiatric education by Franklin G. tiate between normal, neurotic, psychopathic, psy-
Ebaugh and Charles A. Rymer (74) had reflected the chotic, and intellectually defective behavior” (77).
influence of Meyer. Transitional in character, their The deliberations at these conferences subsequently
work began with the observation that the dominance led to the preparation of a statement by the APA Com-
of the organic point of view in medical education mittee on Medical Education (77-79). It defined the
prevented “the proper recognition of the place of psy- minimum that all physicians should know about psy-
chiatry in the medical curriculum.” The concept of chiatry and the means by which medical schools could
organic disease was so pervasive that “functional corn- teach such knowledge and skills to their students. The
ponents are difficult to grasp and appear in the nature committee recommended that during the first 2 years
of improbability.” Other elements contributed to the all medical students be exposed to theories of person-
denigration of psychiatry: a moralistic view of mental ality growth, development, structure, and integration;
disorders, the emotional reaction of medical students adaptive needs; social and cultural forces affecting per-
to psychiatric concepts, and the seeming hopelessness sonality and behavior; the role of language and men-
of mental conditions. Desirable changes, Ebaugh and tation; the part played by emotions in physiological
Rymer concluded, had to rest on three fundamental functioning; and psychopathology. The curriculum
principles: the concept of man as a whole, the adop- should not attempt to train physicians to become psy-
tion of “a genetic-dynamic concept of mental disor- chiatrists but, rather, to develop “well-rounded physi-
ders,” and the inseparable relationship of psychiatry cians, who, in their relationships with all patients, rec-
and medicine (mediated by the psychosomatic ap- ognize the importance of unconscious motivation, the
proach) with a recognition of the “emotional factors in role of emotional maladjustment in the etiology and
disease.” chronicity of illness, the emotional and personality
After 1945, by way of contrast, American psychiatry problems engendered by various illnesses; and who ha-
to an unprecedented degree was shaped by psychoana- bitually see the patient in his family and general envi-
lytic theory, which emphasized the psychological ronmental setting” (78).
mechanisms that mediated between instinctual biolog- That psychodynamic insights quickly dominated the
ical drives and the pressures of the external environ- teaching of psychiatry in medical schools was apparent
ment. Change was already evident by the end of the from a GAP survey in 1959-1960 (80). Out of 93 U.S.
war. In 1946 the American Board of Psychiatry and and Canadian institutions, 88 taught psychodynamics,
Neurology gave its stamp of approval to psychody- 87 taught personality growth and development, and
namic principles; this anticipated the emergence of a 77 taught psychotherapy and clinical syndromes. The
more psychoanalytically oriented psychiatry. Training number of hours in the curriculum devoted to psychi-

Am J Psychiatry 148:4, April 1991 429


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ally every chairperson of a department of psychiatry
Mass, Worcester State Lunatic Hospital, 1841, pp 40-41
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reference (as contrasted with the descriptive or or- Mass, Worcester State Lunatic Hospital, 184S, pp SO-Si
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