The Dimensional Side to Personality

We have been looking at Take Two (from June 21) in the DSM-5’s proposed update to personality disorders. In Take One (from Feb 2010), the DSM-5 attempted to combine categories (as in “which one?) with dimensions (as in “how much?”) into a hybrid system, using interchangeable parts that could best be described as modular. The concept was far-reaching. The catch was that it appeared to be very unwieldy in practice.

Yesterday, we looked at how the DSM-5’s Take Two tackled the categorical side of personality, using a dimensional twist. Today, we look at the DSM-5’s Take Two of the dimensional model, built on categorical pieces, but a different set of categorical pieces from Take One.

Take One, in essence, was based on a sort of reverse Five-Factor Model (such as “antagonism” in place of “agreeableness”) measuring 37 different trait facets on a four-point scale. Take Two is far more modest in scale, but may be much more useful.

Consider, for instance, the following four individuals:

Jane, 28, displays classic borderline symptoms - unstable self-image, trouble maintaining relationships, and so on. But she is working as a manager in a city government. Does the borderline label really apply?

Bill, in his 20s, flies off the handle, uses drugs, and has run-ins with the law, but does not meet the criteria for antisocial. But clearly, his behavior warrants clinical attention.

Sally, 14, is acting out like someone with borderline, but is her behavior more attributable to being a teen?

Joey, in his 50s, deals with major depression and diabetes, and has major issues getting along with his caregivers. Is there a diagnosis that doctors can apply to patients they don’t like?

Enter the Levels of Personality Functioning Scale. This employs the self and interpersonal functions from Criterion A used in all six categorical diagnoses and rates them in terms of severity from 0 to 4. Thus, in 0 (well-adjusted), we see these kind of qualities: “ongoing awareness of a unique self”, “sets and aspires to reasonable goals”, “capable of understanding others”, “maintains multiple, satisfying, and enduring relationships”, and so on.

Meanwhile, way over on 4, we see “boundaries with others are confused and lacking”, “poor differentiation of thoughts from actions” - well, you get the picture.

Then we’re asked to consider the six (mostly interchangeable) trait domains that form the basis of the six personality disorders: Negative Affectivity, Disinhibition, Antagonism, Psychoticism, and Compulsivity. Only this time we are viewing these domains as stand-alone entities rather than in the context of a full-blown personality disorder.

Let’s return to our individuals, who represent abbreviated versions of the examples served up by the DSM-5.

Jane, according to the DSM-5, would rate a diagnosis of borderline, “but her level of personality functioning might be rated as less impaired than that of the more typical borderline patient, with enhanced prospects for successful treatment.” In other words, Jane is a good prognosis patient.

Bill, under the old DSM, would probably sail under the diagnostic radar or fall through the cracks. Perhaps he would be diagnosed as Personality Disorder NOS (not otherwise specified), which tells us nothing. Under the DSM-5, we are told, Bill would be coded as “Personality Disorder Trait Specified,” emphasis on trait specified, such as hostility and impulsivity. These traits would then “serve as specific foci of clinical attention.”

Sally may show signs of emerging borderline, but the DSM-5 indicates the wise course is to hold off on this diagnosis, and instead note her as having a low level of personality functioning, with reference to specific traits such as emotional lability. These features can then be closely tracked as Sally matures.

Joey may not have a personality disorder, but he could be written up for “antagonism,” and impairment in interpersonal personality function. The DSM-5 doesn’t say this, but the best way of treating Joey’s depression and diabetes is to treat the personality issues that sabotage his being a successful patient.

***

Thus, in terms of functional impairment and various traits, in all four cases we are seeing evidence of “something” going on - from a personality disorder with a good prognosis to a clinical condition as serious as any personality disorder to a situation of wait-and-see to a pressing concern that merits some sort of intervention.

This may not be a perfect system, and already a predictably rotten tomato review has come in from Allen Frances, head of the criminally horrendous DSM-IV, who characterized Take Two as “an impossible mess to the rest of us.”

Dr Frances may well be right, but for all the wrong reasons. Dr Frances has indicated in all his DSM-5 writings to date that he sees himself as merely as the keeper of his precious DSM-IV, which is a very different proposition than lending his professional wisdom to improving the lives of those dealing with serious personality issues. In the final analysis, any attempt to pin down something as infinitely complex as personality is doomed to be flawed. Success, then, is modest, to be measured in terms of less flawed than the effort before.

Could the DSM-5 have done a better job? Of course it could have. Is the version it turned in way better than the sorry DSM-IV mess that Dr Frances is so in denial about? Don’t make me answer that.

Previous pieces:

Personality Disorders - The DSM-5 Has Another Go
Take Two on Personality Disorders

Take Two on Personality Disorders

Yesterday I reported on the DSM-5’s second go at revising the various diagnoses classified under Personality Disorders. The big issue is incorporating the concept of “dimensionality” into what to date has been a “categorical” system.

Category is all about either-or, all or nothing. Is it borderline, for instance, or is it normal? Is it borderline or is it antisocial? Lumping symptoms into categories is useful to a point, but simplistic labeling has its very obvious drawbacks.

Dimensionality acknowledges a lot more possibilities. Could it be a bit of Borderline, for instance, plus a bit of Antisocial? Maybe we should dispense with labels altogether and see what’s really going on. Impulsivity? Hostility? Lack of empathy? Dimensionality obviously best approximates reality, but at the expense of clarity and workability.

The DSM-5’s answer is a hybrid system, built on interchangeable parts. Assemble the parts one way to build a classic categorical diagnosis. Assemble the same parts another way to come up with a dimensional perspective. In this sense, it is more accurate to describe the new system as “modular” - think IKEA - rather than hybrid.

Okay, let’s see what we have second time around ...

The DSM-IV lists 10 personality disorders. The DSM-5 on its first go eliminated five, leaving us with Borderline, Antisocial, Schizotypal, Avoidant, and Obsessive-Compulsive (not to be confused with OCD). On its second go, the DSM-5 restored Narcissism.

This time around, the DSM-5 imposes strict order on its six categorical disorders. Thus, whether it’s Borderline or Antisocial or the other four we’re talking about, we see in common:

Significant impairments in personality functioning, broken down into impairments with self-function (involving issues with identity and/or self-direction) and impairments in interpersonal functioning (involving issues with empathy and/or intimacy).

This is Part A of the diagnosis. In Part B, we are looking at "pathological personality traits" organized into “domains.”

Let’s start with Part A. Below is a table of the Borderline and Antisocial Part A criteria side-by-side:

Criterion A	Borderline	Antisocial
1. Impairments in self functioning a.	Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.	Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
1. Impairments in self functioning b.	Self-direction: Instability in goals, aspirations, values, or career plans.	Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.
2. Impairments in interpersonal functioning a.	Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.	Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another. b.
2. Impairments in interpersonal functioning b.	Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.	Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

OK, clearly someone with borderline is living in a different interior world than someone with antisocial. Now let’s compare Part B criteria side-by-side (minus the lengthy descriptions):

Criterion B	Borderline	Antisocial
Negative Affectivity	Emotional lability Anxiousness Separation insecurity Depressivity
Disinhibition	Impulsivity Risk taking	Irresponsibility Impulsivity Risk taking
Antagonism	Hostility	Manipulativeness Deceitfulness Callousness Hostility

Note first the interchangeable parts. Borderline and Antisocial share two “domains” in common, Disinhibition and Antagonism. Thus a picture emerges of individuals prone to flying off the handle (often at you, their nearest victim), regardless of their diagnostic label. Criterion C makes it clear that these impairments “are relatively stable across time and consistent across situations.” In other words, we are talking about a clear and sustained pattern of bad behavior, not just a bad hair day.

But also notice the differences. Antagonism comes far more fully loaded in the Antisocial diagnosis. Meanwhile, those with Antisocial come up empty in the Negative Affectivity department. An abusive outburst may look the same, but over time we see different patterns. Moreover, the underlying dynamics are wholly different - one appearing to arise from an inflated ego, the other from an almost lack of ego.

In a sense, Antisocial shares a thing or two in common with Narcissism. Indeed, in the DSM-5’s first version, Narcissism was folded into the Antisocial diagnosis. The DSM-5 keeps its restored Narcissism diagnosis short and sweet, with only one domain (Antagonism) with two personality traits (Grandiosity and Attention-seeking).

Meanwhile, we see Borderline leaning in the direction of Avoidant, with both individuals in effect running scared, sharing the same personality trait of Anxiousness under Negative Affectivity, but with different ways of responding to their respective insecurities.

Thus, even in making categorical distinctions, we see dimensionality at work.

One important point: There are more domains than what you see listed under Borderline and Antisocial. Thus, in addition to Negative Affectivity, Disinhibition, and Antagonism, we also have Psychoticism (a major feature of Schizotypal) and Compulsivity (a major feature of Obsessive-Compulsive).

***

Don’t worry if you’re confused. At this stage, it is simply enough to know that the DSM-5 is making an attempt to show dimensionality in its categories, namely that:

1. Regardless of diagnosis, individuals with personality disorders share in common major difficulties in self-function (relating to self) and in personal function (relating to others).
2. Individuals across the various diagnoses tend to share various traits common to other diagnoses, as well.

At the same time, the DSM-5 is also red-flagging key distinctions. These disorders are related, yet separate, kinda, sorta - if you get the drift.

Next: The DSM-5 takes on dimensions ...

Personality Disorders - The DSM-5 Has Another Go

On June 21, the DSM-5 workgroup responsible for bringing order to personality disorders substantially changed what it originally posted on the DSM-5 site back in Feb, 2010. Most of us could see this coming. As the workgroup explained in its most recent update: “All parts of the model have been simplified and streamlined in response to comments received and to critiques in the published literature.”

A little background ...

Unlike the rest of the DSM-5, the 2010 roll-out of Personality Disorders was no mere light dusting of the status quo. This was a major home-improvement, a hugely ambitious effort that sought to integrate two different ways of looking at mental illness - categories (as in “which one?”) with dimensions (as in “how much?”) into something workable.

Personality, after all, cannot be easily categorized. Yet, we do need categorical bearings. Dimensionality is far more in sync with clinical reality, yet much more difficult to sort and freeze into comprehensible diagnostic nuggets. The workgroup’s answer to this dilemma was essentially a modular system. (The diagnostic literature refers to “hybrid,” but “modular” - think IKEA - is far more accurate.)

Thus, the DSM-5 retained diagnostic categories such as Borderline and Antisocial, but built them with interchangeable parts. Accordingly, individuals with either illness may have the following hostility “personality trait” in common:

Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults ...

This particular trait is a subset of the antagonism “domain.” But quick comparison between the two categories reveals very different loadings. Those with antisocial have far more antagonism traits (such as callousness) than those with borderline. (The new version lists only one antagonism trait for borderline, down from two in the old version.) Meanwhile, borderline comes heavily loaded in negative affectivity traits (such as emotional lability) while we see nothing of the sort in antisocial.

Thus, a few shared traits, but clearly defined separation, which hopefully results in less diagnostic confusion.

That brings us to the dimensional element. In their initial roll-out, the DSM-5 essentially took apart and reassembled the exact same categorical bits and pieces in a different way to see “how much” of say borderline or antisocial (or avoidant or schizotypy or obsessive-compulsive) one has.

In other words, the real world is not black and white, much less divided into all-or-nothing choices. Imagine: Under the DSM-IV, a person who is one symptom shy for not only borderline, but also antisocial and narcissism is technically normal. How crazy is that? The DSM-5’s solution was to look at the entire gamut of personality as something analogous to blood pressure, from healthy to unhealthy, with an eye on the various loadings.

One may or may not require clinical attention, but a dimensional assessment can be an enormous help in knowing thyself.

Great concept, but the DSM-5’s first draft was monumentally unwieldy, calling for clinicians to rate 37 facets making up six domains on a four-point scale. Who has time for that?

It was back to the drawing board for the DSM-5 work group. Eighteen months later, the blood pressure principle remains the same, but now, in place of version number one, we have a new dimensional entity called Personality Disorder Trait Specified (PDTS).

Oh-oh! Are we in for yet another mouthful of diagnostic alphabet soup, this time looking like a misspelling of PTSD? Or is the DSM-5 about to make life easier for us?

More to come ...

The Year That Was - Almost Over, But Not Letting Go: Part II

My second (first here) idiosyncratic installment in looking back on how 2010 unfolded:

Old Movie of the Year: Groundhog Day

Updating the DSM is an exercise that affords us that rare opportunity to think mental illness afresh. The last time this happened was in the late seventies with the publication of the ground-breaking DSM-III of 1980. Think of the DSM-III as the old DOS operating system. Its successor editions (the last one was 1994) were essentially DOS updates. In Feb this year, the American Psychiatric Association unveiled its draft to DOS-5 - um DSM-5 - due for publication in 20013.

In sticking to DOS, as I reported here on numerous occasions, those responsible for the next DSM - which sets the scene for the next 20 years - are keeping us stuck in 1980 Groundhog Day forever.

If nothing else, a soul-searching discussion would have been useful. Hell, I would have settled for an instant message. An instant message where numerals pose as words, even. Is this asking too much? Yes, apparently.

Psychiatrist of the Year: Emil Kraepelin

Okay, he’s sort of dead - well, completely dead - which is a rather large technically. But even dead, this guy leaves the live psychiatrists for dead. (Wait, let me rephrase that.) Kraepelin, who was born the same year as Freud, coined the term, manic-depression, which - contrary to conventional thinking - is not synonymous with bipolar.

Kraepelin saw all forms of depression (even unipolar depression) in an obvious relationship with clear overlap. This translates into a lot of unipolar depressions behaving like bipolar, even if mania is not involved. This may also explain why antidepressants do not work for a good many people, and may indeed be harmful. The DSM-III of 1980 can be forgiven for getting this wrong. The DSM-5, due out in 2013, cannot.

No doubt about it: If we could somehow “undead” Kraepelin, he’d be saying take a match to the DSM and start over. Instant message: "G8 stuff, homey! All 4U! :) :)"

Person of the Year: You

That’s right, you - patients and loved ones. In April this year, I delivered a keynote to DBSA Kansas. As part of my talk, I asked my audience to come up with a one-sentence description of depression. The answers bore some relationship to the DSM, but were much more insightful and in touch with reality:

“Like having two doberman pinschers waiting for you to get out of bed in the morning.”

“You're on a raft, in the middle of a huge ocean, you can't see any land anywhere, on any horizon, and you're totally becalmed.”

“It's like trying to walk through mud up to your neck.”

These were just some of the responses, very much in line from what I have been hearing from fellow patients and loved ones for years. But then again, only we know what we have to live though. Too bad psychiatry isn’t interested in hearing from us. “Is that a better list than the DSM list?” I asked my audience. “Congratulations,” I concluded, “you guys have beat the best psychiatrists in the world. Give yourselves a round of applause.”

More to come ...

Personality Disorder: Understanding Dimensionality

The story so far: The DSM-5, due out in 2013, will be the same old book in new covers. The exception is personality disorders, which gets a major overhaul. Not coincidentally, this is the one realm of mental illness where big pharma is conspicuously absent.

My last two blog pieces - Decisions, Decisions, and Bringing Order - looked at the changes on the “categorical” side of personality disorders. Five out of ten of the present disorders will get the boot, while the five left standing (antisocial/psychopathy, avoidant, borderline, obsessive-compulsive, and schizotypy) receive further clarification. The weakness with categories is inevitable overlap, but rather then pretending this doesn’t exist, the DSM-5 openly adopts interchangeable parts, with six “trait domains” (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) further subdivided into “facets.”

Thus, the new borderline “type” (which replaces the term “disorder”) is loaded with six negative emotionality trait domains and two antagonism domains, while the new antisocial/psychopathy type is heavy on antagonism (six in all) and light on negative emotionality (zero, in fact). The two borderline antagonism facets (hostility and aggression) reappear word-for-word in antipsychocial/psychotic.

Kind of like IKEA. The parts may be the same, but each piece of furniture - one hopes - is very different. So what would happen if we were to dispose of the concept of furniture altogether? Funny you asked.

Enter the “dimensional” model. The same bits and pieces are there - namely the general trait domains of negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy, plus the more specific facets - but instead of looking for labels, we are looking for shadings. Instead of asking “Which one?” (as in borderline or antisocial) we are asking “How many?” and “How much?”

The DSM-5 trait domains are derivative of, and roughly correspond to, the traits in the five-factor model (FFM), already in wide use in clinical practice. The FFM tests for “openness to experience”, “conscientiousness”, “extraversion”, “agreeableness”, and “neuroticism” (OCEAN).

A quick scan, however, reveals that the FFM and DSM-5 investigate essentially the same phenomenon from entirely different viewpoints (“extraversion” vs “introversion”, “agreeableness” vs “antagonism”, “conscientiousness” vs “disinhibition” and “compulsivity”). Whereas the FFM looks at our potential, the DSM looks at what is holding us back.

A good illustration of this is the FFM’s “openness to experience” trait, which has no apparent correspondence in the DSM-5. The opposite to openness to experience is stuck in the mud, which you can hardly associate with any kind of mental disorder. In this context, stuck in the mud is simply less desirable than being creative and intellectually adventurous.

Now let’s examine the one DSM-5 trait with no seeming FFM counterpart. “Schizotypy” broadly describes strange thinking and behavior. Its opposite? May I suggest stuck in the mud? In other words, in a DSM setting, stuck in the mud comes across as a desirable trait. Certainly, no one calls 911 to complain about their boring wife or husband.

The DSM-5 calls for clinicians to rate all 37 facets which make up the six domains on a four-point scale, which invites the instant criticism of clinical unwieldiness. According to Allen Frances, who chaired the DSM-IV, blogging on Psychology Today:

Unfortunately, the reach of DSM-5 far, far exceeds its grasp. Only by going to the website yourself and reviewing the DSM-5 dimensional suggestions can you get a feel for just how remarkably ad hoc, idiosyncratic, and cumbersome they are. I have discussed the suggestions for dimensional personality disorder ratings with a number of experts (and this is also my area) and none of us could decipher the proposal, much less conceive of its ever being workable. One described it as an example of "too many research cooks spoiling a clinical broth".

Dr Frances’ criticism may well be valid, but it also can be interpreted as an egregious case of DSM-worthy “lazy clinician syndrome.” We see this every day in doctors who profess to be far too busy to monitor their patients for weight and blood sugar levels and other red flags when prescribing meds with notoriously high metabolic risks, not to mention other high crimes and misdemeanors.

Personality is fiendishly time-consuming and complex. Clinicians want it quick and simple. But what about our interests?

Much more to come ...

Previous Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

Bringing Order to Personality Disorder

Bringing Order to Personality Disorder

Yesterday, we inspected the house-cleaning performed by the DSM-5 workgroup charged with bringing order to personality disorder. Unlike the rest of the DSM-5, this particular crew actually rolled up its sleeves and went to work. No mere light dusting for them. Five of ten of the personality disorders got tossed. The remaining five (now referred to as “types” rather than disorders) received a major refurbishing and a sense of congruency.

The grand piano, in effect, has been retuned and refinished and moved from the laundry room to the living room, though questions still remain as to what to do with the moose head now in the dumpster (think narcissism). These are the “categorical” reforms. There is a new element of “dimensionality” which we will get into later. Sticking with categories ...

The old (and still current system) was only useful in sorting out the obvious (such as green from blue) but of very little value where the colors blended (green, for instance, contains blue). An impulsive and angry individual with a skewed view of self and others, for instance, may be a candidate for both borderline and antisocial. Throw in a sense of me-me-me/I-I-I, and the narcissism diagnosis comes into play.

The new (and future) system acknowledges the overlap, but puts the reader on notice that we are not exactly dealing with the same phenomenon. The first thing that sticks out in comparing the new borderline to the new antisocial/psychopathy, for instance, is that the former comes loaded with six “negative emotionality” symptoms and only two “antagonism” ones while the latter is heavily laden with six antagonism symptoms and zero negative emotionality ones.

As for narcissism (may it rest in peace), a number of the old narcissist traits have been  folded into the new antisocial/psychopathy diagnosis. Not one appears in the new borderline diagnosis. Yes, it would be nice to have the narcissism diagnosis back in the picture (and I will be making that case in a future piece), but in this context its absence brings into sharper relief the inflated/lack of sense of self that separates borderline from antisocial.

The DSM-IV bunched the ten personality disorders into three clusters (A, B, and C), but with only five types left to choose from in the DSM-5, there is no sense in retaining these walls of separation. Again, we are dealing with overlap and loading. The new “avoidant,” for instance, contains nearly as many negative emotions as borderline (five in all, two of them the same as borderline) plus five “introverted” ones (such as “intimacy avoidance”) with nothing in the “antagonism” department.

Meanwhile, we know obsessive-compulsive (the personality disorder, not the Axis I diagnosis) and schizotypy are horses of a different color, but nevertheless they do share some of the primary colors across the personality spectrum.

So what are we looking at? According to the DSM-5:

Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.

This harkens back to the Freudian-influenced DSM-I of 1952 and the DSM-II of 1968 when even the likes of schizophrenia were seen as maladaptations to one’s environment. The DSM-5 revives the idea of maladaptation, but dials it back to personality disorders. In other words, personality type is a tip-off to our default protection mechanisms.

Do we, for instance, try to dominate those around us? (Antisocial.) Or do we freak out and lose it? (Borderline.) Or do we withdraw into a comforting cocoon? (Avoidant.) Maybe we look for order where none exists. (Obsessive-compulsive.) Perhaps we harbor unusual perceptions of reality. (Schizotypal.)

We may argue over what else should be there (such as Narcissism), and what more could have been done to clarify the different types, but when all is said and done, we are looking at a greatly improved navigational system.

Meanwhile, we all have personality in abundance and come preloaded with all manner of quirks and flaws. We may be successful adapters, but - trust me - we will all see a bit of ourselves in the DSM looking glass. In this sense, we are likely to get more out the DSM-5 than our clinicians. 

Much more to come ...   

Recent Personality Posts

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

The Draft DSM-5 - Rip It Up and Start Over: Part I

Yesterday, the American Psychiatric Association’s DSM-5 Task Force released its much-anticipated draft to the next DSM, scheduled for completion in 2013. The document is available for viewing and comment on the APA’s website.

Where to start? Let’s go with my diagnosis - bipolar - as well as the bane of my life, depression. First some background:

Written observations on depression and mania go back to ancient times. How could Plato, for instance NOT notice Socrates acting weird? But observations do not equate to understanding, and, crazy as it sounds, what was beyond the grasp of ancients continues to elude today’s experts, namely:

How do depression and mania relate? Part of the same phenomenon? Or separate? A bit of both?

How do depression and mania fit into the human condition? Natural temperament? Or outside force that takes over the mind? A bit of both?

By the last half of the nineteen century, medical science had connected depression to mania. “Folie circulaire,” the French called it. In the early twentieth century, the pioneering German diagnostician, Emil Kraepelin (pictured here), coined the term manic-depression. But here’s the rub - manic-depression to Kraepelin and generations to follow was not synonymous with what we now call bipolar. Manic-depression also embraced what we now call unipolar depression.

Kraepelin saw depression as a “recurring” phenomenon. Some individuals cycled up into raving mania, then back down into depression (often with long periods of remission). Others simply cycled up into milder states.

In essence, Kraepelin saw depression and mania as occupying opposite ends of the same spectrum, different but closely related, with the same underlying cyclic features. Kraepelin also viewed manic-depression as a biological illness, but nevertheless occupying a spectrum that embraced the temperaments that influence our personality.

Kraepelin’s model proved to be a bit too overreaching. In the 1960s, Jules Angst and others identified “chronic” depression and parsed it out from “recurrent” depression. But the Kraepelin model still held. During the 1970s, Frederick Goodwin and others regarded recurrent depression as a close cousin to bipolar rather than a sibling of chronic depression.

This bears repeating: The leading investigators of the day viewed manic-depression as embracing both bipolar and recurrent depression. Chronic depression was seen as a separate phenomenon.

Another way of viewing the spectrum, pioneered by Angst, is by conceptualizing “pure” mania at one end and pure depression at the other, with a lot of mixing it up in the middle. Thus, severe depression with a bit of mania might look like this - Dm - while hypomania with some depression would be represented as - md. And so on. Under this view, “mixed” states (think agitated depression or dysphoric mania) are seen as closer to the rule rather than the exception.

Meanwhile, we had Freud to consider. Freud’s followers saw depression and mania (and other states) as not necessarily biological, but as maladaptive reactions to one’s environment. Freud was the dominant mindset of psychiatry when the APA published the DSM-I in 1952, replete with its inclusion of “manic-depressive reaction.”

Oddly enough, “manic-depressive reaction” embraced Kraepelin’s wide view of the illness, but as an outward expression of underlying psychosis. Since Freudian psychiatrists wrote off those they saw as “psychotic” as hopeless and uncooperative, there was little interest in working with these patients. Their fate was institutional neglect.

“Neurosis” and “behavior” by contrast, defined psychiatry’s walking wounded as well as its meal ticket. The DSM-I made provision for both depression, and manic-depression lite (cyclothymia) as either a manifestation of anxiety-driven neurosis or as embedded in one’s personality. This accorded with the Freudian mindset of rooting out the underlying neurosis or behavioral quirk rather than helping patients manage symptoms. Hence there was little professional interest in depression and other ills as entities unto themselves. Hence, there was little interest in the DSM.

The DSM-II of 1968, largely a rerun of 1952, met with the same underwhelming response. But change was in the air. First-generation psychiatric meds, coupled with the realization that not many patients actually got better under Freudian therapy, give rise to a new era of diagnostic psychiatry, with Kraepelin as its inspiration. Leading the charge was Robert Spitzer, with a modest brief to tweak the DSM so it harmonized with international standards.

Spitzer had other ideas. With a strong supporting cast of psychiatric researchers who valued science over dogma, Spitzer set about producing a document that would allow professionals worldwide to communicate in the same language. A major innovation was the “symptom list” that represented a giant leap forward from Freud and his neurotic muck.

What was widely understood by those working on what was to become the DSM-III of 1980 was that their efforts would represent a work-in-progress. With psychiatric science in its infancy, it was a given that new data and new insights would supplant the best guesses that Spitzer and his team were coming up with. Mistakes were inevitable, but you had to start somewhere. Just so long as you could correct them later.

Just so long as you didn’t cement yourself into a corner for the next 30 years.

Next: The DSM cements itself into a corner for the next 30 years ...

Further reading:

• Spitzer and the DSM - Part V
• Spitzer and the DSM - Part IV
• Robert Spitzer and the DSM - Part III
• Robert Spitzer and the DSM - Part II
• Robert Spitzer and the DSM - Part I