When we left off in the early 20th century in the last issue of HIAS, A Brief History of Psychiatric Diagnosis, Part I, a few themes had emerged:

Keep these themes in mind as we explore the origin story of the Diagnostic Statistical Manual of Mental Disorders.

Though it was Richard von Krafft-Ebing and Josef Adolf Hirschl who propagated the biological model of mental illness thanks to their work with syphilis, it is German psychiatrist Emil Kraepelin who is most responsible for the genesis of the DSM and its stronghold over our modern psychiatric system.

Born in 1856, Kraepelin’s work began to attract attention in 1893. Kraepelin ran a clinic at the University of Dorpat and determined that because patients often showed similar symptom patterns, he could use those patterns to classify psychiatric disorders. For example, he observed that manic-depressive insanity did not deteriorate into dementia praecox (what we now call “schizophrenia.”) Dementia praecox, on the other hand, appeared in adolescence and progressed to dementia and institutionalization. One did not morph into another, indicating to Kraepelin that despite some similar symptoms, they were two separate ailments.

Kraepelin took this theory and applied it to all expressions of psychiatric distress that existed at the time. He coined the term “depression”, distinguishing it from the melancholia umbrella that had described human suffering for centuries, and separated the “paranoid thinking of schizophrenia” from “paranoia.” He was fixated on objectivity and measurability, eschewing notions of stress, environment, personality, and their potential impact on mental illness.

He was also a rampant eugenicist. A letter to the editor published in the American Journal of Psychiatry put it bluntly:

In a 1919 paper titled “Psychiatric Observations on Contemporary Issues,” Kraepelin proclaimed that “dreamers, poets, swindlers and Jews” possess “distinctly hysterical traits” and fall outside the bounds of normality, adding that Jews exhibit “frequent psychopathic disposition.”

Kraepelin died in 1926, but his belief that “reasonable policies of racial hygiene” were the solution to Germany’s “degeneration” problem deeply influenced Nazi ideology and the rise of the Third Reich.

While an obvious display of eugenics was playing out in Europe during the first half of the 20th century, the American Psychiatric Association (APA) was busy with a more inconspicuous systemization. In 1913, the APA set up a statistics committee that eventually took responsibility for classifying psychiatric diseases. Combining American observation with Kraepelin’s work, these publications ruled American psychiatry through World War II.

We need to pause for a moment in order to highlight an oft-ignored aspect of this early American classification. It must be noted that as reported by the American Psychiatric Association itself, “Between 1892 and 1947, 31 presidents of APA acted in leadership positions in eugenics organizations, during their time as president, but also in the years surrounding their presidencies.”

Let that sink in for a minute. During the time in which the foundation for all modern psychiatric diagnostic strategies was built, the people in charge of creating that system held the same beliefs as Hitler. Literally, your kid’s ADHD diagnosis or your bipolar diagnosis is rooted in the same categorization and rationale that led the Nazis to exterminate six million Jews.

Combine this with the Social Darwinist movement pervading white-collar industries at the time, and it’s no surprise that the intellectual elite worked to sort folks into acceptable and flawed stock. And don’t think this was an act of good intentions gone awry. Even the modern IQ test that we still use today, which was developed around the same time, is rooted in eugenics. Developed by noted American eugenicist Henry H. Goddard, the IQ test ranked those he considered “feebleminded” into three categories of perceived incompetence: pre-verbal “idiots” illiterate “imbeciles,” and high-functioning “morons.” According to a law review of the landmark murder trail Atkins vs. Virginia, which hinged on the definition of mental retardation, Goddard “found morons wherever he looked: criminals, alcoholics, prostitutes, and anyone ‘incapable of adapting themselves to their environment and living up to the conventions of society or acting sensibly.’”

But by 1948, though the foundation for systemization was already laid, German eugenic sentiments weren’t exactly popular among the collective. Thus, the APA asked its Committee on Statistics to rewrite the diagnostic system. A rebranding, if you will.

Spearheaded by George Raines, the first edition of the Diagnostic Statistical Manual of Mental Disorders pulled away from German language and theories, instead drawing from the en-vogue influences of Sigmund Freud and Swiss psychiatrist Adolf Meyer. Both Freud and Meyer attributed psychological distress to childhood experiences and in Freud’s case, sexual repression. Kraepelin’s symptom-based sorting system still remained, but because of this shift, psychotherapy dominated psychiatric thinking for a short time.

Right around the time the DSM-I was making its way into clinical practice, psychopharmacology was on the rise after the first mood-altering drug, iproniazid, was accidentally discovered in a tuberculosis ward in 1952. Iproniazid induced euphoria in terminal tuberculosis patients and phenomena so profound, the drug was given to 400,000 depressed people to see if it would have the same effect. It did, but it also caused the blood vessels to constrict to dangerous levels, and administration of the drug was stopped. However, its brief existence brought the chemical imbalance theory of mental illness back to the forefront, and the DSM-II was written with this in mind.

It is at this point that the “pill for every ill” strategy leaves psychiatric wards and enters the homes of everyday folks, in part due to the introduction of tranquilizers and benzodiazepines aimed at women in the early 1960s.

In the early 1970s, after the US/UK Diagnostic Project determined that American psychiatrists and British psychiatrists operated by wildly different criteria for diagnosing schizophrenia (a not-so-surprising twist given that there wasn’t and still isn’t any medical test for schizophrenia or any other mental illness), American psychiatry determined it needed to tighten up its diagnostic strategy.

Robert Spitzer, a biometrician at Columbia University, was assigned the task. It is Spitzer who came up with the checklist, in that in order to meet the criteria for a certain mental illness, the patient had to experience X symptoms out of a list of Y.

The DSM-III also introduced bipolar disorder, borrowing the term from yet another set of World War II-era German psychiatrists, Karl Kleist and his student Karl Leonhard. We all know where this leads. According to Edward Shorter, PhD., “The term went on to become among the most popular diagnoses in psychiatry, as well as the foundation of pharmaceutical fortunes selling ‘mood stabilizers.’”

The DSM-III also added attention deficit disorder to the lexicon, as well as post-traumatic stress disorder and a variety of anxiety disorders.

Shorter continues, “What psychopharmacology had begun, DSM-III finished off; the [psycho]analysts were shown the exit sign from the field, or at least from its commanding heights…the DSM-III began a rapprochement between psychiatry and the rest of medicine.”

Since the publication of the DSM-III in 1980, the “bible” of psychiatric diagnosis has been revised three times, with the DSM-V appearing in 2013. From a clinical level, little has changed in the world of diagnoses since the DSM-III appeared. Patients are still judged by a checklist of diagnostic criteria, psychotherapy and root cause are generally ignored, and no test, scan, or lab exists to confirm or refute a biological or chemical cause for mental illness.

One thing, though, is noticeably different. The size of the Diagnostic Statistical Manual of Mental Disorders has swelled with each edition.

The DSM-III registers at 494 pages and weighs 1.9 pounds.

The DSM-IV is 886 pages and 3.4 pounds.

The updated DSM-V, published in 2022, is 1050 pages and weighs 4.6 pounds.