Which of us is crazy and who isn’t and why? These are the questions that psychiatrists and the rest of us have been trying to answer since the late 18th century and the advent of moral treatment, when mad men and women were unchained and treated as human beings. One hundred years later, Emil Kraepelin actually drew a line demarcating one group from the other: on the one side, were those individuals who experienced hallucinations, delusions; were affectively dysregulated; and cognitively disorganized, i.e., had disturbed speech and attention deficits. On the other side of the line was everybody else, i.e., those whose behavior was normative.
Kraepelin went on to postulate that persons who were mad were mentally ill, were suffering from a neurophysiological pathology; that the symptoms they exhibited were attributable to or caused by the fundamental pathology, and that the pathology itself could be further sub-divided into a system of classifications or nosology. He identified three: dementia praecox, which Bleuler later re-classified as schizophrenia; manic depression, which included both bi-polar and unipolar deprression; and the paranoias. Karl Jaspers, a younger contemporary, later added what amounted to the personality disorders and anxiety-related disorders.
These are the schemata under which Western psychiatry has operated ever since, with some notable exceptions largely driven by class differences among their patients. For example, here in the U.S., American psychiatrists, indeed all mental health professionals, were trained in Freudian psychoanalysis. Nonetheless, poor persons and persons of color were those most likely to be confined in large state institutions where Kraepelinian principles governed and, much like today, were rarely afforded psychotherapy as a treatment option; persons of means were largely treated in outpatient settings by therapists trained in psychodynamic approaches. All this came to an abrupt end with the publication of the DSM-III in 1980. Freud and psychoanalytic conceptions of mental disorders were out and Kraepilinian concepts—or as per Gerald Klerman’s triumphalist notion, neo-Kraepelinian—were in.
DSM-III had multiple objectives, some clinical, some political. Primarily, evidence was to be gathered through extensive field trials to demonstrate that mental disorders were true medical illnesses, of neuro-biological origin, best treated by medical means, i.e., psychoactive medications. The validity of the diagnoses presented—DSM-III classified 163 distinct diagnoses, up from DSM-II’s 137 (1968) and DSM-I’s 94 (1952)—i.e., their construct validity, would then no longer be open to question. Further, the inter-rater reliability, i.e., the extent to which clinicians and researchers, particularly the latter, could agree on a diagnosis, would be significantly improved.
In sum, psychiatrists, having demonstrated that they treated bona fide illnesses, would unquestionably be seen as bona fide members of the medical profession, distinct and apart from all other mental health professions, and would have to be regarded as such by their peers as well as by the insurance companies that paid their fees. Their status as physicians would also guarantee them clinical deference from other mental health professionals and their statutory capacity to write prescriptions would install them as gatekeepers to the mental health system and pre-eminent collaborators of the pharmaceutical industry. In sum, psychiatrists’ leadership of the mental health system would be unchallenged.