As I was researching my book A Disease called Childhood: Why A.D.H.D. Became an American Epidemic, I came across an interesting pattern in the history of psychiatry. In my mind I made up a name for this pattern and called it “neo-Kraepelinian Regret,” named after the 19th century German psychiatrist Emil Kraepelin. Kraepelin was interested in classifying mental disorders by their symptoms so that psychiatrists would have a common language with which to communicate. His most famous contribution is his classification of the different forms of psychosis into manic depression, dementia praecox (which later became known as schizophrenia), and paranoia.
Kraepelin also speculated, but could not prove, that mental disorders had biological causes. Toward the end of his life, however, Kraepelin began to have second thoughts. He came to believe that that the line differentiating the psychotic disorders, and even the line differentiating mental health and mental illness, were not as sharp as he had previously believed.
Why is this relevant today? For most of the twentieth century, Kraepelin’s views about psychiatry were overshadowed by the ideas of his more famous contemporary Sigmund Freud. Unlike Kraepelin, Freud theorized that there was a continuum between mental health and mental illness, with no sharp line differentiating them. All of us could become mentally disturbed given certain life circumstances. But in 1980, Kraepelin’s ideas resurfaced with full force, embodied in the neo-Kraepelinian manual known as the DSM-III.
We are all familiar with what happened next. Kraepelin’s interest in classification and speculation about biological causes of emotional problems has dominated American psychiatry and our lives ever since the publication of the DSM-III and its successors.
But here’s the interesting thing. Along with Kraepelin’s ideas came, in time, a deluge of neo-Kraepelinian regret. Robert Spitzer, the author of the neo-Kraepelinian DSM-III, acknowledged that no biological markers have ever been identified for the mental disorders in his manual (other than organic disorders like epilepsy and Alzheimer’s disease). Psychiatrist Allen Frances, lead author of the DSM-IV, has admitted that his manual cast too wide a net for the A.D.H.D. diagnosis. Psychiatrist Edward Hallowell, whose books promoted the A.D.H.D. diagnosis and stimulant treatment for both children and adults, has his own regrets. He says he is sorry that he told parents that stimulant drugs were “as safe as aspirin.”
And, according to a recent New York Times article (Feb 2, 2015), even Dr. Peter Jensen, former head of child psychiatry at the National Institute of Mental Health and a longtime outspoken advocate for medication treatment of A.D.H.D., is starting to backpedal. In a small study of parents of A.D.H.D. kids, Jensen found that parental love and advocacy for one’s child produced the best outcome, with few parents mentioning medication. As I was reading the article in the Times yesterday, I reflected that here was yet another case of neo-Kraepelinian regret.
Thomas Insel, too, has retreated from the most recent neo-Kraepelinian manual, the DSM-5, calling it a set of definitions much like a dictionary. According to Insel, the manual’s weakness is a lack of “validity” since there are no objective laboratory tests for the various diagnoses. In other areas of medicine, Insel observes, “symptoms alone rarely indicate the best choice of treatment.”
However, we cannot include Insel among the those doctors who experience neo-Kraepelinian regret. Insel has not yet given up on the biological model of mental illnesses or the idea that mental disorders are discrete entities. On the contrary, in launching the Research Domain Criteria Project, he hopes that genetics, brain imaging and neuroscience will unlock the biological causes of mental illness. Only time will tell if this endeavor will lead to yet another wave of neo-Kraepelinian regret.
