A Historical Dictionary of Psychiatry

Edward Shorter is an historian at the University of Toronto who has written a superb summary of psychiatry’s history during the last 250 years. It is the first such book to be organized in a “dictionary” format. It amply rewards a complete reading. But it is also well organized for those who want to look up specific topics. Shorter’s lively interest in his subject matter animates his book; he often selects from the massive amount of material he researched those facts that are the most fascinating.

He is realistic about the shortcomings of each of the paradigms that have come and gone over the history of psychiatry, including the biological paradigm. He observes that “biologism too represents a kind of fad...[that] will almost certainly yield pride of place to other approaches that lie yet undiscovered” (p. viii). He may be overlooking the virtue of pragmatism in clinical psychiatry that allows us to integrate all useful theoretical models, clinical experiences, and research findings in our clinical work. He also seems unaware of the numerous ways in which recent research in neuroscience and cognitive psychology has validated many of the assertions of psychoanalysis. When any theory becomes a “secular religion” (p. 6), its adherents wear blinders, and patients suffer. He acknowledges the inappropriate tendency of psychiatry to become “intertwined with the corporate sector,” with the pharmaceutical industry “steer[ing] psychiatric diagnosis in the direction of the drugs a company has to offer” (p. 9).

The scholarship of this book is exemplary. Shorter cites dozens of articles from 19th century European medical and psychiatric journals. Sadly, even the current European psychiatric literature is poorly known to mental health professionals in the United States. Shorter’s knowledge of European languages and his resourcefulness in tracking down seemingly inaccessible journals enriches our understanding of our intellectual history. He quotes generously, bringing to life some of our prominent forebears. I was intrigued to learn that Benjamin Rush wrote in 1812, “Depression of mind may be induced by causes that are forgotten” (p. 79). Esquirol anticipated Freud’s descriptions of conflicts between the id and the superego when he wrote in 1838, “Acting abnormally, the patient is led to [instinctive] actions dictated by neither reason nor sentiment, that his conscience says is wrong but that his willpower no longer has the force to suppress” (p. 197).

It is always instructive to learn in retrospect which subsequently validated discoveries were initially met with “derision” (p. 42). Such was the reception of Berger’s invention of the electroencephalogram. It is also enlightening to learn some of the reasons that other innovations were forgotten. Falret was not given credit for discovering obsessive-compulsive disorder “because he buried the disease label amidst a rambling account of ‘intelligent insanity’” (p. 198). Kahlbaum’s substantial contributions to the understanding of paranoia were overlooked “because he chose such an ungainly word for delusions: ‘diastrephia’” (p. 207).

Shorter helps restore credit for other forgotten discoveries. For example, it was Southard in 1915 who first observed enlarged cerebral ventricles in schizophrenia. Delirium tremens was described in the Talmud. It was Graham Greene’s brother Raymond who coined the term “premenstrual syndrome” in 1953. Kraepelin anticipated Freud’s multi-causal theory of the “complemental series” when he wrote, “The more that the actual cause of insanity has its locus in the overall predisposition of the person, the more trivial need be the external impetus that brings about a lasting and customarily incurable disorder of the entire personality” (p. 229). Shorter also allows the reader to reconstruct some forgotten paths of intellectual influence; for example, Reil’s 1803 ideas about “energy imbalances” causing psychosis presage 20th century theories of “chemical imbalances” causing psychosis and depression, and both echo ancient theories of imbalances of bodily “humors” causing mental illness. Carl Rogers’ “client-centered therapy” advocated several principles that must have influenced Kohut’s development of self psychology: “complete acceptance of the patient as he or she is...and a ‘sensitively accurate empathic understanding’” (p. 251).

The book convincingly documents the ubiquitous role of cultural conditions in influencing prevalent concepts of mental illness in different eras. Shorter notes that compared with other medical specialties, psychiatry is “particularly vulnerable to social changes” (p. 3). One recurrent theme is popular and professional preferences for organic explanations of psychological symptoms. Neurasthenia was the most popular “nervous” diagnosis at the turn of the last century, until it “began to lose favor as it was psychiatrized” (p. 188). It was the introduction of disability insurance in the 19th century that stimulated interest in the impact of psychological trauma. Shorter occasionally notes the subjectivity of the innovator and the influence of personal traits on his or her contributions. For example, he says of Kraepelin’s classification of personality disorders, “Inevitably, a list of this nature represents as much the compiler’s pet peeves as it does scientifically validated disorders. Kraepelin himself led a highly ascetic lifestyle and was completely teetotal; it is unsurprising he would pathologize social drinking and ‘pleasure-seeking’” (p. 214).

In the second sentence of his preface, Shorter writes about the “virtual death” of psychoanalysis, and he acknowledges his own “preference for the biological approach” (p. viii). Such candor is one of the many appealing qualities of Shorter’s book. Readers who are unaware of the demise of psychoanalysis can keep Shorter’s bias in mind. It may explain a puzzling omission from Shorter’s vast bibliography—Henri Ellenberger’s The Discovery of the Unconscious, a widely respected history of psychodynamic psychiatry (1) .

In a perfect world, we would know the etymology of each word we use. Fortunately, our imperfect world affords us the continual pleasure of learning new etymologies (from the Greek words for the “true story” of a word’s origin). Shorter tells us, for example, that “hebe” in hebephrenia is Greek for youth, that “synapse” comes from the Greek word meaning “to clasp,” and that the Greek roots of bulimia ( bous and limos ) mean “hungry enough to eat an ox.”

In helping us see more clearly where we have come from, Shorter’s excellent book can help us shape a better future for psychiatry.