Changes in the Psychiatric Landscape

DSM-III established diagnostic reliability in psychiatry. The power of DSM-III and its subsequent revisions has been enormous, permeating the whole mental health field, determining insurance reimbursement, influencing court proceedings, and exerting a profound cultural impact. Reliability, however, is not the same as validity. In rewriting our book, we found numerous elements in DSM discordant with our clinical experience. In our opinion, DSM is most valuable in bringing clarity to the diagnosis of severe psychiatric disturbances, such as psychoses and affective illnesses. It is less helpful in the more murky area of what were previously called neuroses and in the axis II diagnoses. For instance, the DSM-IV taxonomy of anxiety disorders, with the exception of obsessive-compulsive disorder, may be more illusory than real. “Pure” forms of these conditions are rare, and one type frequently overlaps with another, as comorbidity studies have shown (1) . This speaks to our clinical experience of the amorphous nature of the anxiety disorders and their common underlying template—a constitutionally based alteration in the psychology of anxiety.

The diagnosis of posttraumatic stress disorder (PTSD) appeared in the DSM-III nomenclature on anxiety disorders in 1980. The diagnosis has become increasingly popular, although we wonder if this popularity is not a reflection of the hidden, erroneous, but comforting idea that the patient and his or her premorbid psychodynamics have nothing to do with the onset of chronic PTSD. The patient remains “pure” and an object of compassion for the terrible event that has occurred and caused his or her troubles. However, trauma is common in everyday life, and although severe trauma often causes acute PTSD, the high percentage of people who do not develop chronic PTSD after even severe trauma has suggested to many observers that an intervening variable reflecting predisposing psychological factors exists between trauma and chronic response.

With regard to axis II diagnoses, we found a number of problems with DSM taxonomy. For instance, the DSM-IV criteria for histrionic personality disorder focus on a more primitive variant than that described in the older literature on the hysterical personality . DSM-IV describes one end of a continuum that overlaps with the borderline personality disorder patient but excludes the well-integrated and better-functioning histrionic patient, who represents a personality type rather than a disorder and who tends to be more stable and to have better impulse control. The elimination of the DSM-II diagnosis of hysterical personality disorder and its replacement by histrionic personality disorder in DSM-III essentially removed a valuable clinical diagnostic entity and replaced it with only one of the subsets of the syndrome.

Masochism has become a contentious term. Although we believe that masochism and masochistic behavior are valuable psychopathological concepts, there has been a groundswell of social-political opposition to the diagnosis based on the premise that such labeling is a form of “blaming the victim.” We feel that this argument ignores everyday clinical reality and may subvert appropriate therapeutic interventions. Patients who present with a history of unnecessary suffering, self-defeating behaviors, and recurrent self-induced disappointments in life are ubiquitous in clinical practice. The self-defeating patient made a brief appearance in DSM but vanished in latter editions. Regardless of the eventual evolution of the official classification of masochistic patients, their existence is apparent.

The emergence of the diagnostic categories of borderline personality disorder and narcissistic personality disorder is another important development in clinical psychiatry since 1971. Both borderline personality disorder and narcissistic personality disorder were “discovered” in the consulting room of the psychodynamically oriented psychiatrist. They are clinically derived concepts. The borderline personality disorder patient was first recognized when patients who initially seemed to be appropriate candidates for dynamic psychotherapy became worse in the course of treatment and revealed far more serious psychopathology than was suspected in the initial evaluation. Similarly, the delineation of narcissistic personality disorder began with the struggle of psychoanalysts and psychodynamically oriented psychiatrists to understand a group of particularly difficult-to-treat patients—patients who were neither psychotic nor classically neurotic, who were not responsive to traditional psychotherapeutic interventions, and who were characterized not so much by observable psychopathological phenomenology as by inferred psychodynamic patterns. Their problems were internal and related to the way in which they experienced themselves and others. It seemed from the beginning that narcissism was more of a theme in mental life than a distinct nosological category. It was essentially universal, although more prominent in some patients than in others, and it could be associated with a wide range of pathological states, from relatively healthy to seriously disturbed.

Thirty-five years ago, schizophrenia, manic-depressive illness, and major depression were believed to be of psychogenic origin. “Pathological” parenting was evoked as a “cause” of psychosis. Parents were all too often blamed by the psychiatric profession for the onset of devastating psychotic illnesses. The period when these ideas were influential was an unfortunate episode in American psychiatry, one that wreaked considerable harm by making parents and caregivers feel personally responsible and guilty. Fortunately, a reformation was in the making. Genetic studies began this transformation by demonstrating the centrality of inheritance in the origins of psychosis. The advent of effective antipsychotic medications further bolstered a view that neurochemical disturbances lie at the heart of psychotic illness. Research studies utilizing technological developments such as positron emission tomography and functional magnetic resonance imaging have demonstrated cerebral changes in schizophrenia, supporting the view that the schizophrenic syndrome is, in important ways, a neurodevelopmental disorder. Unfortunately, therapeutic developments in pharmacology and increased biological knowledge have led to a marked diminution in the attention given to the subjective experiences of individual psychotic patients. Fewer clinicians are now interested in making sense of the psychotic patient’s strange behavior and peculiar communications, except for the purpose of diagnostic classification. However, psychosis can be expressed only through the personality of the individual patient; hence, that person’s psychology, personal history, and particular character structure determine many aspects of the psychotic “experience” and should be recognized and addressed in the clinical engagement.

With the advent of antidepressant medications, the focus of interest in the treatment of depressed patients has also shifted from psychological understanding to symptomatology and phenomenology. Clinicians try to classify the type of depression in order to prescribe the most effective medication. Such attempts are made despite the fact that pharmacotherapy and psychotherapy have been shown to be of roughly equal efficacy in the treatment of mild to moderate depression and despite the fact that many patients respond best to a combination of medication and psychotherapy.

In the past 35 years, the importance of neurobiological factors in the etiology of psychiatric illness has become increasingly clear. However, environment and developmental experience have been shown to have a powerful influence on neurobiology. We agree with Gabbard, who wrote that “virtually all major psychiatric disorders are complex amalgams of genetic diatheses and environmental influences. Genes and environment are inextricably connected in shaping human behavior” (2) .

Thirty-five years ago, ego psychology dominated American psychoanalysis and, by extension, psychodynamic thinking. Alternative models of psychodynamics were dismissed as heretical and ill-founded. The ego-psychological model was, in essence, a one-person psychology that saw the clinician as an observer-interpreter. The analytic posture of the clinician was one of objectivity, neutrality, abstinence, and relative anonymity. Kohut’s work on narcissism in the 1970s (3) began a revolution in American psychoanalysis. He emphasized psychological deficits, abandoned drive theory, and promulgated the power of the therapeutic relationship. Contemporaneous with this development, a two-person psychology was explicated: the clinician was influenced by the patient, just as the patient was influenced by the clinician. In our own experience, this ferment of psychodynamic thought about the complex nature of the clinical situation led to the adoption of a pluralistic view of psychodynamics. This view draws on ego psychology, object relations theory, self psychology, interpersonal, and relational models in an interchangeable manner, employing these models as tools to be used when they are helpful—depending on the diagnosis and pathology of the individual patient and the nature of the treatment—and then to be discarded when they interfere with the clinician’s understanding of the patient.

Thirty-five years ago, the social relationship between patient and doctor was viewed as asymmetric. The physician was the authority. Pronouncements and edicts were to be accepted by the patient with little question. Although psychiatry is, by its very nature, far more interactional and engaged with the patient as a person than other medical specialties, it still possessed an authoritarian cast in 1971. Dramatic changes have occurred since then. Patients now are better informed, believe that their bodies and minds belong to them, and wish to be involved in treatment decisions. The therapeutic alliance between doctor and patient has become the foundation of treatment efforts in all of medicine. The assertion of the intrinsic rights of patients has its origins in the cultural changes that began in the 1960s. The civil rights movement, the feminist movement, and the gay liberation movement all provided catalysts for the questioning of authoritarian and paternalistic dogma and for the assertion of individual identities. We now understand that the experience of being “different” is universal and that psychiatry is enriched by recognizing and exploring that experience, validating its existence and universality, and attempting to understand how it influences the patient’s life.

We have been impressed by how much psychiatry, like all other disciplines, is context bound. Modern psychiatry reflects the surrounding social, political, and cultural forces. That was true in 1971. It will be true 35 years from now.

In 1971, psychiatry and psychotherapy seemed simpler. This “simpler” age has passed, and we are now aware of a richer and more complex clinical world. Our experience is consonant with the postmodernist view that blurs the boundaries between subject and object. Our internal struggles to make sense of our patients’ subjective experience and behavior have led us to a new, more complicated, and more personally demanding clinical position. In some ways, we have been humbled by the changes in the psychiatric landscape; in other ways, we have been uplifted—in summary, we have been changed.

Address correspondence and reprint requests to Dr. Michels, Department of Psychiatry, Weill Medical College, Cornell University, 418 E. 71st St., Suite 41, New York, NY 10021; [email protected] (e-mail).