Affective Disorder:

The New Imperium

Phillip R. Slavney Eugen Bleuler formulated schizophrenia as a disjunctive category based on universal, dimensional phenomena that were regarded as pathognomonic of the disorder. In consequence, schizophrenia came to dominate diagnostic practice in American psychiatry. This report suggests that affective disorder has been formulated in a similar way, and with a similar result. The nature of disjunctive categories is examined and their replacement by conjunctive categories for schizophrenia and affective disorder is anticipated. Copyright 0 1991 by W.B. Saunders Company

M

ANY PSYCHIATRISTS now regard sleep, appetite, energy level, and libido as aspects of mood to be described in the mental status examination, rather than phenomena in their own right to be discussed in the review of systems or history of the present illness. Once such vital functions are subsumed under the affective realm, insomnia, anorexia, listlessness, and sexual indifference become, @of&o, evidence of depressive disorder. While it is true that these symptoms regularly occur in depressive states, they are also found in other conditions, including demoralization, anxiety, hypothyroidism, hepatitis, and cancer. Why do psychiatrists think of depressive disorder so readily? And why do they sometimes insist on that diagnosis even in the absence of a change in mood or self-attitude? Some answers to these questions may be found in the history of reasoning about schizophrenia, a disorder that for many years dominated diagnostic practice in American psychiatry. In what follows, my emphasis is methodological, rather than clinical, for I wish to examine how the structure of categories determines their use. SCHIZOPHRENIA

AS A DISJUNCTIVE

CATEGORY

A disjunctive category is one in which a basic concept can be expressed in different, but equivalent, ways.‘,’ Citizenship is such a category: an individual can be a citizen of a country if he is born there or if he lives there for several years or if he marries a native. The concept behind the category, citizenship, is that a person “belongs” somewhere, that he owes allegiance to his country and is entitled to its protection. Schizophrenia, as defined by Eugen Bleuler, was a disjunctive category. The basic concept, a disturbance of thinking, could be expressed as loosening of associations or abnormal affect or ambivalence or autism.’ These “fundamental signs” were considered pathognomonic of the disorder, and, once detected, the differential diagnosis was resolved, even when the clinical picture seemed to suggest another condition: “The symptomatological differentiation of schizophrenia from manic-depressive psychosis can only be based on the presence of the specific schizophrenic symptoms. All the phenomena of

From the Department of Psychiatry and Behavioral Sciencesof the Johns Hopkins University School of Medicine, Baltimore. MD. Address reprint requests to Phillip R. Slavney, M.D., Meyer 4-181, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21205 Copyright 0 1991 by W B. Saunders Company OOlO-44OXl9Il3204-0004$03.00/O Comprehensive

Psychiatry,

Vol. 32, No. 4 (July/August),

1991: pp 295-302

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manic-depressive psychosis may also appear in our disease; the only decisive factor is the presence or absence of schizophrenic symptoms. Therefore, neither a state of manic exaltation nor a melancholic depression, nor the alternation of both states has any significance for the diagnosis. Only after careful observation has revealed no schizophrenic features, may we conclude that we are dealing with a manic-depressive psychosis.“’ (p. 304)

Careful observation was necessary because the “fundamental signs” of schizophrenia were dimensional phenomena that appeared “in varying degrees and shadings on the entire scale from pathological to norma1.“3 (p. 13) Loosening of associations, for example, ranged ‘Ifrom a maximum which corresponds to complete conjksion, to a minimum which may be hardly noticeable,“3 (p. 21) while affective disturbance in mild cases could be “absent or disguised.“3 (p. 41) On dimensions such as these, even subtle disturbances might indicate a schizophrenic disorder. Careful observation was also necessary because the “fundamental signs” of schizophrenia were “distortions and exaggerations of normal processes,” rather than alien phenomena like hallucinations.’ (p. 294) Schizophrenia disrupted mental functions present in everyone, so that anyone consulting a psychiatrist might show evidence of the disorder. Since all patients with manic-depressive illness think, for example, schizophrenia could be diagnosed if their thought was expressed in a certain way. That Bleuler based the concept of schizophrenia on universal, dimensional phenomena increased the likelihood that the diagnosis would be proposed, not only for individuals who were thought-disordered and hallucinated, but also for those who seemed, at first, to have peculiar or troubling personalities. Although Bleuler was aware of this danger, he cautioned that the manifestations of schizophrenia could “fluctuate within the limits of what is regarded, if not as healthy, at least as ‘not mentally ill.’ Character anomalies, indifference, lack of energy, unsociability, stubbornness, moodiness, the characteristic for which Goethe could only find the English word, ‘whimsical,’ hypochondriacal complaints, etc., are not necessarily symptoms of an actual mental disease; they are, however, often the only perceptible signs of schizophrenia.“’ (p. 294)

Indeed, Bleuler’s diagnostic reasoning led him to conclude that subtle presentations of the disorder were much more common than obvious ones: “There is also a latent schizophrenia, and I am convinced that this is the most frequent form, although admittedly these people hardly ever come for treatment. It is not necessary to give a detailed description of the various manifestations of latent schizophrenia. In this form, we can see in nuce all the symptoms and all the combinations of symptoms which are present in the manifest types of the disease.“’ (p. 239)

Bieuler’s way of defining schizophrenia encouraged many psychiatrists (especially in the United States) to diagnose the disorder quite readily. Distracted speech could be taken as loosening of associations, stoicism as affective blunting, indecisiveness as ambivalence, and a desire for solitude as autism. The search for ever more subtle indications of schizophrenia produced both a lowering of the diagnostic threshold and proposals for a variety of atypical presentations4-’ Although cautionary voicesk9 were raised about the use of the term schizophrenic to describe any unusual thinking or behavior, the following classification illus-

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trates how broadly defined-and had become by 1970:

how disjunctive-the

category of schizophrenia

“The typical schizophrenias, in which the fundamental symptoms described by Bleuler are clearly present, are as follows: simple schizophrenia hebephrenic schizophrenia, catatonic schizophrenia (in both stuporous and excited forms), paranoid schizophrenia, mixed schizophrenia, and undifferentiated schizophrenia. Patients may not show all the defects described by Bleuler and thus may not demonstrate the characteristics of the typical schizophrenias. In such cases, the patient may more properly be diagnosed as demonstrating one of the atypical schizophrenias, as follows: schizo-affective psychosis, acute homosexual panic (Kempf’s disease), acute paranoia (also known as acute polymorphic delirium, exhaustion psychosis, or combat psychosis), ambulatory schizophrenia (of which the three major subtypes are pseudoneurotic schizophrenia, pseudopsychopathic schizophrenia, and borderline character), postpartum schizophrenia, and periodic catatonia.““’

Even as the category of schizophrenia was reaching its greatest compass, a reaction was taking place, and over the last several decades the disorder has been more narrowly defined in the United States than it had been before. Two major stimuli for this change were the epidemiological research of Morton Kramer” and the United States-United Kingdom Diagnostic Project,” both of which demonstrated that American psychiatrists diagnosed schizophrenia more often-and affective disorder less often-than their British counterparts did. The subsequent replacement of dimensional Bleulerian criteria by categorical Schneiderian ones13”4at many academic centers further constricted the boundaries of schizophrenia, as did the introduction of diagnostic systems incorporating Emil Kraepelin’s view of schizophrenia as a chronic illness.‘5.‘6 AFFECTIVE

DISORDER

AS A DISJUNCTIVE

CATEGORY

These developments, and the advent of lithium therapy,” brought new attention to the affective disorders, and clinical assessment began to focus more on the patient’s experience of mood than on his expression of thought. No pathognomonic signs and symptoms were proposed for affective disorder, but changes in mood, self-attitude, and vital sense were given increasing significance in differential diagnosis. Indeed, as empirical studies demonstrated that characteristic features of schizophrenia, whether Bleulerian’8,19 or Schneiderian,“-‘* could be found in affective disorder, it became possible to paraphrase Bleuler’s claim and say: “All the phenomena of schizophrenia may also appear in our disease; the only decisive factor is the presence or absence of affective symptoms.” Yet how does one determine the presence or absence of affective symptoms? Because the phenomena of interest (mood, self-attitude, sleep, appetite, energy level, and libido) are universal and dimensional in nature, the methodological problem is similar to that faced by Bleuler with the “fundamental signs” of schizophrenia. Just as all patients with manic-depressive illness have thoughts, so, too, all patients with schizophrenia have moods. Even Kraepelin’s emphasis on the importance of an episodic course for the diagnosis of affective disorder did not completely resolve the problem: “Manic-depressive

insanity. . . includes on the one hand the whole domain of so-calledperiodic

and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of [confusional or delirious insanity].

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Lastly we include here certain slight and slightest colourings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders, on the other hand pass over without sharp boundary into the domain of personalpredisposition. In the course of the years I have become more and more convinced that all of the above-mentioned states only represent manifestations of a sing/e morbidprocess.“” (p. 1)

The “personal predispositions” (also called “fundamental states”) were seen primarily in mood, but could be observed in self-attitude and behavior, as well. Thus, Kraepelin noted that people with depressive temperaments were indecisive and retiring,” (p. 122) while those with manic temperaments were irresponsible and argumentative.15 (p. 128) Such presentations of affective disorder resembled the “latent” cases of schizophrenia described by Bleuler, not only because they were subtle and frequent, but also because they could “throughout the whole of life exist as peculiar forms of psychic personality without further development.“‘s (P. 118) The view that certain personality types are affective disorders is best represented today by the work of Hagop Akiskal and his associates, who believe that “the more subtle, ambulatory and lifelong varieties of affective illness . . . . have been generally relegated to the vague sphere of the personality disorders,” where their true character is obscured.” Akiskal endorses the idea of “fundamental states,” and note that personality can be “as much an expression of the affective pathology as the more commonly recognized symptomatic episodes of the illness.“24 In an examination of the relationship between personality traits and affective states, Akiskal suggests that in patients with chronic intermittent depressions whose personality disturbances “take the form of manipulativeness, temper tantrums, impulsivity, episodic promiscuity, repeated conjugal failure, drug-seeking behavior, dilettantism, and suicidal gestures . . . . the affective component is often primary.“” Although Akiskal is circumspect in his claims, less thoughtful clinicians might come to regard particular traits and behaviors as inseparable from affective disorder. Should this occur, Kraepelin’s notion of “fundamental states” will have the same effect on diagnostic practice as did Bleuler’s notion of “fundamental signs.” Kraepelin believed that individuals with “slight forms” of affective disorder were extremely common; that many were never treated by physicians; and that, even when treatment was provided, the patients were regarded as suffering from “over work, nervousness, neurasthenia, hysteria, and so on.“” (p. 133) Such instances of the condition were difficult to recognize both because they were mild and because they were masked by somatic symptoms. In affective disorder, then, as in schizophrenia, careful observation was necessary. Given that somatic complaints occur in depressive disorders, the existence of depressive disorders marked only by somatic complaints seemed reasonable, and a number of “depressive equivalents” were suggested? As with the category of schizophrenia, then, the category of affective disorder has become progressively larger, and the diagnostic threshold progressively lower. It, too, is a disjunctive category because the criteria for membership can be satisfied not only if the patient is depressed or manic or in a mixed state, but also if he is anorexic or histrionic or obsessional or in pain, for all these phenomena have been taken to represent the basic concept of a disturbance in mood. Despite the constraining influence of official classifications and the skepticism of certain

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psychiatrists,27.28 a range of affective disorders has been proposed that includes illnesses in which mood change is prominent29”2 and illnesses in which it is subtle or absent: “In addition to the typical forms of depression associated with the traditional symptomatology, there are cases in which one or other of the symptoms of depression is encountered in an exaggerated or attenuated form. Developments in psychiatric knowledge and changes in the type of patients who consult psychiatrists have now made it possible to recognize more clearly certain less pronounced forms of depression, often referred to as early, ambulatory, or incomplete forms. In recent years particular interest has been devoted to those forms in which the actual depressive symptomatology is concealed behind character disturbances, changes in attitude towards food or sex, drug dependence, or, as is most frequently the case, behind various somatic manifestations of a persistent nature and suggestive of specific organic lesions. Among the very large number of terms employed to describe this syndrome are the following: masked depression, depressio sine depressione. depressive equivalent, latent depression, and hidden depression.“‘”

The “large number of terms” employed in this 1973 catalog do not appear in DSM-III-R34 or ICD-9,3” but the type of thinking they reflect is commonplace in the practice of psychiatry.‘6-4’ Although there is more experimental support for a broad affective spectrum than there was for a broad schizophrenic spectrum, both notions arose as careful observers enlarged the boundaries of disjunctive categories. CONJUNCTIVE CATEGORIES AND THE DISEASE CONCEPT Schizophrenia came to be overdiagnosed, in part, because it was constructed as a disjunctive category based on universal, dimensional phenomena. The same thing may have happened with affective disorder, and for the same reason. My point here is not to deny the existence of mild or atypical forms of illness (especially in the kin of certain patients), but to emphasize that, when using disjunctive categories based on dimensional phenomena, it is difficult to avoid overextending them. Although the nosological problems inherent in dimensional reasoning have been examined by students of affective disorders,42-44less attention has been paid to the consequences of formulating those disorders as disjunctive categories. Membership in a disjunctive category is given on the basis of criteria that allow it to encompass a variety of individuals. The concept behind the category (e.g., disturbance of mood) is expressed by characteristics that can replace one another in fulfilling admission requirements (e.g., grandiosity or distractibility or diminished need for sleep). Because each requirement need not be possessed by every group member, disjunctive categories have relatively heterogeneous compositions and blurred boundaries. In psychiatry, this category structure may prove most useful for personality types,45,46but it will likely be replaced by another structurethe conjunctive category-for schizophrenia and affective disorder. In a conjunctive category, membership is given on the basis of criteria that allow it to define exactly who belongs. Characteristics are linked to one another by and rather than or, so that each criterion must be possessed by every group member. As a result, conjunctive categories have relatively homogenous compositions and distinct boundaries. An individual qualifies for the conjunctive category, “Huntington’s disease,” if he has hereditary dyskinesia and atrophy of the caudate nucleus and a particular gene on the short arm of chromosome 4. These attributes define

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members of the category more and more precisely until the essential criterion-an etiological one-is satisfied. Huntington’s disease has been elucidated through the logic of the disease concept.* In this method of reasoning, there is a sequence of observations and explanations that usually proceeds from the recognition of clinical syndromes (e.g., hereditary dyskinesia) to the identification of pathological entities (e.g., atrophy of the caudate nucleus) to the discovery of etiological agencies (e.g., a particular gene on the short arm of chromosome 4). With many psychiatric disorders for which disease reasoning is thought appropriate, this sequence has progressed only to the recognition of clinical syndromes, which are often formulated as disjunctive categories. As pathological entities and etiological agencies underlying those syndromes are revealed, diagnoses will become increasingly conjunctive in structure. It is unlikely that disease reasoning will prove suitable for all the illnesses considered part of the affective spectrum, but it is probable that several conjunctive categories resting on pathological entities and etiological agencies will emerge. Until then, it is well to remember the nature of disjunctive categories and the process whereby affective disorder came to replace schizophrenia as the imperial diagnosis in American psychiatry. ACKNOWLEDGMENT The author would like to thank J. Raymond DePaulo, Jr., Susan E. Folstein, Paul R. McHugh, Jacqueline L. Slavney, and Joseph H. Stephens for their suggestions.

REFERENCES 1. Bruner JS, Goodnow JJ, Austin GA: A Study of Thinking. New York, NY, Wiley, 1956, pp 41-43 2. McHugh PR, Slavney PR: The Perspectives of Psychiatry. Baltimore, MD, Johns Hopkins University, 1986, pp 26-37 3. Bleuler E: Dementia Praecox or the Group of Schizophrenias [1911], translated by Zinkin J. New York, NY, International Universities, 1950 4. Zilboorg G: Ambulatory schizophrenias. Psychiatry 4:149-l%, 1941 5. Federn P: Principles of psychotherapy in latent schizophrenia. Am J Psychother 1:129-144,1947 6. Hoch P, Polatin P: Pseudoneurotic forms of schizophrenia. Psychiatr Q 23:248-276,1949 7. Mace NC, Koff SA, Chelnek I, et al: Diagnostic problems in early schizophrenia. J Nerv Ment Dis 110:336-346,1949 8. Kahn E, Pokorny AD: Concerning the concept of schizophrenia. Am J Psychiatry 120:856-860, 1964 9. Schorer CE: Mistakes in the diagnosis of schizophrenia. Am J Psychiatry 124:1057-1062,1968 10. Rosenbaum CP: The Meaning of Madness: Symptomatology, Sociology, Biology and Therapy of the Schizophrenias. New York, NY, Science House, 1970, pp 39-40 11. Kramer M: Cross-national study of diagnosis of the mental disorders: Origin of the problem. Am J Psychiatry 125:1-11,1969 (suppl) 12. Cooper JE, Kendell RE, Gurland BJ, et al: Psychiatric diagnosis in New York and London: A comparative study of mental hospital admissions, Maudsley Monograph No. 20. Institute of Psychiatry, London, England, Oxford University, 1972 13. Taylor MA, Heiser JF: Phenomenology: An alternative approach to diagnosis of mental disease. Compr Psychiatry 12:480-486, 1971 14. Spitzer RL, Endicott J, Robins E: Research diagnostic criteria: Rationale and reliability. Arch Gen Psychiatry 35:773-782,1978 15. Kraepelin E: Manic-Depressive Insanity and Paranoia, translated by Barclay RM, edited by Robertson GM. Edinburgh, Scotland, Livingstone, 1921

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16. Feighner JP, Robins E, Guze SB, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63,1972 17. Baldessarini RJ: Frequency of diagnoses of schizophrenia versus affective disorders from 1944 to 1968. Am J Psychiatry 127:759-763,197O 18. Winokur G, Clayton PJ, Reich T: Manic Depressive Illness. St Louis, MO, Mosby, 1969, p 69 19. Ianzito BM, Cadoret RJ, Pugh DD: Thought disorder in depression. Am J Psychiatry 131:703-707. 1974 20. Carpenter WT, Strauss JS, Mulch S: Are there pathognomonic symptoms in schizophrenia? An empiric investigation of Schneider’s first-rank symptoms. Arch Gen Psychiatry 28847.852,1973 21. Taylor MA, Abrams R: The phenomenology of mania: A new look at some old patients. Arch Gen Psychiatry 29: 520-522, 1973 22. Pope HG, Lipinski JF: Diagnosis in schizophrenia and manic-depressive illness: A reassessment of the specificity of “schizophrenic” symptoms in the light of current research. Arch Gen Psychiatry 35811~828. 1978 23. Akiskal HS, Rosenthal TL, Haykal RF, et al: Characterological depressions: Clinical and sleep EEG findings separating “subaffective dysthymias” from “character spectrum disorders.” Arch Gen Psychiatry 37:777-783, 1980 24. Akiskal HS: Cyclothymic and related disorders, in Georgotas A, Cancro R (eds): Depression and Mania. New York, NY, Elsevier, 1988, p 87 25. Akiskal HS. Hirschfeld RMA, Yerevanian BI: The relationship of personality to affective disorders: A critical review. Arch Gen Psychiatry 40:801-810, 1983 26. Kielholz P (ed): Masked Depression. Bern, Switzerland, Huber, 1973 27. Carpenter WT. Stephens JH: The diagnosis of mania, in Belmaker RH. van Praag HM (eds): Mania: An Evolving Concept. Jamaica, NY, Spectrum, 1980, p 16 28. Andreasen NC: The clinical differentiation of affective and schizophrenic disorders, in Zales, MR (ed): Affective and Schizophrenic Disorders: New Approaches to Diagnosis and Treatment. New York. NY, BrunneriMazel, 1983, p 47 29. Klerman GL: The spectrum of mania. Compr Psychiatry 22:11-20,198l 30. Akiskal HS, Cassano GB: The impact of therapeutic advances in widening the nosologic boundaries of affective disorders: Clinical and research implications. Pharmacopsychiat 16:111-118. 1983 31. Coryell W, Winokur G: Depression spectrum disorders: Clinical diagnosis and biological implications, in Post RM, Ballenger JC (eds): Neurobiology of Mood Disorders. Baltimore, MD, Williams & Wilkins, 1984, pp 102-106 32. Alarcon RD, Walter-Ryan WG, Rippetoe PA: Affective spectrum disorders. Compr Psychiatry 28:292-308, 1987 33. Pichot P, Hassan J: Masked depression and depressive equivalents-Problems of definition and diagnosis, in Kielholz P (ed): Masked Depression. Bern, Switzerland, Huber, 1973, pp 61-62 34. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3, revised) (DSM-III-R). Washington, DC, APA, 1987 35. World Health Organization: Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, 9th rev (ICD-9) ~011. Geneva, Switzerland, WHO, 1977 36. Blazer DG: Depression in Late Life. St Louis, MO, Mosby, 1982, pp 206-207 37. Charles SC: Depression and physical illness, in Val ER, Gaviria FM, Flaherty JA (eds): Affective Disorders: Psychopathology and Treatment. Chicago, IL, Year Book Medical, 1982, pp 70-72 38. Akiskal HS: Mood disturbances, in Winokur G, Clayton P (eds): The Medical Basis of Psychiatry. Philadelphia, PA, Saunders, 1986, p 386 39. Hudson JI, Pope HG: Depression and eating disorders, in Cameron OG (ed): Presentations of Depression: Depressive Symptoms in Medical and Other Psychiatric Disorders. New York, NY, Wiley. 1987, p 53 40. Lipscomb PA, Katon W: Depression and somatization, in Cameron OG (ed): Presentations of Depression: Depressive Symptoms in Medical and Other Psychiatric Disorders. New York, NY, Wiley, 1987. p 202 41. Zohar J, Insel TR: Obsessive-compulsive disorder: Psychobiological approaches to diagnosis, treatment, and pathophysiology. Biol Psychiatry 22:667-687, 1987

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42. Kendell RE: The classification of depressions: A review of contemporary confusion. Br J Psychiatry 129:15-28,1976 43. Akiskal HS: Diagnosis and classification of affective disorders: New insights from clinical and laboratory approaches. Psychiatr Dev 2:123-160,1983 44. Goodwin FK, Jamison KR: Manic-Depressive Illness. New York, NY, Oxford University, 1990, pp 74-84 45. Widiger TA, Frances AJ: The DSM-III personality disorders: Perspectives from psychology. Arch Gen Psychiatry 42:615-623,1985 46. Slavney PR: Perspectives on “Hysteria.” Baltimore, MD, Johns Hopkins University, 1990, pp 64-66