Book Review

The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder

N Engl J Med 2007; 357:947-948August 30, 2007

Article

The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder
By Allan V. Horwitz and Jerome C. Wakefield. 287 pp. New York, Oxford University Press, 2007. $29.95. ISBN: 978-0-19-531304-8

This book identifies a central problem that cries out for correction, just when we are awaiting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), which has been promised for 2012. As the title of this book — The Loss of Sadness — implies, psychiatrists who are influenced by the diagnostic practices that are encouraged in the DSM have become surprisingly imperceptive to the emotional miseries that life events evoke in their patients. These psychiatrists tend to perceive all such states of mind as major depressive disorder, with the result that they may reach for the prescription pad before they take a history. They practice, with the DSM as their guide, what Sir William Osler once dubbed “penny-in-the-slot therapeutics.” Horwitz and Wakefield have written a record of how the classification of psychiatric disorders has been thought about in the field of psychiatry. They elucidate the naturalness of the various forms of human sadness — grief, shame, guilt, homesickness, despair, anguish — from infancy to adulthood, from culture to culture, and from age to age.

The authors concentrate on the problems of psychiatric discourse and research that emerged in the 1960s and early 1970s. During those years, the discipline suffered a breakdown in the consistency of diagnoses at the same time that effective and specific medicines for the treatment of psychiatric disorders — including lithium, phenothiazines, and antidepressants — were being discovered. The need for a common nomenclature and an agreed-on method of diagnosis led to the publication in 1980 of the third edition of the DSM (DSM-III), which was intended to promote consistency and reliability in the practice of diagnosis by differentiating all the known psychiatric disorders on the basis of their symptoms.

Horwitz and Wakefield acknowledge that the DSM-III transformed psychiatric practice, promoted research, and supported the growth of pharmacologic treatments — with much benefit to the professional confidence and development of psychiatrists. They vividly describe how the good done by this transformation and the old problems it solved blinded many to what was being lost in the process. Concentrating on depression, Horwitz and Wakefield describe how practicing psychiatrists gradually came to think about and treat specific states of demoralization and discouragement that arose from life contexts in the same way they treated pathologic mood disorders. They document the way in which this “importing of pathology” impaired the effectiveness of practice and research in the field of mental health.

The authors note that the DSM-III — by sorting conditions according to their resemblances, rather than by seeking essential differences — medicalized human suffering, diminished attention to human meaning in the field of psychiatry, and hampered communication between patients and physicians. This process encouraged psychiatrists to think only in terms of medications and also cut them off from advocating for social progress that might have helped to reduce the number of patients with psychiatric problems arising from context. Moreover, the cross-cultural work of psychiatrists floundered as they lost touch with local sources of conflict and meaning in worlds that were distinct from the world of the urban American.

These considerations draw attention to other groupings in the DSM-III and later editions that are based on symptoms — including anxiety, post-traumatic stress disorder, and dissociative disorder. These diagnoses may obscure important distinctions between a patient with a mental disorder and a person who is responding naturally to life circumstances. This problem in contemporary psychiatric discourse derives from the approach of the DSM. The editors of the DSM-III and its subsequent editions, by choosing to use a method that is based on symptoms in order to assure reproducibility and diagnostic reliability, presented what amounts to a naturalist's field guide, with mental disorders as the subject, rather than birds, trees, or wildflowers. The sine qua non of field guides (as all birders know) is reliability and the consistency of labels, and such guides usually provide decision trees that are identical in character to those in Appendix A of the DSM-III and the DSM-IV. But field guides are always prone to problems of validity and may lead the user to confuse similar species. It is this kind of difficulty in validity that Horwitz and Wakefield have identified in the approach of the DSM to depression.

In presenting their solution to the problem of validity, the authors emphasize the evolutionary background of the emotional responsiveness of humans to life situations and so distinguish what is normal from what is pathologic in mood states. This distinction has great value, but in practical terms it may not illuminate or ease the problem of how to rationally treat patients. The matter of “construct validity” reaches into the essential nature of mental conditions and must be dealt with in any system of classification that will improve subsequent editions of the DSM.

With the DSM, psychiatrists not only lost sadness as a basic construct but also lost touch with the different contexts in which sadness emerges. The understanding of these contexts is crucial for the planning of coherent therapeutic interventions and research programs. This book demonstrates how much a medical discipline can learn from thoughtful colleagues in the other scientific disciplines (sociology, in this case). The challenging thesis of the authors extends in two directions — they note what psychiatrists have been overlooking in treatment and research, but they also criticize their colleagues in sociology who have been too quick to accept contemporary psychiatric diagnoses when trying to show how adverse social conditions produce emotional reactions.

Nearly 30 years — a whole generation — have passed since the DSM-III was published. It did its job and did it well, but now the problems inherent in its method hinder progress and burden practice. As Horwitz and Wakefield proclaim, if the DSM-V merely expands on, rather than amends, its predecessors, the field of psychiatry — to its detriment — will spend another decade engrossed in a field guide, tolerating thoughtless therapies.

Paul R. McHugh, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21287
pmchugh1@jhmi.edu