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

Allan V. Horwitz and
Jerome C. Wakefield

he Diagnostic and Statistical Manual of Mental Disorders (DSM) is a book of operational "rules" that define the official criteria for a psychiatric illness. If a patient's behavior fits a certain number of these rules, he or she is considered to have a mental disorder and may be treated accordingly. In this sense, the DSM is less of a medical guide than a codification of proscribed behavior, much like the American Law Institute's Model Penal Code, which allows lawyers to determine whether crimes such as assault or theft have occurred.

The authors of The Loss of Sadness have one narrow goal: to convince the APA to make a distinction between normal depression ("sadness") and abnormal or "dysfunctional" depression. The authors trace the concepts of sadness and depression as recorded throughout history, and then describe the development of the DSM, particularly its third revision, DSM-III. In the 1970s, psychiatrists put the DSM on the couch and, after expensive hour-long sessions into the childhood traumas experienced by the DSM-I and II, realized that it had become maladjusted. After extensive psychotherapy and a little surgery, the DSM-III was pronounced cured and released in 1980.

The rule-based approach taken by DSM-III was a major improvement over previous versions. First and foremost, the DSM was now theory-neutral. The social contexts of the disorders, along with most of the old Freudian psychodynamic concepts, such as unconscious conflicts and defense mechanisms, were purged. This had the effect of ensuring consistency in diagnosis so that, for the first time, different psychiatrists could arrive at the same diagnosis for a given patient. Standardizing diagnosis also benefited interactions with the legal system and insurance companies. But the price was a set of baroque and arbitrary rules. For example, Major Depressive Disorder (MDD) requires that the person be depressed for at least two weeks, and not be in a state of bereavement, unless the bereavement has lasted more than two months.

Left unanswered was the important question of whether the diagnosis is correct or even meaningful. There is a widespread and growing feeling, especially among biologists, that "mental illness" is not a real phenomenon. In this view, what psychiatrists would call "mental illness" is, depending on the patient, either a symptom of some underlying brain disease or a normal response of a healthy individual to an unhealthy environment; the concept of "mental disease" is an unfortunate metaphor that has held back progress in the field for almost a century. As David Rosenhan said, "Psychiatric diagnoses are in the minds of observers and are not valid summaries of characteristics displayed by the observed." Besides MDD, the DSM also describes a smorgasbord of related disease entities such as "Adjustment Disorder With Depressed Mood", "Dysthymic Disorder", "Conduct Disorder", and "Mood Disorder Not Otherwise Specified", all of which are on very shaky ground from a medical point of view.

Horwitz and Wakefield take pre-DSM syndromes such as "combat neuroses" (or "shell shock") as an example of how the industry confuses illness and normal responses to stress. In the years after WWII, it was believed that combat neuroses affected huge proportions of soldiers. One report estimated that the average soldier would have a psychiatric breakdown after 88 days of combat, and 95% would break down after 260 days of combat. Later, some psychiatrists claimed that almost every person in society at large had some sort of mental disorder---creating a potential gold mine for couch manufacturers. These figures relied on questionnaire-based community mental health surveys that often equated decontextualized symptoms with pathology. In other words, they often showed that virtually everyone, with the possible exception of the investigator, was crazy.

Although use of these surveys has declined, studies purporting to show improbably high incidences of major depression continue, and are widely cited. The authors say these inflated figures undermine the credibility of the field by suggesting that it promotes a brave new world scenario where everyone is coerced into being fully medicated and artificially happy.

Although adding the word "dysfunctional" to the definition of MDD, as the authors suggest, may sound reasonable, this approach would go against the trend in the DSM, whose focus on measurable symptoms reflects psychiatry's ambition to be accepted as a scientific discipline. Psychiatrists would probably also argue that even minor depression should be treated, because it could lead to major depression, or be confused with it. If sadness and depression cannot be reliably discriminated, shouldn't all sadness be treated as potentially life-threatening? Biologists would counter that, as with pneumonia, a person either has a disease or he doesn't, and the presence of arbitrary, unscientific rules should be a red flag that the disease entity is poorly understood, and the entire taxonomy needs to be re-evaluated.

Although the authors remain firmly committed to the paradigm of mental illness, the book is an honest discussion of the problems involved in establishing functional diagnostic criteria. Unfortunately, in the absence of a scientific understanding of depression, there is no objective way to distinguish the DSM from any other book of rules, such as one that the Soviet Union might have used during the 20th century to "treat" political dissidents. Nonetheless, no one can dispute that depression is a very real phenomenon. Despite its flaws, the effect of the DSM has been nothing short of revolutionary. Even so, tweaking the definition of Major Depressive Disorder in the DSM feels uncomfortably like rearranging the deck chairs on the Titanic.