"Madness" no more: How definitions of mental illness have changed over the years

By Vera H-C Chan and Claudine Zap


In 1952, the Diagnostic and Statistical Manual of Mental Disorders weighed in at a wispy 50 pages. In 1994, DSM-IV numbered 943 pages. The DSM-5 will actually be less than that — still, when comparing the versions, "one thing you're struck with right away is the increase of diagnostic categories," says David Baker, director of the Archives of the History of American Psychology at the University of Akron. "It's largely a kind of a mirror on the culture... It's not purely objective."



Not surprisingly, well before the DSM came into existence, respected intellectuals were espousing psychological theories on why females went into hysterics, the sickness that made slaves want to run from their masters, and the upper-class ailment triggered by hard work and social upheaval. Here’s a look at disorders, past and present, that fell out of fashion, got caught up in other illnesses, or changed its name.

Drapetomania

Well before the DSM came into existence, a whole host of slave-related diagnoses justified the institution of slavery. In 1854, Samuel Cartwright, a surgeon and psychologist from Louisiana, took the Greek words for "runaway slave" and "crazy" and expounded on drapetomania in The Georgia Blister and Critic (above). His essay in the monthly Southern periodical, which focused specifically on "diseases and physical peculiarities of the Negro race," did blame this "disease of the mind" on white masters who either treated slaves as equals or "treated them cruelly." One prescribed treatment was amputating toes.

Other slave-related diagnoses centered on brain size and work aptitude—all musings that Baker says were "totally irrelevant to the practice of psychiatry and were never considered mental disorders per se—certainly not in the North." The theories didn't stand up too much in the South either following the Civil War.

Female hysteria

You can of course thank Sigmund Freud for illuminating or stigmatizing the better half in a condition called female hysteria. "The pejorative [definition] would be emotional excess,” Baker explains, “women who could not manage their emotions and exhibited conversion disorders." Symptoms included fainting, nervousness, muscle spasms, loss of physical control.

The diagnosis lingered through the second-half of the 50th century, and testified to how so much of American psychology was tied to Freudian theory. One of the most popular treatments for hysteria was hypnosis, as demonstrated by French neurologist Jean-Martin Charcot (above), although he would later question his own theories. Freud studied under Charcot and would even name his firstborn, but the student would later depart from the master and dispute the neurological, aka physical, origins of female hysteria.

Neuresthania

A diagnosis can be a badge of honor—and a sign of your class. Take neurasthenia. First coined in 1869 by George Miller Beard, the middle to upper class manifested the symptoms of neurasthenia first, explains Lisa Held, a Ph.D. candidate in the history and theory of psychology at Canada's York University. The condition had upward of 75 symptoms, which included malaise, poor appetite, weakness in the back and spine, hysteria, insomnia, headache, even uterine displacement or excessive masturbation. Treatment was just as varied, from electricity (supposedly provided by the illustrated brush) to castration.

"It was really considered a disease of modernity," Held explains to Yahoo News, as people had trouble coping with the changing role of women, the move from a rural to an urban culture, and general social upheaval. People as famous as Charles Darwin and Sigmund Freud were considered neurasthenic. "This wasn't seen as something to be ashamed of," Held says. "It was a mark of your class. If you had neurasthenia, it was because you were working so hard."

The condition lasted 30 years and was even exported to Europe, before waning around 1910, partly heaving under its own symptomatic load, partly because when the lower classes started getting it, it really wasn't worth having anymore. It never entirely disappeared but branched out or was subsumed into other illnesses. Some see some elements of neurasthenia in the current condition chronic fatigue syndrome.

Mental retardation

President Barack Obama hugs nine-year-old Rosa Marcellino, from Edgewater, Md., after he signed the Twenty-First Century Communications and Video Accessibility Act of 2010, Friday, Oct. 8, 2010, in the East Room of the White House in Washington. Rosa's Law is named after Marcellino who has Down syndrome. (AP Photo/Charles Dharapak)

Transgenderism

One of the more high-profile shifts in the DSM-5 is the elimination of gender identity disorder, known as transgenderism, which was defined in the previous manual as strong and persistent cross-gender identification. The concept didn't entirely disappear: Now there's gender dysphoria, described as the condition of someone who feels unwell or unhappy with his or her gender.

The diagnostic change has stirred up some controversy in the transgender community. Some have applauded the removal, noting the stigma that a term in the manual creates. "All psychiatric diagnoses occur within a cultural context," said Jack Drescher, a member of the American Psychiatric Association subcommittee working on the revision. "We know there is a whole community of people out there who are not seeking medical attention and live between the two binary categories. We wanted to send the message that the therapist's job isn't to pathologize."

Yet to remove it entirely would cause a pragmatic problem: a lack of insurance coverage for those seeking surgery or hormone treatment. "There was a split in the community if it should remain in the DSM or not. How do you qualify for medical care if you don't have a disorder?" Darrel A. Regier, the vice chair of the DSM-5 Task Force, told Yahoo News. He sees the new term as a compromise for both sides of the debate. "We won't call it a disorder by calling it gender dysphoria, but it remains in the DSM."

Homosexuality

Homosexuality was removed as a disorder in 1987 when the DSM III-R was published, 30 years after Evelyn Hooker’s landmark paper, "The Adjustment of the Male Overt Homosexual" in 1957. A friendship, a nose for scientific study, and a sense of social justice led Hooker (above) to study homosexual men, at a time when homosexuality was a criminal perversion treated with "ice pick lobotomies, electroshock, chemical castration with hormonal treatment or aversive conditioning."

What she did, Baker tells Yahoo News, is administer psychology tests to men who identified as gay or straight, then asks experts to differentiate from their results — and the experts couldn't. It took other research, such as the Kinsey report, before homosexuality was removed from the DSM III with a compromise: ego-dystonic homosexual, which meant someone disturbed over being gay.

Dyslexia

Ever since the concept was introduced, dyslexia has been a godsend to TV writers: At least two students on the Fox show "Glee" have been diagnosed, the latest being newby Ryder Lynn (pictured). But no longer: Dyslexia, along with Dyscalculia and Disorder of Written Expression, will fall under the broader Specific Learning Disorder.

Before, learning disorders separated into reading, math, and written expression categories. “Research has shown that these areas of learning are highly interrelated and shouldn’t be divided as though they were separate disorders,” notes a Scientific American post. “The new diagnosis allows a clinician to identify any other learning difficulties with those specifiers.” The change though sparked an online petition arguing that the move would “disenfranchise those millions" and doctors from using a "well-described and well-validated clinical entity.”

Hypochondriasis

The unhealthy insistence that one is ill when there is little or no physical cause has been a malingerer's diagnosis for centuries (and plenty of Woody Allen movies). Formerly classified under "Somatoform Disorders," hypochondriasis will now be split into two entries under "Somatic Symptoms and Related Disorders." The major difference, according to the blog Everyday Health, is that the old guidelines required that there be no medical explanation for a patient's physical symptoms.

The new diagnosis, though, "could be applied to someone who has a legitimate physical condition, like heart disease or fibromyalgia" but exhibits excessive concern about existing symptoms. For those who are excessively concerned with physical symptoms where none exist, the diagnosis is termed "illness anxiety disorder."

James Butcher, professor emeritus of psychology at the University of Minnesota, wrote in an email to Yahoo News that the diagnostic category got axed because "the committee held the belief that the term was derogatory."