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The fascinating and controversial history of personality disorders.
The concept of personality disorders rose to prominence in the
early twentieth century and has consistently caused controversy
among psychiatrists, psychologists, and social scientists. In
Personality Disorders, Allan V. Horwitz traces the evolution of
defining these disorders and the historical dilemmas of attempting
to mold them into traditional medical conceptions of disorder.
Using the Diagnostic and Statistical Manual of Mental Disorders, or
DSM, as a guide, Horwitz explores the group of conditions that make
up personality disorders and considers when they have been tied to
or separated from other types of mental illnesses. He also examines
how these disorders have often entailed negative moral and cultural
evaluations more focused on perceived social deviance than on
actual medical conditions. Deep conflicts exist in a variety of
disciplines in determining the nature of these disorders. During
the twentieth century, a particularly sharp division arose between
researchers who study personality disorders and the clinicians who
treat them. Because researchers strive to develop general laws and
clinicians attempt to understand individuals' specific problems,
their values, methods, and goals often conflict. Synthesizing
historical and contemporary scholarship, Horwitz examines
controversies over the definitions and diagnoses of personality
disorders and how the perception of these illnesses has changed
over time.
The first comprehensive history of "psychiatry's bible"-the
Diagnostic and Statistical Manual of Mental Disorders. Over the
past seventy years, the Diagnostic and Statistical Manual of Mental
Disorders, or DSM, has evolved from a virtually unknown and
little-used pamphlet to an imposing and comprehensive compendium of
mental disorder. Its nearly 300 conditions have become the
touchstones for the diagnoses that patients receive, students are
taught, researchers study, insurers reimburse, and drug companies
promote. Although the manual is portrayed as an authoritative
corpus of psychiatric knowledge, it is a product of intense
political conflicts, dissension, and factionalism. The manual
results from struggles among psychiatric researchers and
clinicians, different mental health professions, and a variety of
patient, familial, feminist, gay, and veterans' interest groups.
The DSM is fundamentally a social document that both reflects and
shapes the professional, economic, and cultural forces associated
with its use. In DSM, Allan V. Horwitz examines how the manual,
known colloquially as "psychiatry's bible," has been at the center
of thinking about mental health in the United States since its
original publication in 1952. The first book to examine its entire
history, this volume draws on both archival sources and the
literature on modern psychiatry to show how the history of the DSM
is more a story of the growing social importance of psychiatric
diagnoses than of increasing knowledge about the nature of mental
disorder. Despite attempts to replace it, Horwitz argues that the
DSM persists because its diagnostic entities are closely
intertwined with too many interests that benefit from them. This
comprehensive treatment should appeal to not only specialists but
also anyone who is interested in how diagnoses of mental illness
have evolved over the past seven decades-from unwanted and often
imposed labels to resources that lead to valued mental health
treatments and social services.
A comprehensive history of PTSD. Post-traumatic stress disorder-and
its predecessor diagnoses, including soldier's heart, railroad
spine, and shell shock-was recognized as a psychiatric disorder in
the latter part of the nineteenth century. The psychic impacts of
train crashes, wars, and sexual shocks among children first drew
psychiatric attention. Later, enormous numbers of soldiers
suffering from battlefield traumas returned from the world wars. It
was not until the 1980s that PTSD became a formal diagnosis, in
part to recognize the intense psychic suffering of Vietnam War
veterans and women with trauma-related personality disorders. PTSD
now occupies a dominant place in not only the mental health
professions but also major social institutions and mainstream
culture, making it the signature mental disorder of the early
twenty-first century. In PTSD, Allan V. Horwitz traces the
fluctuations in definitions of and responses to traumatic psychic
conditions. Arguing that PTSD, perhaps more than any other
diagnostic category, is a lens for showing major historical changes
in conceptions of mental illness, he surveys the conditions most
likely to produce traumas, the results of those traumas, and how to
evaluate the claims of trauma victims. Illuminating a number of
central issues about psychic disturbances more generally-including
the relative importance of external stressors and internal
vulnerabilities in causing mental illness, the benefits and costs
of mental illness labels, and the influence of gender on
expressions of mental disturbance-PTSD is a compact yet
comprehensive survey. The book will appeal to diverse audiences,
including the educated public, students across the psychological
and social sciences, and trauma victims who are interested in
socio-historical approaches to their condition. Praise for Allan V.
Horwitz's Anxiety: A Short History "The definitive overview of the
history of anxiety."-Bulletin of the History of Medicine "A lucid,
erudite and brisk intellectual history driven by a clear and
persuasive central argument."-Social History of Medicine "An
enlightening tour of anxiety, set at a sensible pace, with an
exceptional scholar and writer leading the way."-Library Journal
More people today report feeling anxious than ever before-even
while living in relatively safe and prosperous modern societies.
Almost one in five people experiences an anxiety disorder each
year, and more than a quarter of the population admits to an
anxiety condition at some point in their lives. Here Allan V.
Horwitz, a sociologist of mental illness and mental health,
narrates how this condition has been experienced, understood, and
treated through the ages-from Hippocrates, through Freud, to today.
Anxiety is rooted in an ancient part of the brain, and our ability
to be anxious is inherited from species far more ancient than
humans. Anxiety is often adaptive: it enables us to respond to
threats. But when normal fear yields to what psychiatry categorizes
as anxiety disorders, it becomes maladaptive. As Horwitz explores
the history and multiple identities of anxiety-melancholia, nerves,
neuroses, phobias, and so on-it becomes clear that every age has
had its own anxieties and that culture plays a role in shaping how
anxiety is expressed.
In this timely and provocative critique of modern psychiatry, Allan
V. Horwitz examines current conceptions of mental illness as a
disease. He argues that this notion fits only a small number of
serious psychological conditions, and that most conditions
currently regarded as mental illness are cultural constructions,
normal reactions to stressful social circumstances, or simply forms
of deviant behavior. According to Horwitz, the formulation of
mental illness as disease benefits various interest groups,
including mental health researchers and clinicians, prescriptive
drug manufacturers, and mental health advocacy groups, all of whom
promote disease-based models. Presenting case studies in maladies
such as hysteria, multiple personality disorder, and depression, he
examines the major causes and treatments of mental illness, paying
special attention to the use of pharmaceuticals. While biologically
based causes and treatments fit some of the entities formulated,
Horwitz finds that more often than not, social responses offer far
more suitable remedies.
Between Sanity and Madness: Mental Illness from Ancient Greece to
the Neuroscientific Era examines several perennial issues about
mental illness: how different societies have distinguished mental
disorders from normality; whether mental illnesses are similar to
or different from organic conditions; and the ways in which
different eras conceive of the causes of mental disorder. It begins
with the earliest depictions of mental illness in Ancient Greek
literature, philosophy, and medicine and concludes with the
portrayals found in modern neuroscience. In contrast to the
tremendous advances other branches of medicine display in answering
questions about the nature, causes, and treatments of physical
diseases, current psychiatric knowledge about what qualities of
madness distinguish it from sanity, the resemblance of mental and
physical pathologies, and the kinds of factors that lead people to
become mentally ill does not show any steady growth or, arguably,
much progress. The immense recent technological advances in brain
science have not yet led to corresponding improvements in
understandings of and explanations for mental illnesses. These
perplexing phenomena remain almost as mysterious now as they were
millennia ago.
Since the emergence of Western philosophy and science among the
classical Greeks, debates have raged over the relative significance
of biology and culture on an individual's behavior. Today, recent
advances in genetics and biological science have pushed most
scholars past the tired nature vs. nurture debate to examine the
ways in which the natural and the social interact to influence
human behavior. In What's Normal?, Allan Horwitz brings a fresh
approach to this emerging perspective. Rather than try to solve
these issues universally, Horwitz demonstrates that both social and
biological mechanisms have varying degrees of influence in
different situations. Through case studies of human universals such
as incest aversion, fear, appetite, grief, and sex, Horwitz first
discusses the extreme instances where biology determines behavior,
where culture dominates, and where culture overrides basic
biological instincts. He then details the variety of ways in which
genes and environments interact; for instance, the primal drive to
eat and store calories when food supplies were scarce and
behavioral patterns in a society where food is abundant and obesity
stigmatized. Now that it's often easier to change our biology
rather than our culture, an understanding of which behaviors and
traits are simply normal or abnormal, and which are pathological or
necesitate treatment is more important than ever. Wide-ranging and
accessible, What's Normal? provides a crucial guide to the
biological and social bases of human behavior at the heart of these
matters.
In this surprising book, Allan V. Horwitz argues that our current
conceptions of mental illness as a disease fit only a small number
of serious psychological conditions and that most conditions
currently regarded as mental illness are cultural constructions,
normal reactions to stressful social circumstances, or simply forms
of deviant behavior.
"Thought-provoking and important. . .Drawing on and consolidating
the ideas of a range of authors, Horwitz challenges the existing
use of the term mental illness and the psychiatric ideas and
practices on which this usage is based. . . . Horwitz enters this
controversial territory with confidence, conviction, and
clarity."--Joan Busfield, "American Journal of Sociology
"
"Horwitz properly identifies the financial incentives that urge
therapists and drug companies to proliferate psychiatric diagnostic
categories. He correctly identifies the stranglehold that
psychiatric diagnosis has on research funding in mental health.
Above all, he provides a sorely needed counterpoint to the most
strident advocates of disease-model psychiatry."--Mark Sullivan,
"Journal of the American Medical Association"
"Horwitz makes at least two major contributions to our
understanding of mental disorders. First, he eloquently draws on
evidence from the biological and social sciences to create a
balanced, integrative approach to the study of mental disorders.
Second, in accomplishing the first contribution, he provides a
fascinating history of the study and treatment of mental disorders.
. . from early asylum work to the rise of modern biological
psychiatry."--Debra Umberson, "Quarterly Review of Biology"
Depression has become the single most commonly treated mental
disorder, amid claims that one out of ten Americans suffer from
this disorder every year and 25% succumb at some point in their
lives. Warnings that depressive disorder is a leading cause of
worldwide disability have been accompanied by a massive upsurge in
the consumption of antidepressant medication, widespread screening
for depression in clinics and schools, and a push to diagnose
depression early, on the basis of just a few symptoms, in order to
prevent more severe conditions from developing.
In The Loss of Sadness, Allan V. Horwitz and Jerome C. Wakefield
argue that, while depressive disorder certainly exists and can be a
devastating condition warranting medical attention, the apparent
epidemic in fact reflects the way the psychiatric profession has
understood and reclassified normal human sadness as largely an
abnormal experience. With the 1980 publication of the landmark
third edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-III), mental health professionals began diagnosing
depression based on symptoms--such as depressed mood, loss of
appetite, and fatigue--that lasted for at least two weeks. This
system is fundamentally flawed, the authors maintain, because it
fails to take into account the context in which the symptoms occur.
They stress the importance of distinguishing between abnormal
reactions due to internal dysfunction and normal sadness brought on
by external circumstances. Under the current DSM classification
system, however, this distinction is impossible to make, so the
expected emotional distress caused by upsetting events-for example,
the loss of a job or the end of arelationship- could lead to a
mistaken diagnosis of depressive disorder. Indeed, it is this very
mistake that lies at the root of the presumed epidemic of major
depression in our midst.
In telling the story behind this phenomenon, the authors draw on
the 2,500-year history of writing about depression, including
studies in both the medical and social sciences, to demonstrate why
the DSM's diagnosis is so flawed. They also explore why it has
achieved almost unshakable currency despite its limitations. Framed
within an evolutionary account of human health and disease, The
Loss of Sadness presents a fascinating dissection of depression as
both a normal and disordered human emotion and a sweeping critique
of current psychiatric diagnostic practices. The result is a potent
challenge to the diagnostic revolution that began almost thirty
years ago in psychiatry and a provocative analysis of one of the
most significant mental health issues today.
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