CHAPTER XIV. The Classification of Mental Diseases

THE CLASSIFICATION OF MENTAL DISEASES

When the American Psychiatric Association first approached the problem of formulating a definite scheme for the collection of statistical data relating to mental diseases it was immediately confronted with the necessity of adopting an official classification of psychoses purely for purposes of uniformity. This undertaking, which suggested no difficulties at the outset, led to all kinds of unexpected complications and embarrassments. Classifications of "insanity" are almost as old as the terms mania and melancholia and have been given a grossly exaggerated importance by the space which for so many years has been devoted to a consideration of this subject in textbooks. This, if nothing else, appears to have been demonstrated quite clearly by the discussions of the last few years.

A review of the literature of psychiatry shows that attempts to classify the psychoses date back almost to the beginning of medical history. Hippocrates is said to have recognized three forms of mental disorders—mania, melancholia and dementia, although there is some question as to his having used those terms in accordance with their present significance. Celsus also described three forms of insanity. The first, which was accompanied by febrile symptoms, he termed phrenitis. The second was characterized by sadness and caused by black bile. The third was accompanied in some cases by false images, while in others the whole mind or judgment was impaired. The Roman law divided the dementes or mad into two classes, the excited or violent (furiosi) and those deficient in intellect (menti capti). Aretaeus discussed mania, melancholia and dementia, apparently regarding them as all manifestations of some one disease process. Melancholia, he said, "does not affect all the faculties of the mind; the patients are sad and dismayed; they are without fever." He described it as only an initial stage of mania. Caelius Aurelianus did not regard melancholia as a form of insanity, "from which disease it differs in that the stomach chiefly suffers, while in Madness it is the head." Galen in his writings referred to amentia or dementia, imbecility, mania and melancholia.

In the sixteenth century Felix Plater devised the following classification: 1. Mentis imbecillitas: Hebetudo, tarditus, oblivio, imprudentia. 2. Mentis consternatio: Somnus immodicus, carus, lethargus, apoplexia, epilepsia, convulsio, catalepsis, ecstasis. 3. Mentis alienatio: Stultitas, temulentia, amor, melancholia, hypochondriacus morbus, mania, hydrophobia, phrenitis, saltus viti. 4. Mentis defatigatio: Vigiles, insomnia. Linnaeus in 1763 called his fifth class of diseases Mentales, divided into three orders: Ideales, Imaginarii and Pathetici. Sauvages in the same year included Hallucinationes, Morositates and Deliria under the heading of Vesaniae in his "Nosologia Methodica." Vogel in 1764 divided Paranoiae into mania, melancholia, and amentia. Cullen in 1772 included insanity or the Vesaniae in the neuroses, divided into four groups—Amentia, Melancholia, Mania and Oneirodinia. He described eight varieties of melancholia and three of mania. Oneirodinia included somnambulism and nightmare. According to Jelliffe, Plocquet described six varieties of delirium in his treatise on paranoia in 1772. Pinel in 1791 limited himself to four classes of insanity—mania, melancholia, dementia and idiotism. He looked upon melancholia as a delirium exclusively directed upon one object or series of objects and accompanied by sadness. Idiotism was an advanced form of dementia. Esquirol in 1838 modified Pinel's scheme somewhat and described Lypemania, Monomania, Mania, Dementia and Imbecility or Idiocy. The active discussion of classifications of various kinds led Pritchard to make the following interesting comment in 1822: "I cannot conceive anything more preposterously absurd than the attempt to classify diseases with all the divisions and technology of a botanical or zoological system, and to force what is essentially disorder and confusion to assume the appearance of that order and symmetry which nature displays in the arrangement of the organized world. An aetiological classification is the only mode of terminology and arrangement that can be of any practical advantage, and that is all that we have to consult." He nevertheless published a classification of his own which was essentially psychological in principle, although containing nothing new.

The German school of this time was exceedingly prolific in the production of classifications, as will be shown by the following interesting and elaborate scheme of Flemming's published in 1844:—

FAMILY-AMENTIA—MENTAL DISEASES

First Group—Infirmitas (Feeblemindedness).

Varieties:

A. According to etiology: 1. Inf. primaria, or congenita (Idiocy) 2. Inf. secundaria, or acquisita (Imbecility) a. Inf. e. morbo (Brain injuries, encephalitis, epilepsy, etc.) b. Inf. senilis

B. According to degree: 1. Inf. adstricta, or partial feeblemindedness (Weakness of a single mental faculty) a. Dysmnesia (weakness of memory) b. Inf. adstr. surdo-mutorum (feeblemindedness of the deaf and dumb) c. Inf. adstr. coecorum (feeblemindedness of the blind) 2. Inf. sparsa—General (absolute or relative weakness of general mental faculties)

Second Group—Vesania. First Order:—Dysthymodes or Dysthymia.

Varieties:

A. According to types: 1. Dys. transitoria or subita (acute) 2. Dys. continua (chronic) 3. Dys. remittens (remittent)

B. According to degree: 1. Dys. adstricta (limited or partial) a. Dys. atra (melancholia or lypemania) 1. Homesickness. 2. Ferocitas et morositas ebriosorum (Alcoholic excitement and ill humor) b. Dys. candida (cheerful dysthymia or melancholia hilaris) c. Dys. mutabilis (changeable or alternating) 2. Dys. sparsa (apathica)—General dysthymia (melancholia attonita).

Second Order:—Vesania anoëtos or Anoësia—Deliria of various forms.

Varieties:

A. According to types: 1. Anoësia transitoria or subita (acute) Species: a. A. e febre—fever delirium b. A. e potu—alcoholism c. A. ex affectu—affective d. A. semisomnis—confusion of drunken sleep e. A. Somnambula—somnambulism 2. Anoësia continua—chronic 3. Anoësia remittens—remittent.

B. According to degree: 1. Anoësia adstricta—partial or limited a. A. ad sensationes—hallucinatory delirium b. A. ad cogitationes—delusional delirium 2. Anoësia sparsa—general a. Delirium tremens

Third Order:—Vesania Maniaca (Mania).

Varieties:

A. According to types: 1. Mania transitoria or subita—acute a. M. s. a febre—encephalitic delirium b. M. s. a potu—alcoholic mania c. M. s. ex affectu—affective mania d. M. s. e partu—puerperal mania e. M. s. e mordo occulto—amentia occulta, which includes the above forms. 2. Mania continua—chronic mania 3. Mania remittens—remittent mania

B. According to degree: 1. Mania adstricta seu instinctiva—partial or limited mania. (Mania sine delirio of Pinel.) (Moral insanity, monomania.) 2. Mania sparsa—general mania.

This is said to have been based on Jacobi's somato-aetiological theory (1830) that "there is no disease of the mind existing as such, but that insanity exists solely as the consequence of disease, either functional or organic, in some parts of the body system." Heinroth saw in the various mental disorders a disturbance of one or the other of the normal functions of the mind which he divided into three classes. "If the cause of derangement is in relation to one of these manifestations of mental existence—and to one or another it must belong, since the mind is ever occupied with phenomena related to one out of the three classes—we have only to inquire to which modification the disorder actually refers itself, or whether it affects the feelings, the understanding, or the will. Since one of these has possession of our consciousness, or is at least predominant at every point of time, whichever function of the mind happens to be that which is falling into disorder, by it the form of insanity is determined." Griesinger in 1845, on the other hand, was of the opinion that all classifications must in the end return to the principal forms previously described—mania, melancholia and dementia. In 1860 Morel announced his well-known classification: Hereditary Insanity, which included imbecility and idiocy; Toxic Insanity (alcohol, lead, mercury, etc., as well as cretinism); Insanity produced by the transformation of other diseases (hysterical, epileptic, hypochondriacal); Idiopathic Insanity (general paresis, etc.); Sympathetic Insanity, and Dementia, "a terminative state."

Maudsley spoke of Affective or Pathetic, and Ideational Insanity. The former was divided into maniacal perversion, melancholic depression and moral alienation. The latter included general forms (mania or melancholia), partial forms (monomania or melancholia), dementia (primary and secondary), general paralysis and imbecility. Régis described five forms of mania, five of melancholia, two of insanity of double form, and a systematized progressive insanity. In addition to these, he divided constitutional insanity into two groups—the degeneracy of evolution and the degeneracy of involution. Krafft-Ebing included melancholia, mania, primary dementia, exhaustion psychoses and terminal conditions in his group of psychoneuroses. Under the heading of degenerative forms he described constitutional affective insanity, paranoia and periodical insanity. Neurasthenic, epileptic, hysterical and hypochondriacal psychoses were grouped together under the constitutional neuroses. In addition to this he described chronic intoxications, organic brain diseases and arrested development. At a meeting of the International Congress of Alienists in 1889 the following classification was adopted: 1. Mania; 2. Melancholia; 3. Periodical Insanity; 4. Progressive Systematical Insanity; 5. Dementia; 6. Organic and Senile Dementia; 7. General Paralysis; 8. Insane Neurosis (hysteria, epilepsy, hypochondriasis, etc.); 9. Toxic Insanity; 10. Moral and Impulsive Insanity; and 11. Idiocy. Ziehen had a classification scheme which represented an advance in some respects. Mania and melancholia were described as affective psychoses, and paranoia as an intellectual disorder. He also referred to mixed or combined forms. Imbecility, general paresis, terminal deteriorations, etc., were grouped together under the general heading of psychoses with intellectual defects.

The British Medico-Psychological Association has had an official classification for many years. This was quoted by Savage in 1907 as follows:—

1. Congenital or infantile mental deficiency (idiocy or imbecility) occurring as early in life as it can be observed: (1) Intellectual a. Without epilepsy b. With epilepsy (2) Moral 2. Insanity arising later in life: (1) Insanity with epilepsy (2) General paralysis of the insane (3) Insanity with the grosser brain lesions (4) Acute delirium (acute delirious mania) (5) Confusional insanity (6) Stupor (7) Primary dementia (8) Mania a. Recent b. Chronic c. Recurrent (9) Melancholia a. Recent b. Chronic c. Recurrent (10) Alternating Insanity (11) Delusional Insanity a. Systematized b. Non-systematized (12) Volitional Insanity a. Impulse b. Obsession c. Doubt (13) Moral Insanity (14) Dementia a. Secondary or terminal b. Senile

An elaborate classification was also officially adopted by the Royal College of Physicians of England about the same time. This recognized seven varieties of mania, seven of melancholia and six of dementia. The subject of classifications would not be complete without a reference to Kraepelin. His eighth edition (1910-1915) showed the following:—

1. Psychoses accompanying Injuries to the Brain: Concussion Traumatic delirium Traumatic epilepsy Traumatic enfeeblement

2. Psychoses accompanying Diseases of the Brain: Meningitis Brain tumors Abscesses Hemorrhages Thrombosis Embolism Encephalitis Multiple sclerosis Lobar sclerosis Huntington's chorea Amaurotic idiocy

3. The Intoxication Psychoses: Acute: Endogenous—Uraemia, Eclampsia, Acute yellow atrophy of the liver. Exogenous—Ether, Santonin, Hashish, Nitrous Oxide Gas, Atropin, Hyoscin, Carbonic Oxide Gas, etc. Chronic: Alcohol: Delusional (jealousy) Delirium Tremens Korsakow's Psychosis Acute Hallucinosis (paranoid) Alcoholic paralysis and pseudo-paralysis Morphine Cocaine

4. The Infectious Psychoses: Fever delirium Infection delirium Acute confusion (amentia) Infective exhaustive conditions

5. The Psychoses of Syphilis: Syphilitic neurasthenia Gummatous growths Syphilitic pseudo-paralysis Syphilitic apoplexy Syphilitic epilepsy Paranoid forms Tabetic psychoses Hereditary syphilis

6. Dementia Paralytica: Paralytic, Depressive, Expansive and Agitated forms

7. The Senile and Presenile Psychoses: Presenile psychoses Arteriosclerotic psychoses Senile deterioration

8. The Thyroigenous Psychoses: Basedow's Disease Myxoedema Cretinism

9. The Endogenous Dementias: Dementia praecox: Dementia simplex Hebephrenia Depressive dementia Circular form Agitated form Periodical form Katatonia Paranoid form Schizophasia Paraphrenia: Systematica Expansiva Confabulans Phantastica

10. The Epileptic Psychoses.

11. The Manic Depressive Psychoses: Manic form Depressive form Mixed form

12. The Psychogenic Disorders: Nervous exhaustion Dread neurosis The Induced psychoses The psychoses of the Deaf The Accident or Traumatic neuroses The Psychogenic disorders of Prisoners The Querulants

13. Hysteria

14. Paranoia

15. The Constitutional Disorders: Nervousness The Compulsion neuroses The Impulsion neuroses Sexual perversions

16. The Psychopathic Personalities: The Excitable The Unstable The Impulsive The Eccentric The Liar and Swindler The Antisocial The Quarrelsome

17. Defective Mental Development (oligophrenia)

At the annual meeting of the American Medico-Psychological Association in 1869 Nichols called attention to the statistical studies proposed by the International Congress of Alienists in 1867. As a result of his efforts a series of twenty-one statistical tables was prepared and used unofficially for several years, although never formally adopted. A committee reported again on this subject in 1896, but without any definite action being taken. The Italian psychiatrists have had a classification which has been in general use by them for some time. Interest in this subject has been stimulated by the frequent publications of Kraepelin during the last thirty years. Meyer and Hoch have been largely responsible for bringing his work to the attention of the profession in this country, and Kraepelin's classification with some modifications has come into very general use here. It was not until the publication of its twenty-first annual report in 1909 that the New York State Commission in Lunacy adopted a modern classification of psychoses.

At that time there were practically as many different forms of statistical reports in the United States as there were hospitals. In the meanwhile almost every textbook published during the last fifty years has announced a new classification of mental diseases. They have been based on etiology, pathology, symptomatology and psychology. English, French, German, Italian and American classifications have appeared, each representing, as a rule, different schools of psychiatry. Kempf would discard the term psychosis altogether and speak only of neuroses as "more consistent with the integrative functions of the nervous system." For diagnostic purposes he proposes to separate the benign from the pernicious processes and classify them according to their psychological mechanisms as suppression, repression, compensatory, regression and dissociation neuroses. The easiest way out of all these difficulties, as Southard has said, would be "to deny the existence of entities in mental disease. There are two forms of this contention; first, that mental disease is nothing more or less than insanity, an entity itself, a genus with but one species, or secondly, that all victims of mental disease are individually to be provided with entities, that is, all examples of mental disease are sui generis. The development of psychiatry has killed the former contention stone dead, but the latter contention still flourishes to an extent among those who overstress the individual factor. And this latter contention is bolstered up by the existence of so many psychopathic patients of whom a diagnosis cannot be rendered for practical or theoretical reasons. However, there are no really consistent advocates of the sui generis plan of classification." It is interesting to note that he concedes ... "that the American Medico-Psychological Association's classification, adopted as it has been by a great number of American institutions and by the United States Government for war purposes, is a reasonably good classification and aware that its constituent elements fairly well correspond with what all American psychiatrists agree upon."

Southard raises the question as to how this classification can be used for diagnostic purposes. He answers this query by suggesting "A key to the practical grouping of mental diseases" ... "to be followed, when necessary, like a botanical key in the search for the classification of a plant."... "It is a key to study and not an analytical classification with any pretence to finality."... "The plan is not so much an excursion into nosology as an essay in the technique of psychiatric diagnosis for the tyro."

The problem presenting itself in the adoption of a classification purely for statistical purposes was not a question of a scientific grouping of the psychoses based on either etiological, anatomical, pathological, clinical or prognostic considerations. It was a question of compiling a tabulation or list of clinical entities recognized generally by American psychiatrists, subject to such changes and modifications as may be necessary to make it conform to accepted standards. As a matter of fact, no adequate reason for a classification of mental diseases for any other than statistical purposes has even been advanced by the authors of our textbooks on psychiatry. They do not contribute anything of value whatever to our knowledge of symptomatology, diagnosis or treatment. Practically the only point on which the writers of our textbooks agree is that there is no one fundamental principle upon which a satisfactory classification can be based. It is unfortunate that tradition seems to demand the serious consideration of a problem which many believe admits of no solution and which would mean little or nothing to the future of psychiatry if it were solved. The views of the Committee on Statistics are shown by a quotation from the report made to the Association at its meeting in New York in 1917:—"Your Committee feels that the first essential of a uniform system of statistics in hospitals for the insane is a generally recognized nomenclature of mental diseases. The present condition with respect to the classification of mental diseases is chaotic. Some states use no well-defined classification. In others the classifications used are similar in many respects but differ enough to prevent accurate comparisons. Some states have adopted a uniform system, while others leave the matter entirely to the individual hospitals. This condition of affairs discredits the science of psychiatry and reflects unfavorably upon our Association, which should serve as a correlating and standardizing agency for the whole country. The large task of your Committee therefore has been the formulation of a classification which it could unanimously recommend for adoption by the Association. The task was accomplished only after several prolonged conferences at which classifications now in use in various states and countries, and the recommendations of leading psychiatrists were considered. The classification finally adopted is simple, comprehensive and complete; it copies no other classification but includes the strong features of many others; it meets the demands of the best modern psychiatry but does not slavishly follow any single system. In short, your Committee has endeavored to formulate a classification that could be easily used in every hospital for the insane in this country and that would meet the scientific demands of the present day."

Since the compilation of statistical data relating to the various activities of the hospitals for mental diseases in this country was definitely decided upon by the Association at its meeting in 1913, the membership of the Committee on Statistics has from time to time included the following:—Dr. Thomas W. Salmon, Medical Director, National Committee for Mental Hygiene; Dr. Owen Copp, Physician in Chief and Superintendent, Pennsylvania Hospital, Department for Nervous and Mental Diseases; Dr. E. Stanley Abbot, Medical Director, Public Charities Association of Pennsylvania; Dr. Henry A. Cotton, Medical Director, New Jersey State Hospital, Trenton; Dr. L. Vernon Briggs, Boston, former member of the Massachusetts State Board of Insanity; Dr. Adolf Meyer, Professor of Psychiatry, Johns Hopkins University; Dr. Albert M. Barrett, Professor of Psychiatry and Neurology, University of Michigan; Dr. George H. Kirby, Director of the Psychiatric Institute, New York City; Dr. Samuel T. Orton, Professor of Psychiatry and Director of the Psychopathic Hospital, University of Iowa; Dr. Frankwood E. Williams, Associate Medical Director, National Committee for Mental Hygiene; Dr. Elmer E. Southard, Director of the Massachusetts State Psychiatric Institute; Dr. C. Macfie Campbell, Director of the Boston Psychopathic Hospital, and the writer. Associated with the committee officially were: Dr. August Hoch, formerly Director of the Psychiatric Institute, New York; Dr. H. M. Pollock, Statistician of the New York State Hospital Commission; Miss Edith M. Furbush, Statistician of the National Committee for Mental Hygiene, and various others.

The Association's classification of mental diseases at this time (1921) is as follows:

1. Traumatic psychoses: (a) Traumatic delirium (b) Traumatic constitution (c) Post-traumatic mental enfeeblement (dementia) (d) Other types 2. Senile psychoses: (a) Simple deterioration (b) Presbyophrenic type (c) Delirious and confused types (d) Depressed and agitated type (e) Paranoid types (f) Pre-senile type (g) Other types 3. Psychoses with cerebral arteriosclerosis 4. General paralysis 5. Psychoses with cerebral syphilis 6. Psychoses with Huntington's chorea 7. Psychoses with brain tumor 8. Psychoses with other brain or nervous diseases: (a) Cerebral embolism (b) Paralysis agitans (c) Meningitis, tubercular or other forms (to be specified) (d) Multiple sclerosis (e) Tabes dorsalis (f) Acute chorea (g) Other diseases (to be specified) 9. Alcoholic psychoses: (a) Pathological intoxication (b) Delirium tremens (c) Korsakow's psychosis (d) Acute hallucinosis (e) Chronic hallucinosis (f) Acute paranoid type (g) Chronic paranoid type (h) Alcoholic deterioration (i) Other types, acute or chronic 10. Psychoses due to drugs and other exogenous toxins: (a) Opium (and derivatives), cocaine, bromides, chloral, etc., alone or combined (to be specified) (b) Metals, as lead, arsenic, etc. (to be specified) (c) Gases (to be specified) (d) Other exogenous toxins (to be specified) 11. Psychoses with pellagra 12. Psychoses with other somatic diseases: (a) Delirium with infectious diseases (b) Post-infectious psychosis (c) Exhaustion delirium (d) Delirium of unknown origin (e) Cardio-renal diseases (f) Diseases of the ductless glands (g) Other diseases or conditions (to be specified) 13. Manic-depressive psychoses: (a) Manic type (b) Depressive type (c) Stuporous type (d) Mixed type (e) Circular type (f) Other types 14. Involution melancholia 15. Dementia praecox: (a) Paranoid type (b) Catatonic type (c) Hebephrenic type (d) Simple type (e) Other types 16. Paranoia or paranoid conditions 17. Epileptic psychoses: (a) Epileptic deterioration (b) Epileptic clouded states (c) Other epileptic types (to be specified) 18. Psychoneuroses and neuroses: (a) Hysterical type (b) Psychasthenic type (c) Neurasthenic type (d) Anxiety neuroses (e) Other types 19. Psychoses with psychopathic personality 20. Psychoses with mental deficiency 21. Undiagnosed psychosis 22. Without psychosis (a) Epilepsy without psychosis (b) Alcoholism without psychosis (c) Drug addiction without psychosis (d) Psychopathic personality without psychosis (e) Mental deficiency without psychosis (f) Others (to be specified)