06 juin 2008

L'émotion nous égare : c'est son principal mérite.


Dante Gabriel Rossetti, The Holy Grail, 1860.
By the late 1960s it was no longer acceptable to treat all depressed patients as if they were suVering from a single condition because some treatments were eVective for some patients and not for others. One group, for example, examined 33 studies that had assessed medication treatments of depression and could not find a diagnostic formulation that had predictive strength. The DSM-II and ICD-8 classifications had poor reliability, best demonstrated in international studies.

An operationally defined diagnostic scheme was oVered in the Research Diagnostic Criteria (RDC).44 Its usefulness encouraged the American Psychiatric Association to update the oYcial classification in DSM-III of 1980.45 Lacking a defined theory of psychiatric illness, however, the classes represented a consensus among observers who used diVerent texts, idiosyncratic personal clinical experiences, and diVerent psychological and pharmacologic theories as guidelines. For some disorders, a Kraepelinian template can be recognized (e.g., the schizophrenia criteria); for others, a psychological template is apparent (e.g., dissociative disorders). The committees represented diverse constituencies and the final formulations were designed to be accepted by the average psychiatrist who would vote it up or down in an American Psychiatric Association election.46Within a few years, dissatisfaction with the classification called for revisions (DSM-IIIR) in 1987 and in 1994 (DSM-IV).

Melancholia was ignored as each revision added new categories in response to the needs of diVerent practitioner groups. In the first DSM classification, four different depressive reactions were identified, with four subtypes for ‘‘aVective reactions.’’ In the 1968 version, two additional subtypes were added. By 1980, four major mood disorders were identified, with 10 subtypes. For major depression, an additional three subtypes were listed. ‘‘Melancholia’’ could still be specified as either present or absent for major depression but was not recognized as a specific disorder. As the core disorder of mood, the DSM-III commission oVered a single concept of ‘‘major depression’’ (with descriptors of single episode or recurrent) and with the variant
bipolar depression (with mixed, manic, and depressed variants).

Depressive disorder not otherwise specified and abnormal bereavement were two additional entities. Psychosis became a specifier of mood disorders. A syndrome of ‘‘dysthymia’’ was revived. The concepts of melancholia, melancholic depression, and involutional depression were discarded.

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