* The book you are about to read is a brilliant tour de force of scholarship and analysis from two of our leading thinkers about psychiatric diagnosis and the nature of mental disorders. Allan Horwitz and Jerome Wakefield’s The Loss of Sadness represents the most cogent and compelling “inside” challenge to date to the diagnostic revolution that began almost 30 years ago in the field of psychiatry. The authors begin by arguing for the existence of
a universal intuitive understanding that to be human means to naturally react with feelings of sadness to negative events in one’s life. In contrast, when the symptoms of sadness (e.g., sad feelings, difficulty sleeping, inability to concentrate, reduced appetite) have no apparent cause or are grossly disproportionate to the apparent cause, the intuitive understanding is that something important in human functioning has gone wrong, indicating the presence of a depressive disorder. Horwitz and Wakefield then persuasively argue, as the book’s central thesis, that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship of symptoms to the context in which they emerge. The psychiatric diagnosis of Major Depression is based on the assumption that symptoms alone can indicate that there is a disorder; this assumption allows normal responses to stressors to be mischaracterized as symptoms of disorder. The authors demonstrate that this confusion has important implications not only for psychiatry and its patients but also for society in general.
The book’s thesis is of special interest to me, because I was the head of the American Psychiatric Association’s task force that in 1980 created the DSM-III (i.e., the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the Association’s official listing of recognized mental disorders and the criteria by which they are diagnosed). This was the first edition of the Manual to offer explicit symptomatic criteria for the diagnosis of each mental disorder. Now in its fourth edition, the DSM is generally considered to have revolutionized the psychiatric profession. It serves to define how researchers collect their samples, what conditions insurance companies will reimburse, what conditions courts and social agencies treat as illnesses, and how individuals themselves interpret their emotional experiences. The DSM ’s standardization of psychiatric diagnosis by using explicit rules for making a diagnosis has been critical to the explosion of research and knowledge in the mental health field. It has allowed clinicians and researchers with different theoretical perspectives, and thus different languages, to communicate with each other. It has also addressed doubts about psychiatry’s scientific status, such as concerns about the reliability of its diagnoses.
Yet the very success of the DSM and its descriptive criteria at a practical level has allowed the field of psychiatry to ignore some basic conceptual issues that have been lurking at the foundation of the DSM enterprise, especially the question of how to distinguish disorder from normal suffering. This book will bring
increased attention to these conceptual problems.
* Interventions such as grief counseling and efforts that force people to acknowledge their grief have not been shown to be very effective and can be harmful. Indeed, an alarmingly high number of grieving people worsen after receiving treatment.
* Although the permanency of the loss associated with grief distinguishes it from most other losses, grief need be no different in principle from intense sadness that arises, for example, after the unsought end of a love affair, the news that one’s spouse has been unfaithful, the dissolution of a marriage, the failure to achieve one’s cherished life goals, the loss of financial resources, the loss of social supports and relationships, or the diagnosis of a serious illness in oneself or a loved one. 40 Even the death of beloved pets or celebrities whom
one does not personally know can create periods of low mood, low initiative, and pessimism as normal reactions to loss. 41 The DSM ’s own general definition of mental disorder provided in its introduction excludes all “expectable and culturally sanctioned response(s) to a particular event, for example, the death of a loved one” from its definition of mental disorder, using grief as the prototypical excluded category. Yet, emotionally painful responses to other particular loss events such as marital, romantic, health, or financial reversals plainly can be just as “expectable and culturally sanctioned” responses as those of bereavement and should therefore fall under the definition’s exclusion as well. The criteria for MDD, however, do not follow out this logic, and they contain no exclusions for other loss responses comparable to the one for bereavement.
Marital dissolution is perhaps the most common trigger of intense normal sadness that can be severe enough to meet DSM symptomatic criteria for depressive disorder. The intense sadness that follows the loss of romantic attachments has long been a central literary theme. The double suicides of Romeo and Juliet, for example, do not result from mental disorder but from a tragic misunderstanding after the perceived loss of a lover. Other literary suicides, such as Emma Bovary’s or Anna Karenina’s, stem from realizations that the consequences of stigmatized romantic entanglements are inescapable.
Current research supports the intuition that severe losses of intimate attachments naturally lead to sadness responses: in many studies marital dissolution is more consistently and powerfully associated with depression than any other variable. Indeed, rates of depressive episodes that meet DSM criteria are comparable for persons who experience marital dissolution and those who experience bereavement. People who undergo marital dissolution are far more likely to develop first onsets of MDD over a 1-year period than people who do not.