Uploaded by Kenneth Kendler

Historical precedents for the DSM-III bereavement exclusion criteria for major depression

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Psychological Medicine
cambridge.org/psm
Original Article
Cite this article: Kendler KS (2018). Historical
precedents for the DSM-III bereavement
exclusion criteria for major depression.
Psychological Medicine 1–10. https://doi.org/
10.1017/S0033291718000533
Received: 25 September 2017
Revised: 6 December 2017
Accepted: 8 February 2018
Key words:
Bereavement exclusion criteria; depression;
DSM-III; history
Author for correspondence:
Kenneth S.Kendler, E-mail: [email protected]
vcuhealth.org
Historical precedents for the DSM-III
bereavement exclusion criteria for
major depression
Kenneth S. Kendler
Department of Psychiatry, Virginia Institute of Psychiatric and Behavioral Genetics, and Medical College of
Virginia/Virginia Commonwealth University, Richmond, VA, USA
Abstract
Background. I review the historical antecedents of the two key features of the bereavement
exclusion (BE) for major depression (MD) criteria initially proposed in DSM-III: (i) a
context-dependent approach to the evaluation of MD which required that the diagnosis be
given only when course, symptoms and signs are ‘out of proportion’ to experienced adversities, and (ii) bereavement is the sole adversity for which this context-dependent approach
should be utilized.
Methods. A review of 49 textbook and review articles on depression or melancholia published
1880–1960.
Results. Seventeen (35%) of the 49 texts advocated for a context-dependent approach to the
diagnosis of MD. Most advocates relied on an intuitive clinical understanding of when the
depressive features were v. were not commensurate with the experienced adversities. Several
authors suggested that specific symptoms or course of illness could differentiate MD from
‘normative’ sadness. Others noted that patient reports of psychological causes of their depression should be treated skeptically. While death of loved ones was the most frequently noted
specific adversity associated with MD, no author considered it qualitatively different from
other stressors or suggested that it alone should be considered when diagnosing MD in a
context-dependent manner.
Conclusions. A key underlying assumption of the BE criteria – a context-dependent approach
to the diagnosis of MD– was advocated by a significant minority of earlier psychiatric
diagnosticians, although problems in its clinical implementation were sometimes noted. No
historical precedent was found for the application of the context-dependent approach only
to bereavement, as proposed in DSM-III.
The debate over the bereavement exclusion (BE) criteria for major depression (MD) – that MD
should not be diagnosed if the symptoms can be ‘better accounted for by bereavement’
[(American Psychiatric Association, 1994) 327] – was one of the most heated and publicized
in the DSM-5 revision process (Zachar et al. 2017). One part of this debate was about historical
precedents, about whether the BE criteria was a novel idea when first proposed in DSM-III
(American Psychiatric Association, 1980) or had prior historical precedents in the psychiatric
literature on the diagnosis of MD (Horwitz et al. 2007; Kendler, 2008; Wakefield, 2013). A
central issue in these discussions is whether MD should be diagnosed solely on the basis of
the presenting history, symptoms, and signs (the context-independent position) or whether
the diagnostician should take into account psychosocial adversities recently experienced by
the patient (the context-dependent position). If the depressive symptoms were considered commensurate with the level of adversity, the context-dependent position would suggest that a
diagnosis of MD should not be given.
In this paper, I address these questions through a review of 49 descriptions of MD or melancholia (hereafter for simplicity ‘MD’) in psychiatric textbooks or articles published from
1880 to 1960. Rather than focusing narrowly on the BE criteria, I sought to provide an historical context to this debate by addressing, in these historical documents, three inter-related
questions:
© Cambridge University Press 2018
(1) Does the author consider psychosocial adversities to predispose to mental illness generally
and MD more specifically? If yes, is bereavement noted as one such possible adversity?
(2) Does the author advocate for a context-dependent approach to the diagnosis of MD?
(3) Does the author endorse the key features of the BE criteria – that is, an acceptance of the
context-dependent approach to the diagnosis of MD but its restriction only to cases of
bereavement and not to other kinds of adversity?
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2
Methods
I sought to assemble a substantial and representative number of
psychiatric texts that described in reasonable detail the diagnostic
approach to MD. I began with texts I had assembled for two prior
projects: psychiatric textbooks written in 1900–1960 (Kendler,
2016) and textbooks and review articles on MD published from
1880 to 1900 (Kendler, 2017). Because large amounts of text –
including sections on the etiology of mental illness – had to be
reviewed, I limited these texts to either those published in or
translated into English. In total, adding a few new texts that I
located in the interim, I examined 49 texts from authors in the
following countries: USA – 26, UK – 15, German – 2, France –
2, and one each from Austria, Canada, and Switzerland. Of
these, 45 were textbooks and four were review articles.
My review went through three stages. First, I determined
whether the text contained a general discussion on the etiology
of mental illness. Most of the longer textbooks contained such a
section, but these were missing from some of the shorter ‘handbooks’ and from all of the review articles. If this section was present, I read it carefully to see if it contained a discussion of the
impact of recent psychosocial adversities. In the earlier texts,
these were labeled ‘moral’ causes of illness. If adversities were
noted, I then determined if bereavement was considered one
such cause. Several texts described ‘emotional reactions’ as possible causes such as fright, fear or grief. I did not count these
instead requiring that the author listed specific ‘events’ such as
romantic loss, business difficulties or death of loved ones.
Second, I examined carefully the section on MD including the
introduction, which often contained a ‘definition’ of the syndrome by the author, the description of symptoms and signs,
and in particular the section on differential diagnosis. It was
here that I sought a description of the potential role that recent
psychosocial adversities should play in the diagnosis of MD.
When present, this was, interestingly, most frequently noted in
the initial ‘definition’ section of MD and less frequently in the discussion of differential diagnosis. Many of these texts contained
descriptions about the differential diagnosis of MD with ‘milder’
psychiatric disorders such as neurasthenia or later neurotic or
‘reactive’ depression. These were not of interest to this inquiry
that focused on the distinction between MD and a ‘normative’
reaction which was not considered to represent a mental illness.
Third, in those texts which raised the issue of the discrimination between MD and a normative response to recent adversities,
I carefully examined which adversities were listed to see if
bereavement was among them. I required that death (or an
equivalent phrase) be specifically noted. I did not count a mention of ‘grief’ alone as from context, this term was often used
broadly in these texts to refer to an emotional reaction to a
range of losses. I also recorded, as an internal control, the presence of financial or business losses in the list of adversities that
often precede MD. Finally, I never utilized any material in these
texts that were only presented as part of a case history.
A limitation of this study is that I cannot prove that these texts –
which often ran to hundreds of pages – did not contain an important statement addressing one of these three issues that I missed.
One cannot definitively prove a negative. However, with one exception – the recent English translation of Kraepelin’s sixth edition
(Kraepelin, 1990) – I located searchable PDFs of all documents
which were originally published before 1910. For these, I did relevant word searches to reduce the chances of missed key phrases.
For the more recent texts, I utilized their indices. Nonetheless, it
Kenneth S. Kendler
is not unlikely that I missed some important phrases in a few of
these texts. The p values were reported two-tailed.
Results
General findings
Of the 49 texts reviewed, 19 had no general section on the etiology
of mental illness (Table 1). Among the 30 that did, 19 (63%)
noted that specific recent adversities predisposed to illness risk.
Of those 19, 11 (58%) mentioned bereavement as one such
adversity. Examples include the following:
Severe mental and physical strains, reverses in business, loss of property
and friends, masturbation, sexual excesses, religious excitement, anxiety
in any and all its forms (may induce onset of melancholia) (Punton,
1898). About twenty-four per cent of all cases of insanity are ascribed
to moral causes, among which are classed domestic troubles, grief over
death of friends, business worries, anger, religious excitement, love affairs,
fright, and nervous shock (Church & Peterson, 1900). A sudden calamity,
loss of a dearly loved relative or friend, reverse of fortune, political catastrophe, or a shock or fright preceding from some awful spectacle or violent
quarrel, or near approach to death – these are the things which unhinge
the mind (Blandford, 1886).
In the sections on MD, 29 of the authors (59%) stated that
adversities in adult life were a relevant etiologic factor in depression. Of those 29, 17 (58%) mentioned bereavement as a specific
risk factor. The next most frequently noted adversities were financial problems (15% or 52%) and romantic difficulties (7% or
24%). Examples of these descriptions included:
Disappointments, excessive mental application and strain, reverses in
business, masturbation, loss of property, loss of children …, may act as
direct causes in the development of the disease (of MD) [(Stearns,
1893) 128]. In nearly one half of all cases of melancholia, emotional disturbances from the death of wife, husband, or child are mentioned in the
clinical histories of patients. Vivid emotions of any kind, the shock of
business reverses, the loss of property, actual want (are also common antecedents) (Berkley, 1900). (Melancholia) … is often excited by severe
domestic or financial losses, by severe illnesses and overwork [(Dana,
1904) 642]. The psychological precipitants (of MD) may be of the most
diverse types; but broken love affairs and bereavements are particularly
prominent (as well as) professional disappointments and ‘disgrace with
fortune or men’s eyes’ [(Curran & Guttmann, 1945) 164].
Seventeen of the 49 texts (35%) advocated for the contextdependent position – that MD should be diagnosed only when
the symptoms and signs displayed were out of keeping with the
recent experiences of the patient (Table 1). These 17 texts were
not distributed evenly across countries or time periods. Of the
15 UK authors, 10 (67%) advocated for the context-dependent
position, while this view was adopted by only seven of the 34
other authors (21%) (χ2 = 9.75, df = 1, p = 0.002). Taking
Kraepelin’s publication in 1899 of this sixth edition – with its introduction of his mature concept of manic-depressive illness – as an
historical watershed, the context dependence of MD was advocated
by 13 of 27 (48%) of the authors publishing before 1899 but only
four of 21 (19%) publishing after (χ2 = 4.37, df = 1, p = 0.04).
Rationales for the context-dependent position
Table 2 provides relevant quotes from all authors advocating for
the context-dependent position on the diagnosis of MD. Most
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Adversity and all forms of
mental illness
Advocates for context-dependent
approach to the diagnosis of
depression
Adversity and depression
Author
Year
Country
Diagnosis
Noted
Includes
death of
loved ones
Russell (Russell, 1881)a
1881
USA
Melancholia
NA
NA
+
+
−
−
Worcester (Worcester, 1882)
1882
USA
Melancholia
NA
NA
+
+
−
−
Hammond (Hammond, 1883)
1883
USA
Melancholia
−
−
−
−
−
−
Spitzka (Spitzka, 1883)
1883
USA
Melancholia
NA
NA
−
−
−
−
Savage (Savage, 1884)
1884
UK
Melancholia
+
+
+
+
+
−
Folsom (Folsom, 1886)
1886
USA
Melancholia
+
−
−
−
−
−
Blandford (Blandford, 1886)
1886
UK
Melancholia
+
+
+
+
+
−
Lewis (Lewis, 1889)
1889
UK
Depression
NA
NA
+
−
+
−
Mercier (Mercier, 1890)
1890
UK
Melancholia
+
−
+
−
+
−
1891
(1895)
France
Melancholia
+
+
+
+
−
−
1892
Canada
Melancholia
+
+
+
−
+
−
1892
(1893)
Germany
Melancholia
+
+
+
+
+
−
−
+
+
−
+
−
−
−
Regis (Régis, 1895)
D. Clark (Clark, 1892)
Kirchhoff (Kirchhoff, 1893)
Noted
Includes
death of
loved ones
Business or
financial
problems
For all
adversities
For
bereavement
only
+
+
Tuke (Tuke, 1892)
1892
UK
Melancholia
NA
NA
+
+
Gray (Gray, 1893)
1893
USA
Melancholia
NA
NA
+
+
Stearns (Stearns, 1893)
1893
USA
Melancholia
NA
NA
+
+
Shaw (Shaw, 1894)
1894
USA
Melancholia
NA
NA
−
−
−
−
Burr (Burr, 1894)
1894
USA
Melancholia
+
+
−
−
−
−
Farquharson (Farquharson,
1895)a
1895
UK
Melancholia
NA
NA
+
−
+
+
−
Maudsley (Maudsley, 1895)
1895
UK
Melancholia
−
−
+
+
+
+
−
A Clark (Clark, 1897)
1897
UK
Melancholia
−
−
−
−
+
−
Kellogg (Kellogg, 1897)
1897
USA
Depression
+
+
−
−
+
−
1897
(1903)
Austria
Melancholia
+
+
−
−
+
+
−
+
−
+
−
−
+
+
−
−
−
Krafft-Ebing (Krafft-Ebing, 1903)
Punton (Punton, 1898)a
1898
USA
Melancholia
NA
NA
a
1898
Germany
Melancholia
NA
NA
+
+
Chapin (Chapin, 1898)
1898
USA
Melancholia
NA
NA
−
−
Ziehen (Ziehen, 1898)
+
Psychological Medicine
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Table 1. Summary of key results from 49 textbooks and articles published on depression or melancholia from 1880 to 1960
(Continued )
3
4
Adversity and all forms of
mental illness
Adversity and depression
Advocates for context-dependent
approach to the diagnosis of
depression
Noted
Includes
death of
loved ones
Noted
Includes
death of
loved ones
Business or
financial
problems
For all
adversities
For
bereavement
only
+
−
−
Author
Year
Country
Diagnosis
MacPherson (Macpherson, 1899)
1899
UK
Melancholia
−
−
+
+
Church (Church & Peterson, 1900)
1899
USA
Melancholia
+
+
+
+
−
−
1899
(1990)
Germany
Depression
+
−
+
−
−
−
Potts (Potts, 1900)
1900
USA
Melancholia
NA
NA
−
−
+
−
Berkley (Berkley, 1900)
1900
USA
Melancholia
−
−
+
+
+
−
1903
(1905)
France
Depression
+
−
−
−
−
−
Dana (Dana, 1904)
1904
USA
Melancholia
+
−
+
−
−
−
Paton (Paton, 1905)
1905
USA
Depression
−
−
+
−
−
−
White (White, 1907)
1907
USA
Depression
+
−
+
−
−
−
Craig (Craig, 1912)
1912
USA
Melancholia
+
−
+
+
−
−
Cole (Cole, 1913)
1913
UK
Melancholia
+
+
+
−
+
−
Dercum (Dercum, 1913)
1913
USA
Melancholia
NA
NA
+
+
−
−
Jelliffe (Jelliffe & White, 1923)
1915
USA
Depression
NA
NA
−
−
−
−
1916
(1924)
Switzerland
Melancholia
+
−
−
−
−
−
Kraepelin (Kraepelin, 1990)
De Fursac (De Fursac, 1905)
Bleuler (Bleuler, 1976)
+
+
+
Buckley (Buckley, 1920)
1920
USA
Depression
+
−
−
−
−
−
Yellowlees (Yellowlees, 1932)
1932
UK
Depression
NA
NA
−
−
+
−
Sadler (Sadler, 1936)
1936
USA
Depression
+
+
−
−
−
−
Noyes (Noyes, 1936)
1936
USA
Depression
−
−
−
−
−
−
−
−
−
−
Gordon (Gordon et al. 1936)
1938
UK
Melancholia
−
−
−
−
Muncie (Muncie, 1939)
1939
USA
Depression
NA
NA
+
−
Henderson (Henderson &
Gillespie, 1944)
1944
UK
Depression
−
−
−
−
−
−
Curran (Curran & Guttmann,
1945)
1945
UK
Depression
+
−
+
+
−
−
Mayer-Gross
(Mayer-Gross et al. 1954)
1954
UK
Depression
NA
NA
+
−
−
−
Ulett (Ulett & Goodrich, 1956)
1956
USA
Depression
NA
NA
−
−
−
−
+
Journal article. All other documents are textbooks. When a second date is provided, i.e. the date of the publication of the translation. Ziehen’s article was originally published in English. NA – not applicable because relevant section was not present in
the text. + means present; − means absent.
a
Kenneth S. Kendler
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Table 1. (Continued.)
Psychological Medicine
authors described their rationale only briefly but others commented more extensively. The phrases most frequently used to discriminate MD as a mental illness from normative depressive
symptoms were that, in the context of experienced adversities,
the symptoms and signs were ‘unreasonable’, ‘not justified’,
‘disproportionate’, and, most commonly, ‘out of proportion’.
Alternatively, some authors noted that the stressors were ‘insufficient’, or did not ‘correspond’ or ‘warrant’ the resulting depressive
symptomatology. Several authors use the phrase ‘natural’ to
describe a normative context-dependent depressive syndrome.
Implementing the context-dependent position
Several authors comment, in a more practical vein, on how the
context-dependent position might work in clinical practice
(Table 2). Blandford tells readers that ‘Your diagnosis here will
be aided if you compare the way in which people in general are
affected by such matters with the case before you… (Blandford,
1886)’. Farquharson (Farquharson, 1895) suggests that following
patients over time will help as true melancholia becomes ‘more
and more independent’ of any precipitating stressors. Maudsley
(Maudsley, 1895) notes that in the patient with a non-pathological
depression, the ‘dejected mind rallies … and presently recovers its
tone’. Krafft-Ebing (Krafft-Ebing, 1903) states that the symptom
of a ‘general inhibition of the mental activities’ is indicative of
true melancholia.
Table 3 contains more extended comments by five of our
authors on the challenges of distinguishing between MD and a
normative depressive syndrome. Blandford (Blandford, 1886)
gives three poignant examples of cases where, in his own words,
the depressive symptoms were clearly ‘out of proportion’ to the
experienced stressors. Tuke (Tuke, 1892) raises the concerns of
how to interpret claims by the depressed patient that his symptoms are in reaction to stressors. You can rule this out, he argues,
when the depressive symptoms derive from delusional beliefs. But
he then notes the ‘large class’ of patients where their explanation
for their melancholy ‘may possibly be true’. He urges caution in
concluding that such beliefs are necessarily false.
Gray takes a different tack, suggesting, as did Krafft-Ebing, that
symptoms can be helpful in the differential diagnosis. True cases
of melancholia, he suggests, are ‘mechanical and lethargic’ and
suffer from ‘marked insomnia’. While the normative depressive
reaction typically has a more demonstrative ‘outbreak of tears
or manifestation of grief’, the true depressive has a ‘quiet unreasoning melancholy’.
In one of the more fascinating of our texts, Ziehen (Ziehen,
1898) describes a mental status examination for the diagnosis of
a depressive syndrome. He cautions against always taking the
patient’s explanation for their depression literally (‘he refers the
anxiety and dejection to a fancied crime, disease or poverty’)
and suggests that any supposed cause ‘must be carefully inquired
into, either through the patient himself or his relatives’. In determining whether the depressive symptoms are commensurate with
the stressors, ‘the relatives should be asked as to how the patient
formerly behaved under like circumstances’.
Finally, Yellowlees (Yellowlees, 1932) also gives an extensive
description of the problems of the diagnosis of MD. He argues
that the clinical presentation of true depression ‘is completely different’ from the normative depressive syndrome. He later gives a
few details on how such a distinction might be made (e.g. a ‘deadening of responses’ and markedly impaired volition) and ends
5
with suggesting substantial skepticism about the patient’s own
explanation for his depression.
Discussion
The questions
In DSM-5, the diagnostic criteria for panic disorder and specific
phobia require that the diagnoses take account of the psychosocial
context in which symptoms arise. Panic attacks are required to be
‘unexpected’ and the symptoms of specific phobia must be ‘out of
proportion’ to the actual danger to which the subject is exposed.
By contrast, for schizophrenia, the diagnosis is made independent
of the psychosocial context in which the symptoms arise.
The BE debate in DSM-5 centered around two issues, the historical backgrounds of which are reviewed in this paper. The first
and larger question is whether MD should be diagnosed in a
context-dependent manner – like panic disorder and specific phobia – or a context-independent manner like schizophrenia. If
diagnoses of MD need to be made accounting for psychosocial
context, the second and more focused question in the BE debate
is whether the relevant context should be restricted to bereavement or to apply more generally to any severe recent adversity.
The goal of this paper was to provide an historical background
to this debate. Given evidence that our current concept of MD
can, with considerable fidelity, be traced back to 1880 (Kendler,
2016, 2017), that was a logical starting point on my inquiry.
The year 1960 was chosen as a concluding date so as to end
our inquiry substantially before the DSM-III revolution in psychiatric nosology.
Main results
Out of the wide diversity of findings, I emphasize four points,
moving from less to greater specificity with respect to the BE
debate. First, the recognition that recent psychosocial adversity
is causally related to psychopathology in general and MD more
specifically goes back a long way, far before the empirical studies
of stressful life events that began rigorously in the 1960s (Paykel
et al. 1969; Brown et al. 1973; Frank et al. 1994). However, the
pathogenic nature of such events was noted by only about 60%
of authors and when a set of illustrative events were provided,
the list, while diverse, was typically short. While death of relatives
was relatively often mentioned, it was never treated as a special or
distinct kind of adversity.
Second, our historical review provides mixed support for the
context-dependent approach to the diagnosis of MD. It was a
minority opinion expressed in about a third of the texts.
However, the 17 authors who argued that depression requires a
judgement that it is ‘unexpected’, or ‘out of proportion’ to experienced adversities represented a vocal minority, some of whom
defended their position forcefully and at length. Of note, the
context-dependent position was not found in the texts we examined from the two most prominent of our authors (Kraepelin and
Bleuler) nor was this position supported by a number of the leading lights of early and mid-twentieth century US and British
psychiatry (e.g. White, Jelliffe, Henderson, and Mayer-Gross).
However, some well-known late nineteenth century figures, especially Maudsley and Krafft-Ebing, were advocates.
Third, a range of views were expressed on how a contextdependent approach to the diagnosis of MD would be implemented. Most frequently, the authors appeared to rely on their clinical
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6
Kenneth S. Kendler
Table 2. Quotations from authors who advocate for the context-dependent approach to the diagnosis of depression or melancholia
Author
Year
Country
Savage (Savage, 1884)
1884
UK
Melancholia is a state of mental depression, in which the misery is unreasonable either
in relation to its apparent cause, or in the peculiar form it assumes p. 151
Blandford (Blandford, 1886)
1886
UK
You will constantly be met with the argument, raised either by the patient or his friends,
that it is only a state of grief arising from some adequate cause. He has lost a relative or
a sum of money, or suddenly discovered that he is a sinner, or has some bodily ailment
… . Your diagnosis here will be aided if you compare the way in which people in general
are affected by such matters with the case before you…, you will sometimes find that
there is no assignable cause for the gloom, or that if there is, it is one totally out of
proportion to the mental distress you witness
Lewis (Lewis, 1889)
1889
UK
Painful mental states are of course normal under certain conditions in health and sanity.
As in the intellectual sphere it is but human to err, so in the emotional sphere it is but
human to suffer, and to feel acutely: hence it is not the intensity of mental pain that
characterises this phase of disease, for if the anguish be the outcome of
commensurately painful circumstances, we regard it as but a natural reaction… If,
however, the mental pain is the result of trivial exciting agencies, if moral or physical
agencies arouse emotional states out of all proportion to what would occur in the
healthy mind, then we … we speak of the result as pathological depression. pp. 115–6
Mercier (Mercier, 1890)
1890
UK
Simple depression - a feeling of unhappiness which is not justified by the circumstances
of the individual, and for which he is unable to account. pp. 340–41.
D. Clark (Clark, 1892)
1892
Canada
… remember this (mental depression) is distinct from natural despondency, for the
latter is common to all humanity. Not to possess mental depression at times would be a
suspicious deprivation in any person; it would be abnormal.
Tuke (Tuke, 1892)
1892
UK
A disorder characterised by a feeling of misery which is in excess of what is justified by
the circumstances in which the individual is placed. p. 787 …
Gray (Gray, 1893)
1893
USA
Melancholia is to be differentiated from sadness due to grief or anxiety. p. 598
Farquharson (Farquharson, 1895)
1895
UK
Melancholia is characterized by the presence of mental depression out of proportion to
any exciting cause and tending to become more and more Independent of any such
external agency. p. 722
Maudsley (Maudsley, 1895)
1895
UK
If his sadness be due to misfortune, bereavement, soured hope, disdained affection,
crosses or losses in business, or other sufficient blow to self-interest or selflove, his
dejected mind rallies, when in good health, and presently recovers its tone; his grief was
natural, grief proceeding from a natural motive and proportionate to its cause. But if his
sadness is due to internal failure of the springs of reaction, without external cause or in
measure and duration out of all proportion to such cause as there may have been, then
it is morbid.
A Clark (Clark, 1897)
1897
UK
Melancholia is a morbid state beyond the melancholy or depression which are more or
less common in everyday life. p. 103
Kellogg (Kellogg, 1897)
1897
USA
Mental suffering, when commensurate with the exciting cause, is normal, but when it is
disproportionate to the same it constitutes a pathological condition termed a state of
mental depression. p. 712
1897
(1903)
Austria
Ziehen (Ziehen, 1898)
1898
Germany
(After an extensive examination) …. It is then to be considered whether the existing
dejection corresponds in its duration and intensity to the unfortunate event or exceeds
the physiological limits. p. 567
Potts (Potts, 1900)
1900
USA
Melancholia is a disorder of the mind and body, due to an excitement of the depressive
emotions. These emotions are often temporarily excited by various causes, but when
excited without cause or to a greater extent and for a longer period than is justified by
the cause, melancholia may be said to exist.
Berkley (Berkley, 1900)
1900
USA
By melancholia proper is meant a simple affective insanity … characterized by mental
pain which is excessive, out of all adequate proportion to its cause… p. 130.
Cole (Cole, 1913)
1913
UK
The ordinary feeling of discomfort and misery, which afflicts some mortals from time to
time, and which is characterised as ‘a fit of the blues,’ is a state of melancholy which
does not pass the border-line of the pathological state we commonly call Melancholia.
By Melancholia we mean an intense feeling of depression and misery, such as the
physical condition of the patient does not warrant, and which has no proper
relationship to the external circumstances of the patient. p. 105
Yellowlees (Yellowlees, 1932)
1932
UK
Depression … is usually considered pathological when it exists ‘out of all proportion to
any ascertainable cause’
Krafft-Ebing (Krafft-Ebing, 1903)
The fundamental phenomenon in melancholia consists of the painful emotional
depression, which has no external, or an insufficient external, cause, and general
inhibition of the mental activities, which may be entirely arrested.
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7
Table 3. More extended quotes regarding the operationalization of a context-dependent position of distinguishing major depression from normative depressive
symptoms
Author
Year
Country
Blandford (Blandford, 1886)
1886
UK
If a lady mourns the death of a daughter which happened several years ago, and accuses herself
of having caused it, you will hardly think it ordinary sorrow. If the money lost is small in amount,
causing no real difference in the patient’s circumstances, you will not see in it a reason for his
folding his hands and utterly neglecting his business, family, and friends. When a man suddenly
discovers, without any process of introspection, reflection, or counsel from others, that he is
wicked and beyond the hope of salvation, the chances are that he is suffering from religious
melancholia … p. 138
Tuke (Tuke, 1892)
1892
UK
… In order to say with any confidence that the malady exists, it is necessary to know the
circumstances of the individual in order to judge whether the misery experienced is justified by
them or no. It may be that the misery is so profound that scarcely any circumstances, however
adverse, would be a justification for it, and in such cases the diagnosis is not difficult; or it may
be that the feeling of misery may be accounted for by a reason which is palpably and manifestly
the outcome of a delusion, as that the patient has been deprived of his wings, or has had
another person’s brains substituted for his own. But there is a large class of cases in which the
reason alleged may possibly be true, and, if true, would justify the feeling of unhappiness. If a
patient appears afflicted with melancholy, and declares that he is on the brink of ruin; that his
wife is unfaithful: that he is a wicked and dishonest man; that he is liable to arrest; it is
necessary to be very cautious in regarding his statements as unfounded. It may be that they are
true, and that his feeling of misery is only the normal and natural feeling that such
circumstances ought to inspire.
Gray (Gray, 1893)
1893
USA
Sadness from grief or anxiety seldom makes a patient so mechanical and lethargic as does true
melancholia. Great shock of a mental nature may stun a patient for a certain period, but it will
be usually succeeded by a certain outbreak of tears or manifestation of grief, and about such a
person there is not the quiet unreasoning melancholy of a melancholiac, nor is there apt to be
marked insomnia …. pp. 598–9
Ziehen (Ziehen, 1898)
1898
Germany
Why are you sad? Why are you anxious? These questions are of decisive importance. The
melancholiac either says the dejection and anxiety have no cause (‘come of themselves’) or he
ascribes his dejection and possibly his anxiety to the mental shocks preceding the disease
(death, loss of money, etc.,), or he refers the anxiety and dejection to a fancied crime, disease or
poverty. The significance of the first answer is evident; if the patient knows no cause for his
dejection and anxiety, they are at any rate characteristic of melancholia, primary depression and
anxiety. If the patient makes the second answer, i.e. if he refers his dejection to mental shocks
which have actually preceded the disease, then these mental shocks must be carefully inquired
into, either through the patient himself or his relatives. It is then to be considered whether the
existing dejection corresponds in its duration and intensity to the unfortunate event or exceeds
the physiological limits. So the relatives should be asked as to how the patient formerly behaved
under like circumstances. It will often enough be learned that in similar cases he has been
somewhat dejected for a time, but never so long or so intensely. Ask the patient: are you sad
only when you think about - this misfortune, or otherwise? The patient often answers very
correctly now ‘all is gloomy to him.’ If, besides
the dejection, anxiety also exists, the stated misfortune only suffices to cause the first, his
anxiety is without a motive. The patient’s attention can be called to this gap by saying to him
quietly: I well appreciate your dejection, but why are you anxious? Many patients then admit its
lack of foundation, and so the primary emotional disorder characteristic of melancholia is
proven. If, finally, the patient cites his crimes, sickness or poverty as a cause, it is to be
determined whether his self-accusations, his fear of illness or his financial worry have an actual
foundation or not. In regard to the self-accusation, an inquiry of the relatives quickly settles the
matter usually. pp. 566–8
Yellowlees (Yellowlees, 1932)
1932
UK
… Pathological depression … is, in a sense, a caricature of normal depression, as is constantly
stated but it is distinguished form it by its one intrinsic characteristics and not be reference to
the present or absence of any presumed adequate cause. The student must grasp from the
outset that the very mildest attack of pathological depression is completely different in its
essentials from what would be regarded as a ‘normal’ reaction to the most powerfully
depressing ‘cause’… (and) there is rarely any excuse for failing to distinguish between the two.
p. 22
(He goes on to suggest that the ‘lowering of activity’ and ‘deadening’ of response rather than the
unhappiness that indicates a true depression and later notes that volition is markedly impaired
in true but probably not in ‘normal’ depression p. 25) He searches his life for events or for
conduct which, in his opinion, would justify his present state of depression… p. 27
experience and empathic understanding to judge whether the
patient’s clinical history, symptoms, and signs were ‘out of proportion’ to the reported adversities. As a reader, my sense was
that these clinicians were going through the mental exercise of
‘imagining’ whether the particular set of symptoms seen in
their patient would arise in a ‘normal’ person, given this context
of these particular stressors. But several authors realized that this
approach had a major problem. Depressed individuals had what
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8
Kenneth S. Kendler
we would today call ‘cognitive distortions’ and ‘a search after
meaning’. So, their reports of causative adverse events could not
always be trusted. Relatives should be interviewed to confirm
such reports and even to inquire how the patient coped with similar difficulties in the past. A few authors took a different approach,
suggesting that clinical symptoms or course of illness could successfully distinguish MD from a normative depressive response.
Only a few symptoms were listed and these were not highly
consistent across authors.
Finally, the historical context of the second central issue in the
BE debate can be easily addressed. Bereavement was often mentioned as an example of adversities that predisposed both to mental illness generally and to MD specifically. However, no author
proposed that the context-specific diagnostic approach to MD
should be confined to bereavement. So, in the narrow sense,
given the authors we have reviewed here, the BE criterion as
operationalized in DSM-III was without historical precedent
Other issues
Why was the context specificity of MD most frequently advocated
by British authors? In his masterly history of nineteenth century
British psychiatry (Scull et al. 1996), Scull argues that Bucknill
and Maudsley were amongst the most dominant psychiatric figures in the British Isles in the latter nineteenth century.
Maudsley strongly advocated for the context-specific position on
MD diagnosis (Maudsley, 1895). Bucknill co-authored the most
influential psychiatric text in the mid-nineteenth century
England (Bucknill & Tuke, 1858) [published too early (1858) to
include in our survey]. This text also takes a context-specific position on melancholia. In a portion of the book written by
Bucknill, he poses a question about the impact of adversity in a
person with and without a prior predisposition to mental illness.
In considering the diagnosis of melancholia in such cases,
Bucknill writes ‘…it may only be possible to found a distinction
upon the relative intensity of the natural and of the pathological
emotion’ [(Bucknill & Tuke, 1858) 310]. In a rather profound
insight into the problem of context specificity for psychiatric disorder as a whole, Bucknill later writes
Grief, fear, and anxiety are all natural to the mind; delusion and hallucination are unnatural. Disease has to be ascertained from the degree and origin of the former (i.e. melancholia), while the mere existence of delusion
(in what we would now call psychotic illness) is often enough to guide the
judgment [(Bucknill & Tuke, 1858) 310].
Finally, Bucknill’s co-author, Daniel Tuke, of the famous Tuke
family of Quaker reformers who played a key role in the development of moral therapy, edited the influential Dictionary of
Psychologic Medicine (Tuke, 1892). The section on melancholia
in this book took a clear context-dependent position. So, it
appears that the leadership of British psychiatry in the late nineteenth century was in favor of the context-dependent diagnostic
approach to MD, a situation without parallel in the other
countries we examined.
Authors writing after publication of Kraepelin’s influential
sixth edition – with its articulation of his mature concept of
manic-depressive illness (Trede et al. 2005) – were significantly
less likely than earlier authors to argue for the context specificity
of MD. The reason for this was evident in reviewing these texts.
When authors accepted Kraepelin’s diagnostic concept of manicdepressive illness, the points of emphasis in their treatment of
MD shifted toward the genetic, constitutional, and biological
with less attention or interest in environmental or psychological
influences. This is consistent with Kraepelin’s views as articulated
in his sixth edition:
Manic-depressive insanity … is a very common disorder (the causes of
which) have to be looked for essentially in a pathological predisposition.
I was able to find a hereditary tendency in about 80% of my cases….
The development of the disorder is generally independent of all other
external causes, even though the patient and those around him usually
refer to some incident or other by way of explanation [(Kraepelin,
1990) 302–303].
Conclusions
About two-thirds of psychiatric texts published from 1880 to 1960
that described general etiologic factors in mental illness recognized recent adversities as important influences. In their discussions of MD, 60% of authors noted the etiologic importance of
recent adversities and of these about half mentioned bereavement.
Bereavement was frequently mentioned as a recent adversity that
predisposed to mental illness in general and MD more specifically. However, no author suggested that it was qualitatively different from other stressors.
The context-dependent approach to the diagnosis of MD
receives mixed support in this historical review. It was a minority
position over the time period of this review and its advocates did
not include the most influential of continental psychiatrists nor
the twentieth century leaders American or British psychiatry.
But, it received relatively consistent and articulate support from
nineteenth century British authors.
These advocates most commonly suggested an empathic
‘understandability’ criterion for the judgment about the context
specificity of MD. However, a number of authors noted both
the problem of biased patient reporting and the difficulty of discriminating when the MD was truly ‘out of proportion’ to the precipitants. Some authors suggested that certain signs and
symptoms could discriminate ‘true’ from ‘normative’ MD but
no broad consensus about the most informative features was evident. It is, in this context, worthwhile quoting the view on this
problem from what is widely regarded as the outstanding twentieth century monograph on MD by A. Lewis. He discusses his
attempt to apply previously proposed criteria to separate his
very carefully studied 61 melancholic patients into those whose
illness could easily be understood as contextual (or ‘psychogenic’)
v. endogenous:
The criteria were applied…But the more one knew about the patient, the
harder this became. A very small group of nine case emerged (in which)
… it could be said that the situation in these cases have been an indispensable efficient cause for this attack… There was a small group of 10 in
whom one could not in the least discover anything in their environment
which could have been held responsible for the outbreak of the attacks.
But all the others were understandable examples of the interaction of
organism and environment, i.e., personality and situation; it was impossible to say which of the factors was decidedly preponderant (Lewis, 1934).
Of note, this review found no historical precedent for the BE
criteria as first proposed for DSM-III – i.e. that ruling out a diagnosis of MD because it was ‘out of proportion’ to stressful events
should apply only to those who have experienced bereavement.
My goal for this review was a scholarly one – to clarify the historical antecedents of the BE debate. I make no claim that
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Psychological Medicine
historical positions taken by earlier expert clinicians are necessarily the correct ones. Indeed, many of the issues raised by the BE
debate can be and have been subject to empirical inquiry.
Nonetheless, historical opinions are relevant in that they permit
us to contextualize these issues and allow us to see how they
were viewed and understood by the major figures in our field in
past generations.
Acknowledgements. Peter Zachar Ph.D. provided helpful comments on an
earlier version of this essay.
Conflict of interest. The author reports no conflicts of interest.
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