(PSYCHIATRIC TIMES) - The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder
by Allan V. Horwitz
and Jerome C. Wakefield; New York: Oxford University Press, 2007
312 pages • $29.95 (hardcover)
When historians try to understand why psychiatric diagnosis abandoned validity for the sake of reliability in the years surrounding the millennium, they will rely on The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. In measured tones and exacting prose, Horwitz and Wakefield deliver not only a devastating critique of the DSM diagnostic criteria for depression but also a thoughtful and authoritative assessment of how they came to exist and persist.
Their main point is simple. For thousands of years physicians relied on the presence or absence of an adequate cause to distinguish ordinary sadness from abnormal depression. Starting with DSM-III, however, consideration of causes was abandoned. Instead, any combination of a sufficient number, intensity, and duration of symptoms now suffices to diagnose major depression. There is one telling exception—symptoms that occur within 2 months of bereavement. Horwitz and Wakefield ask: What about those whose symptoms are precipitated by divorce or loss of a job? Do they all have mental disorders? Of course not.
The authors' analysis derives from Wakefield's definition of mental disorders as "harmful dysfunctions" arising from abnormalities in the evolved mechanisms that regulate emotions and behavior. Emotions, including negative emotions such as anxiety and sadness, exist only because they gave a selective advantage in certain situations. Normal and abnormal emotions can be distinguished only by determining if the person is in one of those situations.
Loss is certainly the crucial situation that elicits sadness, but is depression just excessive sadness as the authors report? Many now believe that sadness and normal depression symptoms are aroused by different situations: respectively, a specific loss versus continuing pursuit of an unreachable goal. Horwitz and Wakefield review this research, but they do not pursue the implications, perhaps because the task of deciding what is and what is not normal is already problematic enough.
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