The Natural History of Mania, Depression and Schizophrenia

The Natural History of Mania, Depression and Schizophrenia

G Winokur, MT Tsuang

Washington (DC): American Psychiatric Press; 1996. 372 p

The resident had just presented his formulation of a case. I posited that hysteria might be an important aspect. He seemed genuinely puzzled, even when I told him that terms like “hysteria” and “hypochondriasis” had been available for more than 2 millennia. “But,” he said, “for my boards, I only need to know DSM-IV.”

“Well,” I thought, “if you’re so keen on cookbook psychiatry, why did you not stay with cooking rather than spoiling psychiatry?”

So here is the rub. What are we to do with this charming, scholarly work full of medical science when the psychiatric world has moved as it were, from bookshelves to the Internet? Or is that being too generous? While I acknowledge that the American Psychiatric Association committees have slaved to obtain syndromes made up of a concatenation of symptoms, it might be an overstatement to suggest that these have the same historical significance as the stirrup, the Gothic arch, and the printing press. They might conceivably be compared with gunpowder, however, since it changed the overthrow of castles from sieges lasting several years to crumbling walls in a few days. So the biopsychosocial anamnesis that can take a considerable time to collect might well be thought in the modern era to be replaceable by a convenient American Psychiatric Association cluster analysis.

Nevertheless, the book The Natural History of Mania, Depression and Schizophrenia is based upon the approach recommended by Adolph Meyer at Johns Hopkins at the beginning of this century. What is now called the “biopsychosocial” model is really the same model with a new name and the same methodology by which psychiatric diagnoses and formulations are developed all over the world. Thus psychiatrists in Iowa, London, Sydney, and Bombay have for decades collected the history of the present illness, the family and personal history, and a mental state examination before proposing a formulation for a patient. Examples of these, in copperplate handwriting, lie in the archives of mental hospitals everywhere.

So what is different about Iowa? The answer is professors George Winokur and Ming T Tsuang. Winokur moved to Iowa from Washington University in St Louis a quarter of a century ago. That university, like several in North America and many in Western Europe, did not see psychoanalysis as the Second Coming and fastidiously kept psychiatry on the Meyerian track. In Iowa, Winokur was joined by Tsuang, who eventually became a professor of psychiatry at Harvard. In the best tradition of psychiatric nosology, generously referred to in the preface, they dug like archeologists into their archives and collected a fascinating cache of data hitherto known as the Iowa 500. Case material was available from 1920 and seemed to be comprehensive; thus, “the quality of material in terms of documenting symptomology was quite sufficient for making diagnoses according to modern diagnostic criteria that had been published for research purposes.”

Nevertheless, there is a caveat. Old data have to be updated and massaged as psychiatry goes through another convulsive spasm in terms of the lexicon and nosology. As seen in the Stirling County and Lundby studies, this can be done. So what did they find? A lot. The Iowa 500 was made up of admissions to the Iowa Psychopathic Hospital (later the Iowa Psychiatric Hospital) between 1934 and 1944 and consisted of 100 bipolar disorder, 225 unipolar disorder, and 200 schizophrenia patients (with a few subsequent changes in diagnosis). The study started in 1971 and completed a 27- to 30-y follow-up of a psychiatric population originally “treatment-naive” in modern terms.

The book itself is made up of 15 chapters, and each contains reams of facts. Each chapter requires careful scrutiny. Perhaps the most salutatory is number 15 entitled “The Contribution of the Iowa 500 to Diagnosis and Classification of the Affective Disorders and Chronic Non-affective Psychosis.” Using symptoms, demographic criteria, and admission criteria, the authors demonstrated that the original diagnoses were stable over time. Thus: “These data strongly suggest an unequivocal separation of the primary affective disorders from the chronic non-affective psychoses according to the factors involved in the medical model.”

The authors worked, albeit inconclusively, on schizoaffective disorder (the border state) and on the types of affective disorder and chronic nonaffective psychoses. They concluded that “the Iowa 500 has presented new ways of investigating clinical entities and family illness… However it is clear that psychiatric illnesses or diseases are often composed of overlapping syndromes and . . . subsequent studies should be planned in a different fashion and less clear cut diagnostic groups should be included as index cases.”

Essentially, what we have here is a wonderful, though somewhat old-fashioned (especially the font), longitudinal study in the best psychopathological fashion. It is descriptive, as psychiatry has remained to this day, but many residents will likely, and regrettably, find it anachronistic. For those of us trained in the Meyerian sense in the best psychiatric institutions of Europe, North America, and Australasia, it validates what we have been doing all of these years. It is not about receptors and cookbooks, but it does provide a warm, fuzzy feeling. All who like a historical perspective to their work should read it.