II. What is a “disorder?”

Understanding the historical development of the terms will shed some light onto the origin of the term ‘disorder.’ Robert Spitzer, MD was the guiding force behind the sea of change of the 1980 DSM-III. Spitzer, initially trained in psychoanalysis as per the psychoanalytic hegemony in the mid-20th century, quickly decided that was not his calling. He gravitated to the realm of computer sciences and bio-metrics at Columbia where he began to work in the area of diagnosis.

Following the Stonewall riots for gay rights in 1969, the American Psychiatric Association was under increasing pressure to de-classify homosexuality as an official mental disorder as listed in the DSM-I & II.

Spitzer was asked to broker the deal within the American Psychiatric Association to convince the membership to abolish the classification of homosexuality as a mental disorder in 1973. Due to his political skills, he was appointed to be in charge of the revised DSM-III to be published in 1980.

In an attempt to develop more reliability in psychiatric diagnosis (albeit at the expense of validity) trying to legitimize psychiatry as a medical specialty, he decided to break away from the psychoanalytic influence in the DSM-I and II by making the DSM-III “atheoretical” i.e., without alluding to causation. This included a refusal to specify mental conditions as “diseases.”

In doing so, he had to negotiate the concerns and ire of various constituencies: the psychoanalytic community did not want to give up their concept of “neurosis;” and the psychological community did not want the new DSM to determine disease entities as they feared being excluded by insurance companies as non-medical providers.

Spitzer chose the term “disorder” which has continued to populate the current DSM-5. There is no other specialty of medicine that uses the term “disorder,” i.e., there is no cancer disorder, no heart disorder, no rheumatoid arthritis disorder, or diabetes disorder. In fact, psychiatry is the only medical specialty that has a diagnostic and statistical manual i.e., a DSM. Choosing the nebulous term “disorder” was intended to not offend various groups. (See Decker and Shorter in resources.)

The vote to overcome these objections and approve the DSM-III proved to be almost as tight as the voting rights act of 1965. The determined Spitzer proved to be the “LBJ” of psychiatry.

New “disorders” appear to grow like weeds

I am unaware of any other specialty of medicine that has had such an exponential growth of diagnoses (”disorders”) since 1980 as has psychiatry. Our medical colleagues must be baffled as to how this takes place.

Version	Year	Number of diagnoses
DSM-1	1952	102
DSM-2	1968	182
DSM-3	1980	265
DSM-3-R	1987	292
DSM-4	1994	297
DSM-4-TR	2000	365
DSM-5	2013	157
DSM-5-TR	2022	158

https://www.verywellmind.com/the-diagnostic-and-statistical-manual-dsm-2795758

Some of these “disorders” are real diseases like schizophrenia and what we call today “bipolar”. Both of these diseases are more than 80% heritable.

“Heritability summary estimates were as follows: bipolar disorder (85%), schizophrenia (81%), Alzheimer’s disease (75%), cocaine use disorder (72%), anorexia nervosa (60%), alcohol dependence (56%), sedative use disorder (51%), cannabis use disorder (48%), panic disorder (43%), stimulant use disorder (40%), major depressive disorder (37%), and generalized anxiety disorder (28%).”

(O. J. Bienvenu, et.al., Psychiatric ‘diseases’ versus behavioral disorders and degree of genetic influence. Published online by Cambridge University Press: 12 May 2010)

Notice the DSM defined MDD and GAD to have low heritability rates and cannot be considered diseases. In fact, gene studies indicate they have considerable genetic overlap and cannot be considered separate entities.

This is an example of how DSM definitions with overlapping symptoms masquerade as separate “disorders,” i.e., they do not exist in nature like schizophrenia or Bipolar.

KS Kendler, Major depression and generalized anxiety disorder: Same genes and (partly) different environments – revisited, British Journal of Psychiatry 1996; 168(suppl 30): 68–75.

Kendler, K. S., et al (1992b) Major depression and generalized anxiety disorder: same genes, (partly) different environments? Archives of General Psychiatry, 49, 716–722

Both MDD and GAD were terms invented by Robert Spitzer prior to the DSM-III as a concession to the psychoanalytic establishment for eliminating Depressive Neurosis (i.e., chronic mild depression and anxiety), so doctors could continue to get reimbursed by insurance companies with other codes.

As we can see, the use of the term disorder has muddled the diagnostic process, distracting clinicians away from diagnosing a real disease entity like Kraepelin’s comprehensive Manic Depressive illness (MDI) of which ‘Bipolar’ is a smaller subset, which has never been disproven over the past century.

The use of the term disorder was a “side step” away from embracing a medical model and hopefully can be discarded in future classification systems.

Hunter Yost MD

Dr. Yost is a board certified psychiatrist who provides telemedicine services to psychiatric hospitals and clinics since 2014 and does not have a private practice for individual patients.