Abstract
The Kraepelinian syndromal approach to diagnosis taken by DSM-III and its successors, which defines disorders by their clinical phenomenon, has come under rising criticism with increasing calls for an etiologically based nosology. The relative virtues of a syndromal versus etiologic psychiatric nosology have actually been debated within our field for a long time. To deepen and historically contextualize our current discussion, I review in detail the proposal for etiologic diagnostic systems for insanity by David Skae (1814–1873). While his proposal was intuitive and appealing to some, others questioned its viability and utility pointing out a number of potential problems in its implementation that remain relevant today. Something critical might be lost for psychiatric disorders, they argued, if mental symptoms were removed from diagnostic criteria. Etiologically based diagnoses work best for mono-causal disorders and those where the causes all operate on the same scientific level. However, psychiatric disorders are highly multifactorial with a wide diversity of risk factors spread across biological, psychological and social-environmental domains so identification of a particular cause on which to base diagnoses would be difficult. Not only do individual risk factors contribute to many different disorders but most disorders are influenced by many etiologic factors. With respect to causes and disorders, psychiatry is characterized by a ‘many to many’ relationship which would make an etiologic nosologic system inherently problematic. Finally, causes and effects can be devilishly difficult to distinguish for psychiatric illness and, while clinically based nosologies aid in differential diagnosis, etiologically based system might not operate similarly.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Craddock N, Owen MJ . The Kraepelinian dichotomy - going, going... but still not gone. Br J Psychiatry 2010; 196: 92–95.
Cuthbert BN, Insel TR . Toward the future of psychiatric diagnosis: the seven pillars of RDoC. BMC Med 2013; 11: 126.
Morel BA . Traité des maladies mentales [Treatise on mental diseases]. Victor Masson: Paris, 1860.
The Classification of Insanity. JMS 1861; 7: 286–296.
Schroeder van der Kolk JLC . Die Pathologie ùnd Therapie Der Geisteskrankheiten Auf Anatomisch-Physiologischer Grundlage. Druck Und Verlag Von Friedrich Vieweg Und Sohn: Braunschweig, 1863.
Schroeder van der Kolk JLC . The Pathology and Therapeutics of Mental Diseases: Translated from the German by James T. Rudall. Samuel Mullen, Collions Street East: Melbourne, 1869.
Stearns HP . Classification of mental diseases. A J Insanity 1888; 44: 350–360.
Kellogg TH . A Text-Book on Mental Diseases for the use of Students and Practitioners of Medicine. William Wood & Company: New York, NY, 1897.
Skae D . The Morisonian Lectures on Insanity for 1873: Lecture I (Edited by T.S. Clouston,MD). J Ment Sci 1874; 19: 340–355.
Tuke JB . A Pathological Classification of Mental Disease. Br J Psychiatry 1870; 16: 195–210.
Fish F . David Skae, M.D., F.R.C.S., Founder of the Edinburgh School of Psychiatry. Med Hist 1965; 9: 36–53.
Barfoot M . David Skae: resident asylum physician; scientific general practitioner of insanity. Med Hist 2009; 53: 469–488.
Skae D . The Morisonian Lectures on Insanity for 1873: Lecture II (edited by TS Clouston). J Ment Sci 1874; 19: 491–507.
Skae D . The Morisonian Lectures on Insanity for 1873: Lecture III. J Ment Sci 1874; 20: 1–20.
Skae D . The Morisonian Lectures on Insanity for 1873: Lecture IV (edited by TS Clouston). J Ment Sci 1874; 20: 200–2011.
Skae D . The Morisonian Lectures on Insanity for 1873: Lecture V (edited by TS Clouston). J Ment Sci 1875; 21: 1–18.
Skae D . The Morisonian Lectures on Insanity for 1873: Lecture VI (edited by TS Clouston). J Ment Sci 1875; 21: 19–38.
Skae D. Of The Classification of the Various Forms of Insanity on A Rational and Practical Basis: Being an Address Delivered at the Royal College of Physicians, London, At the Annual Meeting of the Association of Medical Officers of Asylums on 9th July, 1863. University of Glasgow Library: Royal College of Physicians of London; 1863.
Crichton Browne J . Skae's classification of mental diseases: a critique. Br J Psychiatry 1875; 21: 339–365.
Clouston TS . Skae's classification of mental diseases. Br J Psychiatry 1876; 21: 532–550.
Skae NM . Classification of mental diseases (Article II)(1876-77). J Psychol Med Ment Pathology 1876; 2: 195–237.
Clouston TS . Obituary: DAVID SKAE, M.D. JMS 1873; 19: 323–324.
Stevens M . Life in the Victorian Asylum: The World of Nineteenth Century Mental Health Care. Pen and Sword, 2014.
Skae D . Contributions to the natural history of general paralysis. Edinburgh Med J 1860; 5: 885–905.
Kendler KS . Toward a philosophical structure for psychiatry. AJP 2005; 163: 433–440.
Howes OD, Murray RM . Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet 2013; 383: 1677–1687.
Kendler KS, Gardner CO, Prescott CA . Toward a comprehensive developmental model for major depression in women. AJP 2002; 159: 1133–1145.
Kendler KS, Gardner CO, Prescott CA . Toward a comprehensive developmental model for alcohol use disorders in men. Twin Res Hum Genet 2011; 14: 1–15.
Kendler KS . The dappled nature of causes of psychiatric illness: replacing the organic-functional/hardware-software dichotomy with empirically based pluralism. Mol Psychiatry 2012; 17: 377–388.
Kendler KS . The structure of psychiatric science. AJP 2014; 171: 931–938.
Kendler KS . Levels of explanation in psychiatric and substance use disorders: implications for the development of an etiologically based nosology. Mol Psychiatry 2012; 17: 11–21.
Miller GA . Mistreating psychology in the decades of the brain. Perspect Psychol Sci 2010; 5: 716–743.
Kirov G, Rees E, Walters J . What a psychiatrist needs to know about copy number variants. BJPsych Adv 2015; 21: 157–163.
Levinson DF, Duan J, Oh S, Wang K, Sanders AR, Shi J et al. Copy number variants in schizophrenia: confirmation of five previous findings and new evidence for 3q29 microdeletions and VIPR2 duplications. AJP 2011; 168: 302–316.
Antoniou A, Pharoah PDP, Narod S, Risch HA, Eyfjord JE, Hopper JL et al. Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case series unselected for family history: a combined analysis of 22 studies. AJHG 2003; 72: 1117–1130.
Cross-Disorder Group of the Psychiatric Genomics Consortium(PGC-CDG). Genetic relationship between five psychiatric disorders estimated from genome-wide SNPs. Nat Genet 2013; 45: 984–994.
Kendler KS, Bulik CM, Silberg J, Hettema JM, Myers J, Prescott CA . Childhood sexual abuse and adult psychiatric and substance use disorders in women: an epidemiological and cotwin control analysis. Arch Gen Psychiatry 2000; 57: 953–959.
Beveridge A . Madness in Victorian Edinburgh: a study of patients admitted to the Royal Edinburgh Asylum under Thomas Clouston, 1873–1908.2. Hist Psychiatry 1995; 6: 133–156.
Schaffner KF . Behaving: What's Genetic, What's Not, and Why Should We Care?1st ed.Oxford University Press: New York, NY, 2016.
Kendler KS . DSM issues: incorporation of biological tests, avoidance of reification, and an approach to the "box canyon problem”. Am J Psychiatry 2014; 171: 1248–1250.
Kendler KS . The transformation of American psychiatric nosology at the dawn of the twentieth century. Mol Psychiatry 2015; 21: 152–158.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The author declares no conflict of interest.
Rights and permissions
About this article
Cite this article
Kendler, K. David Skae and his nineteenth century etiologic psychiatric diagnostic system: looking forward by looking back. Mol Psychiatry 22, 802–807 (2017). https://doi.org/10.1038/mp.2017.32
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/mp.2017.32
This article is cited by
-
Advances in the computational understanding of mental illness
Neuropsychopharmacology (2021)
-
Computational approaches and machine learning for individual-level treatment predictions
Psychopharmacology (2021)
-
The origin of our modern concept of mania in texts from 1780 to 1900
Molecular Psychiatry (2020)
-
Psychotherapy and the Professional Identity of Psychiatry in the Age of Neuroscience
Academic Psychiatry (2020)