ARTICLE IN PRESS

Social Science & Medicine 65 (2007) 536–547

www.elsevier.com/locate/socscimed

The survival of psychiatric diagnosis

David Pilgrim
Department of Social Work, University of Central Lancashire, Blackburn, Lancashire, UK
Available online 30 April 2007

Abstract

Past and current debates about applying medical diagnoses to psychological difference in society are examined.
Beginning with a brief historical overview from antiquity to ‘anti-psychiatry’ and a summary of recent debates, the article
then offers two case studies of common diagnoses (‘depression’ and ‘schizophrenia’). The main challenge for social science
is no longer about what is wrong with psychiatric diagnosis (that is now well rehearsed) but how to account for how and
why it has survived. In answering this question about survival, inter-disciplinary work could attend to the pre-empirical
positions of mental health researchers; the ways in which mental disorders are similar and different to physical disorders;
and the interest work of different social groups defending or attacking psychiatric diagnoses in varying contexts.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: Psychiatric diagnosis; DSM; ICD; Depression; Schizophrenia

Introduction mental health professionals, like clinical psycholo-

Psychiatric diagnosis has weathered nearly a
century of criticism. It is now in a contradictory
position. On the one hand, many consider it to be
pseudoscientific and an unhelpful form of medica-
lisation, which obscures our understanding of the
social causes and consequences of madness and
misery and the social control implicit in the role of
professionals. On the other hand, many social
groups still accept its legitimacy.
This acceptance is not limited to the psychiatric
profession (the most obvious beneficiary and
defender). Indeed, many of the most robust attacks
on psychiatric diagnosis have come from psychia-
trists themselves. Some patient groups and espe-
cially their relatives still embrace diagnosis. Even
gists, making competing bids for legitimacy in the
field, equivocate about abandoning psychiatric
labelling. The mass media and policy makers also
find it simpler to utilise diagnostic-related groups
(DRGs) than deal with the complex variability of
madness and misery in unique contexts.
Historical summary
This paper examines the above ambiguous
current picture and offers a provisional analysis
about the survival of psychiatric diagnosis. It starts
with a look back to trace trans-historical debates
about madness, misery and categories.
Antiquity

Tel.: +44 01772 201201. Many of the current controversies about psychia-
E-mail address: dpilgrim@uclan.ac.uk. tric diagnosis have antiquarian resonances. For

0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2007.03.054
 ARTICLE IN PRESS
D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
example, ancient philosophers were ambivalent
about the value of madness. Socrates considered
that madness and sanity had equal value. For him,
positive aspects of mad rapture included prophesy-
ing (a ‘manic art’); mystical initiations and rituals;
poetic inspiration; and the madness of lovers
(Screech, 1985). However, as Rosen (1979) notes,
in ancient Greece and Rome, madness was asso-
ciated stereotypically, as today, with aimless wan-
dering and violence. The modern English use of the
term ‘to be mad’ reflects this conflation of lunacy
and fury. Thus the ambiguity introduced about
madness by Socrates was not necessarily shared
more generally at the time.
As Leuder and Thomas (2000) point out, an irony
of Socrates being idealised as the epitome of
rational thought and a founder of philosophy is
that he freely admitted to experiencing what are
now called ‘command hallucinations’ (then called
his ‘daemon’). Pythagoras also heard voices. So too
did Mohammed, Joan of Arc and Luther. And Jesus
and the Buddha could both be accused of being
deluded and of operating grandiose certainty about
the meaning of life. All might now be thought of as
being schizophrenic.
The Socratic view was not shared by Hippocrates,
who objected to speculation about the aetiology of
madness and favoured instead close behavioural
observation. For example, he opposed the common
assumption, of his time, of mental abnormality
being seated in the heart and diaphragm or phren
(hence later English terms such as ‘schizophrenia’,
‘frenzy’, ‘frenetic’ and ‘frantic’). He argued that
with no direct evidence of causation, this assump-
tion should be dropped in favour of simply
observing and recording the patient’s speech and
action.
Although Hippocrates may have pleaded for
close observation, the question still remained (as it
does today) as to whether this should be in relation
to single symptoms or collections. For example,
Galen adopted a single symptom approach in
Roman medicine—studying separate conditions of
sadness, excitement, confusion and memory loss.
The emergence of psychiatry
In the 18th century, the Scottish physician Cullen
suggested a classificatory system about what he
called the ‘neuroses’. This very wide notion, which
today would subsume most mental disorders,
contained the aetiological premise that madness
537
and misery reflected damage to the nervous system
and the alteration of nervous energy (hence the
remaining notion of ‘nervousness’).
In late 18th century, France, de Sauvages offered
a general classification of diseases of ten broad
categories, the eighth of which was ‘insanity’. Just
prior to the French Revolution Pinel, following the
strictures of Hippocrates on close observation,
anticipated the more recent trend of basing the
classification of mental illness on groups of symp-
toms and suspending aetiological speculation or
assertion. Pinel delineated categories such as: mania
with delirium; mania without delirium; melancholia;
confusion; and idiocy.
Subsequently, German alienists also began to
categorise. For example, Kahlbaum argued psycho-
logical dysfunction could be observed in patients
about their judgement (‘paranoia’), their moods
(‘dysthymia’) or their will (‘diastrephia’) (Lanczik,
1992). This empiricist approach to classification
found its most noteworthy champion in Kraepelin
(1883), who set the scene for the main paradigm in
modern Western psychiatry, characterized by three
main features:
 Mental illnesses were considered by him to be
separate, naturally occurring categories (hence the
epistemological position of ‘medical naturalism’
to be discussed later).
 He considered these illnesses to be a function of
degeneracy—they were inherited conditions, with
a predicable deteriorating course (hence the term
‘dementia praecox’).
 Kraepelin held the view (axiomatically and
echoing Cullen) that all symptoms of mental
illness were caused by diseases of the brain or
nervous system.
Meyer’s minority report
Although the Kraepelinian legacy has dominated
psychiatric thought to the present, an important and
highly respected minority report was issued by
Adolf Meyer (Double, 1990). He began a trend in
the 20th century of those who refused to concede
naturalism and its purported categories of mental
illness and to favour instead dynamic holism,
biographical uniqueness and continua rather than
categories. Meyer developed his ‘psychobiological
approach’ prior to the Second World War.
Meyerian psychiatry was the basis of the later
development of the ‘biopsychosocial model’. The
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538 D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
latter is indebted to Meyer’s work and that of the
biologist Weiss in the 1920s and his student von
Bertalanffy, who developed General Systems The-
ory in the 1950s, with its emphasis on contextual
reasoning in science (Pilgrim, 2002). Meyer con-
ceded the role of broad inherited psychological
tendencies but saw mental illnesses as reactions to
peculiar biographical circumstances. His main
question of interest was not ‘what is this patient’s
diagnosis?’ but ‘why is this particular patient
presenting with these particular symptoms at this
time in his or her life’?
Anti-psychiatry
One of the themes of ‘anti-psychiatry’ during the
1960s was that psychiatric diagnosis was a problem
not a solution. Three examples can be given in this
regard from doyens of the period—Szasz, Goffman
and Laing.
Szasz (1961) argued that minds, like economies,
can only be sick in a metaphorical sense. Conse-
quently, he reasoned, the beneficiaries of socially
constructed mental illnesses are the psychiatric
profession, whose role as a proper medical speciality
is maintained, and those who are sane by common
consent. Szasz did not deny that people were
distressed or acted in unintelligible or dysfunctional
ways but for him these were problems of living, not
symptoms of a medical condition.
Goffman (1961) in his final essay of Asylums
explores the implications of the notion of ‘service’ in
modern society. For Goffman, an expert server
derives their authority or mandate from their special
understanding of what the lay person (or ‘served’)
needs. In the case of a medical service, data is used
to form a construct (a diagnosis) from two
sources—the patient’s communication (their actions
and statements, called ‘symptoms’) and their bodily
state (measurable somatic changes called ‘signs’). A
problem for psychiatry is that it relies far more than
other branches of medicine on symptoms rather
than signs.
Laing’s position about diagnosis shifted over
time. He began with an attempt to revise the
diagnostic language of British object—relations
theory (a version of psychoanalysis) to make it
more existentially relevant to particular patients
(echoing the plea of Meyer) (Laing, 1959). This
social-existential view extended eventually to the
search for social intelligibility of unique symptom
presentations of mad people (Laing, 1968).
These critiques provoked tetchy professional
reactions. Professional leaders rejected them as part
of an unjust and politically inspired anti-medical
attack (Hamilton, 1970; Roth, 1973). An assump-
tion emerged in medical texts that ‘anti-psychiatry’
could be located in the envious and politicised
discipline of sociology (Gelder, Mayou, & Cowen,
2001; Wing, 1978). However, this was a false
attribution: Szasz and Laing were psychiatrists not
sociologists.
Critiques of psychiatric labelling also stimulated a
reinforcement of the principle of diagnosis in the
profession. This is evident in revisions of the
diagnostic and statistical manual of mental dis-
orders (DSM). The DSM system, which began in
1952, and was then revised in 1968, 1980 and 1994
(American Psychiatric Association, 1994), has al-
ways been a product for two audiences. It has had
to accommodate internal professional divisions and
persuade those outside the profession of its legiti-
macy.
In 1980, there were examples of each face to the
document—both aetiological claims and homosexu-
ality disappeared. As Wilson (1993) demonstrates,
when tracking the history of DSM, the 1980 revision
was a re-medicalisation strategy. The older clinically
based biopsychosocial approach to patients’ pre-
senting problems was displaced in 1980 by a medical
form of scientific description based on symptoms.
Thus, DSM can be read as a revisable political
manifesto for the psychiatric profession, as well as a
scientific document. What changed on the political
front was a shift from simply accepting aetiological
assumptions in the profession (both biological and
psychoanalytical) in earlier editions of DSM to the
more cautious symptom checklists (echoing both
Hippocrates and Kraepelin) (Bayer & Spitzer,
1985). But this empiricist shift still retained cate-
gories.
More recent debates
The above brief history brings us to more recent
debates about the standing of psychiatric diagnosis.
The varied work of those like Goffman, Conrad,
Szasz and Foucault has been influential in our social
scientific understanding of psychiatric knowledge.
However, the focus of that work overwhelmingly
was in response to a question about the history and
legitimacy of psychiatric diagnosis. A different
question is now begged. If psychiatric diagnosis
has been criticised on empirical, logical and socio-
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D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
logical grounds, by so many for so long, how and
why has it survived?
In answering this question and clearing the
ground for a new research programme about
psychiatric diagnosis, a number of points can be
made. The first is in relation to separate epistemo-
logical discourses. Broadly three now co-exist:
medical naturalism, radical constructivism; and
critical realism.
(1) Medical naturalism: starts from the premise that
current medical terminology describing mental
abnormality is valid and has global and trans-
historical applicability. Diagnoses such as ‘schi-
zophrenia’ or ‘depression’ are taken to be labels
for naturally occurring phenomena embodied in
their sufferers. Here the object (mental disorder)
is assumed to precede the subject (those using
the term). Mental disorder is assumed to exist
‘out there’ and to be independent of its
observers or diagnosticians. In other words, its
factual status is deemed to be non-problematic.
Cooper (2004), in her critique of DSM, notes
that some of the problems of psychiatric
diagnosis are clearly logical and empirical. If it
does make sense to pursue a project of medical
naturalism, is the current neo-Kraepelinian
orthodoxy up to the task? Cooper argues not
(though she does not rule out a version of
naturalism in the future in principle).
(2) Radical constructivism: inverts the first position
and assumes instead that subject precedes
object. Here the emphasis is on how diagnoses
are context-specific human products. They are
deemed to be socially negotiated outcomes that
reflect the cognitive preferences and vested
interests of the negotiators (in this case in
modern times the psychiatric profession being
the most important, but not the only, group). In
this view, mental disorder does not exist as an
objective natural entity but is a by-product of
psychiatric activity. This position is associated
with Foucauldian reviews of psychiatric knowl-
edge (e.g. Miller & Rose, 1986).
(3) Critical realism: is a bridge between the two
positions in that external reality is deemed to
precede the subject but it is represented by
shifting subjective or inter-subjective activity.
The latter needs to be critically evaluated in
order to identify interests operating (thus it
supports the radical constructivist position to an
extent). But critical realists concede the reality of
539
some sort about mental abnormality (support-
ing to some extent the medical naturalists).
Mental illness is not dismissed as being merely a
by-product of professional activity but it may be
criticised for its poor conceptual validity (e.g.
Pilgrim & Bentall, 1998). Recent critical psy-
chiatrists move between radical constructivism
and critical realism in their writings (e.g.
Double, 1990; Thomas, 1997).
These three positions are laid out to point up the
need for social scientists to check on their own
philosophical starting points about psychiatric
categories. Any research on the latter requires some
pre-empirical reflection. During the past 30 years
social scientists have adopted all three at different
times. The Szaszian counter-orthodoxy pushed
medical sociologists into resolving whether the
symptoms of mental disorder were social constructs,
social products or both (Busfield, 1988).
A different conclusion from Szasz is drawn by
Horwitz (2002). He argues that the ‘major mental
disorders’ are true illnesses but all other categories
should be treated as socially created forms of
deviance. The medicalisation of deviance thesis
could be found in the counter-cultural period when
the Szaszian view was at its height (Conrad, 1992).
But sociologists have not been of one voice in their
reaction to psychiatric knowledge. For example,
some exploring the social origins of mental disorder
have not challenged psychiatric diagnosis in princi-
ple and so have joined the discourse of medical
naturalism (e.g. Brown & Harris, 1978; Newton,
1988).
Similarities and differences between mental and
physical illness
A problem generated by the critiques from Szasz
and Goffman was that the legitimacy of physical
disorders was seen as non-problematic. But grounds
for querying the scientific merits of the diagnosis of
mental disorder can be applied reasonably some of
the time in physical medicine. Many diagnoses of
‘true’ physical pathology are vulnerable to similar
criticisms, such as a lack of aetiological and
treatment specificity.
The neat boundary that Szasz wished to retain
between true and mythological pathology was not
readily available. One reaction from political science
to this disputed boundary was to frame all illness as
deviancy (Sedgwick, 1982). From bio-medicine,
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540 D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
instead, we then found hoped-for-reductionism. By
this logic, all mental illnesses are simply deemed to
be brain diseases (Baker & Menken, 2001; Guze,
1989). This sort of hoped-for-reductionism repre-
sents a dogmatic assertion of medical naturalism.
The logical difficulty of isolating psychiatric
labels for particular critical scrutiny is highlighted
by inflammatory conditions, such as rheumatoid
arthritis, psoriasis, irritable bowel syndrome and
asthma. Like mental disorders, they too ‘run in
families’ but do not follow neat genetic patterns.
They too have weak aetiological specificity and poor
treatment specificity. For example, analgesics, ster-
oids, immuno-suppressants and even chemothera-
pies, developed for cancer, can be applied across a
range of inflammatory conditions.
Part of our post-anti-psychiatry context is the
stronger legitimacy of evidence-based medicine
(EBM). This move towards evidence-based psychia-
try brings with it the general risk of scientism, which
critical psychiatry now faces (Hopton, 2006). But
the ‘front end’ emphasis in EBM on effectiveness of
interventions (independent of the uncertainty over
diagnosis) also highlights this point of blurring
between mental and physical illness. The improved
treatment of asthma is an example in this regard.
In a similar way, treatments, particularly of single
symptoms, may start to define the legitimacy of
psychiatric activity and doubts about categories
may become less and less relevant. This trend may
be reinforced by the convergence of mental and
physical problems, which are chronic (and may
often co-exist), as well as the diagnostic uncertain-
ties created by ‘medically unexplained symptoms’.
Chronic, often now called ‘long-term’, conditions
pose a similar management problem for health
services and similar daily social and existential
challenges for those experiencing them. The ‘trigger-
ing’ diagnosis is often less important in these
conditions than the daily management of their
attendant impairments, stigma and social exclusion.
The professional psychiatric response to the
contention about psychiatric diagnosis (evident in
the constant revision of the DSM system) is to seek
greater consistency in its knowledge claims. How-
ever, the logical problem for DSM is that consis-
tency may improve reliability but it does not prove
validity. And by insisting on aetiological neutrality,
DSM further undermines validity arguments about
its own categories.
When a diagnosis of a functional mental disorder
(one of the ‘major mental illnesses’ or the ‘person-
ality disorders’) is made, it rests completely on what
the patient says and does and the social offence or
incompetence that their conduct signals. This point
can even hold true for the diagnosis of organic
mental illnesses, such as dementia.
Thus, whilst an overlap of epistemic features can
be demonstrated between mental and physical
illness, it is also the case that the former has become
separate for most of us most of the time for a
number of reasons.
 Physical injuries and ailments happen to us,
whereas we are mentally ill. Mental illness
implicates the whole self, which thus becomes
discreditable (Fabrega & Manning, 1972),
though occasionally this negative socio-ethical
attribution has been a feature too of physical
conditions, such as sexually transmitted diseases,
tuberculosis and cancer.
 The body is potentially explicable in physical
terms, whereas human conduct can only be
understood meaningfully via interpretive meth-
ods. Hermeneutics not biomedical science is
required for the task (Ingleby, 1980). Generally,
though not inevitably, physical diagnosis can be
confirmed by measurable bodily signs. Mental
illnesses overwhelmingly are symptom-based di-
agnoses: they are about what people say and do.
 Coercion is applied much more frequently to the
sufferer of one form of illness than the other.
Mentally ill patients are deemed to lack cognitive
capacity about their actions more often than
physically ill patients.
 A final difference is that medicine itself rarely
uses the term mental ‘disease’ (opting instead for
the weaker and more subjectively based ‘illness’
notion).
Two illustrative case studies
Two case studies are given here of common
psychiatric diagnoses, ‘schizophrenia’ and ‘depres-
sion’, to highlight the above current debates.
Relevant historical links are mentioned.
Schizophrenia
This diagnosis predominates in specialist services
with statutory powers to coercively detain and treat
those deemed to be mentally disordered. It is
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D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
applied to patients with experiences that are
idiosyncratic and lack intelligibility, particularly
auditory hallucinations and rigid and irrational
beliefs (delusions). Incoherent speech (‘thought
disorder’) and social withdrawal are often present
but not always. What is in dispute is whether
variants of these experiential idiosyncrasies should
be codified in one diagnostic box of ‘schizophrenia’
and whether its aetiology is genetic or environ-
mental.
Critics tend to reject a categorical approach and,
echoing Meyer, argue for working with particular
presenting problems in biographical context, patient
by patient, obviating the need for the label (Bentall,
2004; Thomas, 1997). A particular dispute, still
present in the wake of ‘anti-psychiatry’, is whether
the symptoms of schizophrenia reflect the chaotic
and disordered behavioural manifestations of a
brain disease or whether they might be intelligible
in terms the person’s current or past life situation.
Some challenges to the scientific validity of
schizophrenia have emerged from a profession
historically subordinated to psychiatry making bids
for legitimacy. Dismissive critiques of the concept
were delivered during a period when, in the British
context, clinical psychology was escaping from
medical dominance. Bannister (1968) examined the
logical requirements for its legitimate application to
patients. He notes that it is possible for two patients
to have first rank symptoms of the label, which are
not the same. As a consequence, both patients are
called ‘schizophrenic’ but their clinical presentations
are completely different. Bannister thus dismisses
schizophrenia as a ‘disjunctive concept’.
Bentall, Jackson, and Pilgrim (1988) add to this
by pointing out that the diagnosis lacks aetiological
specificity and treatment specificity. Causation is
unknown or contested and the same treatment is
often applied by psychiatrists to patients with
completely different diagnoses. The authors note
that reliability about the diagnosis can be increased
by the systematic application of symptom check-
lists, such as DSM-IV. It is not surprising that those
trained under that regime of knowledge will often
agree with one another. The authors go on to point
out that reliability (diagnostic consistency between
doctors and over time) is a necessary but not a
sufficient condition for validity. A valid diagnosis
should be predictive and describe what it is
supposed to describe rather than something else.
Schizophrenia fails on these criteria and so arguably
should be abandoned as worthless.
541
Boyle (1990) describes schizophrenia as a ‘scien-
tific delusion’. Concurring with her disciplinary
colleagues above, she also returns historically to
the patients first used by Kraepelin and Bleuler to
construct ‘dementia praecox’ and ‘schizophrenia’,
respectively. She claims that they manifested quite
different symptoms to modern day patients with the
diagnosis, with their symptom profile being much
closer to that of viral encephalitis lethargica,
common in psychiatric populations at the turn of
the 20th century (Von Economo, 1931). Thus there
is a mismatch between those with the diagnosis
originally and currently.
Mainstream psychiatry has remained immune to
the above attacks and some academic clinical
psychologists have retained a faith in the diagnosis
(Frith, 1992; Tarrier et al., 1998). Psychiatric
epidemiology still treats schizophrenia as a non-
problematic category to count (Haefner et al., 1994;
Jablensky, 1995). Such studies are often enmeshed
with genetic and neuroscience models of aetiology
(e.g. Bakker et al., 2003). Thus, despite several
persuasive critiques being around now for at least 40
years, the diagnosis of schizophrenia retains a
strong legitimacy within psychiatry.
The introduction of major tranquillisers, as part
of the putative ‘pharmacological revolution’ to treat
schizophrenia in the 1950s gave a fillip to this
medical monopoly over madness. However, the
defence of the legitimacy of schizophrenia became
particularly important with the move to desegrega-
tion or community care in most Western countries
during the 1980s, which was prompted not by the
‘pharmacological revolution’ but by fiscal pressures
and changing expectations about mental health
care.
The old asylum had a triple function of: residency
(to warehouse chronicity); risk containment (to
provide social control on behalf of a moral order);
and reducing symptoms (to treat acute episodes).
These functions were to be re-assembled in the
community, with acute psychiatric units being a
back up for risk management. The asylum had been
a physical symbol of medical control over madness.
Without large buildings warehousing the bulk of
those so labelled, the embodiment of schizophrenia
became dispersed, potentially rendering the concept
more precarious.
In this policy context, epidemiological studies
about schizophrenia, which methodically mapped
its incidence and prevalence, could demonstrate the
continued need for medical expertise for the
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542 D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
condition. A new psychiatric regime, without walls,
to manage schizophrenia began to include both new
pharmaceutical technologies (the ‘atypical anti-
psychotics’) and new service delivery teams (‘crisis
intervention’, ‘early intervention’, ‘assertive out-
reach’ and ‘home treatment’).
Turning to lay plausibility, a mixed picture is
evident. On the one hand, those with the label may
accept or reject it, though an indication of it being
less than welcomed is that psychiatrists are often
cautious about sharing the diagnosis with their
patients. Moreover, critical services users can be
found rejecting the label and accounting for their
idiosyncratic experiences by invoking a range of
biographical, social or spiritual accounts (Rogers,
Pilgrim & Lacey, 1993; Romme & Escher, 1993).
Lay people are exposed to media messages
emphasising that schizophrenia and violence are
co-constituted and stigmatising attitudes from non-
patients are common (Sieff, 2003). These cultural
images are so strong that they are also internalised
by patients with the diagnosis (Rogers et al., 1998).
It is also not unusual in the lay arena for confusion
to exist about the professional meaning of the
diagnosis. For example, it is common for the word
‘schizophrenic’ to be used in the vernacular to
describe ‘split personality’ or logically incompatible
personal views in one person, suggesting that the
diagnosis is still readily confused with multiple
personality disorder (Penn et al., 1994).
Depression
Depression is the most common diagnosis of
mental illness, although mainly applied to patients
in primary care, where distress may be labelled
without referral to psychiatric services. Before this
primary care emphasis, Seligman (1975) described
depression as the ‘common cold of psychiatry, at
once familiar and mysterious’.
Despite the prevalence of the diagnosis, lay
people may not always see it as a mental illness
but they do use the term regularly—even alluding to
notions such as ‘clinical depression’, to distinguish it
from common misery (Kleinman, 1988; Rogers &
Pilgrim, 1997). Lay people typically connect depres-
sion with everyday life and its vicissitudes rather
than the alien world of madness, a distinct category
of experience that happens to the ‘other’ (Jones &
Cochrane, 1981). However, the original psychiatric
view of depression clearly reflected insanity; it arose
from Victorian descriptions of asylum-based ‘mel-
ancholia’ in middle class inmates and ‘mopishness’
in poorer lunatics.
The term ‘depression’ was used for the first time
professionally at the turn of the 20th century, and
increasingly after the shellshock problem of the
First World War and in two separate ways. One
continued to link it to a form of madness (‘manic-
depression’, now dubbed ‘bi-polar disorder’),
whereas the other extended the shellshock discourse
depicting depressive reactions to stress and loss
(Kraepelin, 1921; Leonhard, 1959; Stone, 1985). A
division was thereby set up between endogenous
and exogenous depression. The super-ordinate
construct of ‘depression’ could then accommodate
both its link to biologically driven madness and to
intelligible adaptations to life crises, such as the loss
of people or control.
Confirming this expansion of psychiatric interest,
post-structuralist accounts note that, after the First
World War, the ambit of the profession enlarged
from repressive power to include productive power.
During the 20th century, the profession offered help
that was increasingly ‘anxiously sought and grate-
fully received’ (Foucault, 1988; Miller & Rose,
1988); it was no longer simply about the coercive
control of insanity. If bio-determinism and a
coercive function still predominated in the psychia-
tric profession during the 20th century (Moncrieff &
Crawford, 2001), psychotherapeutic models and
voluntarism could still be retained within its remit.
Misery could then be responded to potentially as
either madness or as a reaction to life circumstances.
The shifting and contradictory codifications of
depression have been explored by a number of
reviewers (e.g. Dowrick, 2004; Pilgrim & Bentall,
1998). Here are some summary points about
difficulties with the coherence and consistency of
the concept:
 Psychiatry has not developed a stable position
about types of depression. By the 1960s, the view
prevailed that two distinct forms of depression
existed, one endogenous and the other reactive
(Carney, Roth, & Garside, 1965). However,
others began to argue for a uni-modal distribu-
tion of depressive cases (Kendell, 1968). More
recently the bimodal distribution model has
returned to fashion (Parker, 2000). Moreover,
as McPherson and Armstrong (2006) note,
during these broad trends over time, types of
depression have varied in popularity and have
included a plethora of sub-types. These shifting
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D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
fashions in sub-types of the diagnosis have only
partially followed the strictures of DSM revi-
sions; in clinical practice ‘unofficial’ labels from
the past could still be found.
 Depression has not been readily distinguished
from other diagnoses, especially anxiety states
but also forms of psychosis and adjustment
disorder (Casey, Dowrick, & Wilkinson, 2001).
Chronic depression has also been re-framed at
times as a form of personality disorder (‘dysthy-
mic’).
 Expert texts on depression have emphasised
different core features. Some have claimed that
it is primarily about mood disturbance (Becker,
1977), others that it is largely a cognitive
dysfunction (Beck, Rush, Shaw, & Emery, 1979).
 Experts texts have varied in the number and type
of symptoms required to justify the diagnosis
(Mendels, 1970). Some of these have even
permitted the diagnosis when core symptoms,
such as low mood, are missing (Willner, 1985). A
related confusion is that the term ‘depression’ is
used both as a diagnostic category and as a
symptom. Some codifications that embed aetiol-
ogy in their title (such as ‘endogenous’ or
‘reactive’) are still used in the clinical discourse,
even though DSM has been neutral about
aetiology since 1980.
 Depression is now deemed to be a pandemic
(Murray & Lopez, 1995). However, some cul-
tures have no emotional description of depres-
sion, rendering its global meaning highly
problematic (Wierzbicka, 1999). To insist on this
global status arguably is a form of cultural
imperialism. Western medicine has pre-emptively
assumed that some physical symptoms in minor-
ity ethnic patients are ‘masked depression’,
without conceding alternative ways of account-
ing for these presentations (Fenton & Sadiq-
Sangster, 1996).
 In primary care, some have argued that anxiety
and depression overlap so much that the
diagnoses should be abandoned in favour of a
single one of ‘neurotic distress’ (Shorter & Tyrer,
2003), though this might simply replace two
dustbin categories with one.
 The disputes over aetiology mean that we find
elaborate psycho-social explanations alongside
bio-reductionist assumptions about brain dys-
function. Those favouring psycho-social ac-
counts point to the conceptual difficulty in
situating depression as a skin-encapsulated con-
543
dition. The label is inseparable from the past and
present social context that gives rise to personal
expressions of misery. By contrast, a confluence
of the interests of drug companies and biological
psychiatry has co-constructed a circular bio-
deterministic logic. Depression is deemed to be
a brain disorder requiring anti-depressant med-
icinal treatment. When mood lifts following drug
intake, a biological aetiology of serotonin deple-
tion is proven (Zoloft, 2002). This is like arguing
that a headache is caused by a relative absence of
aspirin in the brain. Moreover, the placebo effect
in drug treatment for depression is so strong that
it undermines the pharmacological rationale
being claimed (Moncrieff & Kirsch, 2005). The
brain disease logic is also advocated strongly by
lobbies dominated by the relatives of psychiatric
patients, such as the National Alliance for the
Mentally Ill in the USA (NAMI, 2002).
The above points suggest that depression is
scientifically dubious. Nonetheless, a working con-
sensus seems to exist, across research, clinical and
lay communities, that it is a legitimate concept, at
least in the bulk of the Western world for now.
McPherson and Armstrong (2006) draw attention
to the maintenance of the concept in Western
psychiatry since the beginning of the 20th century,
reflecting a resolution within the profession of the
struggle for hegemony between bio-determinists and
psychoanalytical therapists. The not-so-hidden-
hand of the drug companies has also played its role
in maintaining the legitimacy of the diagnosis
(Antonuccio, Burns & Danton, 2002; Koerner,
2002). The UK ‘Beat Depression Campaign’ of the
Royal College of Psychiatrists and similar ones
from and other members of the World Psychiatric
Association were sponsored by the pharmaceutical
industry (Pilgrim & Rogers, 2005a, b).
Connecting past and current controversies
It has just been noted that an interest group that
partially drives and sustains particular diagnoses is
the pharmaceutical industry. It is the case that since
the putative ‘pharmacological revolution’ of the
1950s, the drug companies have invested in research
into the treatment of diagnostic categories, thus
shoring up or amplifying their legitimacy. In the
first part of the 20th century, drugs were used but
only as adjuncts to psychiatric treatment. But the
last 50 years has witnessed an important shift of
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544 D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
emphasis. Since the 1950s, we now have ‘anti-
depressants’ and ‘anti-psychotics’ suggesting in their
title that they are magic curative bullets, no longer
simply adjuncts (Moncrieff, 2006).
Despite the undoubted role and relevance of the
drug companies in sustaining diagnostic reifications,
the continuation of scientifically dubious categories
is only partially attributable to their interest work.
The strongest evidence for this claim is that
categorical reasoning was present and powerful
within psychiatry, even when few commercially
important agents were utilised (such as bromides
and paraldehyde).
Turning to clinical psychology, it contains those
attacking a categorical approach but it also has
established researchers who are content to hang on
to the diagnostic coat tails of psychiatry. There are
some socio-cognitive forces that can be identified to
account for this mixed picture. Because psychology
itself is a contested and wide ranging discipline,
touching physiology and neurology at one end of
the range and sociology at the other, it contains
within its’ ranks bio-determinists, who readily see
eye to eye with bio-medical practitioners.
Those clinical psychologists who seek research
grants for their interventions will have to operate in
a context in which medical authority allocates
resources according to the gold-standard methodol-
ogy of randomised controlled trials in clinical
populations. The latter populations must be carved
at the joints of DRGs to warrant grant allocations.
Also, the main therapeutic rationales deployed
and investigated by clinical psychologists are
derived from psychiatric treatment methods. The
commonest example in current times is the applica-
tion of ‘cognitive-behavioural therapy’. The latter
did not emerge from cognitivism within the
academic discipline of psychology but from the
work of clinicians (Beck et al., 1979). These
epistemological trends and financial incentives have
diverted clinical psychologists from a consistent
position about privileging diagnosis or unique
formulation.
Outside of the medical profession, and apart from
the drug companies and conservative elements in
clinical psychology, other interest groups feeding
the survival of psychiatric diagnosis can be noted.
These include politicians and civil servants planning
‘mental health services’ and the morbid interest that
the mass media and the film industry take in mental
abnormality. The relatives of people with psychia-
tric diagnosis also benefit from the putative
certainties of categorical reasoning. These various
interest groups, for different reasons, prefer cate-
gories to the complexity of particular people with
particular problems in particular social contexts.
Professional and industrial interests certainly
shape and sustain labelling but they do not totally
determine its existence. For example, in non- and
pre-psychiatric cultures, psychological difference is
still codified, stigma is still attached and social
exclusion and control are still apparent (Jodelet,
1991; Westermeyer & Kroll, 1978). Mental illness
arguably is a by-product of modern psychiatry but
madness and misery have always been with us, as
have been the societal reactions of fearful distrust,
derision, rejection and social control. The drug
companies certainly benefit from reifications like
‘depression’ and ‘schizophrenia’ to sell their pro-
ducts, but categorical medical reasoning about
madness and misery preceded the ‘pharmacological
revolution’.
The lay plausibility of psychiatric diagnosis is
variegated. Psychiatric labels may be willingly
accepted or cynically dismissed by different social
groups in different socio-historical contexts and
acceptability even varies from one diagnosis to
another. For example, a strong patient lobby exists
to defend the diagnosis of multiple personality
disorder (or ‘dissociative identity disorder’) but the
label of schizophrenia is less willingly embraced by
its recipients.
In contrast to this confusion about schizophrenia,
the general population in developed societies is so
protoprofessionalised (de Swaan, 1991) about the
notion of ‘depression’ that it has now entered the
vernacular. Despite criticisms about the coherence
of the diagnosis, it seems to have a strong lay, not
just professional, credibility, at least in Eurocentric
cultures for now.
In courts of law jurors may accept or reject
psychiatric expert evidence about culpability (‘men-
tal capacity’ in British law) and the presence and
relevance of mental disorder in particular cases. On
the one hand, courts invoke lay judgments about
unsound mind—‘the man-must-be-mad test’ (Hog-
gett, 1990). On the other hand, psychiatric profes-
sionals may not always concur with the application
of this test. The notion of ‘personality disorder’ in
particular creates divisions between and within lay
people and professionals.
Professionals highlight that the general public are
often ignorant or confused about psychiatric
diagnoses (Jorm et al., 1997). But given that the
 ARTICLE IN PRESS
D. Pilgrim / Social Science & Medicine 65 (2007) 536–547
latter are contested and open to so many pre-
empirical and empirical doubts, they have no
inherent right to be privileged. Professional and
lay discourses about mental disorder overlap but
cannot be conflated, and it is open to dispute which
one is superior and when. The role of expert may be
attributed to psychiatrists but whether they have
plausible expertise about psychological difference in
society is a moot point.
The importance of interest work
A remaining challenge for future researchers is in
relation to interest work. What are the cognitive and
financial interests of those attacking and those
seeking to preserve psychiatric diagnosis? The work
of Cooper (2004) was noted above in her critique of
the medical naturalism of DSM. She goes on to
argue that all observations are theory-laden, so the
cognitive preferences of the medical profession
(about the authoritative role of diagnosis) are
important to understand. Moreover, systems like
DSM are shaped by a variety of factors external to
the medical profession but which constantly impact
upon it. Cooper draws particular attention to the
role of health insurance arrangements in the USA in
this regard.
Apart from insurance companies requiring DRGs
(and thus supporting the continuation of reifications
like the two diagnoses discussed above) an impor-
tant external pressure comes from the pharmaceu-
tical industry. DRGs are needed if claims about the
action of say ‘anti-psychotics’ or ‘anti-depressants’
are to have strong legitimacy. Thus the hoped-for-
reductionism of biomedical prescribers and drug
producers coalesce.
Logically, weaker legitimacy still accrues, even if
that aetiological speculation is not invoked. For
example, ‘anti-psychotics’ suppress single symptoms
like auditory hallucinations, some of the time, for
some people. Similarly ‘anti-depressants’ for some
raise mood and efficiency. Indeed, they were even
marketed in this way for those with no diagnosis of
depression (Healy, 1997). Single symptom impacts,
when present, of course tell us nothing about
aetiology and do not require DRGs. For this
reason, pharmaceutical industry marketing clearly
prefers the stronger legitimacy of DRGs and
assumed aetiology. DRGs are also preferred by
health service planners and policy makers. They
have to lump sub-populations of patients together
for their purposes.
545
The two case studies demonstrate that profes-
sionals outside of psychiatry, recipients of diagnoses
and their relatives are internally divided about
particular diagnoses. These non-psychiatric interest
groups play their part in sustaining or undermining
particular diagnoses, at particular points in time,
and so they invite recurrent investigation.
Conclusions
This paper has provided a brief historical account
of the emergence of a categorical medical view
about mental disorder. Even during antiquity, there
were intimations of more recent controversies about
the latter. Madness was for some valuable and for
others clearly dysfunctional, being a source of
aimlessness and violence. Some speculated about
aetiology whilst, others limited themselves to the
close observation and labelling of presenting pro-
blems. The single symptom view competed with
varieties of categories. As psychiatry emerged the
categorical view gained the ascendancy but its critics
within and without played and re-played versions of
the older ambivalence.
Despite (or maybe because of) that ongoing
ambivalence, psychiatric diagnosis survives. The
paper finished on some challenges facing social
science researchers to explain that survival. Three
points of reference were offered to aid this explana-
tion in relation to epistemology, the problematisa-
tion of physical, as well as psychiatric, diagnosis and
the need to investigate interest work.
The two case studies offered of ‘schizophrenia’
and ‘depression’ provided examples of analysis,
using these three points of reference. The beginnings
of this sort of analysis have drawn upon psychiatry,
psychology, social history, sociology and philoso-
phy. This implies the need for continuing inter-
disciplinary collaboration to investigate the survival
of psychiatric diagnosis.
Acknowledgment
The author would like to thank Professor John
Goodacre for his advice on inflammatory condi-
tions.
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