By André B. Sobocinski, Navy Medicine Historian
The Second World War exposed the unsettling fact that the Armed Services needed an updated system for diagnosing mental illness. Many military psychiatrists expressed great frustration with the limited standards and believed they were ill-defined for personnel suffering the stresses of combat and military life. Personnel suffering bouts of anxiety could be classified as having “psychopathic personality.”(10) As one Navy psychiatrist commented, “American psychiatry entered World War II with a system of nomenclature originally devised for the use of mental hospitals and found the system quite inapplicable to a caseload that included 10% of the type of patient usually seen in a mental hospital.”(11)
Throughout the war, over one million service personnel were diagnosed with some sort of mental illness. More than 40 percent of the military discharges and more than a one-third of rejections in the war were due to neuropsychiatric complaints; and according to the BUMED pamphlet The NP Problem (1944) neuropsychiatric conditions accounted for one-sixth of all Navy hospital beds and lead to one-fifth of all medical discharges in the Navy. (12, 13) There are no statistics, however, on the number of personnel who were “over diagnosed” by the limited classification.
In the Army, psychiatrist Col. William Menninger, Medical Corps, U.S.A. (1899-1966) attempted to remedy the situation by establishing a military-specific nomenclature. Published in 1943 as the War Department Technical Bulletin 203 (aka, Med 203), this document would help pave the way for more encompassing mental health classification systems.(14) The publication also marked the first time that “passive-aggressiveness” was listed as a psychiatric disorder. Menninger saw passive-aggressiveness as the leading disorder in the U.S. military and defined it as a “neurotic type reaction to routine military stress, manifested by helplessness, or inadequate responses, passiveness, obstructionism or aggressive outbursts.”(15)
By the end of World War II, the Armed Services, Veterans Administration and Public Health Service were using the Standard Classified Nomenclature of Diseases (revised in 1942 and used by the Navy), Med 203 as well as the Veterans Administration Nomenclature for classifying mental disorders. There was also the International Statistical Classification of Diseases, Injuries and Causes of Death (ICD) which first published a separate mental health nomenclature in 1939. (16) It is little surprise that these multiple systems added to great confusion in the services. Navy psychiatrist Capt. George Raines, Medical Corps, U.S.N. would later recall, “One agency found itself in the uncomfortable position of using one nomenclature for clinical use, a different one for disability rating, and the International for statistical work.”(17)
The year 1948 was a banner year for consolidation. In June 1948, Secretary of Defense James Forrestal directed that the Armed Services prepare a uniform classification and nomenclature of diseases, injuries and conditions for joint use.(18) The result of this was the Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions (SR 40-1025-2/NAMED P-1303/ AFR 160-13A). Like the Med 203, thenew nomenclature followed six separate psychiatric conditions and 22 “psychotic reactions.”(19) Also in 1948, the American Psychiatric Association (APA) convened a Committee on Nomenclature and Statistics to review the “needs for revision … in civilian practice with [the] increasing number of psychiatric outpatients being handled.”(20)
Chaired by Navy psychiatrist Capt. Raines, the APA Committee prepared a draft patterned after Med 203 which it distributed to various organizations in November 1950 for review. (21) The final version was approved and released in 1952 as the Diagnostic and Statistical Manual of Mental Disorders (DSM I). Although not without its own controversies, the DSM I was seen as largely successful in “providing a common authoritative nomenclature for American society.”(22) Now in its fifth printing, the DSM, along with the ICD, are considered standards for classifying psychiatric disorders in the United States today.
(1) Nostalgia was an occupational disease common among Sailors and Soldiers of the world. The condition was usually marked by a loss of appetite, sleep, and left untreated could lead to suicide. Today the “diagnosis” of nostalgia could encompass everything from combat stress to bipolar disorder or even simple feelings of homesickness. Some scholars have looked at the diagnosis of hypochondria and theorized that some of early hypochondriacs could have actually been suffering from neurological disorders like multiple sclerosis. Dementia praecox, literally “precocious madness,” was a term often associated with schizophrenia and sometimes used interchangeably. It should be noted that many cases of madness in the early Navy could be attributed to drug and alcohol abuse, venereal diseases, combat stressors, environmental conditions, and even iatrogenic disorders caused by the uses of mercury and other toxins in medicines.
(2) A precursor to the Manual of the Medical Department, the Instructions served as a reference guide for filling out medical and administrative forms. It also included a supply table and the Statistical Nomenclature of Diseases (taken from the nomenclature established by the Royal College of Physicians and Surgeons in England in 1874).
(3) The term “psychasthenia” appeared around the same time as neurasthenia. As neurasthenia was seen as a physical drain of energy, psychasthenia was a psychological drain of energy. Although neurasthenia is no longer part of official psychiatric diagnoses in the United States, the term is still in use in foreign classification systems.
(4) Tabulation from Report of the Surgeon-General, U.S. Navy to the Secretary of the Navy. Washington, D.C.: Government Printing Office. (Editions 1880-1901)
(5) Since 1855, the military services had used St. Elizabeth’s (aka Government Hospital for the Insane) for the care of its mentally ill.
(6) Manic-Depressive Psychosis originated in 1875 and coined by Jules Falret. Now known as “bipolar disorder.”
(7) Butts, Heber. “Insanity in the Navy.” The Naval Medical Bulletin. Volume IV. October 1910. pp 459-475
(8) Manual of the Medical Department of the United States Navy (Washington, DC: Government Printing Office, 1914). Bellevue Hospital’s nomenclature of diseases and conditions was first published in 1903 and later revised in 1909 and 1911.
(9) In 1918, the committee on statistics American Medico-Psychological Association (later known as the American Psychiatric Association) with National Committee for Mental Hygiene created a classification for mental illnesses (Statistical Manual for the Use of Institutions for the Insane) organizing them into 22 groups. Although ambitious and influential for future systems, this publication was not adopted by the Navy.
(10) Menninger. W.W. Contributions of Dr. William C. Menninger to Military Psychiatry. Bulletin of the Menninger Clinic. Fall 2004; 68, 4. pp 277-295.
(11) Raines, George. “Foreword.” Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: American Psychiatric Association, 1952. World War II brought new precedence to psychiatric care and diagnosis. As Raines would later note, there did not exist any provision for diagnosing psychological conditions induced by combat. The need for sweeping changes for more applicable nomenclature was clear.
(12) Folliard, Edward. “Psychiatry Advance of 50 Years Seen as a Result of War.” The Washington Post; May 28, 1944 pB1.
(13) Published on June 23, 1944, The NP Problem pamphlet describes the treatment and administration policy for mental illnesses in the Navy.
(14) Menninger. W.W. “Contributions.”
(15) Wetzler, Scott; Morey, Leslie C. Psychiatry 62.1 (Spring 1999): 49-59. Resistance to the demands of military discipline seen as a threat later influenced diagnosis in non-military settings. The label remained in the Joint Nomenclature in 1949 and DSM I.
(16) Houts, Arthur. Fifty Years of Psychiatric Nomenclature: Reflections on the 1943 War Department Technical Bulletin, Medical 203. Journal of Clinical Psychology, Vol. 56(7), 935-967 (2000).
(17) Raines, George. “Foreword.” Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: American Psychiatric Association, 1952.
(18) “Diagnostic Nomenclature for Medical Department.” BUMED Circular Letter 49-4, 12 January 1949.
(19) The term reactions come from Adolf Meyer (1866-1950), a prominent Swiss-born American psychiatrist who served as president of the APA. Meyer believed that mental disorders were “reactions” against biopsychosocial stressors.
(20) Widiger, Thomas. “Historical Developments and Current Issues.” The Oxford Handbook of Personality Disorders. New York: Oxford University Press. 2012.
(21) A former head of psychiatry at Naval Hospitals in Bethesda, Md., and Portsmouth, Va., George Raines (1908-1959) was later chief of the BUMED Neuropsychiatric Branch as well as the head of the psychiatric department at Georgetown University. Raines was also an important researcher in the fields of suicide and depression. (Munsey, Everand. Psychiatrist Raines, 51, Dies: Worked on Suicides, Chief at Bethesda. The Washington Post, Time Herald Sept 17, 1959. pgB2)
(22) Widiger, p16.