1 Boring Old Man

<sup>One of the reasons that diagnostic classification has fallen into disrepute among some psychiatrists is that diagnostic schemes have been largely based upon a priori principles rather than upon systematic studies. Such systematic studies are necessary, although they may be based upon different approaches. We have found that the approach described here facilitates the development of a valid classification in psychiatry. This paper illustrates its usefulness in schizophrenia.
The Five Phases
1.Clinical Description
In general, the first step is to describe the clinical picture of the disorder. This may be a single striking clinical feature or a combination of clinical features thought to be associated with one another. Race, sex, age at onset, precipitating factors, and other items may be used to define the clinical picture more precisely. The clinical picture thus does not include only symptoms.
2. Laboratory Studies
Included among laboratory studies are chemical, physiological, radiological, and anatomical (biopsy and autopsy) findings. Certain psychological tests, when shown to be reliable and reproducible, may also be considered laboratory studies in this context. Laboratory findings are generally more reliable, precise, and reproducible than are clinical descriptions. When consistent with a defined clinical picture they permit a more refined classification. Without such a defined clinical picture, their value may be considerably reduced. Unfortunately, consistent and reliable laboratory findings have not yet been demonstrated in the more common psychiatric disorders.
3. Delimitation from Other Disorders
Since similar clinical features and laboratory findings may be seen in patients suffering from different disorders (e.g., cough and blood in the sputum in lobar pneumonia, bronchiectasis, and bronchogenic carcinoma), it is necessary to specify exclusion criteria so that patients with other illnesses are not included in the group to be studied. These criteria should also permit exclusion of borderline cases and doubtful cases (an undiagnosed group) so that the index group may be as homogeneous as possible.
4. Follow-Up Study
The purpose of the follow-up study is to determine whether or not the original patients are suffering from some other defined disorder that could account for the original clinical picture. If they are suffering from another such illness, this finding suggests that the original patients did not comprise a homogeneous group and that it is necessary to modify the diagnostic criteria. In the absence of known etiology or pathogenesis, which is true of the more common psychiatric disorders, marked differences in outcome, such as between complete recovery and chronic illness, suggest that the group is not homogeneous. This latter point is not as compelling in suggesting diagnostic heterogeneity as is the finding of a change in diagnosis. The same illness may have a variable prognosis, but until we know more about the fundamental nature of the common psychiatric illnesses marked differences in outcome should be regarded as a challenge to the validity of the original diagnosis.
5. Family Study
Most psychiatric illnesses have been shown to run in families, whether the investigations were designed to study hereditary or environmental causes. Independent of the question of etiology, therefore, the finding of an increased prevalence of the same disorder among the close relatives of the original patients strongly indicates that one is dealing with a valid entity. We hope it is apparent that</sup>

^{In contrast to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-II), in which the diagnostic classification is based upon the "best clinical judgement and experience" of a committee and its consultants, this communication will present a diagnostic classification validated primarily by follow-up and family studies. The following criteria for establishing diagnostic validity in psychiatric illness have been described elsewhere and may be divided into five phase.}

• John Feighner was a psychiatery resident
• The criteria came from a literature search, not their own patients
• The criteria were hypothetical and had not been vetted by their 5 phases
• The five phases of diagnosis were not part of generating the criteria but rather cut and pasted from their earlier article
• The reliability figures were from somewhere else antedating the criteria [never ever published]

For Dr. Spitzer, charged with the task of redesigning the DSM-II, the Feighner Criteria were a godsend. They gave him a descriptive system to work with and allies who shared his disaffection with the psychoanalysts and their influence on the DSM-II. In his 1974 meta-analysis using Kappa, he demonstrated the unreliability of the DSM-II system and introduced the Feighner Criteria as a template for the Research Diagnostic Criteria [RDC] being tested in an NIMH study with Dr. Robins, a leader of the St. Louis Group [box scores and kappa…]. In 1978, they published reliability studies for the RDC and the DSM was born [the dreams of our fathers I…]. In 1991, in response to challenges that his criteria in the DSM-III had not followed the phases described in these early papers, Dr. Spitzer admitted that they had not validated the catergories as described by Robins and Guze, but continued to contend that there was no etiological bias towards biology, a point he made again in 2001 [dreams of our fathers II…].

In poring over this, I’ve come to see this process as having two distinct dreams. Everybody involved wanted the psychoanalytic influence gone. John Feighner was an young resident who dreamed of making concrete sense of psychiatric diagnosis using the literature to build a phenomenological template. Robert Spitzer had the same goal – a descriptive DSM-III like the one he created. He says he didn’t have an etiologic focus or bias. So I lump the two of them together. The St. Louis Group at Barnes Hospital had a definite etiologic focus – biology, data, biology. They dreamed of picking up where Kraepelin left off and building not only a neo-Kraepelinian DSM-III, but a neo-Kraepelinian psychiatry:

^{1. Psychiatry is a branch of medicine.}
^{2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.}
^{3. Psychiatry treats people who are sick and who require treatment.}
^{4. There is a boundary between the normal and the sick.}
^{5. There are discrete mental illnesses.  They are not myths, and there are many of them.}
^{6. The focus of psychiatric physicians should be on the biological aspects of illness.}
^{7. There should be an explicit and intentional concern with diagnosis and classification.}
^{8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.}
^{9. Statistical techniques should be used to improve reliability and validity.}

^{In the ongoing quest to improve our psychiatric diagnostic system, we are now searching for new approaches to understanding the etiological and pathophysiological mechanisms that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions venturing beyond the current DSM paradigm and DSM-IV framework. This thought-provoking volume produced as a partnership between the American Psychiatric Association, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse represents a far-reaching attempt to stimulate research and discussion in the field in preparation for the eventual start of the DSM-V process, still several years hence. The book:}
• Explores a variety of basic nomenclature issues, including the desirability of rating the quality and quantity of information available to support the different disorders in the DSM in order to indicate the disparity of empirical support across the diagnostic system.
• Offers a neuroscience research agenda to guide development of a pathophysiologically based classification for DSM-V, which reviews genetic, brain imaging, postmortem, and animal model research and includes strategic insights for a new research agenda.
• Presents highlights of recent progress in developmental neuroscience, genetics, psychology, psychopathology, and epidemiology, using a bioecological perspective to focus on the first two decades of life, when rapid changes in behavior, emotion and cognition occur…

• Research Planning Launch/Methods Conference (February 18-20, 2004)
• Personality Disorders Conference (December 1-3, 2004)
• Substance-Related Disorders Conference (February 14-17, 2005)
• Stress-Induced and Fear Circuitry Disorders Conference (June 23-24, 2005)
• Dementia Conference (September 15-17, 2005)
• Deconstructing Psychosis (February 15-17, 2006)
• Obsessive Compulsive Spectrum Disorders Conference (June 20-22, 2006)
• Dimensional Aspects of Psychiatric Diagnosis (July 26-28, 2006)
• Somatic Presentations of Mental Disorders (September 6-8, 2006)
• Externalizing Disorders of Childhood (ADD, CD, ODD, Bipolar Disorder) (February 14-16, 2007)
• Comorbidity of Depression and Generalized Anxiety Disorder (June 20-22, 2007)
• Public Health Implications of Changes in Psychiatric Classification (September 25-28, 2007)
• Autism and Other Pervasive Developmental Disorders Conference (February 3-5, 2008)

I can only guess at why the DSM-5 Task Force was secretive and distanced from their predecessors. I’d bet it had something to do with the specific personalities involved. It usually does, but I don’t know the actual people. There was a tone of secrecy in the air in psychiatry at large and we later learned that there were some fairly dark secrets behind those walls in general. But  it also occurs to me that they were aiming to make some fundamental changes in the DSM [and psychiatry as a whole], messing with Dr. Spitzer’s baby. Likewise, Dr. Frances had resisted diagnostic sprawl, and they were definitely in an annexation frame of mind, rather than urban renewal mode. But whatever their reasons, it looked bad from the outside, like a classic ‘good old boy’ network – up to no good. Even if the were innocent it was a bad move.

And I don’t really know how they got so far behind schedule. It looked like they were so busy dreaming together that they didn’t look at the clock. But my fantasy is that other forces came into play. They’d clearly planned for the grand realization of their St. Louis fathers’ dream – the long desired ‘laboratory studies.’ And they had no alternatives for what to do if they didn’t materialize. And they didn’t materialize. And I doubt they precogged that they would be living in a world of huge, embarrassing lawsuits against the drug companies implicating academic psychiatrists and psychiatric research. I expect they hadn’t banked on Senator Grassley exposing corruption in high places, including the APA president. I doubt they’d considered the ‘empty pipeline’ syndrome earlier, or the flight of the pharmaceutical companies from psychopharmacology, or the intensity of the outcry against overmedication and overmedicalization. The cast of characters are roughly my peers, so they’ve spent their whole careers in the same climate I’ve inhabited [on the other side of the fence]. And I expect they had no reason to know how quickly things can change. Or maybe they’re a bit incompetent. But by the time Dr. Spitzer and Dr. Frances started howling, the DSM-5 Task Force were in deep trouble and had to declare the first of what I hope will be several postponements.

Why did they decide to play their cards with this Revision? That really is the question. They just didn’t yet have the needed "laboratory studies" in hand – not a one. Even if all the negative things hadn’t happened along the way, they would still be in trouble – still coming up empty-handed. Had they come to actually believe their own inflated narratives? Or did they think the world wouldn’t tolerate waiting for something that made "evidence-based" really become evidence based? Was the impact of the overselling of psychiatric medicines already being felt and in need of a boost from hard science? If psychoanalyst Heinz Kohut, the self psychologist, were still alive and called in for a consult, he’d probably say that their collective Archaic Grandiose Self had emerged into consciousness and rendered them reckless and arrogant [and that wouldn't be a half bad way to think]. Another way to say that is "they got too big for their britches." But the point here is not to dissect  the group persona, or even the personae of the individuals, it’s to look at the fate of the dreams of the fathers.

I actually like separating the threads of the DSM story into the dream themes. One is the dream of the St. Louis Group and many others, a dream that psychiatric illness can and will be classified in the same way as medical diseases, based on objective findings – objective biological findings. The other is the dream of resident John Feighner, Robert Spitzer, and Allen Frances that psychiatric patients can be classified based on descriptive symptom complexes and other observation data like family history – and that the classification holds between clinicians [inter-rater reliability] and over time [longitudinal reliability]. In either case, the dream is to use diagnosis for accurate prognostication and effective treatment.

Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia
^{BY ELI ROBINS. M.D.AND SAMUEL B. GUZE, M.D.}
American Journal of Psychiatry. 1970 126[7]:107-111.

^{Since Bleuler, psychiatrists have recognized that the diagnosis of schizophrenia includes a number of different disorders. We are interested in distinguishing these various disorders as part of our long-standing concern with developing a valid classification for psychiatric illnesses. We believe that a valid classification is an essential step in science. In medicine, and hence in psychiatry, classification is diagnosis. One of the reasons that diagnostic classification has fallen into disrepute among some psychiatrists is that diagnostic schemes have been largely based upon a priori principles rather than upon systematic studies. Such systematic studies are necessary, although they may be based upon different approaches. We have found that the approach described here facilitates the development of a valid classification in psychiatry. This paper illustrates its usefulness in schizophrenia…}

1. Clinical Description
2. Laboratory Studies
3. Delimitation from Other Disorders
4. Follow-up Study
5. Family Study

In the diagnostic system, this etiologic ambiguity is reflected in the peculiar use of the word Disorder. On one hand, it’s used as if it were a synonym for the traditional medical term Disease – a pathological condition defined by nature. On the other hand, a Disorder is a condition defined by man in the periodic ritual we call Revisions. Some Disorders approximate the Diseases of unknown etiology in medicine proper, regularly occurring collections of signs and symptoms, with clear borders, with familial tendencies, with longitudinal stability [a "course"], and with a consensus of a potential biological causality. But those particularly medical-ish Disorders uniformly lack laboratory [biomarker] confirmation. The majority of patients seeking care do not have those particularly medical-ish Disorders. They have the not-so-medical-ish Disorders that are created and maintained by committee – a Revision committee like the DSM-5 Task Force.

I am a psychoanalyst, a psychiatrist, an internist, and a person. In the privacy of my own mind, I use that distinction diagnostically. When I listen to a patient’s story, I find that my mind is thinking in one of those modes, and I reflexively check to make sure I’m not running on autopilot and going down a slippery slope on the way to making a categorical error, the bane of a person with multiple minds – thinking psychiatrically when I should be thinking medically, thinking psychoanalytically when I should be smelling Schizophrenia, diagnosing when I should be comforting. But in public, I don’t talk about that – I’m too bruised. I say this to aver the following – I have no wish for a diagnostic system like the DSM-II from now until the end of time. That’s not why I’m writing. I’m talking about it right now because the contemptuousness of the graphic in the last post is actually a part of the current system. The complaint about the inclusion of Neurosis in 1968 is a valid complaint – removed. If the psychoanalysts were that imperious before 1980, shame be upon them and they should go to time out – they’re gone. But there’s something else. That contempt is maintained as a cover for the arbitrariness of this current system, its lack of evidence base, its speculations, its medical-ness co-opted for reimbursement, and its use in the service of a beast of a pharmaceutical industry that’s had a field day with the DSM-III and its Disorders [the medical-ish and the not-so-medical-ish].

It might not sound like it, but I actually think the St. Louis Group was mostly on the up and up. They may have been too harsh about the motives of the analysts of their time, but somewhat on target about their behavior. As we’ve seen, they fudged way more than a little bit with the Feighner Criteria, implying a science base that doesn’t really seem to have been there. But I do think they genuinely thought psychiatry should be organized along more traditional medical lines, including diagnosis. And I expect they really did dream of a future psychiatry that stuck to the biological aspects of mental illness. I’m not even terribly mad about the end run of allying themselves with Robert Spitzer in the "invisible college." It was time for the pendulum to swing. That Spitzer didn’t seek other, balancing counsel was his mistake, not theirs. The St. Louis Group had a dream, and like all dreams – it was heavily informed by hopes and wishes for the future, not a present reality. They claimed way more than they could deliver without exaggerating, so they exaggerated, even cheated some. How they justified that is not ours to know any more than the exaggeration of the analysts. Maybe it’s just what people do in revolutions. What we do know now is that those exaggerations created a system that is currently a monster in its own right. Rather than the future the St. Louis Group and Robert Spitzer envisioned, we have a powerful subclass of corrupted scientist-entrepreneurs allied with the pharmaceutical industry that have been a malignant presence in psychiatry for so long that in the eyes of many, they define the profession.

^{We shall not cease from exploration.
And the end of all our exploring.
Will be to arrive where we started.
And know the place for the first time.}

Diagnostic criteria for 14 psychiatric illnesses [and for secondary depression] along with the validating evidence for these diagnostic categories comes from workers outside our group as well as from those within; it consists of studies of both outpatients and inpatients, of family studies, and of follow-up studies. These criteria are the most efficient currently available; however, it is expected that the criteria be tested and not be considered a final, closed system. It is expected that the criteria will change as various illnesses are studied by different groups. Such criteria provide a framework for comparison of data gathered in different centers, and serve to promote communication between investigators.

This communication presents specific diagnostic criteria for those adult psychiatric illnesses that have been sufficiently validated by precise clinical description, follow-up, and family studies to warrant their use in research as well as in clinical practice. These criteria are not intended as final for any illness. The criteria represent a distillation of our clinical research experience, and of the experiences of others cited in the references.

^{While no psychiatric syndrome has yet been fully validated by a complete series of steps, a great deal of work has been published indicating that substantial validation is possible. This communication is a summary of that work in the form of specific diagnostic criteria. The studies of validation for each illness are cited.}

^{In addition, we in this department have carried out a study of inter-rater reliability and validation of reliability with an 18-month follow-up study of 314 psychiatric emergency room patients [to be published] as well as a seven-year follow-up study of 87 psychiatric inpatients [to be published], each of whom was interviewed personally and systematically. There were four different raters in the emergency room study. Agreement ranged from 86% to 95% about diagnosis with diagnostic criteria similar to those outlined in this report. There were two different raters in the inpatient study; reliability between those raters was 92%. In the emergency room study and in the inpatient study, validity, as determined by correctly predicting diagnosis at follow-up by criteria such as those of this report, was 93% and 92%, respectively.}

Returning to John Feighner’s later narrative [1989] looking back over his residency days:

^{Also, with the progressive use of lithium and other more specific pharmacological treatments at that time, it seemed imperative to me that we refine our diagnostic criteria to assist us in selecting specific treatments for specific patients and to improve communication between research centers.}

Spitzer first came to the university as a resident and student at the Columbia Center for Psychoanalytic Training and Research, after graduating from N.Y.U. School of Medicine in 1957. He had had a brilliant medical-school career, publishing in professional journals a series of well-received papers about childhood schizophrenia and reading disabilities…

At Columbia Psychoanalytic, however, Spitzer’s career faltered. Psychoanalysis was too abstract, too theoretical, and somehow his patients rarely seemed to improve. “I was always unsure that I was being helpful, and I was uncomfortable with not knowing what to do with their messiness,” he told me. “I don’t think I was uncomfortable listening and empathizing — I just didn’t know what the hell to do.” Spitzer managed to graduate, and secured a position as an instructor in the psychiatry department [he has held some version of the job ever since], but he is a man of tremendous drive and ambition—also a devoted contrarian—and he found teaching intellectually limiting…

It’s easy to read Spitzer’s quote and allow it to become a Rorschach inkblot – something to contain any number of thoughts, opinions, or interpretations of his true motives. That’s just the way we think about the DSM-III, a conundrum itself, filled with palace intrigue, old resentment, personae jockeying for power, people fighting over money. I can fill that quote up with thoughts of my own, like "That’s a false dichotomy! Those aren’t exclusive categories! How about both empirical research studies and clinical wisdom from long-term psychotherapy!" or "See, he admits the real controversy about DSM-III was a controversy about who were going to be the leaders! It was political!" I can feel ashamed and angry that my analytic predecessors didn’t directly deal with the problem of third party payments and strike a sensible compromise. I can still feel the sting of the invectives that came my way with the DSM-III revolution, and am not too far from still having a tear in the corner of my eye about having to change courses and leave a career path that fit me like a glove. Likewise, I’m a psychiatrist and I was really taken with the careful parsing of the major clinical syndromes, so I mourned the loss of subtlety that came with the DSM-III’s symptom lists and the accompanying structured interviews. All of this to say that this is hardly an area where I can claim to be able to transcend my own subjectivity. The personal impact was too great [but that doesn't mean I have to be quiet, just that I have to be careful].

^{…I recall a psychoanalyst and chair of a DSM-III oversight committee who commenting on a draft of DSM-III said, “There is so much more that we know.” By this, he meant that DSM-III did not include all of the knowledge that his fellow clinicians had painstakingly learned about human behavior and motivation from the intensive study of patients in long-term psychotherapy. In a sense, the real controversy about DSM-III was a controversy about who were the leaders in the profession and whether progress in our field was most likely to come from empirical research studies or from clinical wisdom collected by intensive long-term psychotherapy.}

The Advent of the “Feighner Criteria”
by John P. Feighner
Department of Psychiatry, University of California San Diego
and the Feighner Research Institute
July 18, 1989

As a beginning resident in psychiatry at Barnes-Renard Hospital, Washington University Medical School in St. Louis, in 1966, it became painfully clear to me that the state of the art of psychiatric diagnoses was frankly in a mess. Trying to draw conclusions from the scientific literature with regards to virtually any area of the major psychiatric disorders was extremely difficult. Patients that were described in one article as having acute schizophrenia, showing a very positive response to electroconvulsive therapy ECT, seemed quite different from patients described in other articles as having a similar disorder and responding poorly to ECT but positively to neuroleptics. Also, with the progressive use of lithium and other more specific pharmacological treatments at that time, it seemed imperative to me that we refine our diagnostic criteria to assist us in selecting specific treatments for specific patients and to improve communication between research centers.

At that time in the Department of Psychiatry at Washington University School of Medicine, there was an enormous amount of epidemiological and natural history studies being done in a variety of psychiatric disorders. In my contacts with numerous people in the department, particularly Dr. Eli Robins and his basic “no nonsense data oriented approach,” it was apparent that something should be done and could be done to better delineate the major psychiatric syndromes. In my third year as a resident, I began to develop specific diagnostic criteria for the affective disorders; and in so doing I discussed with Drs. Robins, Sam Guze, and George Winokur the possibility of expanding these criteria to include the major psychiatric disorders. During my fourth year as a chief resident, I subsequently pursued this more vigorously and with my coauthors set up a Tuesday afternoon committee. At that time I reviewed close to 1,000 articles in the then existing literature and distilled this data into proposed criteria for the various disorders that we were working on at the time. These criteria were refined by the committee’s work, which they subsequently published. It was an exciting time to be in Washington University’s Department of Psychiatry and to work closely with the existing faculty.

One of the things I learned in this process is that, even as a resident, if you have a specific idea and are willing to commit to that idea, much can be accomplished with persistence and hard work. In general I have been very pleased at the overall direction that psychiatric nosology has taken since the advent of our paper, which has generally become known as the “Feighner Criteria.” Certainly, it was my idea and initial energy that started this committee to work, but without the astute, competent, and highly informed contributions of the other authors, it would never have been possible to complete the task that was done in 1969-1970. As an aside, when it came time to take my psychiatric board exam, having reviewed all of the papers necessary to formulate these criteria, it was, as the saying goes, “like a walk in the park.” It was fun and exciting to have had the support of the department and to be provided with the resources of the department to pursue these endeavors. In the training of any clinician, I think it is important to expose all of us to the research process because I think, frankly, it makes more astute clinicians out of us and makes us better able to evaluate scientific progress as it evolves.

---

[The Sd® and SSCJ indicate that this paper has been cited in over 3,950 publications, making it the most-cited paper ever published in a psychiatric journal.]

I came across this reference [Feighner's statement] in the middle of writing this post, while I was looking for a copy of the original paper on-line. I had in mind going through the article to see if I could clarify and reference why I thought of it and its DSM-III expansion as "dumbed down", a simplification, maybe even a trivialization of the subtleties of psychiatric illness independent of my own interests and biases. But after I read his description of the way the criteria came into being, my re-reading of the article took on a different coloring. My former job was Residency Training Director, and I would’ve been glad to have this industrious resident. I read the article as mental illness as seen by a good third year resident, a time in training when you’ve mastered being around mental ill people and are finally beginning to have a map of the territory. And I see why I reacted to the DSM-III the way I did. It’s that very view of mental illness at the time when the picture is just coming together as the blueprint for the learning up ahead. It’s enough of an anchor to allow one to begin to tolerate the confusion and ambiguity that characterizes human behavior, mental life, and mental illness – frozen in time, a snapshot of a developmental stage early in a long process.

After the DSM-III and later DSM-IIIR were launched and in play, people began to look back at the origins and ask if the actual Manuals had lived up to their grand design. One obvious area of criticism was the derivation of the criteria. About the process that lead to the Feighner Criteria, they said that they came from the evaluation of actual cases using:

1. Clinical Description
2. Laboratory Studies
3. Delimitation from Other Disorders
4. Follow-up Study
5. Family Study

While no psychiatric syndrome has yet been fully validated by a complete series of steps, a great deal of work has been published indicating that substantial validation is possible. This communication is a summary of that work in the form of specific diagnostic criteria.

In addition, we in this department have carried out a study of interrater reliability and validation of reliability with an 18-month follow-up study of 314 psychiatric emergency room patients (to be published) as well as a seven-year follow-up study of 87 psychiatric inpatients (to be published), each of whom was interviewed personally and systematically. There were four different raters in the emergency room study. Agreement ranged from 86% to 95% about diagnosis with diagnostic criteria similar to those outlined in this report. There were two different raters in the inpatient study ; reliability between those raters was 92%. In the emergency room study and in the inpatient study, validity, as determined by correctly predicting diagnosis at follow-up by criteria such as those of this report, was 93% and 92%, respectively.

^{It will be apparent below that certain diagnoses are mutually exclusive (primary affective disorders and schizophrenia), while others may be made in the same patient (antisocial personality disorder with alcoholism or drug dependency ; hysteria or anxiety neurosis with secondary depression). More work will be necessary before the full significance of various diagnostic combinations becomes evident.}

An outsider-insider’s views about revising the DSMs
^{by Spitzer RL.}
Journal of Abnormal Psychology. 1991 100[3]:294-296.

…In discussing the development of DSM-III, Widiger et al. noted the increasing role of empirical validation in psychiatry and the five phases for validating a psychiatric diagnosis proposed by Robins and Guze. Their approach led Robins and Guze to recognize only 16 diagnoses that they believed had been validated by follow-up and family studies [Feighner et al., 1972]. Clearly, if the DSM-III Task Force had adopted this strategy, as Widiger et al. implied, it would not have recommended that DSM-III include over 200 categories — most of which were included on the basis of expert clinical judgment [face validity] alone. The Task Force recognized, correctly I believe, that limiting DSM-III to only those categories that had been fully validated by empirical studies would be at the least a serious obstacle to the widespread use of the manual by mental health professionals. The approach that was adopted by the DSM-III Task Force, from Robins and Guze’s recommendations, was the use of specified diagnostic criteria for virtually all of the disorders—the major innovation of DSM-III.

Expert Consensus Versus Empirical Basis: It is understandable that Widiger et al. (1991) emphasized the many ways in which DSM-IV can improve on the process involved in the development of DSM-III and DSM-III-R, such as by systematically reviewing the relevant literature, documenting the rationale for all changes, and conducting many focused field trials. The DSM-IV leadership is to be congratulated for the tremendous effort that is involved in these projects. However, I am troubled by the tendency [intended or not] to play down the major role that expert consensus will have in the final decision-making process for DSM-IV. My own prediction is that when final decisions are made about DSM-IV, they will still be based primarily on expert consensus, rather than on data, as was the case with the DSM-III and DSM-III-R…

^{Are DSM-III and DSM-II1-R Atheoretical With Regard to Etiology? As is well known, the developers of DSM-III and DSM-IIIR claim that—with only a few exceptions, such as the organic mental disorders and adjustment disorder—the classification does not subscribe to any particular etiologic theories. For example, some investigators who have studied panic disorder believe that the disorder arises from learned avoidance responses to conditioned somatic symptoms of anxiety; other investigators believe the disorder results from a dysregulation of biological systems mediating separation anxiety. However, neither etiologic theory has any effect on the diagnostic criteria for the disorder, which are solely based on the descriptive features of the disorder. Therefore, I am puzzled by Millon’s (1991) statement that "despite assertions to the contrary, recent DSMs are a product of implicit causal or etiologic speculation"…}

^{1. Psychiatry is a branch of medicine.}
^{2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.}
^{3. Psychiatry treats people who are sick and who require treatment.}
^{4. There is a boundary between the normal and the sick.}
^{5. There are discrete mental illnesses.  They are not myths, and there are many of them.}
^{6. The focus of psychiatric physicians should be on the biological aspects of illness.}
^{7. There should be an explicit and intentional concern with diagnosis and classification.}
^{8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.}
^{9. Statistical techniques should be used to improve reliability and validity.}

On Values in Recent American Psychiatric Classification
^{by John Z. Sadler, Yosaf F. Huglus and George J. Agich}
The Journal of Medicine and Philosophy 1994  19:261-277.

^{The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed.}

^{One reason why value conflict is not seen as such by DSM-IV – and its predecessors, to be sure – is the apparent adherence of the Task Force to a particular view of classification and science. A large literature establishes that medical practice [and scientific practice as well], including classification, necessarily involves value commitments… For a psychiatric classification example, consider the above mentioned dispute over DSM-III/III-R’s descriptive terms. Psychodynamically oriented psychiatrists believe the nosology ignored theoretically important terms essential to their practice [such as "neurosis" and "defense mechanism"]. The syndromatic approach used by DSMIII/ III-R, however, met the descriptive needs of biological psychiatry much better… The implicit value choice made by the authors of DSM-III/III-R was that the biological descriptive approach was more important than the psychodynamic descriptive approach, presumably for a variety of reasons. We doubt that this preference for biological approaches that is implicit in the descriptive, syndromatic approach was consciously intended by the authors of the DSM-III and III-R. Instead, we suspect that this preference and its associated commitments were more the byproduct of a naive view of science and psychiatric nosology as value-free or value-neutral… Although the notion of value-free or value-neutral science has been discredited by a large number of authors, philosophers and scientists… the view nonetheless persists. The reasons for the rejection of value-neutral language are many, but can be summarily stated:}

^{Values, not cognitions, determine what we select as "important," "crucial," "central," "decisive," or "related." In other words, values lend structure to the field of attention, pre-defining background and foreground, and clustering disparate items into groups. Consequently, "descriptive" statements about psychopathology issue from presupposed value stances that conceal their own deeper sources, compatibilities, and incompatibilities…}

Values and Assumptions in the Development of DSM-III and DSM-III-R:
^{An Insider’s Perspective and a Belated Response to Sadler, Hulgus, and Agich’s “On Values in Recent American Psychiatric Classification”
by ROBERT L. SPITZER, M.D.}
Journal of Nervous and Mental Disease. 2001 189:351–359.

…Let us broadly divide etiological perspectives into two major … groupings: according to the biological perspective, the causes of mental disorders will ultimately be shown to be disturbances in biological functioning that are relatively independent of life experience; according to the psychological perspective, the major causes of mental disorders will ultimately be shown to be disturbances in life experiences. The author challenges anyone to show how grouping disorders together on the basis of their shared descriptive features … inherently suggests favoring either perspective.

…I recall a psychoanalyst and chair of a DSM-III oversight committee who commenting on a draft of DSM-III said, “There is so much more that we know.” By this, he meant that DSM-III did not include all of the knowledge that his fellow clinicians had painstakingly learned about human behavior and motivation from the intensive study of patients in long-term psychotherapy. In a sense, the real controversy about DSM-III was a controversy about who were the leaders in the profession and whether progress in our field was most likely to come from empirical research studies or from clinical wisdom collected by intensive long-term psychotherapy. It is hard to see how the controversy would have been conducted at a higher level if the DSM-III committee had made any clearer their value commitments.

Sadler et al. are correct when they assert that basic values, assumptions, and commitments determine how developers of a classification system of mental disorders approach their difficult task. In this paper, we have presented those values, assumptions, and commitments, which were, for the most part, widely known and were contained in the ongoing DSM-III and DSM-IIII-R literature. It is not true that DSM-III and DSM-III-R gave greater emphasis to reliability than to validity, and it is not true that the DSM atheoretical approach with regard to etiology is implicitly biased toward a particular etiological perspective [organic or behavioral].

1. no a priori principles
2. descriptive criteria
3. follow-up
4. family studies
5. exclusivity
6. reliability
7. undiagnosed psychiatric disorder

Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia
^{BY ELI ROBINS. M.D.AND SAMUEL B. GUZE, M.D.}
American Journal of Psychiatry. 1970 126[7]:107-111.

Since Bleuler, psychiatrists have recognized that the diagnosis of schizophrenia includes a number of different disorders. We are interested in distinguishing these various disorders as part of our long-standing concern with developing a valid classification for psychiatric illnesses. We believe that a valid classification is an essential step in science. In medicine, and hence in psychiatry, classification is diagnosis.

One of the reasons that diagnostic classification has fallen into disrepute among some psychiatrists is that diagnostic schemes have been largely based upon a priori principles rather than upon systematic studies. Such systematic studies are necessary, although they may be based upon different approaches. We have found that the approach described here facilitates the development of a valid classification in psychiatry. This paper illustrates its usefulness in schizophrenia…

Diagnostic criteria for use in psychiatric research
^{by FEIGHNER, J. P., ROBINS, E., GUZE, S. B., WOODRUFF, R. A., WINOKUR, G. & MONOZ, R.}
Archives of General Psychiatry. 1972 26:57-63.

This communication presents specific diagnostic criteria for those adult psychiatric illnesses that have been sufficiently validated by precise clinical description, follow-up, and family studies to warrant their use in research as well as in clinical practice. These criteria are not intended as final for any illness. The criteria represent a distillation of our clinical research experience, and of the experiences of others cited in the references. This communication is meant to provide common ground for different research groups so that diagnostic definitions can be emended constructively as further studies are completed. The use of formal diagnostic criteria by a number of groups, regardless of whether their interests are clinical, psychodynamic, pharmacologic, chemical, neuropsychological, or neurophysiological, will result in a solution of the problem of whether patients described by different groups are comparable. This first and crucial taxonomic step should expedite psychiatric investigation.

Diagnosis has functions as important in psychiatry as elsewhere in medicine. Psychiatric diagnoses based on studies of natural history permit prediction of course and outcome, allow planning for both immediate and long-term treatment, and make communication possible between psychiatrists and other physicians, as well as among psychiatrists themselves. Such functions are of obvious importance in research. In contrast to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders [DSM-II], in which the diagnostic classification is based upon the "best clinical judgement and experience" of a committee and its consultants, this communication will present a diagnostic classification validated primarily by follow-up and family studies…

Primary Affective Disorders.

Depression.

—For a diagnosis of depression, A through C are required.
A. Dysphoric mood characterized by symptoms such as the following: depressed, sad, blue, despondent, hopeless, "down in the dumps," irritable, fearful, worried, or discouraged.
B. At least five of the following criteria are required for "definite" depression; four are required for "probable" depression.
1. Poor appetite or weight loss (positive if 2 lb a week or 10 lb or more a year when not dieting).
2. Sleep difficulty (include insomnia or hypersomnia).
3. Loss of energy, eg, fatigability, tiredness.
4. Agitation or retardation.
5. Loss of interest in usual activities, or decrease in sexual drive.
6. Feelings of self-reproach or guilt (either may be delusional).
7. Complaints of or actually diminished ability to think or concentrate, such as slow thinking or mixed-up thoughts.
8. Recurrent thoughts of death or suicide, including thoughts of wishing to be dead.
C. A psychiatric illness lasting at least one month with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome. (Patients with life-threatening or incapacitating medical illness preceding and paralleling the depression do not receive the diagnosis of primary depression.)

Mania.

—For a diagnosis of mania, A through C are required.
A. Euphoria or irritability.
B. At least three of the following symptom categories must also be present.
1. Hyperactivity (includes motor, social, and sexual activity).
2. Push of speech (pressure to keep talking).
3. Flight of ideas (racing thoughts).
4. Grandiosity (may be delusional).
5. Decreased sleep.
6. Distractibility.
C. A psychiatric illness lasting at least two weeks with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome.

A Re-analysis of the Reliability of Psychiatric Diagnosis
^{By ROBERT L. SPITZER and JOSEPH L. FLEISS}
British Journal of Psychiatry. 1974 125:341-347.

^{… With respect to improving the nomenclature, the St.Louis group has offered a system limited to 16 diagnoses for which they believe strong validity evidence exists, and for which specified requirements are provided. Whereas in the standard system the clinician determines to which of the various diagnostic stereotypes his patient is closest, in the St. Louis system the clinician determines whether his patient satisfies explicit criteria. For example, for a diagnosis of the depressive form of primary affective disorder the three requirements are dysphoric mood, a psychiatric illness lasting at least one month with no other pre-existing psychiatric condition,and at least five of the following eight symptoms: poor appetite or weight loss; sleep difficulty; loss of energy; agitation or retardation; loss of interest in usual activities or decrease in sexual drive; feelings of self-reproach or guilt; complaints of or actually diminished ability to think or concentrate; and thoughts of death or suicide.}

^{A consequence of the St. Louis approach is the necessity for an ’undiagnosed psychiatric disorder’ category for those patients who do not meet any of the criteria for the specified diagnoses. In actual use, this category is applied to 20-30 per cent of newly-admitted in-patients. These two approaches, structuring the interview and specifying all diagnostic criteria, are being merged in a series of collaborative studies on the psychobiology of the depressive disorders sponsored by the N.I.M.H. Clinical Research Branch. We are confident that this merging will result not only in improved reliability but in improved validity which is, after all, our ultimate goal.}

One can only be awed by Robert Spitzer’s industry in those years. At the time, I was in analytic training in his building, the New York Psychiatric Institute. I had no idea of the flurry of activity going on upstairs. The building was always too hot, complicating staying alert in those after lunch classes. I now suspect that it was overheated by Spitzer’s energetic activities and endless debates.

Research Diagnostic Criteria Rationale and Reliability
^{by Robert L. Spitzer, MD; Jean Endicott, PhD; and Eli Robins, MD}
Archives of General Psychiatry. 1978 35:773-792.

^{A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria [RDC]. The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria…}

1. no a priori principles
2. descriptive criteria
3. follow-up
4. family studies
5. exclusivity
6. reliability
7. undiagnosed psychiatric disorder

Diagnosing the D.S.M.
New York Times[op-ed]
By ALLEN FRANCES
May 11, 2012

At its annual meeting this week, the American Psychiatric Association did two wonderful things: it rejected one reckless proposal that would have exposed nonpsychotic children to unnecessary and dangerous antipsychotic medication and another that would have turned the existential worries and sadness of everyday life into an alleged mental disorder. But the association is still proceeding with other suggestions that could potentially expand the boundaries of psychiatry to define as mentally ill tens of millions of people now considered normal. The proposals are part of a major undertaking: revisions to what is often called the “bible of psychiatry” — the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M. The fifth edition of the manual is scheduled for publication next May.

I was heavily involved in the third and fourth editions of the manual but have reluctantly concluded that the association should lose its nearly century-old monopoly on defining mental illness. Times have changed, the role of psychiatric diagnosis has changed, and the association has changed. It is no longer capable of being sole fiduciary of a task that has become so consequential to public health and public policy.  Psychiatric diagnosis was a professional embarrassment and cultural backwater until D.S.M.-3 was published in 1980. Before that, it was heavily influenced by psychoanalysis, psychiatrists could rarely agree on diagnoses and nobody much cared anyway.  D.S.M.-3 stirred great professional and public excitement by providing specific criteria for each disorder. Having everyone work from the same playbook facilitated treatment planning and revolutionized research in psychiatry and neuroscience.

Surprisingly, D.S.M.-3 also caught on with the general public and became a runaway best seller, with more than a million copies sold, many more than were needed for professional use. Psychiatric diagnosis crossed over from the consulting room to the cocktail party. People who previously chatted about the meaning of their latest dreams began to ponder where they best fit among D.S.M.’s intriguing categories. The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism , attention deficit disorders and bipolar disorder in children that has since occurred.

Indeed, the D.S.M. is the victim of its own success and is accorded the authority of a bible in areas well beyond its competence. It has become the arbiter of who is ill and who is not — and often the primary determinant of treatment decisions, insurance eligibility, disability payments and who gets special school services. D.S.M. drives the direction of research and the approval of new drugs. It is widely used (and misused) in the courts.  Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription. The association has been largely deaf to the widespread criticism of D.S.M.-5, stubbornly refusing to subject the proposals to independent scientific review.  Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role.

New diagnoses in psychiatry can be far more dangerous than new drugs. We need some equivalent of the Food and Drug Administration to mind the store and control diagnostic exuberance. No existing organization is ready to replace the American Psychiatric Association. The most obvious candidate, the National Institute of Mental Health, is too research-oriented and insensitive to the vicissitudes of clinical practice. A new structure will be needed, probably best placed under the auspices of the Department of Health and Human Services, the Institute of Medicine or the World Health Organization.

All mental-health disciplines need representation — not just psychiatrists but also psychologists, counselors, social workers and nurses. The broader consequences of changes should be vetted by epidemiologists, health economists and public-policy and forensic experts. Primary care doctors prescribe the majority of psychotropic medication, often carelessly, and need to contribute to the diagnostic system if they are to use it correctly. Consumers should play an important role in the review process, and field testing should occur in real life settings, not just academic centers.  Psychiatric diagnosis is simply too important to be left exclusively in the hands of psychiatrists. They will always be an essential part of the mix but should no longer be permitted to call all the shots.