1 Boring Old Man

^{"There are a number of conditions in psychiatry that can be usefully classified. They include the ones enumerated by Kraepelin [Schizophrenia, Manic Depressive Illness, Melancholia, the Brain Syndromes, etc]; the seemingly neurological problems like Autism, ADHD, dyslexia, etc; the Personality Disorders; and a number of less common definable syndromes. However the majority of mentally ill people do not lend themselves to general classification."}

^{Most experienced clinicians listen carefully to the patient’s personal and family history; weigh this narrative in light of some general diagnostic categories, and arrive a “gestalt” understanding of their patient’s condition. Sure, psychiatrists — like other mental health professionals — are required to “play ball” with third-party payers, and provide the official DSM code for a given patient’s disorder. But this doesn’t mean that psychiatrists place much stock in the DSM’s categorical approach to understanding so-called “mental disorders”…}

^{You have many identities that come in order:}

• First you are a person: A person is someone who cares about others and wants to help them. If they fall down, you help them get up. If they need food stamps, you figure out how to apply.
• Next, you are a doctor: A doctor recognizes when there’s a physical illness that needs treating. If that’s the case, you either treat it or help get treatment.
• Then you are a psychiatrist: A psychiatrist is an expert on those mental diseases [Kraepelin et al] and if they have one, you either treat it or help get treatment.
• Then you are a psychotherapist: A psychotherapist takes a detailed look at the person’s life and personality and identifies the problems, instituting the appropriate psychotherapy if warranted.
• If anybody is left, then you are a psychoanalyst.

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

Sir William Osler [Canadian Physician, 1849-1919]

I’ve heard the argument that what I just said isn’t scientific, or evidence-based, or measurement-based, or medical enough, or … for thirty years without it making much of a dent, so you needn’t bother to enlighten me. If you don’t believe in individual, case-centered, psychotherapy – let’s just agree to disagree. My point here isn’t about that. My point is that outside the major psychiatric syndromes, classification is a moot point – the payload is in the individual’s narrative and experience [I promise to embrace any solidly nailed down biologically treatable condition on the day after it’s discovered].

^{The Tenets of the neo-Kraepelinian approach:}

^{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.}

The implication was, in part, that the rest of medicine actually cared about psychiatric classification and diagnosis. I hate to be a naysayer but the rest of medicine doesn’t think or care about psychiatric classification and diagnosis any more than psychiatrists think or care about the  classification of Chronic Otitis Media or Recurrent Epididymitis. The people that cared were the Insurance Companies and Managed Care providers. Not that they’re unimportant, but we might as well be honest. And from where I sit, I don’t actually see how adjusting our diagnostic criteria to meet their needs has done much for either psychiatrists or psychiatric patients. Just an observation.

Likewise, when I read those Tenets now, they sound anachronistic, tailored to both refute as well as adapt to the criticisms of psychiatry in the 1960s and 1970s, exemplified by Dr. Thomas Szasz [The Myth of Mental Illness]. His essential criticism was that Psychiatry was an agency of the State [Commitment, Involuntary Hospitalization, Forced Medication, Not Guilty by reason of Insanity, etc]. He complained that illnesses were biological and that calling what we call mental illness wasn’t really medical because there were no biological markers. We still have no biological markers, and Dr. Szasz is still complaining [at age 91]. The DSMs didn’t change either thing.

The present DSM categories convey the impression that diseases have “necessary and sufficient” features that define them—akin to the Platonic concept of ideal “forms.” A contrasting view is that of the philosopher Ludwig Wittgenstein, who argued that such “essential” definitions do not represent how language actually works. Wittgenstein wrote, instead, of “family resemblances” that help characterize a particular word or category, in a particular context. By analogy, no single feature or features characterize all five members of, say, the Jones family; however, four of the Joneses have blond hair, three of those four have blue eyes, and four are very tall. We can see the “resemblances” when the Joneses stand together for the family photo. Wittgenstein compared family resemblances to the overlapping fibers of a rope—no single fiber is present throughout the rope, but a large number of fibers overlap so as to create a continuous and recognizable object. The same may be posited with respect to any given psychiatric disease category. There may be no single set of “necessary and sufficient conditions” that define schizophrenia or bipolar disorder; but patients who suffer with either illness resemble one another in very characteristic ways.

Almost contemporaneously with Wittgenstein, philosophers such as Edmund Husserl—and later, existentialists like Jean-Paul Sartre—began to emphasize the unique structure and contents of the individual’s experience: her way of “being in the world.” It is this phenomenological perspective that would inform what I call “disease prototypes” in psychiatry. Essentially, these are narrative accounts of illness that try to capture the most salient and typical features of the condition, emphasizing the typical patient’s subjective experiences. Such prototypes would compose the core of the diagnostic system I am proposing.

^{In short, it is not enough for psychiatrists simply to peck away at the proposed DSM-5. True, we will be stuck with the DSM-5 for the next decade or two, and we should strive to improve it while we still can. But in the longer term, psychiatrists and other mental health professionals owe it to themselves and their patients to think more boldly — and more philosophically — about their diagnostic system.}