the future of an illusion I…

Posted on Friday 27 April 2012

Finally, the curious fact makes itself felt that in general people experience their present naïvely, as it were, without being able to form an estimate of its contents; they have first to put themselves at a distance from it — the present, that is to say, must have become the past — before it can yield points of vantage from which to judge the future…
Sigmund Freud: The Future of an Illusion 1927

It seems to me that there were three interwoven threads in the 1980 revision of the Diagnostic Manual of Mental Disorders. The first was in the negative – something like not Mind, not Psychoanalysis, not Psychobiology. Behind the monotonous complaints of "unproven" or "speculative" is the more reasonable complaint that any theory about the mind can never rise above the level of theory – will always remain in the subjective realm. Medicine is a science and is by definition objective. The second thread comes directly from the general hierarchy of medical nosology that conditions of unknown etiology without distinct biological markers are classified as syndromes – collections of things that occur together including signs, symptoms, course of illness, history, ethnicity, exposure, etc. And finally, there was a third strand operative during the 1970s when Robert Spitzer was assembling the diagnostic scheme we call the DSM-III – 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.

As a young psychiatrist during that period, I never heard the term neo-Kraepelinian. Back then, this was known as the Saint Louis Group’s way of thinking – the people at Washington University. They were biologic psychiatrists who felt that the psychoanalysts and other psychotherapists should not be part of psychiatry. But they weren’t the major force in the equation – it was third party payments from insurers that were on the front burner. Psychiatrists of many ilks were billing for psychotherapy, psychoanalysis, in-patient milieu therapy, group therapy – a whole spectrum of treatments and there was the very real fear that mental illness would no longer be covered by insurance at all. At that time, he only thing that legitimized a diagnosis or a treatment was what the psychiatrist said – nothing objective. And also at that time, competition between psychiatry and other mental health disciplines for the mental health dollar was a definite part  of the mix. So at least in my memory, the turf wars and ideological conflicts certainly raged – but the central organizer of the goings-on in those days was reimbursement.

The schema of the Saint Louis Group was, I believe, a deeply held ideological position. I knew a number of people who trained there, and they were indeed passionate. But their influence on the construction of the DSM-III came from a surprising direction – Dr. Robert Spitzer, an analytically trained psychiatrist in New York. If you don’t know that story, there’s a fine 2005 New Yorker article [The Dictionary of Disorder: How one man revolutionized psychiatry] that lays it out. It’s an essential piece. Putting Spitzer’s story aside for the moment, it’s easy to see why the neo-Kraepelinian approach was perfectly adapted for the times. It placed psychiatry solidly in the medical arena [elgible for medical insurance reimbursment] and addressed the complaints of subjectivity [and implied quackery] that were rampant in that period. And what better format to embed psychiatry in the main-stream of medicine than the coming DSM-III Revision?

It’s interesting to look at the DSM-II [on-line here]. It’s not long – 38 little pages. In the mythology, the DSM-II is described as psychoanalytic, but if you read it – not so much. The neuroses occupy two little pages, and only a couple of the conditions have psychological mechanisms even mentioned. Otherwise, the categories are descriptive. One could eliminate the word neuroses, mark out a couple of sentences, and the whole thing would be syndromatic [including the personality disorders]. On another hand, it was psycho-something in a broad sense as most understood the symptomatic neuroses and the personality disorders to be rooted in the mind and life of the patient – not the brain or some other aspect of biology. Those beliefs had no place in the neo-Kraepelinian thinking about the proper domain of psychiatry.

The way that was dealt with in the DSM-III was to build new categories for the neuroses that were etiologically neutral – creating the possibility that the cause could be biologic. Depressive Neurosis was previously thought to be psychological [exogenous depression] whereas Melancholia was considered probably biological [endogenous depression]. By merging both into Major Depressive Disorder, they created a category that could be biologic. Others were simply transported eg Anxiety Neurosis became the Anxiety Disorders. The transition from neuroses to disorders required more categories for their greater specificity. The major psychiatric syndromes also became Schizophrenic Disorders and Bipolar Disorder instead of Schizophrenia and Manic Depressive Illness. And in the process, the DSM-III became more a textbook of psychiatry than a simple look-up pamphlet. The change to an atheoretical descriptive classification and its consequences is extensively discussed at the beginning of the DSM-III and fleshed out 25 years later in greater detail in this comprehensive review [available on-line]:

Journal of the History of the Behavioral Sciences. 2005 41[3]:249–267.

A revolution occurred within the psychiatric profession in the early 1980s that rapidly transformed the theory and practice of mental health in the United States. In a very short period of time, mental illnesses were transformed from broad, etiologically defined entities that were continuous with normality to symptom-based, categorical diseases. The third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was responsible for this change. The paradigm shift in mental health diagnosis in the DSM-III was neither a product of growing scientific knowledge nor of increasing medicalization. Instead, its symptom-based diagnoses reflect a growing standardization of psychiatric diagnoses. This standardization was the product of many factors, including: (1) professional politics within the mental health community, (2) increased government involvement in mental health research and policymaking, (3) mounting pressure on psychiatrists from health insurers to demonstrate the effectiveness of their practices, and (4) the necessity of pharmaceutical companies to market their products to treat specific diseases. This article endeavors to explain the origins of DSM-III, the political struggles that generated it, and its long-term consequences for clinical diagnosis and treatment of mental disorders in the United States.
Over the last thirty years, the DSM-IIIetc itself has been through several iterations, and the world of psychiatry and mental health have changed dramatically in their wake. But the lead-in to the DSM-5 has been a horse of a very different color – suffused with divisiveness, controversy, and discord.
    "…the curious fact makes itself felt that in general people experience their present naïvely, as it were, without being able to form an estimate of its contents; they have first to put themselves at a distance from it — the present, that is to say, must have become the past — before it can yield points of vantage from which to judge the future."
At issue, are we far enough down the road to look at the roots of this thirty year old revolution to understand the current contentious state of play and predict its future directions?
    April 27, 2012 | 8:46 PM

    Thank you for continuing to flesh all of this out…

    April 28, 2012 | 12:05 PM

    Research Article

    Customization in prescribing for bipolar disorder

    Dominic Hodgkin1,*,
    Joanna Volpe-Vartanian2,
    Elizabeth L. Merrick1,
    Constance M. Horgan1,
    Andrew A. Nierenberg3,
    Richard G. Frank4,
    Sue Lee1

    Article first published online: 19 APR 2011

    DOI: 10.1002/hec.1737

    Copyright © 2011 John Wiley & Sons, Ltd.


    bipolar disorder;
    prescribing decisions;


    For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient’s needs. We test for the existence of customization in physicians’ prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician’s choice among five combinations of drug classes. We find that our observed measure of the patient’s clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician’s prescribing, but the results do not suggest a high degree of customization in physicians’ prescribing, based on our measure of clinical status. Copyright © 2011 John Wiley & Sons, Ltd.

    April 28, 2012 | 1:51 PM

    Can they just stop? Is that an option?

    April 30, 2012 | 8:41 PM

    Thanks, jamzo. They really do not know what the heck they’re doing.

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