1 Boring Old Man

^{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 they 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.