something very wrong…

Posted on Wednesday 30 May 2012

I wrote some rambling series [the future of an illusion…, the dreams of our fathers…] trying to get my mind around those times in the early 1970s when the DSM-III was percolating, and how it came to take the roads it followed. I didn’t have much trouble understanding the animosity about psychoanalysis. Even though I am an analyst, it doesn’t take a rocket scientists to see that it’s not even a close to cost effective treatment, it’s results are highly variable, and psychiatry didn’t need for it to occupy such a large space among its ranks. What I didn’t get was how the DSM-III became a nidus for the equally untenable proposition that all mental illness is rooted in biology – brain disease. And how something that I saw as the most complex of medical specialties had become the most trivial in practice – and how the specialty I had considered the most honest of the lot had become infused with so much corruption.

What I learned was that a single group in St. Louis who called themselves neoKraepelinians had declared:
    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 1970, they published an article [about Schizophrenia] which laid out a pathway to validate diagnoses in psychiatry. In 1972, they published a rudimentary classification of mental illness based on descriptive symptoms done by one of their residents from his literature review, and they repeated their phases for validating diagnoses [though they weren’t followed in the classification they presented]. In 1974, Dr. Robert Spitzer, tasked with leading the DSM-III jumped on the idea of a classification by symptoms – which was to be atheoretical. He basically joined up with the St. Louis Group, and refined the rudimentary list into the Research Diagnostic Criteria, which became the template for the DSM-III. Both Spitzer and the St. Louis group wanted psychoanalysis and other psychological causes out of the DSM-III. The St. Louis Group remained rigidly biological. Spitzer remained atheoretical. And Spitzer et al added an essential ingredient – Kappa – a measure of inter-rated reliability:

The Biological side of things was certainly bigger than St. Louis and both emerged and spread widely after the DSM-III. We all know that. Most of the neo-Kraepelinian tenets were in place. But where was the door opened for the intrusion of PHARMA and the subsequent corruption? The over-medication? How did that happen. Was it planned? In my mind, it centered on the new way of classifying Major Depressive Disorder in the DSM-III. Why in the hell did they lump all of the depressions together? So back to rambling:

I’ll leave you to read what I ended up thinking happened if you want, but here’s the short version. They were determined to have no category that could be construed as replacing Depressive Neurosis – a "psychological depression." So instead of separating depression into melancholic depressions and the "other kind," they sacrificed all the hard work on melancholia and created the heterogeneous and meaningless Major Depressive Disorder.

But there’s something else I want to add. Robert Spitzer and others did something that wasn’t just a mistake, or a way to resolve conflicts, they did something that was actually wrong. Medical Diagnosis is, as they well knew, the center of medicine. It’s more than a classification. It’s a template for the way doctors think about a case. It needs to be focused on giving its user the clearest possible picture of what’s wrong with a patient, and with it, access to all the available medical information about that diagnosis so the practitioner can best serve his/her patient’s needs. Robert Spitzer used the diagnostic system to shape and make changes in the practice and directions of psychiatry. That’s not what a diagnostic system is for – pointing the direction of a specialty. If that’s what the psychoanalysts did before him, shame on them us too. The diagnosis in question – Major Depressive Disorder – arose from a conflict in ideas about which direction psychiatry should move in, not the facts about disease as we knew it at the time. The diseases were clear. We weren’t. And that error has been passed on without modification. It opened the door to the PHARMA/FDA axis and the corruption that followed.

Here we sit 40 years later [1972-2012], and the DSM-5 Task Force is doing the same thing – trying to point the direction of psychiatry – this time towards their dream of a clinical neuroscience – using the diagnostic revision to get us there. And they’ve made an unholy mess doing it. Spitzer got that practice started, and now it is threatening to bring down the house. All they talk about is the implications of diagnoses, and seem to have no sense that they are classifying  psychiatric illness, not how psychiatrists or anyone else should think or treat. Today’s tragedy has its roots in the past – roots in the DSM-III process…

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