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…

We all know that pursuing neuroscience is the right thing for researchers to do, but we don’t know what might be discovered in that future, and we’re in no position to base our diagnostic evaluation of patients now on what might be known later or what we wish we already knew. It’s an arrogant agenda to be sure, but more importantly, it’s a diversion from the assigned task and the harbinger of a DSM-5 that would turn out to be more a victim of neglect than an improved tool.

Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5
^{by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.}
American Journal of Psychiatry 168:672-674, 2011.
[full text available on-line]

^{In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder. In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…}

I take the following quote from their report on their failed Field Trials as the closing parenthesis to the DSM-5 enterprise:

DSM-5 Field Trials in the United States and Canada, Part II: Test-Retest Reliability of Selected Categorical Diagnoses and Analytic Approaches
^{by Darrel A. Regier, William E. Narrow, Diana E. Clarke, Helena C. Kraemer, S. Janet Kuramoto, Emily A. Kuhl, and David J. Kupfer}
American Journal of Psychiatry. 2012 October 30, AJP in Advance

^{"However, maximizing the reliability of our current categorical diagnostic conventions is not the only or ultimate goal. As with all of medicine, the goal is to move beyond reliability to a better assessment of the validity of disorders identified by our diagnostic criteria. The DSM-5 proposal to obtain “cross-cutting” measures of 13 psychological symptom domains, described by Narrow et al., is intended to provide a more dimensional description of patient presentations than can be captured by existing DSM-IV diagnostic criteria and boundaries. This approach is also consistent with the NIMH Research Domain Criteria [RDoC] project, which is attempting to identify both biological and symptomatic dimensional measures of psychopathology that correlate with genetic, neuroimaging, and neuropsychological factors irrespective of current diagnostic boundaries."}

^{"Emil Kraepelin, who pioneered the separation of schizophrenic and affective psychoses into separate diagnostic groups in 1898, noted later in a 1920 publication— prescient in its anticipation of a current polygenetic environmental interaction model of mental disorders—that the strict separation of these categorical diagnoses was not supported. We are now coming to the end of the neo-Kraepelinian era initiated in the U.S. by Robins and Guze with a renewed appreciation of both the benefits and limitations of a strict categorical approach to mental disorder diagnosis."}

^{"The ultimate goal is to build on the progress achieved with categorical diagnoses by continuing with longitudinal follow-up of patients with these diagnoses, incorporating cross-cutting dimensional measures judiciously into the diagnoses where they prove useful, and in some cases recommending simple external tests [such as a cognitive test for mild neurocognitive disorder] that might improve the reliability and move toward a more mature scientific understanding of mental disorders. A noted philosopher of science, Carl Hempel, observed that “although most sciences start with a categorical classification of their subject matter, they often replace this with dimensions as more accurate measurements become possible”. Clinicians think dimensionally and adjust treatments to target different symptom expressions in patients who may have the same categorical diagnosis. The intent of DSM-5 is to provide a diagnostic structure that will more fully support such dimensional assessments with diagnostic criteria revisions, specifiers, and cross-cutting symptom domain assessments. The goal is to support better measurement-based care and treatment outcome assessment in an era when quality measurement and personalized medicine will require new diagnostic approaches."}

Notice that these paragraphs are filled with the technologies and hypotheses of the day – "current polygenetic environmental interaction model of mental disorders", "genetic, neuroimaging, and neuropsychological factors", "measurement-based care", "personalized medicine". This is the stuff of international symposia, of heated debates at neuroscience meetings, or brown bag chats among eager PhD candidates and NIMH fellows given to creative extrapolations. And these are also the thoughts of older neuroscientists nearing the ends of their careers hoping  to finally bring fruition to their long held dreams – beliefs about the trajectory of their science.

But the topic at hand is a usable, reliable diagnostic system for clinicians of all ilks – psychiatrists, social workers, psychologists, professional counselors, first responders, grief counselors – the people who live at the interface between mental health care and the patients seeking it. So while the framers were dreaming of a breakthrough in neuroscience research, the conflict-of-interest prone work-group members were obsessing about their idiosyncratic opinions and leading edge hypotheses like attenuated psychosis syndrome or the infamous somatic symptom disorder. But no-one was minding the shop. Best I can tell, they didn’t even believe in it enough to try. The category Major Depressive Disorder is ill-conceived, a source of endless misleading clinical trials, and fails to discriminate between depressions likely to actually have a biological/genetic substrate and those rooted in the personal experience and narrative. Their approach to the problem of the "Bipolar Child" was to rename the syndrome, not to delve into the diagnostic dilemma at hand. The category Generalized Anxiety Disorder is as over-inclusive as MDD, but wasn’t touched. By any measure, psychiatrists and primary care physicians are globally overmedicating patients – barely mentioned. Withdrawal states from psychoactive medications and other side effects are being either ignored or interpreted as mental illness – an unaddressed problem. And when the Field Trials showed their DSM-5 to be faulty in the only objective criteria we have, reliability, they blamed the system itself.

There’s nothing wrong with their hypotheses and dreams – it’s what scientists do. But the revision of a code book is no place for that kind of dreaming. It’s supposed to be about right now, what we know right now. Dr. Spitzer got away with a radical change in psychiatry using the code book because he found a rational practical key to make it acceptable – reliability. His DSM had holes, loopholes, unintended consequences, down-right mistakes. Subsequent revisions remedied some, but created others. The job of the DSM-5 Task Force was to do something about those problems – not dream of a hypothetical future. Psychiatry is badly off-track. If they wanted to do something big, they could’ve brought us back towards center rather than spin us further into the ether…