legitimacy…

Posted on Sunday 5 May 2013

For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed  by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors. The major justification for the generally atheoretical approach taken in DSM-III with regard to etiology is that the inclusion of etiological theories would be an obstacle to use of the manual by clinicians of varying theoretical orientations, since it would not be possible to present all reasonable etiologic theories for each disorder.
Robert Spitzer, in the DSM-III, p 6.

A long time ago, I took that paragraph at face value, at least the first part. I don’t specifically recall my reaction, but I expect that the second part felt like a rationalization to me. It sure feels that way to me now. While my own focus was primarily in the psychological and social domains, I was interested in the biological too. I  don’t recall feeling that there were competitions. Obviously oblivious is how I now think of my naivety in those days. It only gradually dawned on me that people were talking like all mental illness had a biological basis. Back then, they didn’t often say it ["that all mental illness is biologic"], they just talked as if that were true – hardware rather than software. And there was a lot of all going around back then. The behaviorists saw it as all due to faulty learning. Many of the analysts were close to all with their theories. From my perspective, the DSM-III had unmasked deep fault lines in the psychiatry of the time, but miraculously, it cooled off the public crisis. And there was something else unmasked, a rage against psychoanalysis that I didn’t know was there. It’s still pretty easy to find it if you peek just under the surface.

In bygone days, analysts had interpreted that anger as representing many things other than being justified without looking in the mirror to see what was right about it. So by 1980, there weren’t near enough cheeks to turn and the analysts were slammed. I’m mentioning this, because it was part of my attempt at understanding why so many psychiatrists acted as if all mental illness had a biological basis. I thought that might be because they were bound and determined to close the door on anything that smelled slightly Freudian. I went about my business and never had to directly address this all mental illness is biologic question. But there are ample comments in prominent places that suggest that it remains a central belief. They don’t all say all, but they come mighty close:

"6. The focus of psychiatric physicians should be on the biological aspects of illness."
The Tenets of the neo-Kraepelinian approach
The descriptive approach adopted by the DSM allowed for the development of a classification system that met the field’s need for a common language, without being mired in ideological hypotheses about the causes of psychiatric illness. Questions have been raised by many critics that the DSM’s descriptive approach may have outlived its usefulness and is in fact potentially misleading. Although there is a large body of research that indicates a neurobiological basis for most mental disorders, the DSM definitions are virtually devoid of biology. Instead, DSM-IV definitions are based on clusters of symptoms and characteristics of clinical course… It is our goal to translate basic and clinical neuroscience research relating brain structure, brain function, and behavior into a classification of psychiatric disorders based on etiology and pathophysiology.
"a behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction."
DSM-5 definition of mental disorder
"Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior"
The RDoC assumptions in Transforming Diagnosis

It’s a pretty strange story line if they want to sell their DSM-5 to anyone other than like-minded psychiatrists. And it leaves them high and dry as they’ve based their raison d’être on new biological treatments [drugs]. The reaction of other mental health professionals was civil, but hardly supportive. They’re the ones poised to boycott the DSM-5.

The reason this came to mind [other than Insel's RDoC assumptions] was my recent reading about Emil Kraepelin [all ears…, an open question…]. I won’t rehash all of his comments, they’re there to read. But I think he would’ve eliminated the patients we might have considered neurotic or personality disordered from the domain of mental illness altogether – seeing them as more constitutionally defective, particularly in his 1919 paper entitled ‘Psychiatric observations on contemporary issues.’ It was an extremist right-wing view of the kind still debated on our Capital steps today – only Kraepelin’s version had rough the edge that dominated the German Nationalism of that era: Jews, women, soldiers on disability, criminals, neurotics? It’s a common enough attitude even today, but doesn’t have so open an expression as it did 100 years ago in Germany. Kraepelin certainly had nothing to say good about Freud.

Kraepelin  didn’t seem to have those kinds of opinions of the institutionalized psychiatric patients of his day. As I wrote that last sentence, I was thinking about patients with the Functional Psychoses like Schizophrenia, Manic Depressive Insanity, and Melancholia. But those weren’t the majority of the patients in the Institutions where he worked – outnumbered by patients with complications of Syphilis and Alcoholism. From Shepherd:
Basing his stand on his extensive experience of institutional psychiatry, he expressed himself forcibly on the prevention of alcoholism and syphilis, two of the indisputable causes of severe psychosis. In 1895 he advocated total abstinence from alcohol and thenceforward was a tireless, even a fanatical supporter of anti-alcohol campaigns…

"Attention must be focused above all on the fight against all those influences threatening to destroy future generations, in particular hereditary degeneration and genetic influences resulting from alcohol and syphilis"…

I’ve wandered a bit, so to return to the thread, Emil Kraepelin did not see the patients that were then called neurotic as being among the mentally ill. He viewed them as having a "congenitally inferior predisposition." Such patients didn’t make it into his classifications because he didn’t see them as mentally ill. A biologic cause was a requirement to be classified as having a mental disorder. And that’s where the NeoKraepelinians started in the 1970s: "The focus of psychiatric physicians should be on the biological aspects of illness." And for the DSM-5 Task Force: "a behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction." And that’s where Dr. Insel lives: "Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior."  But I believed what Dr. Spitzer said in the DSM-III. I think he believed it too, at least I hope he did: "Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors." But I don’t think many did. It was window dressing.

That a biologic cause was a requirement to be classified as having a mental disorder helps make sense out of things I haven’t understood. PTSD is the paradigm for an acquired mental illness, yet the literature is full of studies looking for a biological predisposition, some genetic flaw. They were traumatized because they didn’t have something called resiliency. Now, they can’t even leave grief alone. It’s about to be pulled into the world of Major Depression. And if there’s no fit between the biology and the taxonomy, then they’ll go find another taxonomy [the RDoC] – bring  the diagnosis to the biomarker rather than the other way around.

I ended an open question… with: "But did Kraepelin’s notion of constitutional inferiority impact his legacy? our current nosology? I don’t know the answer to that and it’s the worst of things for idle speculation. It is an open question." The more I read about Kraepelin, the Social Darwinism of that period, the Eugenics Movement, etc., the more I think his sociopolitical view of people did color his taxonomy and his view of neurotic illness as constitutional weakness. Whether that has transferred up the historical chain is unclear, even if the opinion has stayed the same. But I do wonder how widespread that view is today?

I’ve said this in a variety of ways before, but while we obsess about reliability, and the longed for validity, there is one parameter in this equation that isn’t discussed enough – legitimacy. In Kraepelin’s world, neurotic illness was simply not legitimate…
  1.  
    wiley
    May 5, 2013 | 9:41 PM
     

    “Resilience” is an interesting one— it makes sociopaths the pinnacle of mental health in response to trauma. I can’t find it just now, but I believe I read in Mask of Insanity an interview with a psychopath who said that he didn’t think something he did to someone was a big deal, because it happened to him and he didn’t think that that was a big deal.

    Another thing I can’t find right now is a study that concluded that around 30% of people in OECD countries are essentially fascist in their outlook. Authoritarians who want to abuse and those who want to be abused (and told what to do and what to think) are engaged in a paradigm of othering and blaming, appointing themselves the judge of who is “strong” and who is lacking.

    Surely, there were a lot of people in Germany, at the time, that did NOT share Kraepelin’s point of view. As it stands, psychiatry with it’s neurotic need to be a biological science is essentially authoritarian and is being used as an instrument of the status quo to label and segregate the “human waste” being produced by globalism and mechanization.

    The fact that the fastest growing category of disability is “mental illness.” is testament to psychiatry’s role as a class enforcer who gets to decide who can and cannot function normally in society while holding society blameless. The serious fascists, want to remove all the safety nets from those who cannot adapt gracefully to whatever is thrown at them. Whether it’s the authoritarians in general or the authoritarians in psychiatry, the number one rule is BLAME THE VICTIM then discount the victim’s interpretation of anything.

  2.  
    Richard Noll
    May 5, 2013 | 11:45 PM
     

    Mickey,

    I wish I could steer you deeper into the literature on Kraepelin’s era in the history of medicine and convince you to read more than Shepherd’s article and internet postings, but I think that would take you too far afield from the valuable spadework you are doing in other rich fields. I’m waiting for my copy of Hannah Decker’s new book on DSM-III which has background on Kraepelin (and Decker’s is a noted Freud scholar), so perhaps there may be something in there for you too.

    I did include a chapter on Kraepelin in a book I did on dementia praecox in which (I hope) I drew attention to the structure of his medical cognition. He reflected the new perspective in medicine which came into existence by 1860 (well before the germ theory of disese) that diseases were ontologically distinct entities separate from the uniqueness of an individual person’s life and were biologically specifiable in the clinic, at autopsy, or in the laboratory. Kraepelin attempted to apply this doctrine of the new scientific medicine to psychiatry.

    In the US, for American asylum medicine to becme psychiatry in the German medical science sense, it had to adopt the European doctrine of disease specificity.. In a very simple way, the logic is that psychiatry to be a legitimate branch of general medicine it must have disease concepts that resemble those specified in the rest of medicine. This, I believe, is still the source of tension in psychiatry. The profession and disease concepts are mutually dependent upon one another, for by definition psychiatry cannot be a branch of modern biomedicine without them.

    In the US, a Meyerian or Freudian psychiatry could have flourished forever outside of the jurisdiction of the greater medical profession as survivals of 19th century therapeutic sects similar to homeopathy in which the uniqueness of the individual’s circumstances was place above generalizations such as disease concepts, but their success in our culture came at the cost of shunning and fleeing the vast nation of the institutionally insane locked in our archipelago of state hospitals. “Prevention” among the maladjusted and neurotic became the unfulfilled promise of the Meyerians and Freudians, but the institutional population kept getting bigger.

    You mention your awareness of the hostility, latent and otherwise, to Freud and psychoanalysis which burst forth in the 1970s and 1980s. One source was a credibility gap fostered, as so much of history is, by the emergence of younger generations. The promises of the older guys (and they were mostly men) in power seemed empty. When Freud ‘s work crossed the ocean the application of psychoanalytic theory and treatment to severe and chronic conditions (melancholia, bipolar disorder, schizophrenia, autism) resulted in giving us refrigerator mothers and other wacky, if not creepy, concepts. Concepts that seemed profound in the 1960s had a distinct “yuck factor” by the 1980s. Allan Hobson once told me years ago that when he was in medical school circa 1960 they were taught that “mothers are pathogens.” This is essentially Arieti’s take in his 1974 book, Interpretation of Schizophrenia which, amazingly, won the 1975 National Book Award for Science. I re-read the whole 800 pages recently — it is horrifying.

    Medical science had simply moved on since WWII, and the older generation of psychoanalytic psychiatrists seemed curiously disdainful of the brain and the body as the first places to look when there was severe mental illness.

    One additional thing to remember about Kraepelin adn Freud’s era: outside of the literary elite, most people — including most physicians — used three basic categories: sane, nervous, and insane. Both nervousness and insanity were widely viewed as biologically-based (constitution, heredity, toxins, and so on). I know that you know the origins of the word “neurosis” — it’s linked to the nerves. This was Freud’s world as well. These are old traditional assumptions about mental illness, and they are deep. And constitutional inferiority was a widely used diagnostic concept in Euro-Anglo-American medicine and was not limited to alienists and neurologists. Adolf Meyer used it often and, as a young man, felt it might be the sources of his own nervouosness because he has from a neuropathic family.

  3.  
    Annonymous
    May 6, 2013 | 12:48 AM
     

    Dr. Noll,

    Thought provoking comment. Thank you. The feelings I have reading your and 1BOMs thoughts about Kraepelin reminds me of feelings I had long ago as I began delvin more deeply into William James. I wish I could recall why but all but the feeling has faded from memory. In any event, thank you again for the comment.

  4.  
    May 6, 2013 | 3:23 AM
     

    Richard,

    Thanks for the comment. I’ve gone as far with Kraepelin as I can get in the Appalchian region. There’s no medical library nearby. I realize that Shepherd may not be a non biased source, but the Kraepelin quotes from him and others are pretty clear. Kraepelin also seemed pretty loose with his ideas of inheritance. I gather that the Social Darwinism and Eugenics movements were gaining steam in lots of places, but were shut down when the Nazis extrapolated them so dramatically.

    I really appreciate the insights and comments. Up here, when I hit a dead end, it’s really a dead end. References and pointers from comments are a great help.

    And ditto to you, Annon…

  5.  
    Richard Noll
    May 6, 2013 | 7:50 AM
     

    Mickey,

    Thanks for tolerating my rather lengthy comments. It’s hard to put historical context into tweets or sound bites.

    Keep up the good work!

  6.  
    May 6, 2013 | 10:51 AM
     

    Professor of psychiatry Emil Kraepelin was most likely tainted by the pervasive quasi-scientific ideas of edogenous, racial differences and the superiority of Nordic people, so-called Aryans, much in vogue, even more so in the aftermath of WWI, much of Europe in ruins, Germany beaten, paying reparations east and west, in need of rational excuses for not caring for millions of wounded, destitute, disabled, weak…
    The time was ripe for blaming the “weaklings, degenerates, paupers” … the state absolved of responsibility to alliviate suffering. A Norwegian pharmacist/racial biologist Jon Alfred Mjöen was among the founders in Berlin? 1912 of The international eugenic federation, with the German Alfred Ploetz.
    Their ideas were later utilized by Nazi doctors, bureaucrats and politicians. The then head of the German Medical Association contacted Hitler in 1935, asking for permission to start the planned euthanasia, the “mercy” killings of those deemed Lebensunwertes lebens, a term minted by the psychiatrist Alfred Hoche. Hitler refused, afraid of his reputation as a respected European statesman. But in september 1939 he approved, the killing of asylum inmates hidden by din of war and the falsified certificates of death issued to relatives.
    I’d consider Kraepelin in tune with his times and one of the first KOLs.
    An interesting peep at a hitherto unknown chapter of Swedish history of biological racism is at http://www.thelocal.se/6041/20070109

  7.  
    Richard Noll
    May 6, 2013 | 11:19 AM
     

    Hoche was an early — and very vocal — critic of the notion of specifiable biological disease entitites in psychiatry. He was especially dismissive of Kraepelin’s dementia praecox concept. One of Hoche’s disciples was Oswald Bumke, a psychiatrist 20 years younger than Kraepelin who, in 1924, was hired by the University of Munich to replace him when he retired from his university chair and from the famous Munich university clinic that he founded. Just a few months before replacing Kraepelin, Bumke gave a lecture in which he directly stated that psychiatry had been led astray by its search for diseases entities based on course and outcome. “What if dementia praecox simply does not exist?” he asked his audience.

    This little historical aside is a reminder that our debates are not new, and that no man is a prophet in his home town — at least not while they ae alive. Just ask Kraepelin and Freud.

  8.  
    ab
    May 6, 2013 | 3:09 PM
     

    Perhaps there is no Schizophrenia.

    There was an interesting piece in the Schizophrenia Bulletin:

    Psychiatric Genocide: Nazi Attempts to Eradicate Schizophrenia
    http://schizophreniabulletin.oxfordjournals.org/content/36/1/26.full

    “The sterilization and murder of hundreds of thousands of
    patients with schizophrenia and other psychiatric disor-
    ders in Nazi Germany between 1934 and 1945 was the
    greatest criminal act in the history of psychiatry. It
    was perpetrated in an attempt to decrease the incidence
    of schizophrenia and purify the race, based upon a mis-
    taken belief that schizophrenia was a simple Mendelian
    inherited disease in which a single gene, or small number
    of genes, is sufficient to cause the disease. Furthermore, it
    should have been known even in 1940 that removing
    cases of schizophrenia from society would have no im-
    pact on the incidence of the disease because the vast
    majority of individuals with schizophrenia do not have
    a family history of the disease and do not reproduce.”

    And I would say that the problem with prognosis is that it can easily become a rationale to do any number of horrifying things in order to avoid a future you believe is coming.

  9.  
    May 6, 2013 | 3:57 PM
     

    Dipping into history is not an aside, in my view, but essential for understanding the dilemmas of today. Scratch the surface and see how much we are carrying along, more or less unconsciously, of remnants that should be looked at in sunlight, disinfected, remembered. I doubt that Kraepelin was much different from his generation of doctors and their successors.

    Biological theories of mental suffering are dangerously related to eugenics, I think.

    Forgotten Lunatics of the Great War, by British psychologist Peter Barham shines a light on the interwar period, authoritarian traditions, suffering and upheavals before the German population let themselves be seduced by Nazi propaganda and medical scientists, harnessed to political masters, presided over life and death.
    It did not start in 1933. The new masters exploited prevalent ideas, attitudes and traditions, to logical extremes. It can happen again.

  10.  
    May 6, 2013 | 5:17 PM
     

    Reliability, Validity, Legitimacy?

    I’m confused,
    I thought we were talking about psychiatry.

    Duane

  11.  
    May 6, 2013 | 5:19 PM
     

    A return to psychiatry’s glory days?
    When these things existed?

    When?
    Where?

    It seems as though the house of cards is collapsing on a profession that deserved to die years ago.

    Good riddance.

    Duane

  12.  
    May 6, 2013 | 5:25 PM
     

    Re: Validity -

    http://www.madinamerica.com/2013/05/chair-of-dsm-5-task-force-admits-lack-of-validity/

    I apologize for the number of comments.

    Duane

  13.  
    wiley
    May 6, 2013 | 6:26 PM
     

    Fascinating article, ab. Thanks

    Berit, this. Yes. While reading the article ab linked to, I had to wonder how many of the people filling up German asylums were soldiers suffering from the particular trauma of trench warfare in WW I. The whole society suffered from that war and the aftermath. In retrospect, there response was kinda predictable.

    My mother, who suffered from complex PTSD (no doubt), had a nervous breakdown in ’69 and was diagnosed with schizophrenia, like 60% of mental patients in the U.S., at that time. Schizophrenia is, historically, a very fluid concept.

    In order to understand our understanding or mental illness and treatement, it is necessary to look at other understandings, otherwise it’s the fish can’t describe water problem.

  14.  
    May 6, 2013 | 8:32 PM
     

    I think that in the minds of the biological psychiatrists, the legitimacy of the profession increases when they come up with more specific diagnoses (rather than nonspecific NOS diagnoses or categories like “neurosis”); whereas in reality, I think the result is often opposite, since a lot of the DSM disorders imply a biological cause without evidence backing that up.

    Having NOS (and with the DSM-5, NEC) diagnoses allows clinicians to remain more humble and maintain some semblance of etiologic neutrality, a topic on which I just wrote more about here if anyone’s interested.

  15.  
    May 7, 2013 | 1:20 AM
     

    AB and Wiley, Thank you!
    There were the “scientific” reasons, purity, supremacy, security, the calculations of costs, the fear and contempt of “weakness”, and of course, feelings of superiority of those in charge of sifting, selecting, judging, labelling. These forces are around, dormant, let loose when conditions are ripe, history tells

  16.  
    Speck
    May 7, 2013 | 2:22 AM
     

    Reminds me of the below article I read.

    The NIMH voiced a similar concern by dropping support for the DSM-5 recently, but it’s not quite to ‘legitimacy’ yet.
    Not sure if it was already linked somewhere yet.

    “The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity.”
    http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

    In medicine, either a patient is sick, or they are not sick. I think psychiatry ran into huge problems when it decided to be a medical specialty.

    I don’t think there’s any legitimacy to ‘mental illness’ myself. Either the nervous system is working properly, or it isn’t. The symptoms people experience are real, but there’s no ‘mind’, just an organ that performs information processing.

    To date, functional diagnostics tests for the brain are limited. The basic principle on which the neurons work is almost completely understood. Subjective observations will never work, and don’t work in any medical field. Science does not allow subjective observations because that’s what science was created to eliminate. yadda yadda

    It’s interesting to wonder how that conversation went 50 years ago, or 200. One things for sure, we have neurology separate from psychiatry. I wonder how wide spread Kraepelin’s views still are in modern American psychiatry.

  17.  
    Richard Noll
    May 7, 2013 | 7:43 AM
     

    One recent book (so many good ones lately) that bridges traditional concepts of “nerves,” “nervousness” and the famous “nervouse breakdown” to 20th century concepts in psychiatry that I can enthusiastically recommend is:

    http://www.amazon.com/How-Everyone-Became-Depressed-Breakdown/dp/0199948089/ref=sr_1_1?s=books&ie=UTF8&qid=1367925748&sr=1-1&keywords=edward+shorter+how+everyone+became+depressed

    Every time Edward Shorter publishes a book I immediately buy one for myself and order one for my university library. In several of his recent books he redirects our attention to the possibility that many mental disorders might be better understood if the medical sciences were more open to the evidence for “whole body” or systemic physiological processes rathen than the exclusive focus on the brain (actually, just the synaptic junction between neurons). The brain is, after all, connected to the peripheral nervous system and is part of an entire body, but we wouldn’t get that impression from reading the scientific literature or the reports of the RDoC working groups. Once upon a time asylum physicians (like Kraepelin, Bleuler, Jung, Meyer, Hoch, and so on) lived in the asylums with the patients 24/7 and, as physicians with extensive training in internal medicine and neurology (a component of internal medicine), they had the opportunity to make daily, intimate observations. They used their 5 senses. The old literature is filled with reports of all manner of signs and symptoms that indicate peripheral processes, not just CNS indicators. I, for one, am hoping for a return to an exploration of systemic hypotheses that involve the endocrine system, immune system, microbiome and other intertwined physiological instruments that play in the symphony of human life. Genes, receptors, neurotransmitters and brain circuits must indeed be investigated, but time and resources must be devoted to the “whole body” as well.

    Just my wish for the future . . . .

  18.  
    wiley
    May 7, 2013 | 8:35 AM
     

    I’ve just recently read a free paper in an Oxford Open journal, on biome reconstitution.

    http://emph.oxfordjournals.org/content/early/2013/05/05/emph.eot008.short?rss=1

    Not only are mind/brain/body not separate, but we humans are not separate from the environment. It’s all so interesting.

  19.  
    May 7, 2013 | 2:01 PM
     

    As I’ve said many times, diagnosis hardly matters when treatment is inevitably a basket of drugs applied arbitrarily.

Sorry, the comment form is closed at this time.