how it seems to me…

Posted on Sunday 27 October 2013

Schizophrenia Bulletin. 2007 33[1]:108-112.
[full text on-line]

During the 19th century and early 20th century, American psychiatry shared many intellectual traditions and values with Great Britain and Europe. These include principles derived from the Enlightenment concerning the dignity of the individual and the value of careful observation. During the 20th century, however, American psychiatry began to diverge, initially due to a much stronger emphasis on psychoanalytic principles, particularly in comparison with Great Britain. By the 1960s and 1970s, studies such as the US-UK study and the International Pilot Study of Schizophrenia demonstrated that the psychodynamic emphasis had gone too far, leading to diagnostic imprecision and inadequate evaluation of traditional evaluations of signs and symptoms of psychopathology. Diagnostic and Statistical Manual of Mental Disorders, Third Edition [DSM-III] was developed in this context, under the leadership of representatives from institutions that had retained the more traditional British-European approaches [eg, Washington University, Iowa]. The goal of DSM-III was to create a comprehensive system for diagnosing and evaluating psychiatric patients that would be more reliable, more valid, and more consistent with international approaches. This goal was realized in many respects, but unfortunately it also had many unintended consequences. Although the original creators realized that DSM represented a "best effort" rather than a definitive "ground truth," DSM began to be given total authority in training programs and health care delivery systems. Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual person’s problems and social context and that is enriched by a good general knowledge of psychopathology. Students are taught to memorize DSM rather than to learn complexities from the great psychopathologists of the past. By 2005, the decline has become so severe that it could be referred to as "the death of phenomenology in the United States."
hat-tip to uri  
Sometimes I read something and write a whole blog post about it, discard it, and just start over. This 2007 article [full text on-line] was an prime example. It’s by neuroscientist Nancy Andreasen at the University of Iowa, one of the Mid-Atlantic centers that spearheaded the DSM-III in 1980:

"However, a few American institutions maintained ties with Anglo-European psychiatry. The institutions have sometimes been called ‘the Mid-Atlantics.’ They included Washington University in St Louis, Johns Hopkins in Baltimore, Iowa Psychiatric Hospital in Iowa City, and New York Psychiatric Institute in New York City." 
She’s contrasting these centers with everywhere else which was under the grip of the psychoanalysts:
"… After World War II, psychoanalysis became the dominant conceptual framework in the United States. For a period of 30–40 years, nearly all the major leaders in American psychiatry embraced psychoanalytic principles and used them to shape psychiatric education and training. This created a new and different zeitgeist." 
Which lead to:
"… psychoanalysis, therefore, also led to a significant de-emphasis on careful observation of signs and symptoms — the ‘bread and butter’ of the early humanistic psychiatrists and the basis for developing a phenomenology. In fact, the psychoanalysts taught that the patient’s self-report of both symptoms and other internal experiences should be discounted."
She then describes the Mid-Atlantic counter-revolution that lead to the DSM-III that liberated psychiatry from its psychoanalytic captivity. I’m afraid that paragraph got to me and so my first run at this post was driven more by anger and frustration than good sense. Her version was the language of the time and place where she trained, and I should be used to that by now – so I started over. She followed with The Development of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition: Lofty Goals in which she talked about what they set out to accomplish. But it’s the following section of her paper entitled What Went Wrong? The Unintended Consequences that I want to talk about. Dr. Andreason says:

"Although the authors of DSM-III knew that they were creating a small revolution in American psychiatry, they had no idea that it would become a large one and that it would ultimately change the nature and practice of the field… DSM-III and its successors… became universally and uncritically accepted as the ultimate authority on psychopathology and diagnosis. DSM forms the basis for psychiatric teaching to both residents and undergraduates throughout most of the United States. Knowledge of the criteria is the basis for most exams — even the Board Certification examinations taken after residency. As a consequence, classics in psychopathology are now largely ignored. The ultimate painful paradox: the study of phenomenology and nosology that was so treasured by the Mid-Atlantics who created DSM is no longer seen as important or relevant. Research in psychopathology is a dying [or dead] enterprise."
Notice that in the earlier part of her story, the source of the problem was clear – the psychoanalysts. But in this section, there’s no subject for the sentences. Things happened that lead to the erosion of the Lofty Goals of the DSM-III, and the study of phenomenology and nosology that was so treasured by the Mid-Atlantics who created DSM  was subverted and became a dying [or dead] enterprise. Who was at fault? Who done it? Apparently nobody. It just happened all by itself. Unintended Consequences. She continues:
How and why did this occur? What is wrong with DSM?
  • First, the criteria include only some characteristic symptoms of a given disorder. They were never intended to provide a comprehensive description. Rather, they were conceived of as “gatekeepers” — the minimum symptoms needed to make a diagnosis. Because DSM is often used as a primary textbook or the major diagnostic resource in many clinical and research settings, students typically do not know about other potentially important or interesting signs and symptoms that are not included in DSM.
  • Second, DSM has had a dehumanizing impact on the practice of psychiatry. History taking — the central evaluation tool in psychiatry — has frequently been reduced to the use of DSM checklists. DSM discourages clinicians from getting to know the patient as an individual person because of its dryly empirical approach.
  • Third, validity has been sacrificed to achieve reliability. DSM diagnoses have given researchers a common nomenclature — but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity.
I would frame things differently, saying that the DSM-III revolution was doomed from the day the book was published, and that the cause of that failure was in the DSM-III itself. Dr. Andreasen implies that it was misinterpreted or misused by some undefined force [those sentences without subjects] and stripped of the essence of the framers intent. I would argue that it was a structurally flawed enterprise that institutionalized several categorical errors.

In an odd way, I feel something of a kindredship with Dr. Andreasen. Just as I wince when she says "psychoanalysis, therefore, also led to a significant de-emphasis on careful observation of signs and symptoms" or "psychoanalysts taught that the patient’s self-report of both symptoms and other internal experiences should be discounted," I would expect her to wince as well if I were to simplify her Mid-Atlantic mentors to absurdity. I’ve done that along the way at times, but hopefully I can avoid it here. I think I’d rather try to explain what I mean when I say they made categorical errors. And I propose to start that quoting one of my own mentors from long ago. My ideas about my role had been crystalized by a comment from a supervisor, Dr. Burness Moore, who once said something like this [with my own elaborations]:

    "You have four identities. The first is Person. There is nothing more important to a sick human being than someone who turns their way and totally focuses on their plight, bringing all that another human being can bring to bear on their particular problem [which is a lot]. Next, you are a Physician. A physician is someone who knows the signs and symptoms of physical illness and can diagnose and help deliver the specific treatment needed. Then you are a Psychiatrist. A Psychiatrist is someone well versed in recognizing the classic psychiatric syndromes and knows their treatment. Then, and only then, you are a Psychotherapist or Psychoanalyst – someone skilled in exploring the unique history and experiences of the individual patient in a search for the causes for their discomfort. Those things come in a specific order for obvious reasons – a hierarchy. Don’t ever get ahead of yourself."
I still think those things. I only recently became aware of Karl Jaspers’ 1913 Allgemeine Psychopathologie. I knew him as the philosopher he became, not the psychiatrist he started out being [see an anniversary…]. But I really liked what he had to say [in both identities]. This is my simplistic rendition of his categories annotated with Dr. Moore’s comments [and some other things]:
It’s not a perfect image. There’s a lot more to the classic psychiatric syndromes than Major Psychosis and certainly not all Personality Disorders are amenable to psychotherapy nor is the domain of the psychotherapist limited to Personality Disorders. After all, Jaspers was writing a hundred years ago. But despite the imperfection of the image, there is a line [labeled The Line] between the psychiatric syndromes and the mental illnesses resulting from the complexities and vicissitudes of human life. Those categories may overlap, or the line may be blurry, but it is a line nonetheless – and the DSM-III eliminated it. That’s a categorical error merging two categories that are more or less distinct creating an artificial and unworkable structure to my way of thinking – a fatal flaw in the DSM-III and its heirs. There is another line [labelled The Other Line] between brain disease and the major psychiatric syndromes that the modern DSM-5 RDoC Clinical Neuroscientists want to eliminate, but they currently still live in a realm of speculation, whether they like it or not. Finally, there is a line between Mental Illness and something called normality [labeled The Final Line] that is under assault by the drug-happy KOLs – currently defended by Dr. Allen Frances [to his credit].

I hasten to add that Dr. Andreasen and her Mid-Atlantic mentors are correct that there was something very wrong with American Psychoanalysis in the period before the DSM-III was introduced. I don’t think they were quite right about exactly what it was. I see it as a categorical error too, introduced by the specific psychoanalysts who came to the US during and after World War II, but that’s for another post.

A hundred years ago, four very bright men were alive and thinking hard about mental illness. A couple of them were colleagues [Alzheimer and Kraepelin]. A couple were enemies [Kraepelin and Freud]. All of them were human, and caught up in the outrageous history swirling around Europe and particularly Germany in their time. But collectively they handed us something on a platter that we have managed to royally screw up – carrying on their differences and failings rather than parsing their wisdom. At least that’s how it seems to me…

Note: Thomas Szasz submitted a response to Dr. Andreasen’s paper that wasn’t accepted for publication. It is here
    October 27, 2013 | 12:26 PM

    Psychiatry’s peak in being effective was the development of the biopsychosocial model, and the multi axis formulation, to make sure those elements were considered in assessing the patient and applying as effective a treatment plan as possible.

    Yeah, well that ain’t convenient to the powers that rule psychiatry now, eh? They have ignored the biopsychosocial model for years, and now have figured out their way to entrench that attitude with so casually dismissing the multi axis model in DSM 5.

    DSM now stands for the Dumbed-down Sensationalized Manual for psychiatry. And the number stands for how many times worse has it been since psychiatry started this manual process. Yeah, it is 5 times worse than it’s ancestral parent DSM 1.

    Besides, I would hope you would consider we are still a species of extremes, make choice A that is polarized, then after the proverbial burn from the poor choice, jump to the opposite polarized choice B and get burned again. We see it politically with choosing Democrats, then Republicans, and back and forth.

    Doesn’t this pendulum ride not only get old, but painful bashing from one end to the other?

    October 27, 2013 | 1:41 PM

    Part of the explanation is given by Kenneth Kendler in his comment to Josef Parnas chapter in the 2012 OUP book Philosophical Issues in psychiatry II: nosology. In page 261 he says: “[…] In the 1970s, we saw a rapid cultural-historical switch from psychoanalysis to biological psychiatry as the dominant paradigm. The latter was hardly more interested in the phenomenology of psychiatric illness than the former. They certainly accepted operationalized diagnostic criteria, but the interest largely ended there. The model would be the senior biological psychiatrist handing any one of a variety of structured interviews to his senior resident and telling him to, “Go get me 20 cases of RDC (Research Diagnostic Criteria (Spitzer et al. 1975)) schizophrenia.”

    Kendler also adds that “[…] the key leaders in American psychiatric nosology – Eli Robins, Sam Guze, Bob Spitzer, Allen Frances and David Kupfer – were not chosen because of the level of sophistication in Continental descriptive psychiatry, and certainly not of phenomenology.”

    This would explain, up to a certain point, why General Psychopathology by Jaspers, is ignored, neglected, unknown in American circles.

    October 27, 2013 | 3:53 PM

    I used to find it therapeutic to mentally pistol whip Freud, then everybody started doing it, and it drained the act of its power. Psychoanalysis from its earliest days rejected the testimony and insight of patients. Freud diagnosed women with “hysteria”— women that he believed had been sexually abused when they were children by family members. The other boys in the club couldn’t believe it, so Freud decided to put forth the hypothesis that these women were in love with the men who abused them and only fantasized about having a romantic relationship with their abusers. Then it became gospel.

    How unfortunate it is that so many women were drawn to psychoanalysis, or caught in it’s trap when they were overwhelmed by “hysteria”. From the dawn of psychoanalysis it was used to gas lamp clients in order to proffer a diagnosis based on mythology. So, women who were suffering from trauma from actual events in their victimized lives were told the most horrible thing they could have been told about themselves, and so was everyone else. Therefore, sexual abuse of girls didn’t happen, it was all in their silly heart-filled heads.

    Recently, I’ve been reading about “hysterical psychosis” which, if I remember correctly, Janet, Jaspers, and to some degree William James recognized as a reaction to trauma. It seems logical that there would be a continuum that would have on the other pole the most common and not entirely debilitating symptoms of PTSD. It seems worth reclaiming the term “hysteria” since PTSD from sexual abuse is likely what so many of Freud’s clients (the ones he made his name with) were suffering from.

    That psychiatry is currently rejecting the actual lives of patients and is dehumanizing is not really the huge break from psychoanalysis that it’s being made out to be. The wide and nearly indiscriminate use of drugs is one difference, but the drive to reduce to people and their experience to a pet hypothesis is the same.

    Of course, not all clinicians and researchers worked with subjects as objects. For most workaday issues of the psyche, being able to talk to a third party confidante who is legally bound to keep your conversations private is a very valuable practice. In the middle of psychiatry’s life thus fare, the biopscyhosocial model and many different kinds of approaches have tried to put the patients and their lives back in the center. But, contemporary psychiatry (the “it”) doesn’t have the time to let people speak for themselves. Why would it? These people are hopelessly broken so what does it matter what they have to say for themselves?

    October 27, 2013 | 3:56 PM

    … the drive to reduce people and their experience to a pet hypothesis is the same.

    Bernard Carroll
    October 27, 2013 | 7:20 PM

    It is true that skills in clinical phenomenology have withered over the past 35 years, and that DSM-III played a role in that decline. The essential tension between DSM-I-II and DSM-III-5 is that between gestalt descriptions and operational descriptions. DSM-III tried to operationalize the earlier gestalt descriptions of psychiatric disorders. The field then made the category error of confusing making a diagnosis with defining a disorder.

    Andreasen and Kendler are correct to point out that checklist diagnoses put clinical validity at risk. The preferred gestalt approach would be to propose differential diagnoses based on the phenomenologic narrative of the patient, then to test those diagnostic possibilities against the DSM operational criteria. The proper role of DSM criteria is not to make diagnoses, much less differential diagnoses, but to verify that the gestalt diagnoses made by clinicians based on the patient’s phenomenologic narrative comply with a minimum symptom profile, as Andreasen noted. Unfortunately, the methodologic imperialism that swept in with DSM-III and structured interviews led to the validity problems we see today – which were not corrected in DSM-5, by the way. Nuance and subtlety were lost – that is what gave us the fictive entity called major depressive disorder.

    October 27, 2013 | 7:40 PM

    “I used to find it therapeutic to mentally pistol whip Freud, then everybody started doing it, and it drained the act of its power.”

    I don’t know what to say to this, except that comment will be the defining lead in to my commentary about antipsychiatry for the next year.

    Until someone tops, or rather, stoops even lower in a submitted comment to a blog or other site about mental health.

    October 27, 2013 | 8:27 PM

    I never really understood Thomas Szasz’s position on why mental illness didn’t exist, but I never really made any attempt to read up on it.

    I had always wondered; if psychiatrists understood the basic principle on which information processing is performed, if they still would have pursued the idea of “Mental Illness”.

    When you get down to it, either the nervous system is working properly, or it’s not. If it’s working properly, then every experience and behavior is the result of evolutionary structures (hard wired) and learned behaviors (learned).

    In other words, ‘mental illness’ isn’t really an illness or disorder by any real measurable standard. It is just undesired behavior because it is perceived as strange, disadvantageous, or dangerous.

    This would mean fetishes, criminal activity, and violent behavior would also qualify as deviations from an arbitrary normal. One would have to decide just as arbitrarily what qualifies as ‘mental illness’.

    This raises the question: How would we measure something we consider abnormal resulting from a system that is operating properly? Psychoanalysis was one approach, the DSM another.

    I’m not surprised that the DSM didn’t work out. It seems like everything that is not a crime simply became a ‘mental illness’, and there’s no process for arriving at the conclusion, there’s just an checklist to match up

    It’s very difficult to tell symptoms produced by physical illness apart from the symptoms of the DSM’s constructed disorders.

    Psychoanalysis did not improve the process by which people were institutionalized for mental illness either, although it was supposed to. Once there, patients were deprived of a legitimate medical evaluation, and liberty, for their label of mental illness.

    I guess that was a specific point of what Szasz seemed to be saying in his reply? The DSM didn’t start that, but psychoanalysis didn’t really address that either.

    Maybe the real failure must have started further back?

    Nick Stuart
    October 27, 2013 | 9:44 PM

    Joel, I have read your blog. If you cannot tell the difference between a strong mental ‘metaphor’ and an extreme act of physical violence then I think I will side with the ‘anti-psychiatrists’ over your good self (even though, like Szasz, I am not anti-psychiatry).

    Nick Stuart
    October 27, 2013 | 10:56 PM

    TinCanRobot. I think Szasz is required reading for anyone involved in psychiatry even if one eventually disagrees. He explains how psychiatry acts as a function of society. Imo ‘The Manufacture of Madness’ and ‘Insanity’ as well as ‘The Myth’ are must reads.

    Mickey. Sorry for derailing the thread.

    October 27, 2013 | 11:00 PM


    Freud famously got that part wrong. He got it right in his earliest writing, but then fell in love with unconscious fantasy and the rest is history. After World War I filled the streets of Vienna with veterans with PTSD, he came a lot closer in Beyond the Pleasure Principle – at least with the trauma of war.

    This topic came up in my first analytic case in training when she retrieved memories of sexual abuse. As the statutes of confidentiality never expire, I can’t tell the whole story except to say that her memories were confirmed by an outside source [a fired domestic] she found across the country late in the analysis. It was forty years ago when the mental health community was waking up about childhood abuse and PTSD. To my supervisor’s credit, he was skeptical early but came around quickly. He presented the case to colleagues far and wide. I’m no Freud apologist. That was hardly the only thing he got wrong. The impact of life events, the actual personalities and behavior of the parents, his psychology of women, etc. are other glaring examples.

    My only comment would be that were there no Freud, my patient, my supervisor, and I would’ve never met. And that meeting had a positive impact on all three of us – actually also on the the maid. The patient now practices child advocacy law.


    That’s fine. I’m the one that put the Szasz paper in there. He deserves to be read.

    October 28, 2013 | 6:53 AM

    Here’s an interesting take on DSM5 as if it were a dystopian novel:

    October 28, 2013 | 3:32 PM

    Until someone tops, or rather, stoops even lower in a submitted comment to a blog or other site about mental health.

    I’ll remember the “low”ness in my comment every time I remember that psychiatrist asking me if I were in love with my stepfather, Joel. You could get over yourself, you know.

    October 28, 2013 | 3:35 PM

    Child advocacy and taking excellent care of children is a wonderful way to repair the damage of predatory parent figures.

    October 28, 2013 | 7:38 PM

    Nick Stuart, a lot of people seem to say Szasz is worth reading. As soon as I can find the free time, I think I’m going to have to read at least a few of those.

    October 28, 2013 | 7:41 PM

    Yeah, thank you for that analytic interpretation, sir. Not looking for any apology from you, but, sorry if you don’t like my rebuttal. What you wrote is there for eternity, until at least if the blog author decides to edit.

    You should check out the video of what a pistol whipping looks like, even if dramatized in a movie scene. Google “video of a pistol whipping” and I would assume you could find examples. Not going to link it here.

    2 wrongs don’t make a right, that one seems timeless to me.

    October 28, 2013 | 8:06 PM

    Oh dear God! First of all, I’m a woman. To compare my cartoon-like fantasy to a real pistol whipping is preposterous. You want me to say only rosy things about a field that produced a doctor who, after being told by a patient that she was sexually abused by her step- father, sat forward and grinned like a pervert then asked if she was in love with her stepfather. Afterward, she was so stunned by his response, that got up, knocked over the chair she had been sitting in, then walked backward out of the office, while he kept sitting there leering at her? Sure he added creepiness of his own, but you want me to pretend that he wasn’t using the doctrine he was taught? Or that that isn’t a significant part of the history of psychiatry? Or that it means nothing now, in a conversation about different incarnations of the DSM and the different phenomologies that have been used to describe and define mental illness and neurosis?

    I’ve mentioned many times that years of counseling from various counselors from various school had a profoundly positive and meaningful effect on my life. It’s not my job to deal with your defensiveness or to tiptoe around it.

    October 28, 2013 | 9:26 PM

    My mistake, so you are a woman. You start off a comment about visualizing assaulting a doctor. If I started off a comment saying I was visualizing raping a woman, is that a difference?

    Your comment stands, a defender has commented at my blog, and I guess your coping skills work as you apply. You are more than welcome to make a comment at my blog to validate and clarify, and take me to task for my alleged misunderstanding. Or not.

    There are losers in my field, and per your last comment, it appears you found “winners” as well. And I never asked nor implied you should tiptoe.

    But, I won’t ignore minimizing the premise of violence.

    Strange to read, or actually NOT read others do not see anything wrong with your first comment at this thread.

    My apologies again for misinterpreting your gender. And I am finished commenting at this thread. Be safe, be well, for what the sign off is worth.

Sorry, the comment form is closed at this time.