Psychiatrist Set Rigorous Standards for Diagnosis
New York Times
By Benedict Carey
December 26, 2015
Architect of the DSM
Psychology Today
By Edward Shorter
December 28, 2015
The Psychiatric Legacy of Robert Spitzer
Mad in America
By Bonnie Burstow, PhD
January 05, 2016
The most influential psychiatrist of his time
Huffington Post
By Allen Frances
January 08, 2016
On rereading, I realized that my comments after Dr. Spitzer’s death [
persists in memory…] weren’t necessarily about Dr. Spitzer, but rather about what I saw as several negative consequences of the DSM-III he shepherded – the diagnosis Major Depressive Disorder that conflated categorically unrelated conditions and the consolidation of power in the American Psychiatric Association. In a way, I was using him as an inkblot to say things I feel strongly about. And reading these other commentaries, I’m not alone in that kind of projection. In the interim, something occurred to me that may or may not relate to him specifically, but at least it’s not just a surrogate for some pre-existing idea. Here are a few quotes from his Introduction to the DSM-III:
[1] "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…"
[2] "Since in DSM-I, DSM-II, and ICD-9 explicit criteria are not provided, the clinician is largely on his or her own in defining the content and boundaries of the diagnostic categories. In contrast, DSM-III provides specific diagnostic criteria as guides for making each diagnosis since such criteria enhance interjudge diagnostic reliability. It should be understood, however, that for most of the categories the diagnostic criteria are based on clinical judgement, and have not yet been fully validated by data about such important correlates as clinical course, outcome, family history, and treatment response. Undoubtedly, with further study the criteria for many of the categories will be revised…"
[3] "The purpose of the DSM-III is to describe clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat various mental disoders. The use of this manual for non-clinical purposes, such as determination of legal responsibility, competency or insanity, or justification for third party payment, must be critically examined in each instance within the appropriate institutional context…"
[4] "In the several years it has taken to develop DSM-III, there have been several instances when major changes in initial drafts were necessary because of new findings. Thus, this final version of DSM-III is only one still frame in the ongoing process of attempting to better understand mental disorders."
I’ve always taken [1] as sincere. If you know Spitzer’s personal history, he was no stranger to matters psychological. His crusade against psychoanalysis was directed at the body psychoanalytic and the hegemony of psychoanalytic theorizing, not an opposition to the impact of personal biography on the psyche. He’d lived through that himself. He wanted psychiatry to fill in the many unknowns in causality based on hard data and evidence rather than what he saw as speculation. And as for [3], he was whistling in the wind. The actuaries knew the DSM-III long before many of us did. It was the time of DRGs [Diagnostic Related Groups] and the "use of this manual for non-clinical purposes, such as determination of legal responsibility, competency or insanity, or justification for third party payment…" flourished whether intended or not.
In [2], he says that the specific diagnostic criteria were added as guides "since such criteria enhance interjudge diagnostic reliability." Inter-rater reliability, as measured by Kappa, was his front-line organizing principle [A Re-analysis of the Reliability of Psychiatric Diagnosis, 1974]. I can easily imagine him saying, "But if we don’t provide criteria for these diagnoses, the inter-rater reliability is going to hell in a hand-basket! They’ll be all over the place just like with the DSM-II." Throughout these comments, it’s easy to see that he was trying to create a diagnostic system that would iterate and evolve – "only one still frame in the ongoing process of attempting to better understand mental disorders."
That’s not what happened. His "one still frame" hung around for a long time frozen in time [like into the present]. It didn’t iterate and evolve, nor did it function as a guide. A year or so after it was released, I was belatedly taking my psychiatry oral board exam in far-off Texas. I had postponed air travel for a few years because of a back problem, and so I was in a cohort of recent graduates from all over the country much younger [and greener] than I. On the bus to the hospital for the exam, they were frantically quizzing each other about these criteria which they had memorized. I thought if that’s what it was going to take to pass the test, I was going to be left in the dust. Fortunately, my examiners were more my age, and the patient I examined was a lonesome cowboy who was depressed for some really good lonesome cowboy reasons. But my point is that these criteria weren’t being seen as guides, they were quotes from a book soon to be dubbed "the Bible of Psychiatry."
And while I believe Dr. Spitzer thought it was "atheoretical" [1], in the most public circles, it was "a" "theoretical" piece of work – and we all know which "theory". I’ve never read anything much in our literature seriously proposing a psychological or a psycho-social etiology for any DSM-III category. We just stopped talking about that and by the time Prozac came on the scene in 1987, psychiatry was off-and-running towards a later time [2002] when the DSM-5 Task Force was launched with its eyes on the prize of adding biological markers to the manual and realizing the neoKraepelinian dream. So if I believe what Dr. Spitzer said in that Introduction [which I do], why didn’t it iterate and evolve? Why did those tentative guide criteria remain mostly unchanged [set in concrete]? Why when he seems to be standing on his head to say these are categories and not diseases is the main argument with others about the medical model of disease? I actually think those are pretty good question.
And so to my later thought. Was there something about the way Dr. Spitzer went about creating the DSM-III that turned it from a guide into "the Bible of Psychiatry"? from tentative to immutable? Or was that something that had to do with other forces? I find it hard to believe that someone who had his finger in every single piece of that revision was a just a neutral figure in all that has happened since. But those are questions I don’t know the answers to – much more interesting to think about than projecting what I already think onto a Rorschach card with his picture on it…
Define the terms and you control the debate.
This tribute article wasn’t actually reassuring:
http://www.clinicalpsychiatrynews.com/views/single-view/dr-robert-spitzer-a-personal-tribute/4764150cda7362a89a40e191c70d56a4.html
“I now understand the process of how you gathered the data,” I said. “But exactly how did you decide on five criteria as being your minimum threshold for depression?”
He took a sip of orange juice and thought for a second. “It was just a consensus. We would ask clinicians and researchers: ‘How many symptoms do you think patients ought to have before you would give the diagnosis of depression?’ And we came up with the arbitrary number of five.”
“But why did you choose five and not four? Or why didn’t you choose six?”
He smiled impishly, looking me directly in the eyes. “Because four just seemed like not enough. And six seemed like too much.”
How about bringing in an expect in statistical nosology at that point? Rather than deciding how much cheese is the right amount to make an omelette sing?
“There are exactly FIVE symptoms necessary to define major depression”:
https://www.youtube.com/watch?v=wncTgMi3pWc
James,
Great video choice!
Thanks. Pick a number, any number!
SCIENCE!
Science? Who called it science?
http://www.dsm5.org/Documents/DOC001.pdf
The usual suspects. My summary: it was legislated through a bureaucracy of experts and therefore is scientific.
LOL. APA is a guild, not a scientific society, and if they think they need to gild the lily then that’s what they’ll do. We don’t post drafts on-line and seek public input on, say, the classification of plants or bacteria.
There is always a need to standardize an imperfect cut off point, whether it be for psychometrics, diagnostic classification or speed limits. I am completely understanding of the fact that it is an estimate. What I am not forgiving about is that the experts are guessing, not estimating.
If I ask you to tell me the approximate number of words in this post, that is an estimate. If I ask you to tell me the approximate number of words in the next post that hasn’t been published that is a guess.
A reasonable estimate is made by charting specificity and sensitivity and coming up with a number that provides a compromise (which can be quantified) between the two interests. For speed limits, its between efficiency and safety.
For example, on the Rey Malingering Test with Recognition (picking this example because I recently studied an article on it), the authors looked at the data and found high levels of specificity and sensitivity at the number 20/30 which wasn’t 100 percent on both but very high on both with steep declines in one number when you move up or down.
That’s a hell of a lot different that saying “five seems right”. Or that there are exactly 57 communists in the Dept of Defense.
The guild has rested on “reliability” for 35 years while ignoring validity.
Exactly. The guild hoped to arrive at validity through reliability, and they ended up getting neither – just look at the dismal kappa values for DSM 5.