Klerman 1978: the critics…

Posted on Saturday 17 December 2016

[continuing from an interesting read…, Schizophrenia: Science and Practice, Chapter 5: The Evolution of a Scientific Nosology, and Klerman 1978: on the medical model…].

In 1978, criticism of psychiatry was in full bloom. At the radical pole were people like R. D. Laing and Thomas Szasz who questioned whether psychiatry should even exist. In 1974, Thomas Szasz had published The Myth of Mental Illness, asserting that Mental Illness was a made-up construct used to control aberrant behavior eg an agency of the  State. And there were other criticisms to deal with. In the US as opposed to the rest of the world, psychoanalytic training was largely limited to physicians. They were prominent in academic and organized psychiatry, and had exerted a strong influence on the DSM-II classification of non-psychotic mental illness. The criticism from both within psychiatry and at large was that psychoanalytic theory and practice was subjective without an evidence or research base; that precise classification was of little interest with no distinction between normal and abnormal; that psychoanalysts were elitist; and that they were charging long therapies on the walking wounded to medical insurance carriers. All of these criticisms were obviously strong influences on Klerman’s neo-Kraepelinian Credo:
American, British, and Canadian psychiatry is today in the midst of a Kraepelinian revival that is becoming the dominant force among research and academic leaders, In contrast, the Meyerian school is currently in a phase of decline in American psychiatry. The Meyerian approach stresses the importance of personal experience and the uniqueness of the individual in his social context, in contrast to the Kraepelinian emphasis on categorizing diseases, an emphasis derived from continental European medicine, The neo-Kraepelinian credo includes nine propositions:
  1. Psychiatry is a branch of medicine.
  2. Psychiatry should utilize modem scientific methodologies and base its practice on scientific knowledge.
  3. Psychiatry treats people who are sick and who require treatment for mental illnesses.
  4. There is a boundary between the normal and the sick.
  5. There are discrete mental illnesses. Mental illnesses are not myths. There is not one but many mental illnesses. It is the task of scientific psychiatry, as of other medical specialties, to investigate the causes, diagnosis, and treatment of these mental illnesses.
  6. The focus of psychiatric physicians should be particularly on the biological aspects of mental 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 such criteria by various techniques. Further, departments of psychiatry in medical schools should teach these criteria and not depreciate them, as has been the case for many years.
  9. In research efforts directed at improving the reliability and validity of diagnosis and classification, statistical techniques should be utilized.
… In this country the neo-Kraepelinian point of view has been most strongly identified with the group at Washington University in St. Louis, whose leading spokesman are Eli Robins, Sam Guze, and George Winokur. Recently, they have been joined by a New York contingent including Donald Klein, whose book on diagnosis and drug treatment has probably been the most influential textbook of psychopharmacology in this country.  Klein has repeatedly asserted that psychiatrists cannot prescribe drug treatment appropriately without a careful description of the patient’s symptoms and syndromes.  Another New York investigator identified with the neo-Kraepelinian approach is Robert Spitzer, chairperson of the American Psychiatric Association Task Force that is drafting the third edition of the Diagnostic and Statistical Manual. The first draft of this volume has been met with controversy over the strongly descriptive approach it takes to psychopathology…
Note: While Adolf Meyer’s thinking had indeed heavily influenced the original DSM [1952], it was the psychoanalytic influence in the DSM-II [1968] that was the target to be supplanted here. Another omitted major player was Mel Sabshin, Director of the American Psychiatric Association from 1974-1997, who initiated and shepherded many of the changes being discussed here. To change sources for just a moment, this is a quote from Dr. Sabshin’s book, Changing American Psychiatry: A Personal Perspective, about the task they had undertaken:
How could a professional organization engineer a scientific revolution that changed its core? According to conventional wisdom, organizations respond; they do not initiate By Ihe 1970a psychiatry in the United States had begun to undergo massive changes. The postwar glow had been replaced by the new pressures for accountability on all of medicine. Many leaders in psychiatry deplored the ideological rifts that had divided the field and they called far a more unified, scientifically based profession. They deplored the "demedicalization" of psychiatry and its severe loss of credibility . I was one of the young leaders who had criticized the ideological divisions within psychiatry and had been searching for ways to improve its scientific status throughout my career. The field’s ideological schisms had weakened us serious, and psychiatrists bitter public disagreements were self-destructive To cover up these differences or to act solely because of the criticism was not in itself sufficient; psychiatry had to adopt a genuine commitment to science rather than to ideology, It needed to change the profession fundamentally if it was to become a respected part of medicine. To accede to the pressures without radical modifications of the field would not have convinced others that the profession had changed. A new strategy was essential! Producing the DSM-llI stated emphatically that psychiatry in America chose an evidence-based practice rather than ideology.
So now back to the Klerman chapter. Klerman is clear on where this was all headed:
The Kraepelinian revival is part of the general movement of psychiatry towards greater integration with medicine. This movement has multiple sources, professional, economic, social, scientific. Whatever its sources, the consequence for psychiatry is a greater concern for medical identity Applied to schizophrenia, there is greater attention to diagnosis in the classical medical tradition and to biological causes and treatments of this disorder.
This chapter by Gerald Klerman and the release of Robert Spitzer’s DSM-III two years later became the rallying texts of record for the dramatic changes in psychiatry that soon followed. The point of this post is to flesh out some of the criticisms of that time that helped shape what happened and what came to be…
    Donald Klein
    December 21, 2016 | 1:14 PM

    We seem to be in a historical and reminiscent mode. , although much of what has been said is correct there are a few misleading ideas that have unfortunately received general acceptance. For instance,that DSM-III had a penchant for evidence based organic treatment is incorrect. DSM-III was intended to be a reliable diagnostic manual and not a therapeutic text. It is true that the emphasis on descriptive diagnosis supported the application to psychiatry of the recent medical ideal of correct diagnosis preceding correct treatment. But there is little in DSM today that refers to treatment. Further neo-Kraepelinians were supposed to abhor,the various causal theories that engaged the mind as opposed to a narrow organicism. in fact the DSM-III task force were out of sync with any who proclaimed an understanding of specific causality , openly declaring that none of these theories were remotely definitive or yielded useful diagnoses.. It is true that in the field of infection, endocrinology, and nutrition there were clear-cut causal bases for a variety of psychopathology, but there was nothing in DSM-III that viewed this as the correct basis for psychiatry.
    The recent accusations, coming from NIMH of all places , that DSM-III focused on reliability rather than validity were perfectly correct if completely misleading. it is elementary psychometrics that there is no validity if there is no reliability. It had been repeatedly shown that psychiatric diagnosis was grossly unreliable , which called into question its status as a science. DSM-III task force recognized this key criticism on its own. It had no guidance from the APA . It was hoped that the establishment of clear inclusion and exclusion criteria would increase reliability. It was open to invalidation by. the test of field trials. Further, there is no overall validity. There are many correlated validities .To complicate matters, very few validities of any sort were available to DSM-III
    To go into the various motivations of a complex cast of characters seems unlikely to convince anyone since we all had different degrees of acquaintanship with relevant facts The view rthat Sabshin and Klerman were in a covert partnership to establish DSM3 does not fit my recollection. Klerman,was an exceptionally lucid,erudite,scientist who had partnered with Myrna Weissman in an enthusiasm for epidemiology and familal studies. When he became ADAMHA chief he fostered the development of the ECA ,under Lee Robins. It was the first national epidemiology. Of great scientific interest ,but tangential to DSM. That Sabshin,the then APA Executive valued critical scientific thinking over baseless diagnostic and therapeutic claims was not my experience.,at all. But it’s possible my limited experience led to a misjudgement..
    Don Klein

    Bernard Carroll
    December 22, 2016 | 2:19 AM

    Don, your point about multiple correlated validities is on target. They comprise face validity, construct validity, predictive validity, discriminant validity. This point links with my mention of an iterative process for advancing nosology. We seldom hit home runs in medical nosology but we do move the ball down the field with successive, multiple convergent validities of the kinds listed above.

    I think I would take issue when you say there is no reliability if there is no validity. A major problem with DSM-III was its innumeracy and its failure to incorporate the various convergent validity dimensions that were available. DSM-III was a data-free exercise. Much of the perceived unreliability in psychiatric diagnosis in the early 1970s was geographic. USA was the outlier, as the cross-national reliability studies found. In the rest of the world, there was generally good reliability for differential diagnoses like melancholic/endogenomorphic depression versus reactive/neurotic depression or like schizophrenia versus mood disorder. The US side were the outliers. They were not just unreliable – they were wrong. When the neo-Kraepelinian initiative took hold in the US, they basically returned to the non-US practice of the 1950s and 1960s. It’s also necessary to recognize the validity of prototypes despite the unreliability of diagnosing intermediate cases.

    As to agendas at work in DSM-III, I think we agree that the task force and Bob Spitzer were not always on the same page as Mel Sabshin and the APA. I would add that Gerald Klerman did a straddle. As Administrator of ADAMHA, he was invested, along with the APA, in justifying psychiatric practice for reimbursement, whatever his scientific objectives. And when you mention the ECA study, I recall a public confrontation with him in 1979 over the planned ECA and the planned National Collaborative Depression Study. Essentially, I challenged him on the issue of the validity of generic major depression, which I predicted would undermine any research efforts. Now we know how serious a misstep that decision to adopt generic major depression was.
    Best, Barney.

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