From it’s earliest days, our DSM-5 Task Force set out to make a change. They were going to realize the dream of the St. Louis fathers of the original DSM-III revision – to move the psychiatric nosology from it’s 30 years of mere description to the longed for biological base that would put us on an equal footing with the rest of medicine. Hard science in psychiatry was booming when they started, and they felt the time was right. They set up a series of conferences – gatherings of experts to lay the base for the coming paradigm shift. And while they were meeting, something happened [a soft version of Rome is burning], but more importantly, something didn’t happen.

The thing that happened was the exposure of widespread scientific corruption in the psychiatric literature and academic medicine, fueled by an alliance with the pharmaceutical industry. The thing that didn’t happen was that the scientific basis for the proposed change didn’t materialize. And further, they had taken the accomplishments of their predecessors, Drs. Robert Spitzer [DSM-III, DSM-IIIR] and Allen Frances [DSM-IV], for granted. They failed to realize that these former successes were built on a base of hard work, organization, and attention to details. The descriptive DSMs are soft systems. Soft systems require a lot of careful shepherding. Systems based on hard science are a walk in the park by comparison – hard data carries the day. They had counted on the coming of the future science for their new system, been lax with the groundwork and preparation required to improve the one we had, and the clock ticked on.

Then they made a big mistake. When the DSM veterans [Spitzer and Frances] began to speak out, DSM-5 Task Force leaders saw them as nosy parkers holding on to the past rather than as wise elders with important counsel. They were aided and abetted by a worst case adviser, Dr. Alan Schatzberg, then president of the APA [and under US Senate scrutiny]. So they pressed ahead. They had banked on future science and lost that round. They made a second wager – that the single pass Field Trials would exonerate them. Well, that was as bad a bet as the first – the Field Trials bombed. They were so bad that they created a bigger problem than before. Earlier, it was their dream of a premature or misdirected paradigm shift that was being wagered, but with those dismal Field Trial results, they will be putting the fate of the whole DSM system and the DSM-5 Manual on the gaming table.

^{For this revision, the APA recruited more than 160 of the top researchers and clinicians from around the world to be members of the DSM-V Task Force, Work Groups and Study Groups. These experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, and public health were rigorously vetted for any conflict of interest using guidelines derived from other academic professional organizations and from the federal government itself and have worked assiduously for over five years to scour the scientific literature and determine whether any changes to existing DSM-4 diagnoses and additions were warranted.  They participated on a strictly voluntary basis and come from several medical and health care disciplines including psychiatry, psychology, pediatrics, nursing and social work…}

There may be times when claims of expertise might be effective, but this doesn’t seem like one of those times. This is a time for demonstrated expertise, and that’s a missing commodity in this story. This is the time for the Trustees of the American Psychiatric Association to just say "No" and take back the helm, since the other people involved don’t seem to know how to act responsibly right now.

Looking at the DSM-5 Web Site, I can’t find that the Field Trial results have been posted, so in the absence of their posting, here’s my collected version for your after-the-dust-has-settled review:

And this is a simple set of distribution graphs for this and previous Field Trials:

On the right is a distribution of the Kappa values from our old system [DSM-II] from Dr. Spitzer’s 1974 meta-analysis of five reliability studies – values considered at the time unacceptable and a reason to radically revise the whole diagnostic system. We set our own standard back in those days, our own benchmark. Dr. Spitzer and his statistician colleagues essentially created and tested Kappa to be the Reliability coefficient for psychiatric diagnosis. If we are going to have any integrity, we can’t change the standards after the results are in.

The protest lead by Dr. Spitzer and Dr. Frances has had two prongs. The one we’ve all followed has been changes like the Attenuated Psychosis Syndrome, dropping the Bereavement Exclusion, or changing the bar in diagnosing Autism – content issues. But both former revision czars have also worried about the process – secrecy, schedules, Field Trials, etc. These Field Trial results focus us on the second set of problems. The Field Trials are not only disappointingly weak, unacceptably low, they are uninterpretable. Mainstream diagnoses like Schizophrenia, Major Depressive Disorder in kids and adults, Generalized Anxiety Disorder, Obsessive Compulsive Disorder – they have Kappas dragging the bottom. Those criteria haven’t changed since the DSM-IV. That can only be an indictment of either the whole DSM system or the DSM-5 Field Trials themselves. There’s no other interpretation, and certainly no interpretation that remotely says that everything is fine, right on schedule, business as usual.

And to make matters worse, there were supposed to be two sets of Field Trials. One to test their new criteria and a second to test the tweaking after the first one. Sounds like science to me. But they cancelled the second trial because of scheduling problems and chose to put their eggs all in one basket – the Field Trials reported in the Philadelphia APA meeting recently. Those results are both weak and uninterpretable.

Psychiatry has been plagued with scientific distortion for a long time. It’s a matter of public record that any number of studies and articles have overstepped the rational bounds of scientific enterprise – overblowing the results of clinical trials, withholding information about adverse events, renaming things like suicidality – spinning the data rather than just reporting it. It’s time for that to stop. We know it, but more importantly, the rest of the medical community and our patients know it.

Several investigators have developed structured interview schedules which  an interviewer uses n his examination of the patient … These techniques provide for a standardized sequence of topics, and ensure that variability among clinicians in how they conduct their interviews and what topics they cover is kept to a minimum…

With respect to improving the nomenclature, the St.Louis group has offered a system limited to 16 diagnoses for which they believe strong validity evidence exists, and for which specified requirements are provided. Whereas in the standard system the clinician determines to which of the various diagnostic stereotypes his patient is closest, in the St. Louis system the clinician determines whether his patient satisfies explicit criteria…

A Diagnostic Interview: The Schedule for Affective Disorders and Schizophrenia
^{by Jean Endicott, PhD and Robert L. Spitzer, MD}
Archives of General Psychiatry. 1978 35:837-844.
[full text on-line]

SUMMARY SCALE SCORES FOR THE CURRENT SECTION OF THE SADS

There are a number of items in the current section of the SADS that are descriptive of specific dimensions of psychopathology. An initial scoring system has been developed through the assignment of items to eight larger summary dimensions. The item assignment was based on knowledge of factor analytic work of scales with similar item content, consideration of the major clinical distinctions usually made in research studies of affective and schizophrenic disorders, and a desire to have a smaller number of clinically meaningful measures on which to compare individual subjects over time or groups of subjects with each other. The names of the summary scales and the item contents are shown in Table 2. The two syndromal scales, which have considerable overlap, were developed to describe features of the depressive syndrome that are frequently associated with depressive mood. The first, Endogenous Features, is limited to those items descriptive of symptoms that have traditionally been considered characteristic of an "endogenous" depressive episode. The other scale, Depressive Associated Features, is broader and includes both the "endogenous" items and some additional items generally assumed to be part of the depressive syndrome…

Research Diagnostic Criteria: Rationale and Reliability
^{by Robert L. Spitzer, MD; Jean Endicott, PhD; and Eli Robins, MD}
Archives of General Psychiatry. 1978 35:773-792.
[full text on-line]

Abstract:

A crucial problem in psychiatry, affecting clinical work as well as research, is the generally low reliability of current psychiatric diagnostic procedures. This article describes the development and initial reliability studies of a set of specific diagnostic criteria for a selected group of functional psychiatric disorders, the Research Diagnostic Criteria (RDC). The RDC are being widely used to study a variety of research issues, particularly those related to genetics, psychobiology of selected mental disorders, and treatment outcome. The data presented here indicate high reliability for diagnostic judgments made using these criteria…

Reliability:

The reliability of the RDC categories with psychiatric inpatients has been tested in three studies. The first two involved joint interviews whereby one rater conducted the interview and the other merely observed. Both made independent ratings. The third study involved a more rarely used procedure, whereby two independent raters interviewed the patient at different times [test-retest]. The kappa coefficients of reliability for these three studies are shown in Table 3…

Study B used the first edition of the RDC and involved pairs of raters at four facilities participating in a Pilot Study of the Psychobiology of the Depressive Disorders sponsored by the Clinical Research Branch of NIMH; the New York State Psychiatric Institute; Renard and Barnes Hospitals, Washington University School of Medicine; Iowa Psychiatric Hospital, University of Iowa Medical School, and Massachusetts General Hospital, Harvard Medical School. The subjects were newly admitted inpatients who met screening criteria for a depressive or manic syndrome. The SADS was used to interview the patients and an RDC diagnosis was made afterwards…

Relationship Among Alternative Classifications of Depressive Disorders:

One of the main purposes of the RDC approach to psychiatric diagnosis is to facilitate the comparison of alternative classification systems for depressive disorders. Table 7 gives the joint classification of diagnoses for 90 patients with a current diagnosis of major depressive disorder (study B). The table should be read across so that the frequency with which subjects given a diagnosis on the left indicates how often they were also given a diagnosis listed on the right. Some of the cell sizes are quite small; therefore, this table is presented primarily for illustrative purposes.

Frequently, there is an assumption that the more commonly used methods for classifying depressed patients are equivalent and that the results of studies using these different systems can be easily compared. For example, it is often assumed that episodes of primary depressive disorder would almost always meet the criteria for endogenous depressive disorder and rarely meet the criteria for situational [reactive] depressive disorder. However, only 64% of patients with a diagnosis of primary depressive disorder also met the criteria for endogenous phenomenology, while 51% of them met the criteria for situational depressive disorder. Similarly, it is often assumed that situational [reactive] depressive episodes would rarely meet the criteria for endogenous depressive disorder whereas they actually met those criteria 42% of the time…

^{[reformatted to fit the page · click image to view full size]}

I admit to not being totally clear about how Table 7 was derived. It’s from Study B, in which one person did the interview using the SADS protocol and the other was an observer. I gather that under Major Depressive Disorder, the raters could chose multiple diagnoses.

…thus accounting for the large % numbers. But the point of the table and the last paragraph quoted from the article above is clear. The table says that the categories we thought of as separate conditions at the time did not separate well in the Study B – for example Endogeneous Depression and Situational Depression [overlapping 37% and 42% depending on which came first]. It’s obvious, given the etiological implications of those names, that the names were not exactly candidates for the purely descriptive DSM-III being constructed. Don Klein had even suggested a cause-neutral term "endogenomorphic" to replace "endogenous." I presume "situational" was associated with "neurotic," a causal term that had to go. But while the terms and their former implications were problems, that could’ve easily been surmounted. I suspect that the values in Table 7 suggested that previous distinctions were not real, mythological, and supported the "lumping" of all of the categories under the one roof – Major Depressive Disorder.

Looking over and over this latter paper, and the SADS interview used to gather this data, I couldn’t get close enough to what they actually did to assess it. The details were just too obscure and I haven’t located the criteria they used for the subclasses. But I was suspicious that those numbers in Table 7 were not an accurate picture. They don’t fit my experience or that of many others. But beyond that, there’s another consideration that seems ignored. Even if they couldn’t find the reliable separation in the varieties of depression, that means to me back to the drawing board, not that those distinctions are necessarily mythic. And it for sure doesn’t mean that all significantly depressed people have the same "Disorder." Lumping, in this case, wasn’t just a passive act. It was an active declaration of unity without any backing of its own – one that had enough negative consequences to deserve the term maelstrom.

^{It is an unsubstantiated claim that the proposed changes to substance abuse and dependence disorders in the new Diagnostic and Statistical Manual of Mental Disorders will lead to millions of people being labeled “addicts.” In fact, the D.S.M.-5 Work Group’s analyses of data from 200,000 people indicate that the minor changes proposed to D.S.M.-5 criteria will not increase the prevalence of substance use disorders. Further input and evaluation from our various review groups, field trials and public comment from our Web site will be assessed before final recommendations are presented to the American Psychiatric Association’s board of trustees.}

^{These proposed changes combine the D.S.M.-IV categories of substance abuse and substance dependence into D.S.M.-5’s substance use disorder. In this one overarching disorder, the criteria have not only been combined but also strengthened. Previous substance abuse criteria required only one symptom, while the D.S.M.-5’s revised mild substance use disorder [not addiction] requires two to three symptoms. This evidence-based change raises the requirements from D.S.M.-IV rather than broadening them. Like the National Institutes of Health, whose research supports the proposed changes, we are confident that the proposed criteria will lead to improved diagnosis for people seeking help for substance use disorders.}

^{The broader language involving addiction, which was debated this week at the association’s annual conference, is intended to promote more accurate diagnoses, earlier intervention and better outcomes, the association said. “The biggest problem in all of psychiatry is untreated illness, and that has huge social costs,” said Dr. James H. Scully Jr., chief executive of the group.}
^{Under the new criteria, people who often drink more than intended and crave alcohol may be considered mild addicts. Under the old criteria, more serious symptoms, like repeatedly missing work or school, being arrested or driving under the influence, were required before a person could receive a diagnosis as an alcohol abuser.}
^{“We can treat them earlier,” said Dr. Charles P. O’Brien, a professor of psychiatry at the University of Pennsylvania and the head of the group of researchers devising the manual’s new addiction standards. “And we can stop them from getting to the point where they’re going to need really expensive stuff like liver transplants.”}

Some critics of the new manual have said that it has been tainted by researchers’ ties to pharmaceutical companies. “The ties between the D.S.M. panel members and the pharmaceutical industry are so extensive that there is the real risk of corrupting the public health mission of the manual,” said Dr. Lisa Cosgrove, a fellow at the Edmond J. Safra Center for Ethics at Harvard, who published a study in March that said two-thirds of the manual’s advisory task force members reported ties to the pharmaceutical industry or other financial conflicts of interest.

Dr. Scully, the association’s chief, said the group had required researchers involved with writing the manual to disclose more about financial conflicts of interest than was previously required. Dr. O’Brien, who led the addiction working group, has been a consultant for several pharmaceutical companies, including Pfizer, GlaxoSmithKline and Sanofi-Aventis, all of which make drugs marketed to combat addiction. He has also worked extensively as a paid consultant for Alkermes, a pharmaceutical company, studying a drug, Vivitrol, that combats alcohol and heroin addiction by preventing craving. He was the driving force behind adding “craving” to the new manual’s list of recognized symptoms of addiction. “I’m quite proud to have played a role, because I know that craving plays such an important role in addiction,” Dr. O’Brien said, adding that he had never made any money from the sale of drugs that treat craving.

I’m not proposing that they learn to respond to criticism better. I think what I’m commenting on is that they don’t actually respond to the content of the criticism. They just say "no," indicating that they haven’t really engaged the issue. That’s the thing that makes their responses so unpalatable. But worse, denying the impact of conflicts of interest in 2012 is going to fall on dead ears. Denying that the new criteria will foster increased prevalence is equally flat. They sound dumb. Experts gain nothing by sounding dumb. Particularly when their changes are only backed up by "expertise."

Translational evaluation of JNJ-18038683, a 5-HT7 receptor antagonist, on REM sleep and in major depressive disorder
^{by Pascal Bonaventure, Christine Dugovic, Michelle Kramer, Peter De Boer, Jaskaran Singh, Sue Wilson, Kirk Bertelsen, Jianing Di, Jonathan Shelton, Leah Aluisio, Lisa Dvorak, Ian Fraser, Brian Lord, Diane Nepomuceno, Abdellah Ahnaou, Wilhelmus Drinkenburg, Wenying Chai, Curt Dvorak, Steve Sands, Nicholas Carruthers, and Timothy W. Lovenberg}
Journal of Pharmacology and Experimental Therapeutics
Published on-line May 8, 2012. [full text on-line]

^{In rodents, 5-HT7 receptor blockade has been shown to be effective in models of depression and to increase the latency to REM sleep and decrease REM duration. In the clinic, the REM sleep reduction observed with many antidepressants may serve as a biomarker. We report here the preclinical and clinical evaluation of a 5-HT7 receptor antagonist, JNJ-18038683. In rodents, JNJ-18038683 increased the latency to REM sleep and decreased REM duration and this effect was maintained after repeated administration for 7 days. The compound was effective in the mouse tail suspension test. JNJ-18038683 enhanced serotonin transmission, antidepressant-like behavior, and REM sleep suppression induced by citalopram in rodents. In healthy human volunteers, JNJ-18038683 prolonged REM latency and reduced REM sleep duration demonstrating that the effect of 5-HT7 blockade on REM sleep translated from rodents to humans. Like in rats, JNJ-18038683 enhanced REM sleep suppression induced by citalopram in humans, although a drug-drug interaction could not be ruled out. In a double blind, active- and placebo-controlled clinical trial in 225 patients suffering from major depressive disorder, neither treatment with pharmacologically active doses of JNJ-18038683 or citalopram separated from placebo indicating a failed study lacking assay sensitivity. A post hoc analyses using an enrichment window strategy, where all the efficacy data from sites with an implausible high placebo response [placebo group MADRS<= 12] and from sites with no placebo response [MADRS>=28] are removed, there was a clinically meaningful and statistically significant difference between JNJ-18038683 and placebo. Further clinical studies are required to characterize the potential antidepressant efficacy of JNJ-18038683.}

 

Ouch! But it gets better. Unhappy that JNJ-18038683 bombed, Janssen reached for their copy of the Cherrypicker’s Manifesto. This is a new statistical method, proposed by fellow Pharma company GSK in a 2010 paper, which consists of excluding data from study centres with a very high [or very low] placebo response rate.

Anyway, after applying this "filter" JNJ-18038683 seemed to do a bit better than placebo, but the benefit over placebo still wasn’t statistically significant - with a p value of 0.057, the wrong side of the sacred p=0.05 line [on page 33].
Yet Page 33′s "trend towards statistical significance" magically becomes "significant" – in the Abstract:

[with] a post hoc analyses (sic) using an enrichment window strategy… there was a clinically meaningful and statistically significant difference between JNJ-18038683 and placebo.

^{Well, no, there wasn’t actually. It was only a trend. Look it up.}

A new population-enrichment strategy to improve efficiency of placebo-controlled clinical trials of antidepressant drugs.
^{by Merlo-Pich E, Alexander RC, Fava M, Gomeni R.}
Clinical Pharmacology Therapeutics. 2010 88[5]:634-642.

^{The rate-limiting factor in the discovery of novel antidepressants is the inefficient methodology of traditional multicenter randomized clinical trials (RCTs). We applied a model-based approach to a large clinical database (five RCTs in major depressive disorder (MDD), involving 1,837 patients from 124 recruitment centers) with two objectives: (i) to learn about the role of center-specific placebo response in RCT failure and (ii) to apply what is learned to improve the efficiency of RCTs by enhancing the detection of treatment effect (TE). Sensitivity analysis indicated that center-specific placebo response was the most relevant predictor of RCT failure. To reduce the statistical "noise" generated by centers with nonplausible, excessively high/low placebo responses, we developed an enrichment-window strategy. Clinical trial simulation was used to assess the enrichment strategy applied before the standard statistical analysis, resulting in an overall reduction in failure of RCTs from ~50 to ~10%.}

^{A post hoc analyses using an enrichment window strategy, where all the efficacy data from sites with an implausible high placebo response [placebo group MADRS<= 12] and from sites with no placebo response [MADRS>=28] are removed, there was a clinically meaningful and statistically significant difference between JNJ-18038683 and placebo. Further clinical studies are required to characterize the potential antidepressant efficacy of JNJ-18038683.}

^{Yet the publication of a fifth revision of the DSM — now promised in 2013 — has been repeatedly postponed, mainly because fundamental problems tied to the approach of the DSM-III proved hard to solve. A most serious problem, common to field guides, is the difficulty of separating entities that are similar in appearance. For example, psychiatrists using the DSM diagnosis “major depression” tend to mingle bereaved patients with both those afflicted by classic melancholia and those demoralized by circumstances…}

An open question for another day is "why didn’t the DSM-III ever correct early mistakes, iterate, find some way to actually become evidence-based in fact rather than just in rhetoric?" While it grew to almost 300 categories from the 15 or so in John Feighner’s first shot – its core changed little as it passed through several revisions. I suppose that it was inevitable that the second dream from St. Louis, a biologically based diagnostic system and psychiatry, would emerge from the whitespace into the actual print. Certainly, the specialty of psychiatry had already made the leap by becoming predominantly biological in its own eyes, in the eyes of the Insurers, and in the eyes of the public. The thing that stood in front of the dream from St. Louis of a neo-Kraepelinian psychiatry was no longer the Freudians or other non-biologists, it was the very pillars of their own movement: evidence, biomarkers, laboratory work – AKA proof [to state the obvious]. It was still lacking.

By the turn of this century, psychiatry was heading for a crisis of biological reductionism that made the mid-century psychoanalysts look like rank amateurs. The escalating appetite of the pharmaceutical industry and the corrupted alliances obvious by the early 2000s were going to nova at some point. It was just a matter of time. Yet the DSM-5 leaders had become so taken with the rhetoric of the hour that they believed it – some because of exciting technologies, some from arrogance and other unsavory forces, and some from the kernel sowed by the neo-Kraepelinians [whose DSM actually had impeded legitimate progress in biological research]. But still they pressed ahead. This would be the public launch of the new age of clinical neuroscience, finally realized. They announced it loudly and spent a lot of time having conferences and meetings being pioneers together behind closed doors [preaching transparency to an unbelieving audience]. By the time they realized that their necessary proofs weren’t materializing, their critics were growing louder, the scandals were becoming everyday fare, pharma was moving to greener pastures, and even their predecessors were trying to help them see their folly. They were hopelessly behind schedule, empty handed, and unwilling to change directions.

Things came to a head last week with the release of the results from their Field Trials.  The silly changes they’d refused to budge on were dismal flops as predicted. But worse, the tried and true diagnostic categories like Generalized Anxiety Disorder, Major Depressive Disorder, even Schizophrenia had results in a range equal to or below those from the pre-1980 system [their claim that they're not comparable appropriately falls on deaf ears]. Either the whole enterprise has been for naught, or more likely, this bunch just doesn’t know what they’re doing. They know how to meet together and speak of grand plans and bask in the dreams of our fathers supplemented with thirty years of basic science [that no one can get to translate to the bedside]. But they didn’t know that their real calling was to leave the dreams from St. Louis for another time, and finally put the dreams of young John Feighner on a solid footing by giving us the best that descriptive criteria can give while we pass the decades it will be before there’s a viable alternative.

<sup>One of the reasons that diagnostic classification has fallen into disrepute among some psychiatrists is that diagnostic schemes have been largely based upon a priori principles rather than upon systematic studies. Such systematic studies are necessary, although they may be based upon different approaches. We have found that the approach described here facilitates the development of a valid classification in psychiatry. This paper illustrates its usefulness in schizophrenia.
The Five Phases
1.Clinical Description
In general, the first step is to describe the clinical picture of the disorder. This may be a single striking clinical feature or a combination of clinical features thought to be associated with one another. Race, sex, age at onset, precipitating factors, and other items may be used to define the clinical picture more precisely. The clinical picture thus does not include only symptoms.
2. Laboratory Studies
Included among laboratory studies are chemical, physiological, radiological, and anatomical (biopsy and autopsy) findings. Certain psychological tests, when shown to be reliable and reproducible, may also be considered laboratory studies in this context. Laboratory findings are generally more reliable, precise, and reproducible than are clinical descriptions. When consistent with a defined clinical picture they permit a more refined classification. Without such a defined clinical picture, their value may be considerably reduced. Unfortunately, consistent and reliable laboratory findings have not yet been demonstrated in the more common psychiatric disorders.
3. Delimitation from Other Disorders
Since similar clinical features and laboratory findings may be seen in patients suffering from different disorders (e.g., cough and blood in the sputum in lobar pneumonia, bronchiectasis, and bronchogenic carcinoma), it is necessary to specify exclusion criteria so that patients with other illnesses are not included in the group to be studied. These criteria should also permit exclusion of borderline cases and doubtful cases (an undiagnosed group) so that the index group may be as homogeneous as possible.
4. Follow-Up Study
The purpose of the follow-up study is to determine whether or not the original patients are suffering from some other defined disorder that could account for the original clinical picture. If they are suffering from another such illness, this finding suggests that the original patients did not comprise a homogeneous group and that it is necessary to modify the diagnostic criteria. In the absence of known etiology or pathogenesis, which is true of the more common psychiatric disorders, marked differences in outcome, such as between complete recovery and chronic illness, suggest that the group is not homogeneous. This latter point is not as compelling in suggesting diagnostic heterogeneity as is the finding of a change in diagnosis. The same illness may have a variable prognosis, but until we know more about the fundamental nature of the common psychiatric illnesses marked differences in outcome should be regarded as a challenge to the validity of the original diagnosis.
5. Family Study
Most psychiatric illnesses have been shown to run in families, whether the investigations were designed to study hereditary or environmental causes. Independent of the question of etiology, therefore, the finding of an increased prevalence of the same disorder among the close relatives of the original patients strongly indicates that one is dealing with a valid entity. We hope it is apparent that</sup>

^{In contrast to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-II), in which the diagnostic classification is based upon the "best clinical judgement and experience" of a committee and its consultants, this communication will present a diagnostic classification validated primarily by follow-up and family studies. The following criteria for establishing diagnostic validity in psychiatric illness have been described elsewhere and may be divided into five phase.}

• John Feighner was a psychiatery resident
• The criteria came from a literature search, not their own patients
• The criteria were hypothetical and had not been vetted by their 5 phases
• The five phases of diagnosis were not part of generating the criteria but rather cut and pasted from their earlier article
• The reliability figures were from somewhere else antedating the criteria [never ever published]

For Dr. Spitzer, charged with the task of redesigning the DSM-II, the Feighner Criteria were a godsend. They gave him a descriptive system to work with and allies who shared his disaffection with the psychoanalysts and their influence on the DSM-II. In his 1974 meta-analysis using Kappa, he demonstrated the unreliability of the DSM-II system and introduced the Feighner Criteria as a template for the Research Diagnostic Criteria [RDC] being tested in an NIMH study with Dr. Robins, a leader of the St. Louis Group [box scores and kappa…]. In 1978, they published reliability studies for the RDC and the DSM was born [the dreams of our fathers I…]. In 1991, in response to challenges that his criteria in the DSM-III had not followed the phases described in these early papers, Dr. Spitzer admitted that they had not validated the catergories as described by Robins and Guze, but continued to contend that there was no etiological bias towards biology, a point he made again in 2001 [dreams of our fathers II…].

In poring over this, I’ve come to see this process as having two distinct dreams. Everybody involved wanted the psychoanalytic influence gone. John Feighner was an young resident who dreamed of making concrete sense of psychiatric diagnosis using the literature to build a phenomenological template. Robert Spitzer had the same goal – a descriptive DSM-III like the one he created. He says he didn’t have an etiologic focus or bias. So I lump the two of them together. The St. Louis Group at Barnes Hospital had a definite etiologic focus – biology, data, biology. They dreamed of picking up where Kraepelin left off and building not only a neo-Kraepelinian DSM-III, but a neo-Kraepelinian psychiatry:

^{1. Psychiatry is a branch of medicine.}
^{2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.}
^{3. Psychiatry treats people who are sick and who require treatment.}
^{4. There is a boundary between the normal and the sick.}
^{5. There are discrete mental illnesses.  They are not myths, and there are many of them.}
^{6. The focus of psychiatric physicians should be on the biological aspects of 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 them.}
^{9. Statistical techniques should be used to improve reliability and validity.}