^{In the ongoing quest to improve our psychiatric diagnostic system, we are now searching for new approaches to understanding the etiological and pathophysiological mechanisms that can improve the validity of our diagnoses and the consequent power of our preventive and treatment interventions venturing beyond the current DSM paradigm and DSM-IV framework. This thought-provoking volume produced as a partnership between the American Psychiatric Association, the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute on Drug Abuse represents a far-reaching attempt to stimulate research and discussion in the field in preparation for the eventual start of the DSM-V process, still several years hence. The book:}

• Explores a variety of basic nomenclature issues, including the desirability of rating the quality and quantity of information available to support the different disorders in the DSM in order to indicate the disparity of empirical support across the diagnostic system.
• Offers a neuroscience research agenda to guide development of a pathophysiologically based classification for DSM-V, which reviews genetic, brain imaging, postmortem, and animal model research and includes strategic insights for a new research agenda.
• Presents highlights of recent progress in developmental neuroscience, genetics, psychology, psychopathology, and epidemiology, using a bioecological perspective to focus on the first two decades of life, when rapid changes in behavior, emotion and cognition occur…

• Research Planning Launch/Methods Conference (February 18-20, 2004)
• Personality Disorders Conference (December 1-3, 2004)
• Substance-Related Disorders Conference (February 14-17, 2005)
• Stress-Induced and Fear Circuitry Disorders Conference (June 23-24, 2005)
• Dementia Conference (September 15-17, 2005)
• Deconstructing Psychosis (February 15-17, 2006)
• Obsessive Compulsive Spectrum Disorders Conference (June 20-22, 2006)
• Dimensional Aspects of Psychiatric Diagnosis (July 26-28, 2006)
• Somatic Presentations of Mental Disorders (September 6-8, 2006)
• Externalizing Disorders of Childhood (ADD, CD, ODD, Bipolar Disorder) (February 14-16, 2007)
• Comorbidity of Depression and Generalized Anxiety Disorder (June 20-22, 2007)
• Public Health Implications of Changes in Psychiatric Classification (September 25-28, 2007)
• Autism and Other Pervasive Developmental Disorders Conference (February 3-5, 2008)

I can only guess at why the DSM-5 Task Force was secretive and distanced from their predecessors. I’d bet it had something to do with the specific personalities involved. It usually does, but I don’t know the actual people. There was a tone of secrecy in the air in psychiatry at large and we later learned that there were some fairly dark secrets behind those walls in general. But  it also occurs to me that they were aiming to make some fundamental changes in the DSM [and psychiatry as a whole], messing with Dr. Spitzer’s baby. Likewise, Dr. Frances had resisted diagnostic sprawl, and they were definitely in an annexation frame of mind, rather than urban renewal mode. But whatever their reasons, it looked bad from the outside, like a classic ‘good old boy’ network – up to no good. Even if the were innocent it was a bad move.

And I don’t really know how they got so far behind schedule. It looked like they were so busy dreaming together that they didn’t look at the clock. But my fantasy is that other forces came into play. They’d clearly planned for the grand realization of their St. Louis fathers’ dream – the long desired ‘laboratory studies.’ And they had no alternatives for what to do if they didn’t materialize. And they didn’t materialize. And I doubt they precogged that they would be living in a world of huge, embarrassing lawsuits against the drug companies implicating academic psychiatrists and psychiatric research. I expect they hadn’t banked on Senator Grassley exposing corruption in high places, including the APA president. I doubt they’d considered the ‘empty pipeline’ syndrome earlier, or the flight of the pharmaceutical companies from psychopharmacology, or the intensity of the outcry against overmedication and overmedicalization. The cast of characters are roughly my peers, so they’ve spent their whole careers in the same climate I’ve inhabited [on the other side of the fence]. And I expect they had no reason to know how quickly things can change. Or maybe they’re a bit incompetent. But by the time Dr. Spitzer and Dr. Frances started howling, the DSM-5 Task Force were in deep trouble and had to declare the first of what I hope will be several postponements.

Why did they decide to play their cards with this Revision? That really is the question. They just didn’t yet have the needed "laboratory studies" in hand – not a one. Even if all the negative things hadn’t happened along the way, they would still be in trouble – still coming up empty-handed. Had they come to actually believe their own inflated narratives? Or did they think the world wouldn’t tolerate waiting for something that made "evidence-based" really become evidence based? Was the impact of the overselling of psychiatric medicines already being felt and in need of a boost from hard science? If psychoanalyst Heinz Kohut, the self psychologist, were still alive and called in for a consult, he’d probably say that their collective Archaic Grandiose Self had emerged into consciousness and rendered them reckless and arrogant [and that wouldn't be a half bad way to think]. Another way to say that is "they got too big for their britches." But the point here is not to dissect  the group persona, or even the personae of the individuals, it’s to look at the fate of the dreams of the fathers.

I actually like separating the threads of the DSM story into the dream themes. One is the dream of the St. Louis Group and many others, a dream that psychiatric illness can and will be classified in the same way as medical diseases, based on objective findings – objective biological findings. The other is the dream of resident John Feighner, Robert Spitzer, and Allen Frances that psychiatric patients can be classified based on descriptive symptom complexes and other observation data like family history – and that the classification holds between clinicians [inter-rater reliability] and over time [longitudinal reliability]. In either case, the dream is to use diagnosis for accurate prognostication and effective treatment.

Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia
^{BY ELI ROBINS. M.D.AND SAMUEL B. GUZE, M.D.}
American Journal of Psychiatry. 1970 126[7]:107-111.

^{Since Bleuler, psychiatrists have recognized that the diagnosis of schizophrenia includes a number of different disorders. We are interested in distinguishing these various disorders as part of our long-standing concern with developing a valid classification for psychiatric illnesses. We believe that a valid classification is an essential step in science. In medicine, and hence in psychiatry, classification is diagnosis. 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…}

1. Clinical Description
2. Laboratory Studies
3. Delimitation from Other Disorders
4. Follow-up Study
5. Family Study

In the diagnostic system, this etiologic ambiguity is reflected in the peculiar use of the word Disorder. On one hand, it’s used as if it were a synonym for the traditional medical term Disease – a pathological condition defined by nature. On the other hand, a Disorder is a condition defined by man in the periodic ritual we call Revisions. Some Disorders approximate the Diseases of unknown etiology in medicine proper, regularly occurring collections of signs and symptoms, with clear borders, with familial tendencies, with longitudinal stability [a "course"], and with a consensus of a potential biological causality. But those particularly medical-ish Disorders uniformly lack laboratory [biomarker] confirmation. The majority of patients seeking care do not have those particularly medical-ish Disorders. They have the not-so-medical-ish Disorders that are created and maintained by committee – a Revision committee like the DSM-5 Task Force.

I am a psychoanalyst, a psychiatrist, an internist, and a person. In the privacy of my own mind, I use that distinction diagnostically. When I listen to a patient’s story, I find that my mind is thinking in one of those modes, and I reflexively check to make sure I’m not running on autopilot and going down a slippery slope on the way to making a categorical error, the bane of a person with multiple minds – thinking psychiatrically when I should be thinking medically, thinking psychoanalytically when I should be smelling Schizophrenia, diagnosing when I should be comforting. But in public, I don’t talk about that – I’m too bruised. I say this to aver the following – I have no wish for a diagnostic system like the DSM-II from now until the end of time. That’s not why I’m writing. I’m talking about it right now because the contemptuousness of the graphic in the last post is actually a part of the current system. The complaint about the inclusion of Neurosis in 1968 is a valid complaint – removed. If the psychoanalysts were that imperious before 1980, shame be upon them and they should go to time out – they’re gone. But there’s something else. That contempt is maintained as a cover for the arbitrariness of this current system, its lack of evidence base, its speculations, its medical-ness co-opted for reimbursement, and its use in the service of a beast of a pharmaceutical industry that’s had a field day with the DSM-III and its Disorders [the medical-ish and the not-so-medical-ish].

It might not sound like it, but I actually think the St. Louis Group was mostly on the up and up. They may have been too harsh about the motives of the analysts of their time, but somewhat on target about their behavior. As we’ve seen, they fudged way more than a little bit with the Feighner Criteria, implying a science base that doesn’t really seem to have been there. But I do think they genuinely thought psychiatry should be organized along more traditional medical lines, including diagnosis. And I expect they really did dream of a future psychiatry that stuck to the biological aspects of mental illness. I’m not even terribly mad about the end run of allying themselves with Robert Spitzer in the "invisible college." It was time for the pendulum to swing. That Spitzer didn’t seek other, balancing counsel was his mistake, not theirs. The St. Louis Group had a dream, and like all dreams – it was heavily informed by hopes and wishes for the future, not a present reality. They claimed way more than they could deliver without exaggerating, so they exaggerated, even cheated some. How they justified that is not ours to know any more than the exaggeration of the analysts. Maybe it’s just what people do in revolutions. What we do know now is that those exaggerations created a system that is currently a monster in its own right. Rather than the future the St. Louis Group and Robert Spitzer envisioned, we have a powerful subclass of corrupted scientist-entrepreneurs allied with the pharmaceutical industry that have been a malignant presence in psychiatry for so long that in the eyes of many, they define the profession.

^{We shall not cease from exploration.
And the end of all our exploring.
Will be to arrive where we started.
And know the place for the first time.}

Diagnostic criteria for 14 psychiatric illnesses [and for secondary depression] along with the validating evidence for these diagnostic categories comes from workers outside our group as well as from those within; it consists of studies of both outpatients and inpatients, of family studies, and of follow-up studies. These criteria are the most efficient currently available; however, it is expected that the criteria be tested and not be considered a final, closed system. It is expected that the criteria will change as various illnesses are studied by different groups. Such criteria provide a framework for comparison of data gathered in different centers, and serve to promote communication between investigators.

This communication presents specific diagnostic criteria for those adult psychiatric illnesses that have been sufficiently validated by precise clinical description, follow-up, and family studies to warrant their use in research as well as in clinical practice. These criteria are not intended as final for any illness. The criteria represent a distillation of our clinical research experience, and of the experiences of others cited in the references.

^{While no psychiatric syndrome has yet been fully validated by a complete series of steps, a great deal of work has been published indicating that substantial validation is possible. This communication is a summary of that work in the form of specific diagnostic criteria. The studies of validation for each illness are cited.}

^{In addition, we in this department have carried out a study of inter-rater reliability and validation of reliability with an 18-month follow-up study of 314 psychiatric emergency room patients [to be published] as well as a seven-year follow-up study of 87 psychiatric inpatients [to be published], each of whom was interviewed personally and systematically. There were four different raters in the emergency room study. Agreement ranged from 86% to 95% about diagnosis with diagnostic criteria similar to those outlined in this report. There were two different raters in the inpatient study; reliability between those raters was 92%. In the emergency room study and in the inpatient study, validity, as determined by correctly predicting diagnosis at follow-up by criteria such as those of this report, was 93% and 92%, respectively.}

Returning to John Feighner’s later narrative [1989] looking back over his residency days:

^{Also, with the progressive use of lithium and other more specific pharmacological treatments at that time, it seemed imperative to me that we refine our diagnostic criteria to assist us in selecting specific treatments for specific patients and to improve communication between research centers.}

Spitzer first came to the university as a resident and student at the Columbia Center for Psychoanalytic Training and Research, after graduating from N.Y.U. School of Medicine in 1957. He had had a brilliant medical-school career, publishing in professional journals a series of well-received papers about childhood schizophrenia and reading disabilities…

At Columbia Psychoanalytic, however, Spitzer’s career faltered. Psychoanalysis was too abstract, too theoretical, and somehow his patients rarely seemed to improve. “I was always unsure that I was being helpful, and I was uncomfortable with not knowing what to do with their messiness,” he told me. “I don’t think I was uncomfortable listening and empathizing — I just didn’t know what the hell to do.” Spitzer managed to graduate, and secured a position as an instructor in the psychiatry department [he has held some version of the job ever since], but he is a man of tremendous drive and ambition—also a devoted contrarian—and he found teaching intellectually limiting…

It’s easy to read Spitzer’s quote and allow it to become a Rorschach inkblot – something to contain any number of thoughts, opinions, or interpretations of his true motives. That’s just the way we think about the DSM-III, a conundrum itself, filled with palace intrigue, old resentment, personae jockeying for power, people fighting over money. I can fill that quote up with thoughts of my own, like "That’s a false dichotomy! Those aren’t exclusive categories! How about both empirical research studies and clinical wisdom from long-term psychotherapy!" or "See, he admits the real controversy about DSM-III was a controversy about who were going to be the leaders! It was political!" I can feel ashamed and angry that my analytic predecessors didn’t directly deal with the problem of third party payments and strike a sensible compromise. I can still feel the sting of the invectives that came my way with the DSM-III revolution, and am not too far from still having a tear in the corner of my eye about having to change courses and leave a career path that fit me like a glove. Likewise, I’m a psychiatrist and I was really taken with the careful parsing of the major clinical syndromes, so I mourned the loss of subtlety that came with the DSM-III’s symptom lists and the accompanying structured interviews. All of this to say that this is hardly an area where I can claim to be able to transcend my own subjectivity. The personal impact was too great [but that doesn't mean I have to be quiet, just that I have to be careful].

^{…I recall a psychoanalyst and chair of a DSM-III oversight committee who commenting on a draft of DSM-III said, “There is so much more that we know.” By this, he meant that DSM-III did not include all of the knowledge that his fellow clinicians had painstakingly learned about human behavior and motivation from the intensive study of patients in long-term psychotherapy. In a sense, the real controversy about DSM-III was a controversy about who were the leaders in the profession and whether progress in our field was most likely to come from empirical research studies or from clinical wisdom collected by intensive long-term psychotherapy.}

The Advent of the “Feighner Criteria”
by John P. Feighner
Department of Psychiatry, University of California San Diego
and the Feighner Research Institute
July 18, 1989

As a beginning resident in psychiatry at Barnes-Renard Hospital, Washington University Medical School in St. Louis, in 1966, it became painfully clear to me that the state of the art of psychiatric diagnoses was frankly in a mess. Trying to draw conclusions from the scientific literature with regards to virtually any area of the major psychiatric disorders was extremely difficult. Patients that were described in one article as having acute schizophrenia, showing a very positive response to electroconvulsive therapy ECT, seemed quite different from patients described in other articles as having a similar disorder and responding poorly to ECT but positively to neuroleptics. Also, with the progressive use of lithium and other more specific pharmacological treatments at that time, it seemed imperative to me that we refine our diagnostic criteria to assist us in selecting specific treatments for specific patients and to improve communication between research centers.

At that time in the Department of Psychiatry at Washington University School of Medicine, there was an enormous amount of epidemiological and natural history studies being done in a variety of psychiatric disorders. In my contacts with numerous people in the department, particularly Dr. Eli Robins and his basic “no nonsense data oriented approach,” it was apparent that something should be done and could be done to better delineate the major psychiatric syndromes. In my third year as a resident, I began to develop specific diagnostic criteria for the affective disorders; and in so doing I discussed with Drs. Robins, Sam Guze, and George Winokur the possibility of expanding these criteria to include the major psychiatric disorders. During my fourth year as a chief resident, I subsequently pursued this more vigorously and with my coauthors set up a Tuesday afternoon committee. At that time I reviewed close to 1,000 articles in the then existing literature and distilled this data into proposed criteria for the various disorders that we were working on at the time. These criteria were refined by the committee’s work, which they subsequently published. It was an exciting time to be in Washington University’s Department of Psychiatry and to work closely with the existing faculty.

One of the things I learned in this process is that, even as a resident, if you have a specific idea and are willing to commit to that idea, much can be accomplished with persistence and hard work. In general I have been very pleased at the overall direction that psychiatric nosology has taken since the advent of our paper, which has generally become known as the “Feighner Criteria.” Certainly, it was my idea and initial energy that started this committee to work, but without the astute, competent, and highly informed contributions of the other authors, it would never have been possible to complete the task that was done in 1969-1970. As an aside, when it came time to take my psychiatric board exam, having reviewed all of the papers necessary to formulate these criteria, it was, as the saying goes, “like a walk in the park.” It was fun and exciting to have had the support of the department and to be provided with the resources of the department to pursue these endeavors. In the training of any clinician, I think it is important to expose all of us to the research process because I think, frankly, it makes more astute clinicians out of us and makes us better able to evaluate scientific progress as it evolves.

---

[The Sd® and SSCJ indicate that this paper has been cited in over 3,950 publications, making it the most-cited paper ever published in a psychiatric journal.]

I came across this reference [Feighner's statement] in the middle of writing this post, while I was looking for a copy of the original paper on-line. I had in mind going through the article to see if I could clarify and reference why I thought of it and its DSM-III expansion as "dumbed down", a simplification, maybe even a trivialization of the subtleties of psychiatric illness independent of my own interests and biases. But after I read his description of the way the criteria came into being, my re-reading of the article took on a different coloring. My former job was Residency Training Director, and I would’ve been glad to have this industrious resident. I read the article as mental illness as seen by a good third year resident, a time in training when you’ve mastered being around mental ill people and are finally beginning to have a map of the territory. And I see why I reacted to the DSM-III the way I did. It’s that very view of mental illness at the time when the picture is just coming together as the blueprint for the learning up ahead. It’s enough of an anchor to allow one to begin to tolerate the confusion and ambiguity that characterizes human behavior, mental life, and mental illness – frozen in time, a snapshot of a developmental stage early in a long process.

1. Clinical Description
2. Laboratory Studies
3. Delimitation from Other Disorders
4. Follow-up Study
5. Family Study

While no psychiatric syndrome has yet been fully validated by a complete series of steps, a great deal of work has been published indicating that substantial validation is possible. This communication is a summary of that work in the form of specific diagnostic criteria.

In addition, we in this department have carried out a study of interrater reliability and validation of reliability with an 18-month follow-up study of 314 psychiatric emergency room patients (to be published) as well as a seven-year follow-up study of 87 psychiatric inpatients (to be published), each of whom was interviewed personally and systematically. There were four different raters in the emergency room study. Agreement ranged from 86% to 95% about diagnosis with diagnostic criteria similar to those outlined in this report. There were two different raters in the inpatient study ; reliability between those raters was 92%. In the emergency room study and in the inpatient study, validity, as determined by correctly predicting diagnosis at follow-up by criteria such as those of this report, was 93% and 92%, respectively.

^{It will be apparent below that certain diagnoses are mutually exclusive (primary affective disorders and schizophrenia), while others may be made in the same patient (antisocial personality disorder with alcoholism or drug dependency ; hysteria or anxiety neurosis with secondary depression). More work will be necessary before the full significance of various diagnostic combinations becomes evident.}

An outsider-insider’s views about revising the DSMs
^{by Spitzer RL.}
Journal of Abnormal Psychology. 1991 100[3]:294-296.

…In discussing the development of DSM-III, Widiger et al. noted the increasing role of empirical validation in psychiatry and the five phases for validating a psychiatric diagnosis proposed by Robins and Guze. Their approach led Robins and Guze to recognize only 16 diagnoses that they believed had been validated by follow-up and family studies [Feighner et al., 1972]. Clearly, if the DSM-III Task Force had adopted this strategy, as Widiger et al. implied, it would not have recommended that DSM-III include over 200 categories — most of which were included on the basis of expert clinical judgment [face validity] alone. The Task Force recognized, correctly I believe, that limiting DSM-III to only those categories that had been fully validated by empirical studies would be at the least a serious obstacle to the widespread use of the manual by mental health professionals. The approach that was adopted by the DSM-III Task Force, from Robins and Guze’s recommendations, was the use of specified diagnostic criteria for virtually all of the disorders—the major innovation of DSM-III.

Expert Consensus Versus Empirical Basis: It is understandable that Widiger et al. (1991) emphasized the many ways in which DSM-IV can improve on the process involved in the development of DSM-III and DSM-III-R, such as by systematically reviewing the relevant literature, documenting the rationale for all changes, and conducting many focused field trials. The DSM-IV leadership is to be congratulated for the tremendous effort that is involved in these projects. However, I am troubled by the tendency [intended or not] to play down the major role that expert consensus will have in the final decision-making process for DSM-IV. My own prediction is that when final decisions are made about DSM-IV, they will still be based primarily on expert consensus, rather than on data, as was the case with the DSM-III and DSM-III-R…

^{Are DSM-III and DSM-II1-R Atheoretical With Regard to Etiology? As is well known, the developers of DSM-III and DSM-IIIR claim that—with only a few exceptions, such as the organic mental disorders and adjustment disorder—the classification does not subscribe to any particular etiologic theories. For example, some investigators who have studied panic disorder believe that the disorder arises from learned avoidance responses to conditioned somatic symptoms of anxiety; other investigators believe the disorder results from a dysregulation of biological systems mediating separation anxiety. However, neither etiologic theory has any effect on the diagnostic criteria for the disorder, which are solely based on the descriptive features of the disorder. Therefore, I am puzzled by Millon’s (1991) statement that "despite assertions to the contrary, recent DSMs are a product of implicit causal or etiologic speculation"…}

^{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.}

On Values in Recent American Psychiatric Classification
^{by John Z. Sadler, Yosaf F. Huglus and George J. Agich}
The Journal of Medicine and Philosophy 1994  19:261-277.

^{The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed.}

^{One reason why value conflict is not seen as such by DSM-IV – and its predecessors, to be sure – is the apparent adherence of the Task Force to a particular view of classification and science. A large literature establishes that medical practice [and scientific practice as well], including classification, necessarily involves value commitments… For a psychiatric classification example, consider the above mentioned dispute over DSM-III/III-R’s descriptive terms. Psychodynamically oriented psychiatrists believe the nosology ignored theoretically important terms essential to their practice [such as "neurosis" and "defense mechanism"]. The syndromatic approach used by DSMIII/ III-R, however, met the descriptive needs of biological psychiatry much better… The implicit value choice made by the authors of DSM-III/III-R was that the biological descriptive approach was more important than the psychodynamic descriptive approach, presumably for a variety of reasons. We doubt that this preference for biological approaches that is implicit in the descriptive, syndromatic approach was consciously intended by the authors of the DSM-III and III-R. Instead, we suspect that this preference and its associated commitments were more the byproduct of a naive view of science and psychiatric nosology as value-free or value-neutral… Although the notion of value-free or value-neutral science has been discredited by a large number of authors, philosophers and scientists… the view nonetheless persists. The reasons for the rejection of value-neutral language are many, but can be summarily stated:}

^{Values, not cognitions, determine what we select as "important," "crucial," "central," "decisive," or "related." In other words, values lend structure to the field of attention, pre-defining background and foreground, and clustering disparate items into groups. Consequently, "descriptive" statements about psychopathology issue from presupposed value stances that conceal their own deeper sources, compatibilities, and incompatibilities…}

Values and Assumptions in the Development of DSM-III and DSM-III-R:
^{An Insider’s Perspective and a Belated Response to Sadler, Hulgus, and Agich’s “On Values in Recent American Psychiatric Classification”
by ROBERT L. SPITZER, M.D.}
Journal of Nervous and Mental Disease. 2001 189:351–359.

…Let us broadly divide etiological perspectives into two major … groupings: according to the biological perspective, the causes of mental disorders will ultimately be shown to be disturbances in biological functioning that are relatively independent of life experience; according to the psychological perspective, the major causes of mental disorders will ultimately be shown to be disturbances in life experiences. The author challenges anyone to show how grouping disorders together on the basis of their shared descriptive features … inherently suggests favoring either perspective.

…I recall a psychoanalyst and chair of a DSM-III oversight committee who commenting on a draft of DSM-III said, “There is so much more that we know.” By this, he meant that DSM-III did not include all of the knowledge that his fellow clinicians had painstakingly learned about human behavior and motivation from the intensive study of patients in long-term psychotherapy. In a sense, the real controversy about DSM-III was a controversy about who were the leaders in the profession and whether progress in our field was most likely to come from empirical research studies or from clinical wisdom collected by intensive long-term psychotherapy. It is hard to see how the controversy would have been conducted at a higher level if the DSM-III committee had made any clearer their value commitments.

Sadler et al. are correct when they assert that basic values, assumptions, and commitments determine how developers of a classification system of mental disorders approach their difficult task. In this paper, we have presented those values, assumptions, and commitments, which were, for the most part, widely known and were contained in the ongoing DSM-III and DSM-IIII-R literature. It is not true that DSM-III and DSM-III-R gave greater emphasis to reliability than to validity, and it is not true that the DSM atheoretical approach with regard to etiology is implicitly biased toward a particular etiological perspective [organic or behavioral].

1. no a priori principles
2. descriptive criteria
3. follow-up
4. family studies
5. exclusivity
6. reliability
7. undiagnosed psychiatric disorder

Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia
^{BY ELI ROBINS. M.D.AND SAMUEL B. GUZE, M.D.}
American Journal of Psychiatry. 1970 126[7]:107-111.

Since Bleuler, psychiatrists have recognized that the diagnosis of schizophrenia includes a number of different disorders. We are interested in distinguishing these various disorders as part of our long-standing concern with developing a valid classification for psychiatric illnesses. We believe that a valid classification is an essential step in science. In medicine, and hence in psychiatry, classification is diagnosis.

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…

Diagnostic criteria for use in psychiatric research
^{by FEIGHNER, J. P., ROBINS, E., GUZE, S. B., WOODRUFF, R. A., WINOKUR, G. & MONOZ, R.}
Archives of General Psychiatry. 1972 26:57-63.

This communication presents specific diagnostic criteria for those adult psychiatric illnesses that have been sufficiently validated by precise clinical description, follow-up, and family studies to warrant their use in research as well as in clinical practice. These criteria are not intended as final for any illness. The criteria represent a distillation of our clinical research experience, and of the experiences of others cited in the references. This communication is meant to provide common ground for different research groups so that diagnostic definitions can be emended constructively as further studies are completed. The use of formal diagnostic criteria by a number of groups, regardless of whether their interests are clinical, psychodynamic, pharmacologic, chemical, neuropsychological, or neurophysiological, will result in a solution of the problem of whether patients described by different groups are comparable. This first and crucial taxonomic step should expedite psychiatric investigation.

Diagnosis has functions as important in psychiatry as elsewhere in medicine. Psychiatric diagnoses based on studies of natural history permit prediction of course and outcome, allow planning for both immediate and long-term treatment, and make communication possible between psychiatrists and other physicians, as well as among psychiatrists themselves. Such functions are of obvious importance in research. 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…

Primary Affective Disorders.

Depression.

—For a diagnosis of depression, A through C are required.
A. Dysphoric mood characterized by symptoms such as the following: depressed, sad, blue, despondent, hopeless, "down in the dumps," irritable, fearful, worried, or discouraged.
B. At least five of the following criteria are required for "definite" depression; four are required for "probable" depression.
1. Poor appetite or weight loss (positive if 2 lb a week or 10 lb or more a year when not dieting).
2. Sleep difficulty (include insomnia or hypersomnia).
3. Loss of energy, eg, fatigability, tiredness.
4. Agitation or retardation.
5. Loss of interest in usual activities, or decrease in sexual drive.
6. Feelings of self-reproach or guilt (either may be delusional).
7. Complaints of or actually diminished ability to think or concentrate, such as slow thinking or mixed-up thoughts.
8. Recurrent thoughts of death or suicide, including thoughts of wishing to be dead.
C. A psychiatric illness lasting at least one month with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome. (Patients with life-threatening or incapacitating medical illness preceding and paralleling the depression do not receive the diagnosis of primary depression.)

Mania.

—For a diagnosis of mania, A through C are required.
A. Euphoria or irritability.
B. At least three of the following symptom categories must also be present.
1. Hyperactivity (includes motor, social, and sexual activity).
2. Push of speech (pressure to keep talking).
3. Flight of ideas (racing thoughts).
4. Grandiosity (may be delusional).
5. Decreased sleep.
6. Distractibility.
C. A psychiatric illness lasting at least two weeks with no preexisting psychiatric conditions such as schizophrenia, anxiety neurosis, phobic neurosis, obsessive compulsive neurosis, hysteria, alcoholism, drug dependency, antisocial personality, homosexuality and other sexual deviations, mental retardation, or organic brain syndrome.

A Re-analysis of the Reliability of Psychiatric Diagnosis
^{By ROBERT L. SPITZER and JOSEPH L. FLEISS}
British Journal of Psychiatry. 1974 125:341-347.

^{… 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. For example, for a diagnosis of the depressive form of primary affective disorder the three requirements are dysphoric mood, a psychiatric illness lasting at least one month with no other pre-existing psychiatric condition,and at least five of the following eight symptoms: poor appetite or weight loss; sleep difficulty; loss of energy; agitation or retardation; loss of interest in usual activities or decrease in sexual drive; feelings of self-reproach or guilt; complaints of or actually diminished ability to think or concentrate; and thoughts of death or suicide.}

^{A consequence of the St. Louis approach is the necessity for an ’undiagnosed psychiatric disorder’ category for those patients who do not meet any of the criteria for the specified diagnoses. In actual use, this category is applied to 20-30 per cent of newly-admitted in-patients. These two approaches, structuring the interview and specifying all diagnostic criteria, are being merged in a series of collaborative studies on the psychobiology of the depressive disorders sponsored by the N.I.M.H. Clinical Research Branch. We are confident that this merging will result not only in improved reliability but in improved validity which is, after all, our ultimate goal.}

One can only be awed by Robert Spitzer’s industry in those years. At the time, I was in analytic training in his building, the New York Psychiatric Institute. I had no idea of the flurry of activity going on upstairs. The building was always too hot, complicating staying alert in those after lunch classes. I now suspect that it was overheated by Spitzer’s energetic activities and endless debates.

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.

^{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…}

1. no a priori principles
2. descriptive criteria
3. follow-up
4. family studies
5. exclusivity
6. reliability
7. undiagnosed psychiatric disorder

A Warning Sign on the Road to DSM-V:
^{Beware of Its Unintended Consequences}
Psychiatric Times
By Allen Frances
June 26, 2009

The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V. Fortunately, the NIMH is now embarked on a fascinating effort to effect the real paradigm shift of basing diagnosis on biological findings. Unfortunately, this is years [if not decades] from fruition… So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality…

Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system. With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities…

Setting the Record Straight:
^{A Response to Frances Commentary on DSM-V}
Psychiatric Times
By Alan F. Schatzberg, MD, James H. Scully Jr, MD, David J. Kupfer, MD, Darrel A. Regier, MD, MPH
July 1, 2009

^{The DSM-III categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the system has not kept up with current thinking. Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism. Science has advanced, treatments have advanced, and clinical practice has advanced since Dr. Frances’ work on DSM-IV. The DSM will become irrelevant if it does not change to reflect these advances…}

APA and DSM-V:
^{Empty Promises}
Psychiatric Times
By Robert L. Spitzer, MD
July 2, 2009

^{The debate over DSM-V has unfortunately taken an ugly turn with the APA leadership suggesting that Dr. Frances’s and my motivation for critiquing DSM-V is financial. People familiar with this controversy might recall that it all began when I asked Darrel Regier if I could look at the minutes of DSM-V Task Force meetings so that I could keep up with the ongoing process. He explained that he could not do this because of confidentiality agreements that all DSM-V participants have been required to sign. Because of my strong belief that DSM has been and should always be a completely open process, I started my effort to get APA to change its ways. Read Dr Frances’ commentary on DSM-V and the APA’s response For brevity’s sake, I will limit my comments regarding APA’s response to Dr Frances’ commentary to the core issue of transparency. APA continues to maintain the empty rhetoric that the DSM-V process is the “most open and inclusive ever”…}

And the rest is history – a three year long debate ensued, often contentious, about the whole process. Those three articles were all published in one week in the month following the APA Annual Meeting in San Francisco. That was quite a week! Here are a few good references about the ongoing story [A Moment of Crisis in the History of American Psychiatry, Inside the Battle to Define Mental Illness, DSM-V: Getting Closer to Pathologizing Everyone?].

In the three years since that week in 2009, a lot has happened. It’s no longer a rhetorical conflict that involves a handful of psychiatrists – it involves the entire specialty of psychiatry, the other mental health professions, the psychopharmaceutical industry, the clinical research industries, the medical reimbursement industry, and help seeking patients far and wide. Of course, Drs. Spitzer, Frances, and Kupfer didn’t cause the conflict any more than the Archduke Francis Ferdinand and his Assassin caused World War I. Their differences were just a focal point for something much bigger than all of them. But as is the case in such situations, the something-much-bigger tends to get submerged in the bluster that follows.

Dr. Spitzer got mad first, and the thing that made him mad was the secrecy [and the process] of the DSM-5 Task Force. Dr. Frances agreed with him about the secrecy, and didn’t care much for the process either, but he stayed out of the fray until he heard the kind of thing the DSM-5 Task Force was thinking about adding eg the Psychosis Risk Syndrome. That played into his own concerns about medicating kids. Then he got mad too and spoke out. Why was that the last straw for him? Speaking of last straws, why did I get so noisy around that same time myself? I wasn’t in these guys league, having been an early casualty in this same DSM-III Revolution – not really on the other side but close enough for government work. I was five or six years retired, thinking little about psychiatry. But in the summer of 2009, two things happened. I started seeing patients as a volunteer and did a review of psychopharmacology as part of that. And I continued to read about Senator Grassley’s investigation into psychiatrists in high places who were crooks – one of whom was the Chairman of a Department I’m still a part of. I’d lived with the dramatic changes in psychiatry after leaving academia and adapted. I’d had a fine career, though it felt a bit like being in exile.

I know what made me so angry. I found out what Dr. Frances and Spitzer couldn’t possibly not have also known – that all was not as it appeared. Corruption was prevalent in our ranks, our literature, and our treatment recommendations to patients. I’m guessing that’s a part of why the secrecy bothered Dr. Spitzer and the Psychosis Risk Syndrome bothered Dr. Frances, among the other things they knew about because they’d been DSMers. They knew that the cuurrent directions in psychiatry had opened to door for rampant corruption and they were both aware of a coming crisis [the one we're in right now]. Did Drs. Kupfer and Regier know too? Were they part of the problem? They would’ve had to put cotton in their ears and wear dark glasses not to know. For one thing, corruption and secrecy are virtually synonyms.

At last, I reach the point of this post. Dr. Frances says above in his opening salvo, "descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift." That’s in the center of this in my mind. While the DSM-III Revolution was, on the surface, a move to make psychiatric diagnosis more scientific and more reliable, it was also driven to exorcise unproven ideology from the diagnostic system and psychiatry at large – at that time specifically psychoanalysis. And that’s what happened. And then…

Psychiatry Should Stay Comfortable In Its Own Skin
^{No Good Comes From Overselling Our Science Base}
DSM-5 in Distress : Psychology Today
by Allen J. Frances, M.D.
June 2, 2011

But there is one source of great and continuing frustration in our field. We are in the midst of a neuroscience revolution that has provided a miraculous and tantalizing window into normal brain functioning. But the vast accumulation of basic science knowledge revealing the mechanisms of normal brain functioning has shed relatively little light on the far greater complexity of what causes psychopathology. As a result, the neuroscience revolution has so far had almost no impact on how we diagnose and treat our patients. The inherent difficulty in translating from basic to clinical science guarantees that we will make only slow progress in unraveling the multitudinous heterogeneity of brain malfunctions that cause mental illness. DSM 5 initially got into trouble because it was ambitious to jump-start a "paradigm shift" in psychiatry – well before there was sufficient scientific knowledge to make this possible. We would not have been burdened by all the dangerous DSM 5 suggestions for unproven diagnoses if its workgroups had not been given the green light to be recklessly creative in promoting their pet innovations… Psychiatry does itself no good when we oversell ourselves…

Psychiatry should live comfortably within its own skin, not make excessive claims. We are largely successful at doing what we do best in our current clinical work. We are eager to advance and incorporate the ever advancing scientific understanding of mental disorders and how best to treat them. But [except for Alzheimer's], psychiatry is likely decades away from anything resembling a paradigm shift. It’s always best to modestly under-promise and then strive to over deliver. The sad tale of DSM 5 is a succession of overblown promises and then disappointing and potentially dangerous under performance. Psychiatry should work hard at what we do well – without reaching beyond our current grasp or raising expectations we can’t possibly fulfill…

The soft spot of the DSM-III was nowhere more evident than in the creation of the category of Major Depressive Disorder. It was in the area of depression that both the psychologically minded and the biologically oriented had made the most progress. In certain depressions, there was a statistically valid marker [not digital as everyone wished - but evidence nonetheless] and somewhat robust treatments [also not digital as everyone wished]. In the biopsychosocial realm, the relationship of some depressions was well understood in relationship to attachment and loss, and the mental mechanisms of some depressions as well as pathological grief had achieved a level of fairly clear clinical usefulness. All of those things hinged on the careful clinical discrimination of the depressions – aka diagnosis. In his zeal to make sure that his DSM-III was free of the problems of the past, Spitzer’s Major Depressive Disorder blunted the very real possibilities of the kind of advances psychiatry actually longs for. The Czar had to be killed and the Red Guard had to re-educate the "Roaders." Any fractionation of depressive diagnosis might have opened the door to Neurosis. So the successes of the past, at the time in their infancy, went the way of the bath water – Depressive Neuroses and Melancholia alike – both descriptively definable. If he didn’t like the names, he could’ve changed them. And not-psychological became biological in the minds of many, who then flourished. That should have been expected and happened relatively quickly.

The stated goal of this DSM-5 Task Force was to insert yet another unproven ideology into the diagnostic system, and thereby reframe psychiatry [A Research Agenda for DSM-V]. I call that ideology clinical neuroscience, borrowing the term from Dr. Tom Insel, Chief of the NIMH, but you could call it neurobiology, or biological psychiatry, or brain science. Whatever you call it, it’s the belief that problems mental are brain/biology problems and that proof is just around the corner. In their prequel, the DSM-5 leaders predicted that the DSM-5 itself would be solidly grounded in biology by the time it was released, though they had to back off from that prediction recently [Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5].

Like the psychoanalysts in the 1950′s and 1960′s, the neuroscientists of the DSM-5 Task Force were so sure that they saw the future clearly that they lost sight of their Task [and relied on Force instead]. Their job was to carefully improve the terrain map of the desert, correcting the errors of earlier cartographers, adding new features only where justified and well documented. Instead, they gave in to their dreams. They failed to notice along the way that their critics weren’t their old enemies, but were rather the people that put them on the map in the first place. And when the second of the former Task Force chiefs, Allen Frances, joined the first, Robert Spitzer, in trying to point out their folly, they instead allied themselves with an APA President, Alan Schatzberg, who was himself a big part of the problem. They failed to see that some of the criticism was directed at his kind of thinking which had opened the door to run-away corruption, that instead of closing old loopholes, they were opening new ones. They ignored the advice about process, transparency, and detail, and ended up with a set of Field Trial outcomes that have us obsessing about their flawed methodology rather than gaining any clarification at all from their work product. Main line diagnoses like Schizophrenia, Major Depressive Disorder, and Generalized Anxiety Disorder with reliability well less than half the way between chance and full agreement among clinicians? Groan…

     ^{but he who studies medicine without patients does not go to sea at all…}