1 Boring Old Man

The missing phrase above is religious doctrine. The Future of an Illusion was written when Freud was around my age. He was speculating on why religious doctrines, some quite bizarre, have such an enormous ability to persist in a culture. His conclusion was that they represented our deepest wishes and assuaged our deepest fears – thus transcending reason. One could easily insert psychoanalysis and psychotherapy in place of religious doctrine as I did on my first reading of this book after a difficult year of being on the wrong side of the DSM-III revolution. I obviously survived the exercise, but it was an instructive lesson to consider. Freud’s book comes back to me now thinking about thirty plus years of neo-Kraepelinian psychiatry – inserting that phrase into Freud’s musings and wondering why it persists unmodified with such tenacity.

^{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…}

Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5
^{by David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.}
American Journal of Psychiatry 168:672-674, 2011.

^{In the initial stages of development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades. Throughout the last 25 years of psychiatric research, findings from genetics, neuroimaging, cognitive science, and pathophysiology have yielded important insights into diagnosis and treatment approaches for some debilitating mental disorders, including depression, schizophrenia, and bipolar disorder. In A Research Agenda for DSM-V, we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…}

In medicine, syndromes emerge over time from differences, sometimes absences – things that originally seemed unique but were later seen in other patients. They came to represent unique subgroups refined over time by an iterative process. Emil Kraepelin had done that for psychiatry. From the collage of sanatorium residents, he was able to identify several syndromes that were different from the majority, most of whom had senile dementia or late manifestations of neurosyphilis. Among the Insane with not syphilis and not senile dementia, he separated out cases of early dementia [Alzheimers Disease], early insanity [Dementia Praecox], and circular or affective insanity [Manic Depressive Illness]. Melancholia had already shown itself in antiquity as had Hysteria – more specifically what Freud called Conversion Hysteria. Kraepelin repeatedly revised his diagnostic schemes over his career. Eugen Bleuler took one of Kraepelin’s categories and refined it further, arriving at a different grouping within Dementia Praecox, adding and subtracting over time to create the new entity – Schizophrenia. The later psychoanalysts rejected Freud’s classification by symptom neurosis and classified by Personality Traits and Disorders. Later Psychiatrists made similar inroads in parsing the Depressive Syndromes along a variety of axes, and were on the track of adding a biological dimension to geneology, natural history, and unique qualities of depressive experience. So it’s not as if Psychiatrists in the twentieth century had ignored nosology. They had followed the same path as other physicians.

In the DSM-III Revision, the task was to remove previous etiological or ideological implications specifically from the classification of the neuroses, with the more unstated agenda of replacing them with those of the Saint Louis Group [6. the focus of psychiatric physicians should be on the biological aspects of illness] merged with a need to meet standards of medical illness that would be recognized by third party carriers. With the Kraepelinian Conditions, the medical model had always been more or less followed, so translation was easy. But with the other [non-Kraepelinian] diagnoses, this was a challenging task because the conditions most in play [the neuroses] had previously been assembled specifically by the absence of biological aspects. Now they had to be unpsychologized. So where the traditional medical syndromes had emerged  from collections of patients that were refined over an extended period of time, the new psychiatric classification reversed the process – defining syndromes anew under revised constraints that then collected the patients. It was simply not possible that it would represent naturally occurring illnesses. And the core assumptions remained unchanged in subsequent revisions.

One can only guess why the commonest of diagnoses was the most mangled of the lot – the depressions – which were all included under a single umbrella. My guess is that they felt if they made any fractionation in depression, no matter what they did, there would be a large subcategory left that would be used to replace Depressive Neurosis, independent from what they called it [and they would’ve been right – we probably would’ve done that]. As it turned out, they initially included a category, Atypical Depression, but it was later dropped because it became the one most commonly used diagnosis. Besides being pretty funny that the most typical depression was Atypical Depression, that says something about the worth of their Major Depressive Disorder category.

With the coming of the DSM-5, the leaders of the Task Force apparently planned to revise the classification along actual biological lines – finally living the dream and abandoning any remnants of the atheoretical orientation that remained. The pharmaceutical industry had turned the diversity and the etiologic ambiguity of the DSM-III to their advantage. While it made proof of efficacy difficult, the size of the market and the implications of chemical imbalance more than made up for their troubles. Other researchers fared much less well, doomed from the start by these broad and arbitrary categories. Even if there are biomarkers or specific treatments for subgroups embedded within these categories, they remain undetectable – lost in the crowd. The hopefulness of the 2002 Research Agenda for the DSM-5 seemed naive even then. But the behavior of the Task Force now, given the cascade of revelations and the non-results in the intervening decade, defies simple explanations.