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Posted on Saturday 12 May 2012

The Robins and Guze article that lead to the DSM-III Revolution was accepted for publication in January 1970, not long after the DSM-II came out – highlighting the fact that the conflict between nature and nurture was living and well before its ink dried. While it’s seen as a Manifesto, it’s only a few lines long:

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…}

The essence of their approach [the St.Louis Group] was to move psychiatry to a diagnostic system based on systematic studies rather than expert opinion. In 1972, they followed with a seminal article laying out sixteen psychiatric diagnoses with descriptive criteria that they considered to be research level diagnoses, now known as the Feighner Criteria which stressed descriptive criteria, follow-up, and family studies as the alternative to "best clinical judgement and experience" AKA expert opinions used in the DSM-I and DSM-II:

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…}

Here’s a sampler of the Feighner Criteria [that might look real familiar]:

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.

Poor appetite or weight loss (positive if 2 lb a week or 10 lb or more a year when not dieting).

Sleep difficulty (include insomnia or hypersomnia).

Loss of energy, eg, fatigability, tiredness.

Agitation or retardation.

Loss of interest in usual activities, or decrease in sexual drive.

Feelings of self-reproach or guilt (either may be delusional).

Complaints of or actually diminished ability to think or concentrate, such as slow thinking or mixed-up thoughts.

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.

Hyperactivity (includes motor, social, and sexual activity).

Push of speech (pressure to keep talking).

Flight of ideas (racing thoughts).

Grandiosity (may be delusional).

Decreased sleep.

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.}

So to no a priori principles, descriptive criteria, follow-up, and family studies, they’ve added mutual exclusivity [see C. in each case]. There’s essentially no comorbidity allowed in these criteria. Robert Spitzer and Statistician Joseph Fleiss added Kappa to the mix two years later – concretely including reliability in the mixture [see box scores and kappa…, self-evident…]:

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.}

In this 1974 paper, they did a meta-analysis of previous inter-rater reliability studies using their Kappa for comparisons [see box scores and kappa…]. In talking about the Feighner Criteria, Spitzer mentions one of the consequences of having such a tightly defined system, "In actual use, this category is applied to 20-30 per cent of newly-admitted in-patients" speaking of his own study. There were people left over that didn’t fit anybody’s diagnostic criteria. They were unsullied by using undiagnosed psychiatric disorder, adding yet another item to the list. He mentioned an N.I.M.H. collaborative study on the psychobiology of the depressive disorders, where he next focused his attention. And it expanded outside the boundaries of depressive illness. Like the Feighner Criteria, the N.I.M.H. Research Diagnostic Criteria [RDC] were advertised as research criteria, but they were headed for your town sooner rather than later as the new DSM-III.

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.

This next study was published as the time for the release of the DSM-III neared. The Research Diagnostic Criteria were a refined subset from the earlier Feighner Criteria. It was to be the reliability study for the coming release of the new diagnostic manual.

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…}

This is a complex paper. I think it’s the one that justified ‘lumping’ the depressions so I’ll likely be back to it later. But for the moment, it’s a message from a time when men were men, and Kappa was KAPPA:

Little wonder Dr. Spitzer introduced his DSM-III in 1980 to a standing ovation at the APA. In a few short years, he had mustered the forces to create a new diagnostic system backed by a hard science – something new for the likes of Psychiatry. The assemblage was at least clapping for his and his colleagues’ accomplishment, and whether you agree with the product or not, you’ve got to give them credit for building it – a Rosie the Riveter level task extraordinaire. Here are the nuts and bolts for review:

no a priori principles
descriptive criteria
follow-up
family studies
exclusivity
reliability
undiagnosed psychiatric disorder

Bernard Carroll

May 13, 2012 | 1:16 AM

You give a good account here of the idealized agenda though the 1970s. The reality fell short of this ideal. The St. Louis group gave a nod to the need for ongoing emendation as further studies are completed. The revisions of DSM-III were never based on evidence from studies, however, but on ad hoc group expert opinion replacing magisterial expert opinion.

The St. Louis group also failed to deliver on the Robins-Guze recommendation to include follow-up and family studies in the diagnostic criteria. None of the Feighner criteria definitions included follow-up, and only one (schizophrenia) included family history. Needless to say, none of the DSM-III criteria included these key elements, either.

The entire DSM-III exercise was a confidence trick, engineered by the APA following the principles of pragmatism, palatability, and payoff for administrative needs. Clinical science took a back seat. It still does, apparently, in DSM-5.
Mickey

May 13, 2012 | 9:04 AM

Thanks for that history. I missed that part of the story. I know that this post is Myth, but I wanted to get the Myth down on paper. Some see Myths as the emergence of a collective unconscious – in the tradition of Jung. Others see them as you do, as tricks – anything but unconscious. And then there’s Freud, who saw them as something like dreams which he thought were wishes and compromises disguised to make them look good, or right. Whatever choice one makes here in conceptualizing things, all is not what it appears to be. And with the DSM-III, it looks to me like there were layers and layers of all of the above that continue to haunt us into the present and look like they’re aiming for the future if allowed…
Donald Klein

May 13, 2012 | 5:21 PM

One of the absurdities is that the revered Robins-Guze article, 1970, cited above, specifically referred to schizophrenia — arguing – I think correctly – that there was overwhelming evidence for splitting schizophrenia into two classes – good and poor premorbid – note this is a patient history based decision – not current symptomatic based.
Evidence is largely the marked difference in prognosis, which , of course, depends on follow up.
This was selected by R-G as the most clear cut nosological distinction.
However, none of the DSMs to date have affirmed this.
Don Klein

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