1 Boring Old Man

^{For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed  by evidence – not always convincing – to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors. The major justification for the generally atheoretical approach taken in DSM-III with regard to etiology is that the inclusion of etiological theories would be an obstacle to use of the manual by clinicians of varying theoretical orientations, since it would not be possible to present all reasonable etiologic theories for each disorder.}
^{DSM-III, page 6.}

The revision of the Diagnostic and Statistical Manual of Mental Disorders in 1980 was more like the Treaty of Versailles at the end of World War I than any consensus of psychiatric thought about diagnosis. Psychiatry had always had Diseases, at least since Emil Kraepelin early in the century – Schizophrenia, Manic-Depressive Illness, Melancholia, etc – the classic psychiatric syndromes. These illnesses were accepted as medical model conditions by most – a collection of signs and symptoms, a somewhat predictable course, the suggestion of genetic factors in family histories, biological approaches to treatment, and something of a consensus that there would come a day when a a biological substrata would be identified. In my mind, these were the Kraepelinian Diseases.

For a variety of reasons, there was a need to purge psychiatry of psychological causation and move to a medical model for the non-Kraepelinian mental illnesses too. The DSM-III did that – lists of symptoms gathered into syndromes called Disorders with no mention of etiology, analogous to or equated with medical diseases.. There was a powerful injunction to eliminate the psychoanalytic concept of neurosis. So in the process of translating the version of syndromes in the DSM-II, there were some odd compromises. The classic Kraepelinian Depression [Melancholia] and the more Freudian Depressive Neurosis were rolled into one category – Major Depressive Disorder. Additionally, the Kraepelinian Manic Depressive Disorder was expanded to cover a greater cohort than before.

^{Perhaps even more significant, Bob and DSM-III helped to save psychiatry as a medical specialty. The previous lack of a proper diagnostic system had set psychiatry adrift – lurching toward hermeneutics and away from healing. DSM-III anchored psychiatry back to medicine and science. Before it,  psychiatric diagnosis was  ignored and virtually useless. Now it was the center of every clinical, research, teaching, forensic conversation. Psychiatric research had lagged medicine – now it is the second best funded [after internal medicine] in most medical schools.}

I would guess that any new paradigm begins with some level of illusion and banks on the future. Likewise, students of the history of science bank on the rise and fall of scientific paradigms for thesis topics guaranteed to insure graduation. It’s easy to see the failings of the last new great idea when you’re in possession of the next one – the promise of the future trumps the tarnished glory of the past.  In addition, the late arrivals to the "old ways" had come at a time when the warts were already showing, and weren’t so enraptured as their predecessors. Aaron Beck, featured speaker at the coming APA, was such a person – a psychoanalyst who changed directions and created Cognitive Behavior Therapy. Two others have already been mentioned in this post – Robert Spitzer and Allen Frances, both graduates of the Columbia Psychoanalytic Institute, both of whom went on to make valuable contributions to the new psychiatry as the principle architects of the DSM revisions that introduced and sustained it. I expect that being in on the downside of an earlier paradigm imparts some wisdom and perspective that carries over to the next. But the future graduate theses about neo-Kraepelinian psychiatry will unlikely follow the typical formula of paradigm ascendency ultimately ending with paradigm exhaustion. There will be a section in the middle about unprecedented scientific corruption that alters the plot line and turns it into something more like a dark summer beach thriller than science docudrama.

Did the DSM-III cause the corruption? Or was it influenced secretively by the Pharmaceutical Industry that took such advantage as the story has played out? I’m told by people who should know that neither was the case, and I have no reason for doubts – but I don’t personally know. But the DSM-III and the resultant changes in psychiatry certainly opened the door wide for the possibility. The next full revision, the DSM-IV, was published in 1994 having been in the works for several years before. Here are some of my old slides showing the timelines of the FDA drug approvals:

By 1994, should the framers of the DSM-IV have known about the deceitful science that would flood psychiatry journals and co-opt so many psychiatrists that was coming? Could they have known? Did they know? What they did know was that Pharmaceutical Industry money was flowing into psychiatry departments at very welcomed rates. I think back then, it was seen as a healthy alliance between academia and industry forged for the greater good. The Clinical Research Industry was in its infancy. By 1994, the enthusiasm for the SSRIs had not yet waned, though we know that the safety and efficacy issues were being questioned against a heavy defense. From my fly-on-the-wall position, two things stand out in memory. First, I heard Dr. Richard Borison give a presentation in the mid-1980s and immediately identified him as a "bought man" [which he turned out to be, busted in 1996]. The fact that our new chairman thought he was great had something to do with my own exodus from academia. Second, I was in Atlanta Georgia. I heard the story that Dr. Charles Nemeroff took his opening tour of facilities as chairman at Emory in a chauffeured Rolls Royce; I looked over his voluminous Curriculum Vita which was circulated; and I met him – all in 1991. The Richter Scale reading was well over 7.0. But those were local experiences and I never generalized those perceptions myself to be as ominous as they turned out to be.