1 Boring Old Man

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.

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[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.