1 Boring Old Man

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.