1 Boring Old Man

An open question for another day is "why didn’t the DSM-III ever correct early mistakes, iterate, find some way to actually become evidence-based in fact rather than just in rhetoric?" While it grew to almost 300 categories from the 15 or so in John Feighner’s first shot – its core changed little as it passed through several revisions. I suppose that it was inevitable that the second dream from St. Louis, a biologically based diagnostic system and psychiatry, would emerge from the whitespace into the actual print. Certainly, the specialty of psychiatry had already made the leap by becoming predominantly biological in its own eyes, in the eyes of the Insurers, and in the eyes of the public. The thing that stood in front of the dream from St. Louis of a neo-Kraepelinian psychiatry was no longer the Freudians or other non-biologists, it was the very pillars of their own movement: evidence, biomarkers, laboratory work – AKA proof [to state the obvious]. It was still lacking.

By the turn of this century, psychiatry was heading for a crisis of biological reductionism that made the mid-century psychoanalysts look like rank amateurs. The escalating appetite of the pharmaceutical industry and the corrupted alliances obvious by the early 2000s were going to nova at some point. It was just a matter of time. Yet the DSM-5 leaders had become so taken with the rhetoric of the hour that they believed it – some because of exciting technologies, some from arrogance and other unsavory forces, and some from the kernel sowed by the neo-Kraepelinians [whose DSM actually had impeded legitimate progress in biological research]. But still they pressed ahead. This would be the public launch of the new age of clinical neuroscience, finally realized. They announced it loudly and spent a lot of time having conferences and meetings being pioneers together behind closed doors [preaching transparency to an unbelieving audience]. By the time they realized that their necessary proofs weren’t materializing, their critics were growing louder, the scandals were becoming everyday fare, pharma was moving to greener pastures, and even their predecessors were trying to help them see their folly. They were hopelessly behind schedule, empty handed, and unwilling to change directions.

Things came to a head last week with the release of the results from their Field Trials.  The silly changes they’d refused to budge on were dismal flops as predicted. But worse, the tried and true diagnostic categories like Generalized Anxiety Disorder, Major Depressive Disorder, even Schizophrenia had results in a range equal to or below those from the pre-1980 system [their claim that they’re not comparable appropriately falls on deaf ears]. Either the whole enterprise has been for naught, or more likely, this bunch just doesn’t know what they’re doing. They know how to meet together and speak of grand plans and bask in the dreams of our fathers supplemented with thirty years of basic science [that no one can get to translate to the bedside]. But they didn’t know that their real calling was to leave the dreams from St. Louis for another time, and finally put the dreams of young John Feighner on a solid footing by giving us the best that descriptive criteria can give while we pass the decades it will be before there’s a viable alternative.