1 Boring Old Man

<sup>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 Five Phases
1.Clinical Description
In general, the first step is to describe the clinical picture of the disorder. This may be a single striking clinical feature or a combination of clinical features thought to be associated with one another. Race, sex, age at onset, precipitating factors, and other items may be used to define the clinical picture more precisely. The clinical picture thus does not include only symptoms.
2. Laboratory Studies
Included among laboratory studies are chemical, physiological, radiological, and anatomical (biopsy and autopsy) findings. Certain psychological tests, when shown to be reliable and reproducible, may also be considered laboratory studies in this context. Laboratory findings are generally more reliable, precise, and reproducible than are clinical descriptions. When consistent with a defined clinical picture they permit a more refined classification. Without such a defined clinical picture, their value may be considerably reduced. Unfortunately, consistent and reliable laboratory findings have not yet been demonstrated in the more common psychiatric disorders.
3. Delimitation from Other Disorders
Since similar clinical features and laboratory findings may be seen in patients suffering from different disorders (e.g., cough and blood in the sputum in lobar pneumonia, bronchiectasis, and bronchogenic carcinoma), it is necessary to specify exclusion criteria so that patients with other illnesses are not included in the group to be studied. These criteria should also permit exclusion of borderline cases and doubtful cases (an undiagnosed group) so that the index group may be as homogeneous as possible.
4. Follow-Up Study
The purpose of the follow-up study is to determine whether or not the original patients are suffering from some other defined disorder that could account for the original clinical picture. If they are suffering from another such illness, this finding suggests that the original patients did not comprise a homogeneous group and that it is necessary to modify the diagnostic criteria. In the absence of known etiology or pathogenesis, which is true of the more common psychiatric disorders, marked differences in outcome, such as between complete recovery and chronic illness, suggest that the group is not homogeneous. This latter point is not as compelling in suggesting diagnostic heterogeneity as is the finding of a change in diagnosis. The same illness may have a variable prognosis, but until we know more about the fundamental nature of the common psychiatric illnesses marked differences in outcome should be regarded as a challenge to the validity of the original diagnosis.
5. Family Study
Most psychiatric illnesses have been shown to run in families, whether the investigations were designed to study hereditary or environmental causes. Independent of the question of etiology, therefore, the finding of an increased prevalence of the same disorder among the close relatives of the original patients strongly indicates that one is dealing with a valid entity. We hope it is apparent that</sup>

^{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. The following criteria for establishing diagnostic validity in psychiatric illness have been described elsewhere and may be divided into five phase.}

• John Feighner was a psychiatery resident
• The criteria came from a literature search, not their own patients
• The criteria were hypothetical and had not been vetted by their 5 phases
• The five phases of diagnosis were not part of generating the criteria but rather cut and pasted from their earlier article
• The reliability figures were from somewhere else antedating the criteria [never ever published]

For Dr. Spitzer, charged with the task of redesigning the DSM-II, the Feighner Criteria were a godsend. They gave him a descriptive system to work with and allies who shared his disaffection with the psychoanalysts and their influence on the DSM-II. In his 1974 meta-analysis using Kappa, he demonstrated the unreliability of the DSM-II system and introduced the Feighner Criteria as a template for the Research Diagnostic Criteria [RDC] being tested in an NIMH study with Dr. Robins, a leader of the St. Louis Group [box scores and kappa…]. In 1978, they published reliability studies for the RDC and the DSM was born [the dreams of our fathers I…]. In 1991, in response to challenges that his criteria in the DSM-III had not followed the phases described in these early papers, Dr. Spitzer admitted that they had not validated the catergories as described by Robins and Guze, but continued to contend that there was no etiological bias towards biology, a point he made again in 2001 [dreams of our fathers II…].

In poring over this, I’ve come to see this process as having two distinct dreams. Everybody involved wanted the psychoanalytic influence gone. John Feighner was an young resident who dreamed of making concrete sense of psychiatric diagnosis using the literature to build a phenomenological template. Robert Spitzer had the same goal – a descriptive DSM-III like the one he created. He says he didn’t have an etiologic focus or bias. So I lump the two of them together. The St. Louis Group at Barnes Hospital had a definite etiologic focus – biology, data, biology. They dreamed of picking up where Kraepelin left off and building not only a neo-Kraepelinian DSM-III, but a neo-Kraepelinian psychiatry:

^{1. Psychiatry is a branch of medicine.}
^{2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.}
^{3. Psychiatry treats people who are sick and who require treatment.}
^{4. There is a boundary between the normal and the sick.}
^{5. There are discrete mental illnesses.  They are not myths, and there are many of them.}
^{6. The focus of psychiatric physicians should be on the biological aspects of illness.}
^{7. There should be an explicit and intentional concern with diagnosis and classification.}
^{8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.}
^{9. Statistical techniques should be used to improve reliability and validity.}