by Darrel A. Regier, William E. Narrow, Diana E. Clarke, Helena C. Kraemer, S. Janet Kuramoto, Emily A. Kuhl, and David J. KupferAmerican Journal of Psychiatry. 2013 170:59-70.… Emil Kraepelin, who pioneered the separation of schizophrenic and affective psychoses into separate diagnostic groups in 1898, noted later in a 1920 publication — prescient in its anticipation of a current polygenetic environmental interaction model of mental disorders — that the strict separation of these categorical diagnoses was not supported. We are now coming to the end of the neoKraepelinian era initiated in the U.S. by Robins and Guze with a renewed appreciation of both the benefits and limitations of a strict categorical approach to mental disorder diagnosis.
The ultimate goal is to build on the progress achieved with categorical diagnoses by continuing with longitudinal follow-up of patients with these diagnoses, incorporating cross-cutting dimensional measures judiciously into the diagnoses where they prove useful, and in some cases recommending simple external tests [such as a cognitive test for mild neurocognitive disorder] that might improve the reliability and move toward a more mature scientific understanding of mental disorders. A noted philosopher of science, Carl Hempel, observed that “although most sciences start with a categorical classification of their subject matter, they often replace this with dimensions as more accurate measurements become possible”.
Clinicians think dimensionally and adjust treatments to target different symptom expressions in patients who may have the same categorical diagnosis. The intent of DSM-5 is to provide a diagnostic structure that will more fully support such dimensional assessments with diagnostic criteria revisions, specifiers, and cross-cutting symptom domain assessments. The goal is to support better measurement-based care and treatment outcome assessment in an era when quality measurement and personalized medicine will require new diagnostic approaches."
At the time this was written, the Task Force had given up on the attempt to add in biological parameters to the DSM-5 [Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5], but their hopes for the cross-cutting dimensions were still alive. I had taken cross-cutting dimensions to mean symptoms that crossed diagnostic entities, but I think there was more to it. They were actually looking for anything that could be measured or quantified, like the kind of thing Madhukar Trivedi was so obsessed with – called measurement based care. Reading it now, it seems as if the practice they were planning for psychiatrists was modeled on the Clinical Trial motif [rather than the other way around], and the measurement would be like those in Clinical Trials – a psychometric of some kind – as in the example above. In fact, we know that’s what they meant from Jane Costello’s DSM-5 resignation letter [summer of 09]:
| 03/27/2009 | Dr. Jane Costello resigns from the DSM-5 Child and Adolescent Disorders workgroup. In her letter of resignation, she said: "…The tipping point for me was the memo from David and Darrell on February 18, 2009, stating “Thus, we have decided that one if not the major difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V”, and going on to introduce an Instrument Assessment Study Group that will advise workgroups on the choice of old scale measures or the creation of new ones." |
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When I look at my timeline of the Affair d’Kupfer, it seems impossible not to conclude that their company with its Computerized Adaptive Testing had been planned to take advantage of the addition of dimensional measures to the DSM-5 from the very start. Insider trading, profiteering, whatever you want to call it, it’s a huge conflict of interest. So one part of my reading of this article was that it strengthened my suspicions of unethical play by Dr. Kupfer and his colleagues.
And while I’ve never been in love with the DSM-anything, it seems to me as if something kind of sleazy went on here that needs to see the light of day. This agenda for the DSM-5 was set over a decade ago. It was at a time when Steven Hyman was Director of the NIMH. And, as a matter of fact, Darrell Regier, who later became Co-Chair of the DSM-5 Task Force was coming to the end of a 25 year career at the NIMH. So somewhere around 2002, Steven Hyman agreed for the NIMH to go in with the APA to fund a long series of symposia based of their agenda for the DSM-V/5; Darrell Regier went from the NIMH to APIRE [American Psychiatric Institute for Research and Education] part of the American Psychiatric Foundation where he has primarily worked on the DSM-5; they published the A Research Agenda for the DSM-5; and, oh yeah, Dr. Robert Gibbons began to work on his CAT psychometrics funded by the NIMH. It now appears to me that there was a grand plan here – a grand plan to use the DSM-5 Revision to effect a major paradigm shift in psychiatry just like the DSM-III had been used in 1980 – a grand plan hatched by the power players at the NIMH, the APA, and the APF. History was going to repeat itself.
So no wonder they tried to wave off Drs. Spitzer and Frances. Those guys were still thinking about categories and reliability. They didn’t want their input. They wanted them to get out of the way of the new version of the new psychiatry. No wonder they spent so little time looking at the categories that were in need of work. They weren’t interested in descriptive categories anymore. Little surprise that they appointed an Instrument Assessment Study Group to come up with ways to measure dimensions. That was the plan in the first place. And perhaps it also explains the most striking feature of this DSM-5 Task Force. They were impervious to infuence from anything – huge changes in the climate of psychiatry, scandals galore, a major rebellion in the public forum, the exit of PHARMA from the scene, failed Field Trials. Nothing had any impact on their course. They were on a predefined mission.
Correct, the hundreds of pages of verbiage is just a beard on the pigeonholing device. Diagnoses in themselves are irrelevant. With any luck, they’ll have computer systems spitting out the “treatment” recommendations: Drug cocktails tailored to the individual’s genetic profile, weight, age, etc.
With any luck, this will be repellent to the general public and they’ll come to their senses and avoid psychiatry and hospitals, where they might be involuntarily treated with psychiatric drugs.
It seems we’re all “precariots” now. Perhaps prestige and access to gargantuan piles of money gives KOLs delusions of being secure in their certitude and authority. I’m thinking that they’re spinning their wheels madly to avoid finding out that they’re no more standing on solid ground than the people they believe they’re helping.
I am not defending the COI component but do you object to dimensional assessments? Do you think the categories we have are valid? Honestly, it does not trouble me that they entered into this process in 2001 with the notion that they wanted to scrap the categories. Human behavior just trikes me as so obviously dimensional. I would argue that psychoanalytic thinking is more of a dimensional way of thinking about human beahvior, emotion and cognition.
Sandra,
I’m afraid that I’m so focused how “dimensional” can be manipulated [like FDA approval by dimension, advertisement by dimension, psychometry via “the cloud,” etc], that I haven’t even thought about it.
In my book, dimensions and categories are complementary. Ever since Max Hamilton developed his depression scale in 1960, we have had dimensional measures of a category called depression. Max always insisted that his scale was not intended for diagnosis of depression but rather for tracking the severity of the disorder following independent diagnosis. In other words, the dimension cannot trump the category. He was actually quite stern on that point. The subsequent history of clinical psychometrics reinforces Max’s position. Until DSM-5.
The DSM-5 Task Force seems to like the idea of cross-cutting dimensional measures of psychopathology, like depression or anxiety. Cross-cutting here means independent of diagnostic categories. It isn’t clear to me what would be gained by that. Why? Because most symptoms are diagnostically nonspecific. A good example is in the recent paper from Kupfer’s group on their cross-cutting anxiety scale. It did a poor job distinguishing patients with depression diagnoses from patients with anxiety diagnoses. Why are we not surprised?
The added value of such cross-cutting dimensional measures has not been established. I for one will be surprised if any added value can be demonstrated for clinicians. As Dr. Mickey points out, that hasn’t stopped Drs. Kupfer, Gibbons and the rest of the gang of five from hand waving all the way to a start-up corporation intent on cashing in. And we should deplore the fact that some of our major journals (JAMA Psychiatry, American Journal of Psychiatry, Journal of Clinical Psychiatry) are acting as enablers by publishing meretricious and self-serving reports of pitiful quality.
The problem with measuring “severity,” is that very quickly differences in degree start to become differences in kind. The difference between melancholia and non-melancholia is a case in point. Or take the difference between psychotic and non-psychotic anxiety. If something is wildly different from something else, it’s a different disease not just higher on the scale.
It was not clear to me what the aims of the Kupfer, Gibbons, et al scales were. It looked like they were creating dimensionality within categories. In my experience as a clinician dysphoria and anxiety, for example, do not clearly separate. That separation has always seemed to exist primarily in the minds of psychiatrists. Nor for that matter does apathy due to some assumed disease state separate clearly from drug induced changes. I am not convinced that melancholia is NOT on a spectrum with other kinds of experiences but perhaps I am not understanding the above comments. Although someone with a classic presentation of melancholia looks very different from someone with less severe forms of melancholia , I observe people who also seem to fall not so clearly into categories. Maybe it is an illusion that this is a dimension but for now, it just looks that way to me.
Going with dimensions does not solve the issue of incorrect categories. Once again, both categories and dimensions have a place and they are complementary. But, dimensions cannot trump categories. The key consideration is that categories capture context whereas dimensions don’t. A current example is the debate about the bereavement exclusion for the category major depression. Sandra would rightly insist on keeping this exclusion, for reasons of context. But, the dimensional depression scores of bereaved people are well within the range of scores for clinically depressed patients. You can’t have it both ways, Sandra.
The issue of incorrect categories, aka diagnostic fuzziness or diagnostic error or uncertainty about where the joints in Nature are positioned, is real, but it won’t be solved by invoking dimensions. We should not expect or promise quick solutions. My favorite example is Parkinson’s disease. The classic studies of diagnostic performance for PD find that around 40% of diagnoses by eminent neurologists are incorrect at autopsy. The incorrect calls actually are Parkinson-like conditions, which number at least half a dozen. It took a very long time to tease these out. But you would be hard put to distinguish these on a symptom-based dimensional movement disorder rating scale.
O.K., most of what most of you are saying confirms my thoughts on dimensional measures. After doing a little search and reading, it looks to me like the dimensional measures are a response to what is becoming the inescapable realization that there are no discrete phenomenons like “schizophrenia” and “personality disorders”.
As far as I can tell, these dimensions are being used to describe specific “symptoms” as being more or less like the traditional categories of schizophrenia, bipolar disorder, personality disorders, etc.; in order to diagnose and medicate in what they think is a more discriminating and discerning manner.
It does nothing to rule out medical causes or social stressors, or drug induced states from psychiatric drugs, illicit drugs, or alcoholism that may resemble symptoms used to make DSM defined diagnoses. And it does nothing to establish whether or not anxiety or low feelings are appropriate to the patient, consumer, or person who is, for whatever reason, sitting in front of a psychiatrist or other mental health professional.
It appears to me to be more equivocating for clinicians in an effort to maintain their authority, and an effort to spur more psychiatric drug development by researchers; which hardly even scrapes the surface of what is overwhelming and making most people miserable and/or anxious, and what is wrong with most drug trials and prescribing habits, respectfully.
Wiley, your third paragraph above well captures my point about context. But I don’t see a need to posit any grand, coordinated conspiracy within psychiatry. Folks from Kupfer and Regier to Insel and Cuthbert are just stumbling along, and a few are eager to make financial hay from ad hoc pseudo-solutions like dimensions.
As for RDoC, it is an armchair theorist’s dream. Striking to me are the absences – there is nothing about experienced pain, nothing about sleep-wakefulness, nothing about psychomotor performance, nothing about energy, nothing about physical disability and its consequences or about the dimension of physical development and its disorders. Especially, there is nothing about psychological processes such as impulsivity, self-awareness, self-reflection, and much more.
Mostly, however, the entire thing is a piece of scholastic pedantry. Insel and Cuthbert would do better to get out of the way and allow good science to emerge from the bottom up.
If it were a grand and coordinated conspiracy, Bernard, I think it would be easier to take apart. Though there is clearly corruption and conflicts of interest at the KOL and DSM committee level, most of what is so unfortunate, harmful, and grandiose about the big picture is mostly the result of historical processes and academic fossilization reaching a point at which the “it” simply can no longer support itself without some manner of force or artifice, until another paradigm— hopefully a healthier and more human one— replaces it. Whether or not psychiatry survives in its current form remains to be seen, but considering the damage that’s being done with its drugs, and life sentences to mental illness its refusal to address:
actual physical conditions with psychiatric symptoms
the fact that everyone has limits and can be laid low or broken by stress and trauma
its ridiculous assertion that 1 out of 4 or 5 people are mentally ill due to an endogenous brain malfunction or a lack of “resilience”
its insistence that those labeled with “mental illness” or mental illness much take drug cocktails for life
its apparent inability to understand the differences between manifestations of “mental illness” or mental illness and the effects of the drugs they prescribe
and it’s refusal to listen to what the people they treat have to say about themselves, the drugs, and their experiences with psychiatry and individual psychaitrists;
makes it harmful, overbearing, maladapted, and resistant to change.
Many things in society— like structural violence, or structural racism— can grow to be toxic and damaging simply by not being examined and challenged enough for a critical mass of people to take it apart. The process hurts, as any endevear demanding empathy does. It’s not just about conceding points, it’s about a view of humanity.
This focus on dimensional analysis strikes me as a grabbing of straws. Of course, if psychiatry were outlawed at this moment, hypothetically, there would not be a structure to replace it and that would present all kinds of problems and leave many people in the lurch. I think movements with critical psychiatrists and other recovery minded mental health professionals are finding promising alternatives right now; but psychiatry is an enormous bit of machinery woven into society on so many different levels to address so many different kinds of problems that the impulse to to tamp it down and make it stick is understandable. Every profession has self-defense mechanisms built into it; it must, to some degree, fight for its life and justify it at the same time.
Wylie, you seem to be describing the sort of thing Kuhn observed about the process of change in science. Yes, it can be messy and it can lead to scientific conflict, sometimes conflated with ideology. When I read your bill of particulars, however, I see a good deal of overstatement and some outright errors. You mentioned psychiatry’s refusal to address:
? actual physical conditions with psychiatric symptoms: NOT SO… WE ARE VERY WELL AWARE OF GENERAL MEDICAL PROBLEMS THAT CAN RESULT IN PSYCHIATRIC SYMPTOMS. THERE EVEN ARE JOURNALS DEVOTED TO THIS TOPIC.
? the fact that everyone has limits and can be laid low or broken by stress and trauma: I CANNOT TELL WHERE THIS ASSERTION COMES FROM…DENIAL OF THIS FACT IS NOT SOMETHING I RECOGNIZE AMONG PSYCHIATRISTS, EVER.
? its ridiculous assertion that 1 out of 4 or 5 people are mentally ill due to an endogenous brain malfunction or a lack of “resilience”: HERE I THINK YOU CONFLATE EPIDEMIOLOGIC DATA WITH IDEOLOGY. THE DATA ARE WHAT THEY ARE. ALL THE DSMs ARE POINTEDLY AGNOSTIC AS TO CAUSES. AND WE ALL RECOGNIZE THAT THERE ARE DEVELOPMENTAL AND SOCIAL FACTORS IN PLAY WITH PSYCHIATRIC DISORDERS… IT’S NOT JUST ENDOGENOUS BRAIN MALFUNCTION.
? its insistence that those labeled with “mental illness” or mental illness (must) take drug cocktails for life: NOT SO. THE MAJORITY OF PATIENTS ARE GIVEN PSYCHIATRIC MEDICATIONS FOR RELATIVELY SHORT PERIODS… WEEKS TO MONTHS. FOR A FEW OF THE MAJOR LEAGUE CONDITIONS WE DO GENERALLY RECOMMEND LONG TERM PREVENTIVE TREATMENT. THERE IS A GOOD REASON FOR THAT… ON THE WHOLE, PATIENTS WITH THOSE MAJOR LEAGUE CONDITIONS DO BETTER WITH THIS MANAGEMENT – LIKE LITHIUM FOR MANIC-DEPRESSIVE ILLNESS.
? its apparent inability to understand the differences between manifestations of “mental illness” or mental illness and the effects of the drugs they prescribe: TO THE CONTRARY, WE ARE WELL AWARE THAT DRUG EFFECTS CAN SUPERVENE ON A CLINICAL DISORDER… WE TEACH ABOUT HOW THAT CAN LEAD TO CLINICAL CONFUSION.
? and it’s refusal to listen to what the people they treat have to say about themselves, the drugs, and their experiences with psychiatry and individual psychiatrists: WHAT REFUSAL? I LISTEN. DR. MICKEY LISTENS. AND HERE IN THE US WE ARE NOT ALONE, NOT BY A LONG SHOT. IN THE UK THERE IS AN ENTIRE MOVEMENT CALLED CPN – THE CRITICAL PSYCHIATRY NETWORK. CHECK THEM OUT.
Bernard… All that CAPS stuff makes my head hurt. I see you’re very “assertive” about issues, but I can’t just even start to read about it because of CAPS.
I did that just to make point and counterpoint transparently clear… nothing more.
Perhaps your “we” understands that, Bernard; but too many patients aren’t getting the benefit of that knowledge. I’d take a bet that most psychiatrists who end up working for state departments can’t afford most of those journals.
My experience with psychiatry and the experience of a whole lot of people in the recovery movement is just like what I described.
wiley has done an excellent job of summarizing many of the key flaws in clinical psychiatry. To them, I would add: Lack of recognition of adverse effects, inability to recognize when drug treatment should cease, and inability to safely discontinue drugs.
Yes, Dr. Carroll, there may be entire journals devoted to every one of these aspects of the profession that harm patients, but clinicians aren’t reading them. There’s the theoretical utopia of the ivory tower, while down below on the ground there are patients telling you they can’t find a psychiatrist they can trust as a doctor.
Psychiatry is not interested in looking at its mistakes — the roadkill of injured patients along the avenue to vast pharma riches. The field would be immeasurably improved if it did, but that would mean actually listening to patients.
In the meantime, for example, we have hundreds of thousands of posts all over the Web from people who’ve suffered prolonged psychiatric drug withdrawal syndrome for years, but clinicians who see it insist it doesn’t exist because nobody in the ivory tower has said it does.
I have no doubt the profession is mostly populated by people who mean well, but that’s not enough. They need to know what they’re doing, too. Twenty years of garbage passing as an “evidence base” has corroded clinical psychiatry to the point it no longer resembles the ideal. The rare good doctor questioning the paradigm is an outlier among psychiatric clinicians, and often keeps quiet so as not to risk ostracism.
By the way, we have started a CPN North America group. If any of the psychiatrists in the crowd want to join, let me know. Right now we are basically just a list and some of send out e-mails from time to time. We are not quite up to the UK standards but who knows what the future may bring.