{"id":23353,"date":"2012-05-15T08:00:33","date_gmt":"2012-05-15T12:00:33","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=23353"},"modified":"2012-05-15T06:00:37","modified_gmt":"2012-05-15T10:00:37","slug":"dreams-of-our-fathers-vi","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/05\/15\/dreams-of-our-fathers-vi\/","title":{"rendered":"dreams of our fathers VI…"},"content":{"rendered":"
In an earlier series [the future of an illusion V…<\/font><\/a><\/strong><\/u>], I wrote about how the ambiguity of the DSM-III about etiology has been used to create the illusion of a biological basis for mental illness without proving it – claiming to be etiology neutral in the process. In this one, I’m on a similar tack, trying to look at this same question of etiology in relationship to the DSM-5 underway now. In their initial article, Robins and Guze of the St. Louis Group laid out five criteria that they believed constitute the phases defining a psychiatric diagnosis: <\/div>\n
\n
Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia<\/font><\/strong>
BY ELI ROBINS. M.D.AND SAMUEL B. GUZE, M.D.<\/sup>
American Journal of Psychiatry<\/font><\/strong>. 1970 126[7]:107-111. <\/div>\n

<\/p>\n

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…<\/sup><\/div>\n<\/blockquote>\n
Then they list:<\/div>\n
    <\/p>\n
  1. Clinical Description<\/li>\n
  2. Laboratory Studies<\/li>\n
  3. Delimitation from Other Disorders<\/li>\n
  4. Follow-up Study<\/li>\n
  5. Family Study <\/li>\n

    <\/sup><\/ol>\n

    As we have seen, in their next paper [1972], they explain the same five phases again though they didn’t use that process to arrive at their well known Feighner Criteria<\/font><\/strong><\/em><\/a>. That pattern has continued to the present [1980-2012], praising the revolution of the DSM-III as being evidence-based as opposed to the case of the 16 years when part of the DSM-II [1968-1980] was based on the psychoanalytic concept of Neurosis, yet not using their revolutionary<\/em> process to define diagnoses – relying instead on the literature and expert opinion [for the last 32 years of the DSM-III, DSM-IIIR, DSM-IV, and DSM-IVTR]. The claim of being evidence-based invariably references the St. Louis Group and the two original articles [mentioned above].<\/div>\n

    In the diagnostic system, this etiologic ambiguity is reflected in the peculiar use of the word Disorder<\/font><\/strong>. On one hand, it’s used as if it were a synonym for the traditional medical term Disease<\/font><\/strong> – a pathological condition defined by nature. On the other hand, a Disorder<\/font><\/strong> is a condition defined by man in the periodic ritual we call Revisions<\/em>. Some Disorders<\/font><\/strong> approximate the Diseases of unknown etiology<\/font><\/strong> 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<\/em> Disorders<\/font><\/strong> uniformly lack laboratory [biomarker] confirmation. The majority of patients seeking care do not have those particularly medical-ish<\/em> Disorders<\/font><\/strong>. They have the not-so-medical-ish<\/em> Disorders<\/font><\/strong> that are created and maintained by committee – a Revision<\/em> committee like the DSM-5 Task Force.<\/p>\n

    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 <\/font><\/strong>[the medical-ish <\/em>and the not-so-medical-ish<\/em>].<\/p>\n

    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.<\/p>\n

    At last, I’ve come to the point of this series. The DSM-5 Task Force was different from the ones before. Instead of living in the etiological ambiguity of their predecessors, they came out of the gate claiming that they were going to call the question. They were going to finally actualize the dreams of our fathers and produce a DSM-5 that contained the complete list – all five of the Robins and Guze phases, including laboratory work. Dr. Frances, in his criticism, says they were trying to create a paradigm shift [that the system couldn’t support]. I’ve come to think of it in a different way. I think of it as their finally confirming the implied 1980 paradigm shift rather than creating a new one. But the difference might be semantic. Whatever you call it, they were on a different tack, sailing in a new direction into uncharted waters – and they didn’t seem to be a bit nervous about doing it. Looking at it now, it seems foolhardy. But back then, they were playing brass bands and talking like conquering heros. So it’s time to take another step back, this time to the dawn of the new century.<\/div>\n","protected":false},"excerpt":{"rendered":"

    In an earlier series [the future of an illusion V…], I wrote about how the ambiguity of the DSM-III about etiology has been used to create the illusion of a biological basis for mental illness without proving it – claiming to be etiology neutral in the process. In this one, I’m on a similar tack, […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-23353","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/23353","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=23353"}],"version-history":[{"count":11,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/23353\/revisions"}],"predecessor-version":[{"id":23363,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/23353\/revisions\/23363"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=23353"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=23353"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=23353"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}