{"id":34057,"date":"2013-03-11T16:19:38","date_gmt":"2013-03-11T20:19:38","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=34057"},"modified":"2013-03-11T16:19:38","modified_gmt":"2013-03-11T20:19:38","slug":"irony-ii-2","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/03\/11\/irony-ii-2\/","title":{"rendered":"irony II&#8230;"},"content":{"rendered":"<div align=\"justify\">The rationale for eliminating the use of Freud&#8217;s theories to explain certain mental illnesses in the DSM-II [or for that matter Adolf Meyer&#8217;s ideas in the original DSM] was that the theories were speculative &#8211; <em><strong><font color=\"#200020\">ideology<\/font><\/strong><\/em> rather than <em><strong><font color=\"#200020\">science<\/font><\/strong><\/em>. In either case, these explanations proposed that the mental problems arose from the mind or life experience of the afflicted person &#8211; in other words, were <em><strong><font color=\"#200020\">acquired<\/font><\/strong><\/em> instead of inborn or biologic. In introducing the DSM-III, Dr. Spitzer explained:     <\/div>\n<ul><sup><strong><\/p>\n<div align=\"justify\">For most of the DSM-III disorders, however, the etiology is unknown. A variety of theories have been advanced, buttressed by evidence &ndash; not always convincing &ndash; to explain how these disorders came about. The approach taken in DSM-III is atheoretical with regard to etiology or pathophysiological process except for those disorders for which this is well established and therefore included in the definition of the disorder. Undoubtedly, with time, some of the disorders of unknown etiology will be found to have specific biological etiologies, others to have specific psychological causes, and still others to result mainly from a particular interplay of psychological, social, and biological factors.<\/div>\n<div align=\"right\">DSM-III Introduction &ndash; page 7.<\/div>\n<p><\/strong><\/sup><\/ul>\n<div align=\"justify\">And while we don&#8217;t often think of it this way, Dr. Spitzer&#8217;s DSM-III actually removed <em><strong><font color=\"#200020\">two things<\/font><\/strong><\/em> with this change:<\/div>\n<ul><sup><strong>       <\/p>\n<li>\n<div align=\"justify\">the specific mental mechanisms hypothesized by either Freud or Meyer.<\/div>\n<\/li>\n<li>\n<div align=\"justify\">the fact that these illnesses were acquired conditions, not caused by biology.<\/div>\n<\/li>\n<p> <\/strong><\/sup><\/ul>\n<div align=\"justify\">Borrowing yet again my schematic from Jaspers&rsquo; <em>1913 Allgemeine Psychopathologie<\/em> [see <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2013\/03\/07\/an-anniversary-2\/\">an anniversary&hellip;<\/a>]:<\/div>\n<p align=\"center\"><img decoding=\"async\" height=\"150\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/jaspers-1.gif\" \/><\/p>\n<p align=\"justify\">In both the DSM and the DSM-II, these psychological formulations from Meyer and Freud were used to explain illnesses in the group Jaspers called&nbsp; <strong><font color=\"#8c1815\">Personality Disorders<\/font><\/strong> [<em>&ldquo;variations of human nature&rdquo;<\/em>] &#8211; by which he meant illnesses <em><strong><font color=\"#200020\">acquired <\/font><\/strong><\/em>in life. We know that they eliminated the psychobiological and the psychoanalytic explanations because they were unproved [and unprovable] hypotheses, but did they also think that these conditions were not acquired? did they think they were biological? or did they think we just didn&#8217;t know which? Insofar as I know, they didn&#8217;t say either way. Now flash forward several decades to the early days of the DSM-V. The people who would ultimately be in charge of the  DSM-V revision of the diagnostic manual began meeting in 1999, and in  2002 published a book about what they had in mind [<a target=\"_blank\" href=\"http:\/\/cs5824.userapi.com\/u11728334\/docs\/059a317ab14b\/David_J_Kupfer_A_Research_Agenda_for_DSMV_23893.pdf\">A Research Agenda for DSM-V<\/a>: edited by David J. Kupfer, Michael B. First, and Darrel A. Regier]:<\/p>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/cs5824.userapi.com\/u11728334\/docs\/059a317ab14b\/David_J_Kupfer_A_Research_Agenda_for_DSMV_23893.pdf#page=18\" target=\"_blank\"><strong><font color=\"#200020\">Need to Explore the Possibility of Fundamental Changes in the Neo-Kraepelinian Diagnostic Paradigm<\/font><\/strong><\/a><\/div>\n<p>  <\/p>\n<div align=\"justify\"><sup><strong>The  DSM-III diagnostic system adopted a so-called neo-Kraepelinian approach  to diagnosis. This approach avoided organizing a diagnostic system  around hypothetical but unproven theories about etiology in favor of a  descriptive approach, in which disorders were characterized in terms of  symptoms that could be elicited by patient report, direct observation,  and measurement. The major advantage of adopting a descriptive  classification was its improved reliability over prior classification  systems using nonoperationalized definitions of disorders based on  unproved etiological assumptions. From the outset, however, it was  recognized that the primary strength of a descriptive approach was its  ability to improve communication among clinicians and researchers, not  its established validity&hellip;<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\"> After a short reminder about the &quot;why&quot; of the DSM-III, DSM-IIIR, DSM-IV systems, they launch into a discussion of the&nbsp; ways it hadn&#8217;t lived up to their expectations:<\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong>In  the more than 30 years since the introduction of the Feighner criteria  by Robins and Guze, which eventually led to DSM-III, the goal of  validating these syndromes and discovering common etiologies has  remained elusive. Despite many proposed candidates, not one laboratory  marker has been found to be specific in identifying any of the  DSM-defined syndromes. Epidemiologic and clinical studies have shown  extremely high rates of comorbidities among the disorders, undermining  the hypothesis that the syndromes represent distinct etiologies.  Furthermore, epidemiologic studies have shown a high degree of  short-term diagnostic instability for many disorders. With regard to  treatment, lack of treatment specificity is the rule rather than the  exception.<\/strong><\/sup><\/div>\n<p align=\"justify\"><sup><strong>The  efficacy of many psychotropic medications cuts across the DSM- defined  categories. For example, the selective serotonin reuptake inhibitors  [SSRIs] have been demonstrated to be efficacious in a wide variety of  disorders, described in many different sections of DSM, including major  depressive disorder, panic disorder, obsessive-compulsive disorder,  dysthymic disorder, bulimia nervosa, social anxiety disorder,  posttraumatic stress disorder, generalized anxiety disorder,  hypochondriasis, body dysmorphic disorder, and borderline personality  disorder. Results of twin studies have also contradicted the DSM  assumption that separate syndromes have a different underlying genetic  basis. For example, twin studies have shown that generalized anxiety  disorder and major depressive disorder may share genetic risk factors.<\/strong><\/sup><\/p>\n<div align=\"justify\"><sup><strong>Concerns  have also been raised that researchers&rsquo; slavish adoption of DSM-IV  definitions may have hindered research in the etiology of mental  disorders. Few question the value of having a well-described,  well-operationalized, and universally accepted diagnostic system to  facilitate diagnostic comparisons across studies and to improve  diagnostic reliability. However, reification of DSM-IV entities, to the  point that they are considered to be equivalent to diseases, is more  likely to obscure than to elucidate research findings.<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\"> Something has happened in these twenty years. If it wasn&#8217;t apparent on first reading, you might read it through again. The word <em>etiology<\/em> only means <em>specific biological cause<\/em>. If many of these conditions have an acquired, psychological cause, then all of these complaints are exactly what you would expect. If the medication is primarily symptomatic [like aspirin or ethanol] rather than disease specific, then the overlap is also what you might predict. In a category like Jaspers&#8217; <strong><font color=\"#8c1815\">Personality Disorders<\/font><\/strong>, there wouldn&#8217;t be any biomarkers to find. And in diagnoses that are so broadly defined as generalized anxiety  disorder or major depressive disorder that could likely contain both acquired and biological cohorts, who even knows what you might find? The neoKraepelinian Tenets said &quot;<em><strong><font color=\"#200020\">6. The focus of psychiatric physicians should be on the biological aspects of illness<\/font><\/strong><\/em>&quot; and that&#8217;s precisely what they&#8217;ve done. And they&#8217;re about to blame the diagnostic paradigm for not giving them what they wanted, without considering the likely possibility that the psychiatric disorders which may actually have biomedical etiologies are too heavily diluted by patients who have problems of life and mind, not genes and brain.<\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong>All  these limitations in the current diagnostic paradigm suggest that  research exclusively focused on refining the DSM-defined syndromes may  never be successful in uncovering their underlying etiologies. For that  to happen, an as yet unknown paradigm shift may need to occur.  Therefore, another important goal of this volume is to transcend the  limitations of the current DSM paradigm and to encourage a research  agenda that goes beyond our current ways of thinking to attempt to  integrate information from a wide variety of sources and technologies&#8230;<\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">I read this with a mixed mind. They may well be right that &quot;<em>research exclusively focused on refining the DSM-defined syndromes  may  never be successful in uncovering their underlying etiologies<\/em>.&quot; It&#8217;s fine with me for the neuroscientists among us to gather at the NIMH to reconsider their priorities and directions, have conferences, symposiums, create an RDoC set of criteria that might focus their explorations [heaven knows they need some focus]. But this approach to revising a clinical diagnostic manual is not the place to be doing that kind of thing, nor is it the job of the <strong><font color=\"#660033\">American Psychiatric Association<\/font><\/strong>. As we now know a decade later, the outcome of this beginning wasn&#8217;t just a bust, it was counter-productive. They didn&#8217;t do <em>any<\/em> reasonable &quot;<em>research exclusively focused on refining the DSM-defined syndromes<\/em>&quot; that I can see. What they did was use this forum to lament the fact that they didn&#8217;t find what they wanted to find in the last twenty years, then dream about the future together [<em><strong><font color=\"#200020\">FutureThink<\/font><\/strong><\/em><em><strong><font color=\"#200020\">&sup2;<\/font><\/strong><\/em>]. I would suggest that the irony here is obvious. They didn&#8217;t find it, in some measure, <em>because of<\/em> thinking like this. They are talking about the whole domain of mental illness and there&#8217;s no way in hell that some biological model of any kind is ever going to fit the whole domain of what we call mental illness, no matter how it&#8217;s defined [&quot;<em>an as yet unknown paradigm shift<\/em>&quot; or not].<\/div>\n<p align=\"justify\">The argument within psychiatry framed as it was thirty plus years ago as <em>psychoanalysis versus biological psychiatry<\/em> is anachronistic at this point. This is about a rational and productive classification of mental disorders. Modern APA directed psychiatry is as ideologically driven as the psychoanalytically dominated APA of the now distant past. The DSM-III claimed to classify <em>all<\/em> mental illness and that was only justified by two things: <em>etiological neutrality<\/em> and <em>proven reliability<\/em>. It wasn&#8217;t what anyone wanted, but it was apparently the best compromise for that time. The subsequent revisions each had strengths and weaknesses but stayed on the same highway. As you can read in the little vignette above, and in spades if you read the whole book, the DSM-V [DSM-5] aimed for a biologically based diagnostic scheme for everything &#8211; abandoning <em>etiological neutrality <\/em>without a blink, with barely any mention. It&#8217;s not a question of throwing out Freud and Meyer this time, it&#8217;s throwing any and all acquired psychological mental illness altogether, with a new DSM-5 definition of mental disorder: &quot;<strong><font color=\"#400040\"><em>a behavioral or psychological syndrome that reflects an underlying psychobiological dysfunction<\/em><\/font><\/strong>.&quot;<\/p>\n<div align=\"justify\">They are alienating all the other mental health specialties who have used the DSMs who would hardly agree with this biological viewpoint or that definition. And by their own repeated admission there is no evidence base for this change of heart, certainly not on a global scale. If academic and organized psychiatry wants to make the change to clinical neuroscience official, they should change the name of the book and only include conditions where they can show evidence justifying inclusion. This time around, they have made it impossible to defend them against charges of disqualifying conflicts of interest and factionalism &#8211; those forces are too obvious to ignore. Dr. Frances proposes that in today&#8217;s factional climate, no mental health group can transcend it&#8217;s ideological and economic interests to produce the DSM we need. I&#8217;m afraid I have to agree with him. The one they began with <strong><font color=\"#200020\">A Research Agenda for DSM-V<\/font><\/strong> sure didn&#8217;t turn out to be it&#8230; <\/div>\n","protected":false},"excerpt":{"rendered":"<p>The rationale for eliminating the use of Freud&#8217;s theories to explain certain mental illnesses in the DSM-II [or for that matter Adolf Meyer&#8217;s ideas in the original DSM] was that the theories were speculative &#8211; ideology rather than science. In either case, these explanations proposed that the mental problems arose from the mind or life [&hellip;]<\/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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-34057","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/34057","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=34057"}],"version-history":[{"count":46,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/34057\/revisions"}],"predecessor-version":[{"id":42773,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/34057\/revisions\/42773"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=34057"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=34057"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=34057"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}