Posted on Thursday 10 May 2012
He who studies medicine without books sails an uncharted sea,
but he who studies medicine without patients does not go to sea at all…
Sir William Osler
In March, I looked into the story of how the authors of the DSM-III, DSM-IIIR, and DSM-IV [Robert Spitzer and Allen Frances] came to be at odds with the current DSM-5 Directors [David Kupfer and Darrel Regier][see
dangerous men…]. It started in April 2007 when Dr. Spitzer asked to look at the minutes of the DSM-5 Task, and after a nine month delay was turned down, citing reasons of confidentiality. Finally, in June 2008, after an article in which the outgoing APA president praised the openness of the DSM-5 group, Spitzer unloaded in an article in the
Psychiatric Times. In a subsequent series of articles, Spitzer continued to attack the secrecy of the DSM-5 Task Force. He asked Allen Frances to join him but Frances declined, though he agreed with the complaint. But then in May, 2009, after hearing about the Psychosis Risk Syndrome at a party at the APA meeting in San Francisco, Allen Frances weighed in with an article of his own in the
Psychiatric Times which contained these prophetic paragraphs:
Psychiatric Times
By Allen Frances
June 26, 2009
The DSM-V goal to effect a “paradigm shift” in psychiatric diagnosis is absurdly premature. Simply stated, descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders.
The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis. The clearest evidence supporting this disappointing fact is that not even 1 biological test is ready for inclusion in the criteria sets for DSM-V. Fortunately, the NIMH is now embarked on a fascinating effort to effect the real paradigm shift of basing diagnosis on biological findings. Unfortunately, this is years [if not decades] from fruition… So long as psychiatric diagnosis is stuck at its current descriptive level, there is little to be gained and much to be lost in frequently and arbitrarily changing the system. Descriptive diagnosis should remain fairly stable until, disorder by disorder, we gradually attain a more fundamental and explanatory understanding of causality…
Indeed, there has been only 1 paradigm shift in psychiatric diagnosis in the past 100 years—the DSM-III introduction in 1980 of operational criteria sets and the multiaxial system. With these methodological advances, DSM-III rescued psychiatric diagnosis from unreliability and the oblivion of irrelevancy. In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III and, at best, DSM-V could only hope to join them in making a modest contribution. Descriptive diagnosis is simply not equipped to carry us much further than it already has. The real paradigm shift will require an increase in our knowledge—not just a “rearrangement of the furniture” of the various descriptive possibilities…
I think of the APA response to Dr. Frances’ article as a nasty-gram written by Dr. Alan Schatzberg, then President of the APA [under investigation at the time by the U.S. Senate for financial impropriety]. It did say that the DSM-III and DSM-IV were outdated and hadn’t kept up with current thinking and the advances of science, but then they accused Drs. Spitzer and Frances of having financial motives behind their complaints:
Setting the Record Straight:
A Response to Frances Commentary on DSM-V
Psychiatric Times
By Alan F. Schatzberg, MD, James H. Scully Jr, MD, David J. Kupfer, MD, Darrel A. Regier, MD, MPH
July 1, 2009
The DSM-III categorical diagnoses with operational criteria were a major advance for our field, but they are now holding us back because the system has not kept up with current thinking. Clinicians complain that the current DSM-IV system poorly reflects the clinical realities of their patients. Researchers are skeptical that the existing DSM categories represent a valid basis for scientific investigations, and accumulating evidence supports this skepticism. Science has advanced, treatments have advanced, and clinical practice has advanced since Dr. Frances’ work on DSM-IV. The DSM will become irrelevant if it does not change to reflect these advances…
Dr. Spitzer responded, continuing his theme of the dangers of the DSM-5 Task Force’s policy of secrecy:
APA and DSM-V:
Empty Promises
Psychiatric Times
By Robert L. Spitzer, MD
July 2, 2009
The debate over DSM-V has unfortunately taken an ugly turn with the APA leadership suggesting that Dr. Frances’s and my motivation for critiquing DSM-V is financial. People familiar with this controversy might recall that it all began when I asked Darrel Regier if I could look at the minutes of DSM-V Task Force meetings so that I could keep up with the ongoing process. He explained that he could not do this because of confidentiality agreements that all DSM-V participants have been required to sign. Because of my strong belief that DSM has been and should always be a completely open process, I started my effort to get APA to change its ways. Read Dr Frances’ commentary on DSM-V and the APA’s response For brevity’s sake, I will limit my comments regarding APA’s response to Dr Frances’ commentary to the core issue of transparency. APA continues to maintain the empty rhetoric that the DSM-V process is the “most open and inclusive ever”…
In the three years since that week in 2009, a lot has happened. It’s no longer a rhetorical conflict that involves a handful of psychiatrists – it involves the entire specialty of psychiatry, the other mental health professions, the psychopharmaceutical industry, the clinical research industries, the medical reimbursement industry, and help seeking patients far and wide. Of course, Drs. Spitzer, Frances, and Kupfer didn’t cause the conflict any more than the Archduke Francis Ferdinand and his Assassin caused World War I. Their differences were just a focal point for something much bigger than all of them. But as is the case in such situations, the something-much-bigger tends to get submerged in the bluster that follows.
Dr. Spitzer got mad first, and the thing that made him mad was the secrecy [and the process] of the DSM-5 Task Force. Dr. Frances agreed with him about the secrecy, and didn’t care much for the process either, but he stayed out of the fray until he heard the kind of thing the DSM-5 Task Force was thinking about adding eg the Psychosis Risk Syndrome. That played into his own concerns about medicating kids. Then he got mad too and spoke out. Why was that the last straw for him? Speaking of last straws, why did I get so noisy around that same time myself? I wasn’t in these guys league, having been an early casualty in this same DSM-III Revolution – not really on the other side but close enough for government work. I was five or six years retired, thinking little about psychiatry. But in the summer of 2009, two things happened. I started seeing patients as a volunteer and did a review of psychopharmacology as part of that. And I continued to read about Senator Grassley’s investigation into psychiatrists in high places who were crooks – one of whom was the Chairman of a Department I’m still a part of. I’d lived with the dramatic changes in psychiatry after leaving academia and adapted. I’d had a fine career, though it felt a bit like being in exile.
I know what made me so angry. I found out what Dr. Frances and Spitzer couldn’t possibly not have also known – that all was not as it appeared. Corruption was prevalent in our ranks, our literature, and our treatment recommendations to patients. I’m guessing that’s a part of why the secrecy bothered Dr. Spitzer and the Psychosis Risk Syndrome bothered Dr. Frances, among the other things they knew about because they’d been DSMers. They knew that the current directions in psychiatry had opened to door for rampant corruption and they were both aware of a coming crisis [the one we're in right now]. Did Drs. Kupfer and Regier know too? Were they part of the problem? They would’ve had to put cotton in their ears and wear dark glasses not to know.
For one thing, corruption and secrecy are virtually synonyms.
At last, I reach the point of this post. Dr. Frances says above in his opening salvo, "descriptive psychiatric diagnosis does not now need and cannot support a paradigm shift." That’s in the center of this in my mind. While the DSM-III Revolution was, on the surface, a move to make psychiatric diagnosis more scientific and more reliable, it was also driven to exorcise unproven ideology from the diagnostic system and psychiatry at large – at that time specifically psychoanalysis. And that’s what happened. And then…
But there is one source of great and continuing frustration in our field. We are in the midst of a neuroscience revolution that has provided a miraculous and tantalizing window into normal brain functioning. But the vast accumulation of basic science knowledge revealing the mechanisms of normal brain functioning has shed relatively little light on the far greater complexity of what causes psychopathology. As a result, the neuroscience revolution has so far had almost no impact on how we diagnose and treat our patients. The inherent difficulty in translating from basic to clinical science guarantees that we will make only slow progress in unraveling the multitudinous heterogeneity of brain malfunctions that cause mental illness.
DSM 5 initially got into trouble because it was ambitious to jump-start a "paradigm shift" in psychiatry – well before there was sufficient scientific knowledge to make this possible.
We would not have been burdened by all the dangerous DSM 5 suggestions for unproven diagnoses if its workgroups had not been given the green light to be recklessly creative in promoting their pet innovations… Psychiatry does itself no good when we oversell ourselves…
Psychiatry should live comfortably within its own skin, not make excessive claims. We are largely successful at doing what we do best in our current clinical work. We are eager to advance and incorporate the ever advancing scientific understanding of mental disorders and how best to treat them. But [except for Alzheimer's], psychiatry is likely decades away from anything resembling a paradigm shift. It’s always best to modestly under-promise and then strive to over deliver. The sad tale of DSM 5 is a succession of overblown promises and then disappointing and potentially dangerous under performance. Psychiatry should work hard at what we do well – without reaching beyond our current grasp or raising expectations we can’t possibly fulfill…
It’s unquestioned that down some road at some future time, biological causes or factors are going to be part of the mental illness nosology. It’s equally unquestioned that one identical twin can be the picture of mental health and the be other be as sick as a goat – that some mental illnesses of significance can comes from biography. The conundrum is that neither of those things should matter in the diagnostic system of psychiatry as it was conceived by Dr. Spitzer et al in 1980. In his system, causes or mechanisms only counted if they were known ["except for Alzheimer's"]. After sixteen years of Neurosis, Freud’s mental mechanisms had to go the way of Reich’s Orgone Box [a disillusionment from Spitzer's youth]. The DSM-5 Task Force had missed a very large point, as had many others. They mistook a failing of Robert Spitzer’s DSM-III Revolution for its essence – a failing so common in revolutions that it ought to be part of the definition. What was good about Spitzer’s direction was to aim for descriptive categories that were reliably grounded in observable phenomena – kappa was king. What was unfortunate was that, like most revolutions, there was another agenda. The old ways had to be ferreted out and exiled – expectable, but it lead to trouble.
The soft spot of the DSM-III was nowhere more evident than in the creation of the category of Major Depressive Disorder. It was in the area of depression that both the psychologically minded and the biologically oriented had made the most progress. In certain depressions, there was a statistically valid marker [not digital as everyone wished - but evidence nonetheless] and somewhat robust treatments [also not digital as everyone wished]. In the biopsychosocial realm, the relationship of some depressions was well understood in relationship to attachment and loss, and the mental mechanisms of some depressions as well as pathological grief had achieved a level of fairly clear clinical usefulness. All of those things hinged on the careful clinical discrimination of the depressions – aka diagnosis. In his zeal to make sure that his DSM-III was free of the problems of the past, Spitzer’s Major Depressive Disorder blunted the very real possibilities of the kind of advances psychiatry actually longs for. The Czar had to be killed and the Red Guard had to re-educate the "Roaders." Any fractionation of depressive diagnosis might have opened the door to Neurosis. So the successes of the past, at the time in their infancy, went the way of the bath water – Depressive Neuroses and Melancholia alike – both descriptively definable. If he didn’t like the names, he could’ve changed them. And not-psychological became biological in the minds of many, who then flourished. That should have been expected and happened relatively quickly.
The stated goal of this DSM-5 Task Force was to insert yet another unproven ideology into the diagnostic system, and thereby reframe psychiatry [A Research Agenda for DSM-V]. I call that ideology clinical neuroscience, borrowing the term from Dr. Tom Insel, Chief of the NIMH, but you could call it neurobiology, or biological psychiatry, or brain science. Whatever you call it, it’s the belief that problems mental are brain/biology problems and that proof is just around the corner. In their prequel, the DSM-5 leaders predicted that the DSM-5 itself would be solidly grounded in biology by the time it was released, though they had to back off from that prediction recently [Neuroscience, Clinical Evidence, and the Future of Psychiatric Classification in DSM-5].
Like the psychoanalysts in the 1950′s and 1960′s, the neuroscientists of the DSM-5 Task Force were so sure that they saw the future clearly that they lost sight of their Task [and relied on Force instead].
Their job was to carefully improve the terrain map of the desert, correcting the errors of earlier cartographers, adding new features only where justified and well documented. Instead, they gave in to their dreams. They failed to notice along the way that their critics weren’t their old enemies, but were rather the people that put them on the map in the first place. And when the second of the former Task Force chiefs, Allen Frances, joined the first, Robert Spitzer, in trying to point out their folly, they instead allied themselves with an APA President, Alan Schatzberg, who was himself a big part of the problem.
They failed to see that some of the criticism was directed at his kind of thinking which had opened the door to run-away corruption, that instead of closing old loopholes, they were opening new ones. They ignored the advice about process, transparency, and detail, and ended up with a set of Field Trial outcomes that have us obsessing about their flawed methodology rather than gaining any clarification at all from their work product. Main line diagnoses like Schizophrenia, Major Depressive Disorder, and Generalized Anxiety Disorder with reliability well less than half the way between chance and full agreement among clinicians? Groan…
They were so busy dreaming together of their paradigm shift in cloistered workgroups, they failed to attend to the organizational necessities of such a project; they failed to listen to the wisdom of their elders; and they allied themselves with the wrongest of crowds – obvious to anyone who read the newspaper of the time. In a single week three years ago, they declined two life-lines and decided to go down with the ship.They may keep spinning their story and publish their book. Some people might even use it. But instead of their grand plan of making it more scientific, they fueled the opposite impression – and they should’ve known.
If there’s any lessons at all for the future, one is that nosology should ride on the trailing edge of innovation and hypothesis, looking for things that are in need of clarification and correcting previous errors rather than involving itself with the whimsey and passion of the leading edge. The other lesson is that matters diagnostic are for clinicians, not dreamers and researchers…
I think this is an open admission of a broken social contract between psychiatry and the public, and it may be a Kuhnian paradigm shifting moment…