Volume 17, Number 2 2010

Association for the AA Advancement of Philosophy and P&P Psychiatry Bulletin

Volume17, Number 2 2010

From the Editor President’s Column

In these remarks let me first extend For many years now, AAPP has been actively involved in the analysis and my deepest appreciation to Allen Fran- critique of the DSMs, including nosology in general, current classifications, diag- ces for his tireless work in the produc- nostic practices, and the interface between science and values. In focusing our tion of this issue of the Bulletin. This attention on the next DSM and the many conceptual and evaluative issues raised project began many months ago with there, we (AAPP members, PPP readers and authors, and others) repeatedly circle my inquiry to Allen as to whether he back to the question of how best to serve our patients. We want the best science would be interested in carrying his cri- possible, so it was appropriate that our most recent AAPP meeting, held in New tique of the DSM-5 process into the Orleans 2010, was on “Philosophical Issues in Evidence-Based Psychiatry.” But pages of the Bulletin, with commentar- we also want to give the best, most accurate, most therapeutic, and most ethical ies and responses. He responded enthu- attention to those we serve—the service users—and so the President’s Column this siastically, and we were off and run- time will try to bring together some threads of these two themes for us to think ning. To that point a central venue for about in the coming year. his DSM publications had been (and Our 2010 conference, organized by Peter Zachar and David Brendel, was a remains) the pages and online space of huge success by all accounts. A central theme was the critical examination of just the Psychiatric Times . The Bulletin what ‘evidence-based medicine’ refers to, what values underpin it, and how well would add a concentrated space and (or not) it applies to psychiatry. Keynote speaker Mona Gupta, for example, ar- format where the conceptual issues he gued that ‘good health’ is a variable that, in psychiatry, requires that we grapple had been addressing—a natural interest with the sometimes ambiguous and always messy terrain of patient values, mental for AAPP—could be pursued further. diagnoses, and ethical justification of psychiatry’s goals, values, and assumptions. In that issue of the Bulletin he chose to I would like to extend that conversation, in the President’s Column, to the reply to the commentators in one long INPP conference in Manchester, England that took place June 28 2010. There, for piece, summarizing his position. the first time, service users were built into the structure and content of the confer- Further discussion of the previous ence. This is no small step: it affirms the epistemological and ethical necessity of Bulletin issue this past Spring led to a not only taking into account, but making central the experiences, values, perspec- further idea: do a second issue, invite tives, and voices of patients themselves. If we truly want evidence-based medicine, commentaries on Allen’s general re- we must count as evidence the contributions that patients make and the wishes sponse from the first issue, structure they express. And if we truly want both evidence- and value-based medicine, we this issue with individual responses to must take into account the values of patients themselves. Narrative psychiatry is each commentator, and cast the net already doing this, as are scholars who study and analyze memoirs, such as Serife wider for further commentary. Allen Tekin and several other presenters who offered case-based analyses. suggested a final idea, that commenta- , tors should be offered a final word fol- Patients are unique and idiosyncratic, of course. That is one thing that makes lowing his responses. As you can see it so difficult to tailor science to patients. Developing a science of psychiatry that from the size of this issue of the Bulle- is responsive to the individual is a daunting task, and the epistemic problem of tin (over 60,000 words), interest in this attending to difference while attempting also to formulate generalizations is a sig- discussion has been great. nificant problem not only for the sciences but for all theorizing. But to frame epis- The above remark leads me to an- (Continued on page 73) other note of appreciation, to our com- mentators, who have themselves put in a lot of work writing their commentar- alluded to in a number of the commentaries—that a proposal to appoint a Con- ies. The level of interest and amount of ceptual Issues Work Group in the DSM-5 process was declined by the DSM-5 work put into these commentaries at- Task Force. I think that those of us working on these two issues of the Bulletin tests to the importance many of our see ourselves (somewhat grandiosely, to be sure) as the missing DSM-5 Concep- colleagues attach to the ongoing DSM- tual Issues Work Group. It will left for historians of psychiatry (our Hannah 5 process. Decker, for one) to describe the parallel work taking place in these months and It is a well-known fact—and one (Continued on page 73)

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A Frances, “Do no Harm” Meets Symposium on DSM-5 Joseph Pierre, Final Comment, p “The Rule of Thirds” , p 35 Part II 12 Nassir Ghaemi, Final Comment, p In this issue of the Bulletin we con- Donald Klein, DSM Purpose and 38 tinue the discussion initiated in the Threshold for Revision, p 13 previous issue. In that issue commen- Joel Paris, The Ideology behind taries were focused on Allen Frances’ A Frances, Second Umpires Eve- DSM-5, p 41 ongoing critique of the DSM-5 process. rywhere, p 13 Dr. Frances followed the commentaries A Frances, The Elusive Definition with a general response directed at all Melissa Piasecki and David An- of Mental Disorder and Problems with the participants . For this issue we are tonuccio , The DSM Debate: Potential Reification, p 42 following a different formal. Commen- Harms Related to Psychiatric Diagno- taries are directed to Frances’ sis, p 14 Michael A. Cerullo, The Illusion ‘Response’ from the previous issue. of Epistemological Problems in the Dr.Frances then follows each commen- A Frances, Diagnosis can be bad Definition of Mental Illness, p 43 tary with an individual response. Fi- for your Health, p 17 nally, each commentator has the op- A Frances, Epistemological Prob- portunity for a ’last word’. Ronald Pies, The Ideal and the lems not easily Solved, p 44 The format for this issue Real: How Does Psychiatry Escape will be the following. A Table of Con- the DSM-5 “Fly-bottle”?, p 18 Avram Mack , Nosology for Begin- tents directs the reader to specific ners: The Context of Psychiatric Classi- commentaries and responses. Follow- A Frances, Sorry But No Easy fication And Diagnosis, p 45 ing the Table of Contents we are first Exit, p 22 republishing Dr. Frances’ Response to A Frances, Thesis/Antithesis/ Commentaries from the previous Bulle- Hannah Decker, The Past and the Synthesis, p 46 tin, so that readers do not have to refer Future: What Constitutes a Mental back to that issue for reference. Illness, p 23 Henry Pinsker, A Grandfather Re- flects on the Younger Generation, p 48 The Web site for accessing A Frances, History Rhymes, p 25 both issues of the Bulletin is: A Frances, The Wisdom of the Warren Kinghorn, The DSM and Ages, p 50 http://alien.dowling.edu/~cperring/ “Do No Harm:” Is a Radical Pragma- aapp/bulletin.htm tism Sufficient?, p 26 Henry Pinsker, Final Comment, p 50 Individual pieces from this A Frances, Pragmatism has its issue can be accessed in Word format Limits, p 27 Avi Peled, The Paradigm Shift for from: Psychiatric Diagnosis is Already Here, G. Scott Waterman, Doing No p 51 http://sites.google.com/site/aapponline/ Harm Redux: The Case For (Ultra) Conservatism?, p 28 A Frances, Only in the Eyes of the Beholder, p 54 Table of Contents A Frances. Ultraconservatives are Radicals in Sheep’s Clothing, p Steven Hayes, Functional First: Allen Frances, DSM in Phi- 30 Creating a Pragmatic and Progressive losophyland: Curiouser and Curiouser, Diagnostic System, p 55 p 3 Scott Waterman, Final Com- ment, p 31 A Frances, Forced Choice: Be Thomas Szasz, DSM: The Pragmatic OR Progressive – Usually Nosology of Nondiseases, p 8 Andre Haynal, About DSM in Hard to be Both, p 57 Philosophyland, p 31 A Frances, An Appreciation Douglas Porter, Weighing the Evi- and Dissent, p 8 A Frances, The Power to Name dence and Rendering Judgment on the is the Power to Harm, p 31 DSM: Do We Need a Supreme Court?, Joseph Pierre, Mental Disor- p 58 der vs. Normality: Defining the Inde- Nassir Ghaemi, DSM-IV, Hippo- finable, p 9 crates, and Pragmatism: What Might A Frances, Yes Surely, More Now A Frances, The Psychiatric Have Been, p 32 than Ever, p 58 Spectrum And Chasing The End of the Rainbow, p 11 2 Volume 17, Number 2 2010

so without any confidence they can Aaron Mishara and Michael survive rigorous analysis by those AAPP Schwartz, Who’s on First: Mental Dis- more expert than I in the tools of phi- 23rd Annual Meeting orders by Any Other Name, p 59 losophic inquiry. Much of what I say below may be simple minded or sim- 2011 A Frances, Phenomenology vs ply wrong. What I do understand The Future of Operationalism, p 63 (perhaps better than anyone) are the practical issues of creating a psychiat- Psychiatric Nosology Aaron Mishara and Michael ric manual and the many good and Schwartz, Final Comments, p 65 bad (intended, unintended) conse- May 14 & 15, 2011 quences it can have. My views on Honolulu, Hawaii John Sadler, Miscellany, Past and deeper meanings are given, and (in conjunction with the American Present, p 66 should be taken, with a large grain of Psychiatric Association salt. Annual Meeting) A Frances, Politics; Lumping vs In the half century since Carl Splitting; What Place For Conceptual- The Epistemological Game izing, p 67 Hempel addressed the World Con- ference on Field Studies in the Men- First Umpire: “There are balls Donald Mender, De-Centering the tal Disorders in 1959, the literature and there are strikes and I call them on the philosophy of psychiatric Subject of DSM, p 67 as they are.” nosology has grown exponentially. Second Umpire: “There are However, it is not clear to what A Frances, I Don’t Believe in balls and there are strikes and I call degree conceptual explorations of Magic, p 68 them as I see them.” psychiatric nosology have actually Third Umpire: “There are no influenced our systems of classifica- tion. Now, as we anticipate the Donald Mender: Final Comment, p balls and there are no strikes until I 69 publication of ICD-11 and DSM-5 call them.” in 2013, what have the lessons of the

James Phillips, Another DSM on last 50 years been, and what should As I recall it, the three umpires we anticipate for the next 50? the Shelf? p 69 are replaying a marathon epistemo- What shall we strive for in the logical game that: 1) began with future? Should future classification A Frances, Using Clinician Proto- Plato; 2) continued in the medieval systems be global and intercultural types vs Criteria Sets In Making Diag- joust between the realists and Oc- in scope? Should they attempt to noses, p 70 cam's nominalists; 3) was revived in serve multiple purposes – clinical, research, and administrative? the post-renaissance debate between James Phillips: Final Comment, p Should we hurry to move beyond Descartes and Vico on the power and descriptive diagnostic criteria? On 71 limits of rational thought; 4) was re- what bases should we make deci- fined by Kant; 5) churned up by sions about lumping and splitting, Claire Pouncey, …Still, I Wonder, Freud; and 6) finally settled by quan- defining ‘mental disorder’, utilizing p 71 tum physicists who have sharply dimensions versus classes, and ar- downgraded the capacity of the hu- ticulating the role of theory in shap- A Frances, An Apology for Dumb man mind to ever fully intuit (much ing our nomenclature? How do we Utilitarianism, p 72 less understand) reality. Closer to my duly consider the social, political, epistemic, and professional values turf, I like to think of Bob Spitzer as that influence a classification and Allen Frances, Afterword, p 72 umpire #1, me as umpire #2, and how it is used? What do develop- Tom Szasz as umpire #3. ments in contemporary philosophy DSM in Philosophyland: Spitzer's DSM-IIIachieved a of science contribute to the future of paradigmatic revolution in psychiatric psychiatric nosology? Curiouser and Curiouser diagnosis and nosology. He intro- Abstracts are welcome address- duced the method of diagnostic crite- ing any of these issues. Allen Frances M.D. ria (originally developed for research purposes) into a tool for general clini- Presentations will be strictly First off, thanks to James Phillips limited to 20 minutes, followed by cal practice. For the first time, psy- for inviting these stimulating commen- 10 minutes of discussion. Ab- chiatrists could agree on diagnoses taries. Second, a confession. My last stracts will be blind reviewed— and make interpretive judgments (and only) formal training in philoso- attach author’s identifying info- across the research/ clinical interface. phy was a freshman course in college mation on separate cover page. Certainly, the level of reliability Abstracts should be 500-600 that went well over my head. Now I achieved by DSM-III was over sold, words and should be sent via have been invited to share my especially when it was used by the email by November 15, 2010 to (probably sophomoric) speculations on average clinician. But DSM-III was a Claire Pouncey, MD, PhD, Pro- the meanings that swirl below the sur- huge leap forward from the useless gram Chair, at face of psychiatric classification. I do [email protected]. 3 Volume 17, Number 2 2010

and neglected guidance offered by the biologists had discovered their dictable results. No decision can be DSM-I and DSM-II. It gave hope that own voice and began making their right on narrow scientific grounds if psychiatry could become scientific and overly ambitious and naïve claims). it winds up hurting people. join in the advances that were being Szasz vigorously presented the view made in the rest of medicine. that mental illness is a medical Descriptive Psychiatry Gets Long DSM-III resulted from and pro- “myth.” Mental disorders were no of Tooth moted the victory of biological psy- more than social constructs that in chiatry over the psychological and so- some cases served a useful purpose, The Dodo: "Everyone has run and cial models that until then were its seri- but in many others could be misused everyone has won and all must ous competitors. In the early dawn of to exert a noxious social control, re- have prizes". its triumph, the biological model was ducing freedom and personal respon- presented with a realist, reductionist sibility. The biological “realists” re- Modern descriptive psychiatry flourish that would have done umpire acted predictably to Szasz' just passed its 200 birthday - if we #1 proud. Mental disorders were real “nominalist” attack. They dismissed measure it from the milestone of entities that existed “out there.” The it. If schizophrenia is a myth, they Pinel's creation of the first psychiatric process of scientific discovery would crowed, it is a myth that responds to classification that resembles our own. elucidate their etiology and pathogene- medication and has a genetic pattern. His work was born from the Enlight- sis using the powerful new methods of But their triumphalism was premature enment belief in a rational world - neuroscience, imaging, and genetics. and based on both weak philosophic some underlying order could be im- The next section will focus on the and weak scientific grounds. It turned posed even on the obvious irrational- disappointing fate of this ambitious out that the neuroscience, genetics, ity of mental illness. The premise was program, but one central point belongs and treatment response of that any domain receiving systematic here. Biological psychiatry has failed to “schizophrenia” follow anything but observation and classification would produce quick, convincing explana- a simple reductionist pattern. The eventually display causal patterns. tions for any of the mental disorders. more we learn about “schizophrenia” This approach was enormously This is because it has been unable to the more it resembles a heuristic, the successful in each of the major para- circumvent the fundamental and inher- less it resembles a disease. digm shifts in science. Always a care- ent flaw in the biological, “realist” ap- This brings us to me (a call'um as ful description preceded a causal proach - mental disorders don't really I see'um) second umpire. In preparing model. Kepler's astronomical obser- live “out there” waiting to be ex- DSM-IV, I had no grand illusions of vations led to Newton's gravity. Lin- plained. They are constructs we have seeing reality straight on or of recon- naeus' classification of plants and made up - and often not very compel- structing it whole clothe from my animals led to Darwin's evolution. ling ones at that. It has, for example, own pet theories. I just wanted to get Mendeleyev's periodic table led to become clear that there is no one proto- the job done - i.e., produce a useful Bohr's structure of the atom. There type “schizophrenia” waiting to be ex- document that would make the fewest have been dozens of descriptive sys- plained with one incisive and sweeping possible mistakes, and create the few- tems vying to describe things so bril- biological model. There is no gene, or est problems for patients. Following liantly that their truth would shine small subset of genes, for Vico, I accepted that much in real life forth. “All have run, but none has “schizophrenia.” As Bleuler intuited, ( and almost everything in psychiatric won prizes.” Descriptive classifica- “schizophrenia” is rather a group of classification) is overlapping, fuzzy, tion in psychiatry has so far been disorders, or perhaps better a mob. and heterogeneous - anything but singularly unsuccessful in promoting There may eventually turn out to be Cartesian and amenable to overarch- a breakthrough discovery of the twenty or fifty or two hundred kinds of ing rationalist principles or mathe- causes of mental disorder. “schizophrenia.” As it stands now the matical precision. Psychiatric classifi- This is doubly disappointing definition and boundaries of cation is necessarily a sloppy busi- given the miraculous advances in our “schizophrenia” are necessarily arbi- ness. The desirable goal of having a understanding of normal brain func- trary. There is no clear right way to classification consisting of mutually tioning. The advances in molecular diagnose this gang and not even much exhaustive, non-overlapping mental biology, brain imaging, and genetics agreement on what the validators disorders is simply impossible to are spectacular - their impact on un- should be and how they should be ap- meet. derstanding psychopatholgy almost plied. The first umpire was called out Instead, the second umpire fol- nil. Why the disconnect? The answer on strikes when the holy grail of find- lows a down-to-earth brand of Ben- lies in a paraphrase of the opening ing the cause of “schizophrenia” turned tham utilitarian pragmatism. His um- lines of Anna Karenina. All normal out to be a wild goose chase. pire's eye is fixed on the end result of brain functioning is normal in more Szasz is the third umpire. He getting to what works best - not dis- or less the same way, but any given quickly saw through the epistemologi- tracted by biological reductionism or type of pathological functioning can cal “no clothes” of umpire #1 and led rationalist models of how things have many different causes. the fight against simple minded bio- should be constructed. A diagnosis is This is also true for all the com- logical reductionism (even well before a call to action with huge and unpre- plex diseases in medicine. A genetics

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company using the Icelandic registry world of shifting, ambiguous, and XIVth International had tremendous success in finding gene idiosyncratic word usages. This is a markers for a dozen diseases, including fundamental weakness of our field. INPP Conference schizophrenia. It recently went bank- Many crucial problems would be rupt because, in each instance, the par- much less problematic if only it were ticular candidate marker explained possible to frame an operational defi- Ethics, Experience fewer than three per cent of the cases of nition of mental disorder that really and Evidence: Inte- the particular disease. There appear to worked. gration of Perspec- be no common genes even for the com- Nosologists could use it to guide mon illnesses. Psychopathology is het- decisions on which aspects of human tives in Psychiatry erogeneous and overlapping not only in distress and malfunction should be its presentation but also in its patho- considered psychiatric - and which September 2-4, 2011 genesis. There will likely be hundreds should not. Clinicians could use it Gothenburg, Sweden of paths to schizophrenia, not one or when deciding whether to diagnose just a few and perhaps no final com- and treat a patient on the border with mon pathway. Where does that leave normality. A meaningful definition the descriptive system of psychiatry? would clear up the great confusion in Conference Organizers Fairly high and dry. Nature has obvi- the legal system where matters of The conference is organized by the ously chosen to deprive us of clear great consequence often rest on Swedish Association for Philoso- phy and Psychiatry in cooperation joints, ripe for carving. There is little whether a mental disorder is present with the University of Gothenburg, indication of any imminent and sweep- or absent. the Swedish Psychiatric Associa- ing etiological breakthrough. Every- Alas, I have read dozens of defi- tion , and the International Net- thing points towards a slow and pains- nitions of mental disorder (and helped work for Philosophy and Psychia- taking retail accumulation of explana- to write one) and I can't say that any try tory power. It is not even clear that the have the slightest value whatever. DSM categorical approach is the best Historically, conditions have become Conference Web Site research tool. The NIMH is embarking mental disorders by accretion and http://maya.phil.gu.se/sffp/ on a project to correlate an integrated practical necessity, not because they sffp_eng.html exploration of neural networks with met some independent set of opera- Contact Information psychopathology. They chose to study tionalized definitional criteria. In- [email protected] dimensions of behavior (e.g. anxiety, deed, the concept of mental disorder [email protected] pleasure seeking, executive function- is so amorphous, protean, and hetero- ing) - not with the standard psychiatric geneous that it inherently defies defi- Preliminary Program disorders which are deemed too com- nition. This is a hole at the center of http://phil.gu.se/sffp/EEE.html plex to have any simple relationship psychiatric classification. And the with a given neural network. Our DSM specific mental disorders certainly categories may not lead the future constitute a hodge-podge. Some de- charge in understanding psychopa- scribe short term states, others life- thology. long personality. Some reflect inner Our descriptive classification of misery, others bad behavior. Some disorders is old and tired. It has worked represent problems rarely or never hard for us and continues to have seen in normals, others are just slight many valuable and irreplaceable func- accentuations of the everyday. Some tions (which we will discuss in the last reflect too little control, others too section). Fiddling needlessly with the much. Some are quite intrinsic to the labels will not advance science and individual, others are defined against may actually do more harm than good varying and changing cultural mores in its effect on clinical care. and stressors. Some begin in infancy, others in old age. Some affect primar- The Elusive Definition of ily thought, others emotions, yet oth- Mental Disorder ers behaviors, others interpersonal relations, and there are complex com- Humpty Dumpty: "When I choose a binations of all of these. Some seem word it means just what I choose it to more biological, others more psycho- mean." logical or social. If there is a common theme it is distress and disability, but When it comes to defining the term these are very imprecise and nonspe- “mental disorder” or figuring out which cific markers on which to hang a defi- conditions qualify, we enter Humpty's nition.

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Ironically, the one definition of DSM-III and DSM-IIIR was that mental disorder that does have great Alice: "But I don't want to go most decisions were fairly arbitrary - and abiding practical meaning is never among mad people” with plausible supporting arguments given formal status because it is tauto- Cheshire Cat: “Oh, you can't help that could have gone either way. logical and potentially highly self serv- it, we're all mad here." Making more arbitrary changes didn't ing. It would go something like . make much sense; “Mental disorder is what clinicians DSM-IV would have been a very 4) The scientific evidence sup- treat and researchers research and edu- different document if I had adopted porting proposed changes was usually cators teach and insurance companies Humpty Dumpty's confident attitude meager. Requiring that all changes be pay for.” In effect, this is historically and used my authority to shape it to based on substantial evidence usually how the individual mental disorders my personal taste. Bob Spitzer, who shut up even the most passionate ad- made their way into the system. had led the efforts to create DSM-III vocates; The definition of mental disorder and DSM-IIIR is a “splitter” whose 5) The literatures are not only has been elastic and follows practice preference is to divide the diagnostic thin but also mostly derived from rather than guides it. The greater the pie into small manageable pieces. highly specialized research settings number of mental health clinicians, the This enhances reliability, but creates that have questionable generalizabil- greater the number of life conditions many new diagnoses and artificial ity to the real world. that work their way into becoming dis- comorbidity (as complex syndromes One's position on the conserva- orders. There were only five disorders are divided into their component tive/innovation continuum is influ- listed in the initial census of mental parts). I joke that Spitzer never met a enced by reactions to the epistemo- patients in the mid nineteenth century, new diagnosis he didn't like. logical question raised previously. If now there are close to three hundred. I am more of a lumper and also you regard the categories in DSM as Society also has a seemingly insatiable very wary of diagnostic fads and the descriptions of “real entities,” you capacity (even hunger) to accept and unintended consequences of introduc- will be eager to change definitions in endorse newly defined mental disorders ing new diagnoses. Given my druth- accord with evidence that they can be that help to define and explain away its ers, DSM-IV would have had fewer, better described in a way that cap- emerging concerns. As a result, psy- lumped categories and tighter criteria tures their real natures. On the other chiatry is subject to recurring diagnos- sets to make it harder to get a diagno- hand, if you believe as I do, that the tic fads. Were DSM-5 to have its way sis. Instead, I chose not to impose this DSM is necessarily more an exercise we would have a wholesale medicaliza- view on DSM-IV. We would apply a in forging a common language than tion of everyday incapacity (mild mem- conservative standard for all changes in finding a truth, you need a strong ory loss with aging); distress (grief, - equally not add new things or take reason to change the syntax. And it mixed anxiety depression); defects in out old ones unless there was sub- turns out that such strong evidence is self control (binge eating); eccentricity stantial evidence to support the usually lacking. This is why the reli- (psychotic risk); irresponsibility change. Many decisions were thus ability and utility goals are so impor- (hypersexuality); and even criminality grand-fathered into DSM-IV that tant (and for all the discussion about (rape, statutory rape). would not have had nearly enough it, validation is not yet particularly Remarkably, none of these newly support to meet the new higher evi- meaningful). proposed diagnoses even remotely pass dentiary standard. The second divide in the conser- the standard loose definition of “what I am not a particularly risk averse vative/liberal split relates to how wor- clinician's treat.” None of these “mental or conservative person in my every- ried one is by real world conse- disorders” has an established treatment day life. So why the conservative tilt quences. As a pragmatist, I was with proven efficacy. Each is so early in setting ground rules for DSM-5? acutely conscious that every change in development as to be no more than 1) The system had previously made by DSM-IV could have enor- “what researchers research” - a concoc- been in great flux with the rapid fire mous practical consequences: 1) de- tion of highly specialized research in- appearance within seven years of termining who got medicines that terests. DSM-III and DSM-IIIR. It needed a could greatly help or greatly harm; 2) We must accept that our diagnostic period of stability; deciding insurance and disability classification is the result of historical 2) The two previous DSMs were claims; and 3) influencing life and accretion and accident without any real the product of an innovative and death forensic issues. Those of a underlying system or scientific neces- charismatic figure who single- more pure research world, innovation sity. The rules for entry have varied handedly moved the field by dint of orientation would argue for over time and have rarely been very his energy, determination, and grit. “following the data” and damn the rigorous. Our mental disorders are no Now that his accomplishments were consequences. In my view, data sets more than fallible social constructs (but realized, it was time for a less person- that are thin and selective are never nonetheless useful ones if understood alized leadership and for the field at sufficient support for changes that and applied properly). large to reclaim responsibility for its can cause considerable mischief. So diagnostic system; there are two contrasting attitudes. The Conservative/Innovation Debate 3) My experience working on Mine, the conservative view, is “Do or Where Have All the Normals no harm - revise the system with a Gone? 6 Volume 17, Number 2 2010

light and cautious touch only when you patients would be mislabeled and from normal mood in someone who is are sure of what you are doing after a receive unnecessary and potentially chronically depressed or hypomania thorough risk/ benefit analysis.” The harmful, mood stabilizing and antip- from substance induced mood elevation conservative approach assumes that sychotic medication. But this risk in someone using drugs. things are there for a reason and are seemed more than counterbalanced The point here is that tiny changes imbricated in a complex set of rela- by the opposing risk posed by uncov- in definition can (and often do) result in tions. I have had the painful experience ered antidepressants for those whose large, unpredictable (and usually un- of changing a word or two in a seem- bipolar tendencies were previously warranted) swings in diagnostic and ingly harmless way and then later missed by the diagnostic system. treatment habits, especially when am- learning that we had helped trigger an Several facts are incontestable plified by drug companies, advocacy “epidemic” of false positives (as in about trends since DSM-IV: 1) with a groups, and the media. Such potentially Attention Deficit Disorder) or a foren- huge push from the pharmaceutical dangerous fads are enough to turn a sic nightmare (e.g., the misuse of industry, Bipolar II has become an lifelong, risk-taking liberal like me into Paraphilia NOS in the extended civil enormously popular diagnosis; 2) so a conservative nosologist. First, last, commitment of sexual offenders). that the ratio of bipolar to unipolar and always - DO NO HARM. One of the commentaries presents patients increased dramatically; 3) quite the opposite view - that the exist- and prescriptions jumped for mood Afterword ing system is so bad that even the ag- stabilizers and antipsychotics (which gressively innovative DSM-V is sug- can cause huge and dangerous weight The Talmud: "We don't see things as gesting far too little change, not too gains), and 4) for different reasons they are, We see things as we are". much. I believe this to be a naïve Carte- rates of childhood Bipolar Disorder sian rationalist view that neglects the have increased forty fold. Some pa- Many people are troubled by the deep roots and far flung branches of the tients are undoubtedly better off for relativism implied in this penetrating diagnostic system. Most of the sug- being diagnosed as Bipolar II. Others insight - but I find it liberating. We will gested DSM-V changes are such really have gained a lot of weight (and risk never have the perfect diagnostic sys- bad ideas that they do not even repre- diabetes and a potentially shortened tem. Our classification of mental disor- sent a meaningful test of the conserva- lifespan) taking a medication that was ders will always necessarily be no more tive/innovator divide. I believe that unnecessary. than a collection of fallible and limited most sensible people informed of their A conservative might prefer that constructs that seek but never find an risks and benefits would veto them such public health experiments be elusive truth. But this is our best cur- (this leaves out the Work Group mem- based on more evidence than was rent way of seeing and communicating bers who are otherwise sensible but too available to us when we made the about mental disorders. And despite all attached to their pet suggestions to be decision to include Bipolar II. We its epistemological, scientific, and even objective about their risks). also had no way of anticipating how clinical failings, the DSM does its job The new suggestions all share the aggressive and successful were the reasonably well if it is applied properly common problem of greatly expanding pharmaceutical industry marketing and its limitations are understood. the reach of “mental disorders” at the efforts to move product. Bipolar II The concern about comorbidity expense of normality. Armies of mil- also illustrates the exquisite and dan- across disorders arises from the mis- lions (perhaps tens of millions) of false gerous sensitivity of the diagnostic conception that each is a “real” and positive “patients” would receive un- system to small changes. The hugely independent psychiatric illness and that necessary and harmful treatments. I consequential decision regarding the clear boundaries should or could be have covered this problem extensively need for potentially very harmful created to separate them. If instead, one elsewhere and won't repeat the details medication rests on the most fragile accepts that each disorder is just a de- here. A better, because much tougher, and unreliable of distinctions - the scription (not a disease), then the com- test case of the conservative/innovator decision whether or not a hypomanic bined descriptions become modular debate comes from the DSM IV intro- episode is present. If the minimum building blocks each of which adds duction of Bipolar II disorder. Here duration of the episode is set at a precision and information. there are strong arguments on both week (or even longer), people at risk The concerns about heterogeneity sides and no clear right answer. for antidepressant worsening will be within diagnoses also reflect a longing We knew that adding Bipolar II missed; if the requirement is 4 days for well defined psychiatric “illnesses.” would be one of the most consequential (or even less), many people will re- Instead, we are dealing with descriptive changes in DSM-IV but went ahead ceive unnecessary medication. The prototypes (“schizophrenia,” “panic (despite our conservative bias) because symptom thresholds for defining a disorder,” “mood disorder,” etc., of what seemed to be compelling hypomanic episode are similarly arbi- through the manual) that are inherently enough research evidence (descriptive, trary and subject to wide swings in heterogeneous and will hopefullly with course, family history, treatment re- sensitivity and specificity, based on time be divided into many true etiologi- sponse) that it sorted better with bipolar very minor adjustments. Making this cally defined illnesses. than with unipolar mood disorders. We even more complicated are the diffi- The greatest misuse of the DSM recognized the risks that some unipolar culties distinguishing hypomania occurs in diagnosing conditions at the

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ders, the immorality of psychiatric border of normality and criminality. coercions and excuses, and the fre- law, education, economics, politics, Clinicians should hold themselves to quent injuriousness of psychiatric psychiatry, the mental health profes- the most rigorous standards when ap- treatments, I set myself a very differ- sions, everyday language – indeed the plying criteria sets in these dangerous ent task: namely, to delegitimize the very fabric of contemporary Western, boundary territories. The DSM incor- legitimating authorities and agencies especially American, society. The con- porates a great deal of practical knowl- and their vast powers, enforced by cept of “psychiatric diagnosis,” en- edge in a convenient and useful format. psychiatrists and other mental health shrined in the DSM and treated by the To not know it castes one outside professionals, mental health laws, discussants as a “problem,” is challeng- the community of common language mental health courts, and mental ing because it is also a solution, albeit a speakers - the language being clinical health sentences. false one. psychiatry. But it should always be In Psychiatry: The Science Medicalization, epitomized by used with pragmatism and clinical of Lies , I cite the warning of John psychiatry, is the foundation stone of common sense. Selden, the celebrated seventeenth ‑- our modern, secular ‑statist ideology, century English jurist and scholar: manifested by the Therapeutic State. *** "The reason of a thing is not to be The DSM, though patently absurd, has DSM: The Nosology of inquired after, till you are sure the become an utterly indispensable legal ‑- thing itself be so. We commonly are social tool. Nondiseases at, what's the reason for it? before we Ideologies – supported by common are sure of the thing.” In psychiatry it consent, church, state, and tradition – are social facts / “truths.” As such, they Thomas Szasz, M.D. is usually impossible to be sure of are virtually impervious to criticism SUNY Upstate Medical University “‘what a thing itself really is,” be- and possess very long lives. The DSM cause “the thing itself” is prejudged is here to stay and so is the intellectual I thank Dr. James Phillips for in- by social convention couched in ordi- and moral morass in which psychiatry viting me to comment on this debate. I nary language and then translated into has entwined itself and the modern am pleased but hesitant to accept, lest pseudo ‑medical jargon. mind. by engaging in a discussion of the Seventy ‑five years ago, in my

DSM (the American Psychiatric Asso- teens, I suspected that mental illness ciation’s Diagnostic and Statistical was a bogus entity and kept my *** Manual of Mental Disorders) I legiti- mouth shut. Twenty ‑five years later, mize the conceptual validity of “mental more secure in my identity, I said so An Appreciation and disorders” as medical diseases, and of in print. Fifty years later, in the tenth Dissent psychiatry as a medical specialty decade of my life, I am pleased to Psychiatrists and others who en- read Dr. Allen Frances candidly ac- Allen Frances, M.D. gage in this and similar discussions knowledging: “Alas, I have read doz- accept psychiatry as a science and ens of definitions of mental disorder Fifty years ago Thomas Szasz was medical discipline, the American Psy- (and helped to write one) and I can't a lonely (and then much reviled) voice chiatric Association (APA) as a say that any have the slightest value in the wilderness when he boldly chal- medical ‑scientific organization, and whatever. Historically, conditions lenged the simple reductionist assump- the DSM as a list of “disorders,” a wea- have become mental disorders by tions of modern biological psychiatry. sel word for “diagnoses” and accretion and practical necessity, not His blow was prophetic and proactive “diseases,” which are different phe- because they met some independent — coming as it did many years before nomena, not merely different words for set of operationalized definitional modern biological psychiatry had ma- the same phenomenon. criteria. Indeed, the concept of mental tured enough to fully articulate its In law, the APA is a legitimating disorder is so amorphous, protean, grand reductionist ambitions. But organization and the DSM a legitimat- and heterogeneous that it inherently Szasz' target had a long past as well as ing document. In practice, it is the APA defies definition. This is a hole at the its seemingly promising future — mod- and the DSM that provide medical, center of psychiatric classification.” ern biological reductionism is an out- legal and ethical justification for physi- This is as good as saying, “Mental growth of the strict materialism of cians to diagnose and treat, judges to illness, there ain’t no such thing,” and nineteenth century brain science. incarcerate and excuse, insurance com- still remain loyal to one’s profession. Most people came to accept that panies to pay, and a myriad other social The fallacy intrinsic to the con- eventually we would discover the un- exchanges to be transacted. Implicitly, cept of mental illness – call it mis- derlying brain dysfunctions causing if not explicitly, the debaters’s task is take, mendacity, metaphor, myth, many, if not every, psychiatric disor- to improve the "accuracy" of the DSM oxymoron, or what you will – consti- der. It was just a matter of time before as a “diagnostic instrument” and in- tutes a vastly larger “problem” than the exponentially growing power of the crease its power as a document of le- the phrase "a hole at the center of neuroscience and genetic tools would gitimation. psychiatric classification” suggests. unravel the admittedly complex rela- Long ago, having become convinced of The “hole” – “mental illness” as tionships between brain and psychopa- medical problem – affects medicine, the fictitious character of mental disor- thology. 8 Volume 17, Number 2 2010

Until fairly recently, there was no to misuse as society's tool to contain but he goes too far in dismissing the reason to believe that Szasz would be and imprison deviance—witness our value and necessity of clinical psychia- proved so right about the protean na- current role in the long term involun- try. ture of psychopathology—and that the tary commitment of sexual offenders. In my view, psychiatry is a high mighty engine of brain research would He is absolutely right that psychiatry clinical art backed by some clinical turn out to be so limited in explaining has gone too far in medicalizing nor- science that helps a lot of people. mental disorders. Everything seemed to mality and criminality. He is abso- Many of Szasz' criticisms of psychiatry favor the cause of the biologists. The lutely right that this leads to inappro- are right on the money, but he weakens astounding technical revolutions in priate treatment and to a reduction in the credibility of his arguments when genetics, molecular biology, brain im- personal responsibility. he is so globally dismissive. I think his aging, computer and cognitive science Which is not to say that Szasz views would have modified if he had were daily providing profound insights gets everything just right or that men- spent more time in the trenches, had into normal brain functioning—more tal illness really is just a myth or seen the devastation caused by the than anyone would dare predict fifty that most diagnoses are a fiction and "mythical illnesses," and experienced years ago. There was every reason to their treatments an imposition. I the relief that comes with prudent diag- expect this explosion of knowledge think there are two factors causing nosis and treatment. about the normal would soon be fol- Szasz to press his views to an exces- lowed by profound insights into abnor- sive extreme that has unfortunately *** mal brain functioning. The smart reduced the acceptance of all that he money was betting on NIMH, not on has gotten right : 1) his powerful Mental Disorder vs Nor- Szasz. dread of the misuse of power and the mality: Defining the But a funny thing happened. Psy- infringement of personal liberties and chopathology refused to cooperate with responsibilities; and, 2) the fact that Indefinable the reductionist program. It turned to be (because, on principle he would not heterogeneous not only in its presenta- participate in involuntary treatment) Joseph M. Pierre, M.D. tion, but also in its causes. And not just his training and clinical experience David Geffen School of Medicine at slightly or temporarily or technically has not included work with severely UCLA baffling. To paraphrase Tolstoy, nor- ill patients. Szasz started his career mal behavior requires brain function- already convinced that most of psy- Yamaoka Tesshu, a young student ing that has gone right in about the chiatry was self-evidently self serving of Zen, visited one master after an- same way; but abnormal behavior can and misguided—too corrupt to par- other. He called upon Dokuon of come from things going wrong in lots ticipate in except on his own terms Shokoku. Desiring to show his attain- of different ways. All the evidence sug- with individuals who could be totally ment, he said: “The mind, Buddha, and gests that there is no low hanging fruit free agents. sentient beings, after all, do not exist. in understanding psychopathology. Szasz critique of psychiatry goes The true nature of phenomena is empti- Almost certainly, there will be many a bit overboard whenever it is based ness. There is no realization, no delu- pathways to each "disorder," none of on rhetoric and politics and is unin- sion, no sage, no mediocrity. There is which will explain more than a few formed by practical clinical experi- no giving and nothing to be received.” percent of the cases. ence. Szasz is correct that psychiatric Dokuon, who was smoking quietly, said Schizophrenia may not be a diagnoses are no more than fallible nothing. Suddenly, he whacked Yama- "myth" but neither is it a coherent dis- social constructs and not true ill- oka with his bamboo pipe. This made ease—nor will it ever likely be seen as nesses. But he greatly undervalues the youth quite angry. “If nothing ex- such. What we call "schizophrenia" is a the clinical, practical, everyday utility ists,” inquired Dokuon, “where did this descriptively and etiologically hetero- of these fallible social constructs. The anger come from?” [1] geneous aggregate caused by problems fact that we don't understand the in what may be hundreds of different pathogeneses of the disorders doesn't Even if you have closely followed pathways. Bleuler intuited this with his eliminate their value in treatment and largely agreed with Dr. Frances’ concept of the group of schizophrenias planning and prognosis. Even with all public critique of the evolving develop- —but he probably never imagined how its powerful scientific tools, most ment of DSM-5 over the past year or so big would be the crowd. Szasz under- treatments in modern medicine re- as I have, it is still sobering to read stood, decades before there could be main empiric and uninformed by any these words from, if not the creator of any scientific proof to confirm his in- deep understanding of why they DSM-IV per se , then certainly its god- tuition, that schizophrenia was no more work. father: than a construct—and much less than a Even though the term …mental disorders don’t really live disease. "schizophrenia" lacks explanatory “out there” waiting to be explained. Szasz has been right and prescient power, most people who meet the They are constructs we have made on many other issues at the core of psy- criteria for the diagnosis suffer up – and often not very compelling chiatric practice. He is absolutely right greatly and do benefit from treatment. ones at that. …Alas, I have read that psychiatry sometimes lends itself Szasz' critiques of psychiatry stand, dozens of definitions of mental dis-

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order (and helped to write one) and the DSM.” Therefore, moving towards a spectral I can’t say that any have the slight- Whether of not something should view of mental disorder in DSM-5 est value whatsoever. …Indeed, the “count” as a mental disorder will al- might very well point us in a better concept of mental disorder is so ways, in the final analysis, be based direction to ultimately achieve validity amorphous, protean, and heteroge- upon value judgments [3,4]. For the in psychiatric diagnosis (note however neous that it inherently defies defi- DSM, the threshold to guide such that establishing construct validity does nition. This is a hole at the center judgments is usually rooted in the not verify that something is a of psychiatric classification.”[2] principle of “clinical significance,” “disorder” – explanatory physiologies The inability to establish a func- currently defined in the DSM-IV by underlie both pathological and normal tional definition of mental disorder is the presence of “clinically significant variants alike). But while this shift more than a hole in psychiatric distress or impairment of function- may be justified on the grounds of nosology, it would seem to be a foun- ing” [5]. Although this recursive “research utility,” most of Dr. Frances’ dational, ground-zero crater that threat- definition begs the question of how to concerns about “unintended conse- ens to render the entire DSM meaning- define “clinically significant,” the quences” pertain to the DSM-IV’s chief less. How can there be a diagnostic answer is intentionally open to sub- aim as a guide to clinical practice. manual that sets out to provide descrip- jective interpretation, and is nonethe- Within the clinical world, Dr. tive criteria for mental disorders if we less, in my view, the correct approach Frances is most concerned that shifting can’t agree on what a mental disorder to take. Such an emphasis on clinical to a spectral model of psychiatric disor- is? In identifying with the Second Um- utility also makes perfectly defensible der – embodied in the newly proposed pire, Dr. Frances casts himself as the Dr. Frances’ stance that “if you be- “psychosis risk syndrome,” “behavioral Justice Stewart of psychiatric diagnosis lieve as I do, that the DSM is more an addictions,” “mild cognitive impair- (“I know [mental illness] when I see exercise in forging a common lan- ment,” and “temper dysregulation dis- it),” though certainly a central purpose guage than in finding a truth, you order” – will likely occur “at the ex- of the DSM is to remove that kind of need a strong reason to change the pense of normality.” Overdiagnosis, subjectivity from the diagnostic equa- syntax.” false positives, and the pathologization/ tion. No doubt, there are myriad medicalization of normal behavior by Of course, Dr. Frances is well forces that are influencing the rush to psychiatrists are already issues of aca- aware of this dilemma and notes that a publish DSM-5, though from a scien- demic debate, not to mention pervasive more pragmatic definition of mental tific standpoint the central motivation fears of the public at large. I share disorder may be “what clinicians treat seems to be a desire to make progress such concerns, but view the situation and researchers research and educators on the establishment of construct (i.e. and the future somewhat differently. teach and insurance companies pay biologic/etiologic) validity for DSM First, I disagree when Dr. Frances for.” This almost tongue-in-cheek defi- disorders. That goal was outlined by suggests that these “softer” ends of nition is correct to a point, but at the Robins and Guze [6] in 1970, but has psychiatric illness spectra don’t meet same time highlights how a unitary gone sadly unrealized despite more the definition of “what clinicians treat.” definition of mental disorder cannot than 40 years of active research, tech- In fact, treatment for mild and sub- possibly satisfy all of the various are- nological advancement, and the evo- threshold disorders is already standard nas that utilize psychiatric diagnosis. lution from DSM-II to DSM-IV. It is practice, just as psychotherapy of the Each of those arenas has its own rea- therefore the hope of DSM-5 archi- “worried well” dates back to its inven- sons for asking the question, “What is a tects that changing the syntax of the tion. Many children in prodromal psy- mental disorder?” and many different DSM in a fundamental way – by chosis research centers have already answers may be required to address the moving to a “dimensional” model of been by treated with antipsychotics more specific questions of what to mental illness – might pave a new prior to referral; kids with mood prob- treat, what to study, what to teach, and pathway towards the validation of lems are often diagnosed and medi- what to pay for. In its preface, DSM- psychiatric disorders. cated for conduct disorder, bipolar dis- IV specifically outlines an intent to Although a truly dimensional order, and/or ADHD; treatment centers serve the needs of both clinical and model is taking shape for the person- abound for behavioral addictions in- research domains, but while those do- ality disorders in DSM-5, elsewhere cluding binge eating and sexual excess; mains are interdependent, each has a the incorporation of “dimensional and our society is obsessed with stem- different aim. With the addition of measures” is more correctly de- ming the tide of age-related change, third parties (such as insurance compa- scribed as the modeling of disorders both physical and mental. nies and the legal system) to the mix, or symptoms as “spectra” that can be Second, though I agree there has things become impossibly entangled. quantified along a continuum, span- not been enough advancement in psy- This state of affairs – that different ning from normality to pathology. chiatric research to warrant a new DSM definitions of mental disorder may be Psychiatric research, as well as a gen- at this time, I see the shift towards required based on careful analyses of eral scientific worldview, supports spectral models of disorder as unavoid- “contextual utility” – is incompatible the notion that categorical distinc- able in DSM-5 and beyond. This in with what for many is the simplest defi- tions are illusory and that the real turn will inevitably lead to etiologic nition of mental disorder – “what’s in world is made of “fuzzy boundaries.” discoveries that allow manipulation and

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intervention regardless of where a pa- with DSM-5 would seem to depend 5. Spitzer RL, Wakefield JC. tient sits on a spectrum, thereby render- on whether one believes that the main DSM-IV diagnostic criterion for clini- ing distinctions between pathology and intent of DSM is to guide current cal significance: Does it help solve the normality even more arbitrary than they clinical practice or to facilitate future false positive problem? Am J Psychia- are now. Therefore, while in current scientific discoveries that might result try 1999; 156:1856-1864. clinical practice many patients resist in the eventual validation of psychiat- 6. Andrews G, Goldberg DP, psychiatric diagnosis and treatment, ric disorders. On the one hand, my Krueger RF, Carpenter WT, Hyman that picture will predictable change as feeling here is that scientific discov- SE, Sachdev P, Pine DS. Exploring the novel interventions open the door to eries should precede DSM revision, feasibility of a meta-structure for DSM- not only better treatment of disorders, not the other way around. But on the V and ICD-11: could it improve utility but enhancement of normality. It may other hand, I believe that psychiatric and validity? Psychological Med 2009; be a far off vision, but for better or illnesses are fuzzily-bounded states 39:1993-2000. worse, if we build it, they will come. that arise from genetically-mediated 7. Kramer PD. Listening to Prozac. The result would be a drastically al- and environmentally-influenced aber- New York: Viking; 1993. tered landscape of mental healthcare rancies in neural networks, and that 8. Moynihan R, Heath I, Henry D. and society at large, in which, as Peter escaping existing DSM categorical Selling sickness: The pharmaceutical Kramer suggested in Listening to Pro- illnesses in favor of dimensional industry and disease mongering. BMJ zac [7], we can make people “better models is a necessity for scientific 2002; 324:886-891.9. than well” through “cosmetic psy- progress in etiologic research and the 9. Kass LR. Beyond therapy: Bio- chopharmacology.” This potential for development of therapeutic interven- technology and the pursuit of happi- “neuroenhancement” highlights the tions. For this reason, there is reason ness, 2003 (available at http:// subjective relativity of “clinical signifi- to be excited about the NIMH’s de- bioethics.georgetown.edu/pcbe/reports/ cance,” where distress and impaired velopment of the Research Domain beyondtherapy/ functioning themselves exist on a spec- Criteria (RDoC), intended as a “next beyond_therapy_final_webcorrected. trum. “What clinicians treat” will ulti- step in a long journey” to “create a pdf , accessed July 1, 2010). mately be defined by the availability of framework for research on patho- 10. Hoop JG, Spellecy R. Phi- interventions rather than “what’s in the physiology, especially for genomics losophical and ethical issues at the DSM.” and neuroscience, which ultimately forefront of neuroscience and genetics: Finally, this view of the future will inform future classification An overview for psychiatrists. Psy- means that clinicians must take care to schemes [11]. Such ongoing efforts chiatr Clin N Am 2009; 32:437-449. not assume that what works at one end underscore how etiologic research 11. Insel T, Cuthbert B, Garvey of a spectrum will work at another. does not need a new DSM to proceed, M, et al. Research Domain Criteria Careful research is needed to determine and suggest that, pending validation (RDoC): Toward a new classification the most effective and safest treatment of the RDoC and demonstration of framework for research on mental dis- strategies along illness spectra. If spec- their clinical utility, DSM-IV is, to orders. Am J Psychiatry 2010; tral disorders appear in DSM-5 before borrow from Winnicott, a “good 167:748-750. such research is done, then it is likely enough” rough guide for clinical that “treatment” will be applied in a work. haphazard fashion. At the same time, The Psychiatric Spectrum while concerns about the “disease mon- References And Chasing The End of gering” interests of Big Pharma and others are valid, particularly at the soft 1. Reps P. Zen flesh, Zen bones: A the Rainbow end of illness spectra [8], there seems collection of Zen and pre-Zen writ- Allen Frances, M.D. to be an inherent fear of pharmacologic ings. New York: Anchor Press. neuroenhancement that extends beyond 2. Frances A. DSM in philoso- Dr Pierre and I agree on almost mere risk-benefit considerations. This phyland: Curiouser and curiouser. everything, but I think we part com- warrants philosophic and ethical reflec- AAPP Bulletin 2010; 17:21-25. pany in our attitudes toward the creep- tion and invites further debate about 3. Pies R. What should count as ing expansion of the psychiatric spec- why many feel that talking to someone, a mental disorder in DSM-5? Psychi- trum (as it increasingly shades out nor- eating right, exercising, and studying atric Times, April 14, 2009 (available mality). Dr Pierre seems to see the in- hard should be encouraged, but taking a at http://www.psychiatrictimes.com/ creasing inclusiveness of psychiatric psychotropic medication, anabolic ster- display/article/10168/1402032, ac- diagnosis as: 1) an inevitable result of oid, or cognitive enhancer should not cessed July 1, 2010. the fuzzy boundaries between mental [9,10]. 4. Pierre JM. Challenging the disorder and normality; 2) as no great Whether or not the DSM should “disease” model. Psychiatric Times, threat because treating sub threshold implicitly sanction such practice August 26, 2009 (available at presentations has already become the through diagnostic expansion is a fur- www.psychiatrictimes.com/display/ practice norm; 3) as potentially useful ther matter of debate, and immediate article/10168/1444765, accessed July in alleviating mild symptoms and even opinions on whether to forge ahead 1, 2010. in providing performance enhancement 11 Volume 17, Number 2 2010

via cosmetic psychiatry; and 4) as an to reduce to a bare minimum the di- tient psychiatrist whose work focuses inevitable trend that defies correction. agnostic threshold for adult ADD. on the treatment of psychosis, I have I don't have inherent moralistic This despite the fact that we know intentionally placed myself in a com- concerns about expanding the bounda- that there is already a large secondary fortable position that allows me to play ries of psychiatric diagnosis and treat- market for stimulants on college cam- the role of Dokuon (from the Zen koan ment (although admittedly it can take puses. If we want college students to that I quoted in my commentary), on a Brave New World feel). But I be- have easy access to stimulants for where despite fuzzy borders, it is most lieve strongly that we shouldn't attempt performance enhancement, let's make often impossible to deny that there are to extend our reach until we are much them available over the counter and conditions that ought to be called more sure of our grasp. Before we not require what may be a spurious “mental disorders” and that warrant stake out our claim to the milder, spec- psychiatric diagnosis for their use. intervention. Second, having worked trum presentations and to performance Decisions that make stimulants even extensively with patients with sub- enhancement, we need to have con- more widely available should be stance abuse disorders, I have acquired vincing scientific evidence of the risks made by the FDA—not just by a a strong skepticism regarding the indis- and benefits of doing so. We need to be small group of ADD experts. criminant use of pharmacotherapy sure that we will not wind up doing Finally, we should touch on the (whether self-administered or pre- more harm than good? We also need a issue of scarce resources. If psychia- scribed), and am keenly aware that thorough public policy debate that goes try and the drug companies focus interventions intended to make people far beyond just the views and interests attention and dollars on the mildest of feel better can often be more harmful in generated from within our profession in conditions, on the worried well, and the long-run. Third, I am already dis- determining what are the appropriate on high performing people striving heartened by what I see as the over- limits of our profession. for even greater perfection, there will diagnosis of DSM-IV conditions such My concern is that psychiatry is necessarily be fewer resources for as bipolar II/NOS, ADHD, and PTSD, rushing pell mell to define as illness a treating the patients with more severe and am therefore opposed to diagnostic number of milder conditions for which conditions who clearly need our help expansion that creeps further into the there are currently no treatments with and for whom we do have treatments softer ends of illness spectra. While I proven effectiveness (other than pla- that have been proven to make an have worked in a “prodromal schizo- cebo and time). This is being done on important difference. phrenia” research clinic and believe the basis of tissue-thin scientific evi- So what is the verdict on spec- this area of research is important, I feel dence; on the recommendation of ex- trum conditions. Before making them that the predictive power of “at-risk for perts in each field who have an under- official, let's wait until we know we psychosis” (at best, 40% at 2-year fol- standable bias toward expanding their can diagnose them accurately and can low-up) and the lack of clear treatment special interest; and without the benefit prove the clinical utility of both the guidelines (e.g. psychotherapy? antip- of serious external review. There has diagnosis and treatment. By all sychotics? antidepressants? omega-3 been far too little consideration of the means, this should be a fertile area of fatty acids?) argue strongly against risks to false positives or of the societal research for reasons both practical inclusion of “psychosis risk syndrome” costs of conducting what amounts to a (the value of early intervention) and in DSM-5. In short, I do not feel that a enormous public health and public pol- theoretical (mental disorders simply new DSM is warranted at this time. icy experiment in promoting the wide- don't have clear categorical bounda- With these biases, I do indeed spread use of medication for unproven ries). But until the research is in, let's view diagnostic expansion as a poten- indications. focus our diagnostic system and our tial threat. Dr. Frances clarifies how- The premature inclusion of the clinical work on the patients who ever that his concerns are for a more largely unstudied spectral diagnoses in definitely need us and let's provide immediate future in which DSM-5 pro- the official nomenclature would give them with treatments that have been posals would predictably leave us them a substance beyond their shadowy proven to work better than placebo. floundering with many more diagnoses, deserts and feed the drug company without safe and evidence-based inter- marketing beast. The medications *** ventions to accompany them. I share (particularly the antipsychotics) are far that concern, but at the same time don’t from benign (even when they are view that future as too different from clearly indicated) and have a simply Final Comment current clinical practice. For me, the dreadful risk/benefit ratio when they more intriguing and dire threat, though are prescribed for people who don't Joseph Pierre, M.D. farther off and ironically more optimis- need them. The judgment on the desir- tic in terms of scientific advancement, ability of cosmetic psychiatry or per- Since it might not be apparent is the real potential for neuroenhance- formance enhancement should be the that Dr. Frances and I agree far more ment to create a dystopian Brave New subject of a broadly inclusive policy than we disagree, I will break from World (or Gattaca , to update the cul- debate. The best example of how not to my usual attempt to maintain neutral- tural reference). Either way, Dr. Fran- slip inadvertently into performance ity in academic writing, and share ces is correct that I view diagnostic enhancement is the DSM 5 suggestion some disclosures. First, as an inpa- expansion as an inevitability, both be-

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cause current APA/DSM-5 leadership recent scientific advances nor the helpful in improving comprehension seems to view the end-game of diag- triumph of biologism. In fact we ex- by professionals. Minor increases in nostic validity as trumping concerns plicitly eschewed etiologically based reliability are not worth the concurrent about potential consequences and be- categorization since both psychogenic confusion. Substantive changes must cause drug companies, clinicians, and and biogenic theories seemed so data pass the high hurdle of demonstrated patients alike will drive the market for free, contradictory, and useless. We clinical utility in terms of improved interventions that hold the promise (if were principally driven by the meth- prognosis or treatment outcome. I not the reality) of making people feel odological discovery that psychiatric doubt if any of the projected field trials better. With this inevitability, it seems diagnostic unreliability was due to can provide such evidence. obvious to me that discussion and de- criterion variance. If (pre-DSM-III) It should be clear that epidemiol- bate by not only policy-makers, but I was told that a patient was schizo- ogical "findings" depend on the par- philosophers, ethicists, clinicians, re- phrenic, I didn't have a clue, but we ticular, often arbitrary—see agorapho- searchers, patients, and the general could lucidly discuss the presence or bia—algorithm used by the epidemi- public alike are clearly necessary. Yet absence of delusions and hallucina- ologist . Usually, this is acting on data I question whether this will happen to tions. The innovation was trying to collected by non-clinicians from a set any significant degree beyond pages make the criteria clear enough to be verbal questionnaire. Therefore, the such as these. clinically communicable by reasona- note-taker has neither the knowledge The values that ultimately underlie bly explicit (operational was the nor the warrant to follow up the often threshold decisions in diagnosis are the buzzword) inclusion and exclusion ambiguous replies. The data base is same types of values that govern opin- criteria, in the guise of polythetic weak, making diagnostic inferences ions about where psychiatry “should” categories. even weaker. be headed. Many, if not most, of us are That some promoted these into We would all like objective find- guilty of passivity when it comes to causal entities contradicted DSM lll ings to increase the firmness of our taking time away from our busy lives in explicit statements that these were diagnoses. For over the past 50 years order to articulate these values and at- (probably multicausal) syndromes relentless biological research has fallen tempt to influence this direction. We (following Sydenham) that had some afoul of artifact, with no outstanding should therefore be grateful for Dr. useful prognostic and hopefully treat- successes except when linked to gen- Frances’s seemingly lone voice among ment implications but best helped eral medical conditions, e.g., infec- his generation of leaders in the field. clinicians to understand each other. tion , exogenous toxicity , vitamin defi- More than anything else though, my That this hampered some researchers ciency ,endocrinological derangement, sense of inevitability here stems from (not research) is too bad, but so many etc. The recent brain imaging, genomic, what is no doubt a timeless observa- things hamper some researchers. neuroscience advances enhance opti- tion. While I am “only” 10 years out of To enter nosologic theory, it is mism but remain too thin to use. Too residency, there already seems to be a surprising that midst some rather bad. palpable division between myself and high-flown verbiage there is no men- Dimensional revision, except for the younger generation of budding phy- tion of evolution, evolved functions the fairly trivial, often too global, se- sicians, where my own dystopian mus- ( often to be discovered), as empirical verity ratings is another abstract frame- ings often seem to fall on deaf ears and benchmarks—or the suggestion that it work rather than a demonstrated useful where the prospect of neuroenhance- is multi-causal dysfunctions— tool. ment is embraced outright. This makes something has gone wrong—that are me suspect that my own values on this manifest as syndromes, which are not *** particular subject might be conserva- social constructs but repeatedly de- tive, outmoded, and in the minority, scribed across cultures. That neural Second Umpires leaving me with only the truism that circuitry, complexified by genomics, Everywhere change, if not progress, is unavoidable. will do the job is possible but in my view doubtful. After all, that is the Allen Frances, M.D. *** view that has led to the by now con- spicuous failure of the heavily re- Dr Klein's remarks are pleasantly searched pharmaceutical industry to surprising since we seem to agree in DSM Purpose and find any actually new psychotropic some ways I did not anticipate. Threshold for Revision agents. All of our current psychotro- 1) I expected Dr Klein to take pic agents are the offspring of seren- the part of the first umpire. He was a dipitous observations. That should central member of the small circle of Donald Klein, M.D. inform our efforts. great pioneers in biological psychiatry Columbia U. School of Medicine As for DSM-5 revision, it should and has been perhaps its most articu-

be clear that verbal changes usually late, influential, and energetic spokes- A few remarks. As a member of lead to more confusion than clarifica- man. I thought Dr Klein would provide the DSM lll Task Force, my recollec- tion. There, field trials may have a the most elegant and persuasive possi- tion is that we were neither driven by point in demonstrating if such are ble defense of the "I see them as they

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are" realist school of biological psy- precisely because the early fruit was questions about the DSM-5, has stirred chiatry. Instead, he and I seem to agree so low hanging). It may be that, from up a vigorous discussion about the completely in sharing a constuctionist here on out, the obstacles to real (not weaknesses of psychiatric diagnostic view of the epistimology of psychiatric just advertising/pharmaceutical) classification as well as troubling ele- diagnosis. I am not sure whether I mis- breakthroughs will be especially dif- ments related to the DSM in general. read him before, am misreading him ficult to surmount. Dr. Szaszs’s critical voice has added now, or (more likely, I hope) we have 4) I agree that evolutionary fac- richness and value to the discussion. come to the same interpretation of the tors combining in complex ways Both Dr. Frances and Dr. Szasz agree scientific evidence accumulated since with current environmental variables on three points: first, our diagnostic DSM-III - that psychopathology defies, (and chance) must play a crucial role system has not led to the identification and probably will continue to defy, in understanding how any behavior of any biomarkers or biological causes easy etiologic answers. As I read his is, and is seen as, deviant. The prob- for mental disorders; second, the diag- remarks, Dr Klein and I are both lem is that the available models of the nostic categories are heterogeneous "second umpires" who believe that evolutionary psychology of normal within categories and often overlap mental disorders are no more than use- behavior are still in their earliest, with each other as well as with nor- ful constructs, certainly not diseases. least tested (and in many cases even malcy; third, diagnoses can cause real 2) Dr Klein is quite right that untestable) stage of development. We harm, not just to a few people, but to DSM-III was explicitly meant to im- are certainly very far from having millions (Frances, 2010). prove reliability in a way that would be testable evolutionary models of psy- Many commentators express relief atheoretical in regard to etiology. But chopathology. Although it is always that the limits of our current diagnostic the publication of DSM-III was also, tempting to develop appealing and system have become the topic of an symbolically at least, a paradigm shift- plausible "just so" stories providing open conversation. Clearly, the reli- ing moment in psychiatric diagnosis— an evolutionary rationale for one or ability of psychiatric diagnosis has marking the rejection of psycho- another mental disorder, there is no been oversold (Beutler & Malik, 2002). dynamic etiologic models and greatly evidence supporting any of them or Moreover, the gap between research promoting the search for etiologies even a clear methodology for testing and clinical settings has not always rooted in biological psychiatry. Its ma- them. been bridged successfully. Criteria sets jor innovation—the criteria sets—were 5) Dr Klein and I agree com- that seemed to work in research set- certainly no more than a tool to im- pletely on several other important tings have not provided reliable diag- prove reliability. The categories and issues. We agree on the need for high nostic tools for clinicians who struggle definitions should not have been rei- thresholds before changing our cur- with the highly variable interpretations fied—but they have been. Although rent definitions. We agree that dimen- of patient data under the pressures of the DSMs have explicitly disavowed sional models are not ready to make reimbursement procedures and the any assumption that the descriptive much of a contribution to DSM5. We vested interests of the pharmaceutical definitions presume anything about agree that the interpretation of the industry. Our “Decade of the Brain” causality, almost all research funding results of epidemiological studies has yet to produce any biomarkers of has been DSM disorder driven, and in should be extremely cautious. Be- psychiatric diagnoses, despite the many cases driven up a blind alley. cause of their severe and inherent claims of advertising websites for phar- The new NIMH RDOC project is a methods limitations, giant inferences maceutical companies that provide col- useful departure to a less procrustean about prevalence rates have been orful animations of neurotransmitters approach, but it will be many years made on the basis of very limited and and the brain in marketing directly tar- (decades?) before we will know fallible data, with no possible way of geting consumers. whether it will be any more successful. evaluating whether the self reported This passionate discussion itself, 3) We agree about the "me tooism" symptoms have clinical significance. however, is a sign of the profession’s pharmaceutical rut. The interesting health, reflecting a willingness to ex- question is its cause. Do the drug com- *** amine the methods and scientific data panies fail to make advances because that form the foundations of our en- what they care about most is market- The DSM Debate: deavors. We wish to expand the dis- ting and lobbying—and "me too" is the Potential Harms Related cussion on the potential for psychiatric safe play? Or are they hampered by the diagnoses to cause harm in both clini- to Psychiatric Diagnosis stultifying DSM categorical approach cal and forensic contexts. We also which perhaps does not provide the wish to suggest ways to mitigate these Melissa Piasecki, M.D. and best signposts to progress? Both are harms. David Antonuccio, Ph.D. undoubtedly at least partly true. But University of Nevada School of there is a even more worrisome third Diagnostic Harms in Clinical Medicine potential problem—that all the low Settings hanging fruit has already been picked by the original serendipitous pioneers Introduction As the DSM creeps further into Dr. Allen Frances, by raising (their serendipity was made possible normal human experience, so does the

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pharmaceutical industry. One example antipsychotic medications is increas- in legal settings, there is no accepted is the growth of the attention deficit ingly common but without safety and alternative. In most legal settings, a disorder category, an example used by efficacy data to guide this practice diagnostic label in itself is not as im- Dr. Frances and an area that presents (Mojtabai & Olfson, 2010). Children portant as the impact of the psychiatric multiple problems. First are the poten- and adolescents may be particularly symptoms on an individual’s functional tial side effects of the medications. at risk (Jerrell & McIntyre, 2008). abilities (such as in a custody situation) Stimulants are Schedule II drugs, some A related phenomenon is the or ability to reason (such as in a com- of which carry black box warnings for “prescribing cascade,” or the pre- petency to stand trial case). The diag- cardiac arrest and psychosis, a reflec- scription of medications to combat nosis of Mental Retardation, however, tion of the potential harm for the indi- the side effects of the medications for is an exception. The Supreme Court vidual and anyone else who may have the original ill (Rochon & Gurwitz, determined in Atkins v Virginia [ Atkins access to the medication. Another con- 1997). This prescribing practice can v Virginia , 536 U.S. 304 (2002)] that cern is the effect of diagnostic creep on lead to harm from interactions that defendants with the diagnosis of Men- self efficacy and personal responsibil- raise the risk of side effects and ad- tal Retardation cannot be sentenced to ity. Receiving a psychiatric diagnosis verse events, particularly in the eld- death. The limits of psychiatric diagno- may create a sense of illness-imposed erly or in children. For example, a sis become clear in these life and death limits and dependency on medications depressed patient may be prescribed cases—even with well validated instru- in order to function. an antidepressant but may experience ments (e.g., I.Q. tests) there will be Expanding diagnostic categories antidepressant induced agitation (e.g. measurement error and differences in by lowering the threshold (e.g., reduc- Preda et al., 2001). The prescriber diagnosis, especially in people who are ing the number of symptoms required) may then order an anxiolytic, a mood at the border of mild mental retardation for a diagnosis, has in some cases, led stabilizer, and even an atypical antip- and low normal I.Q.. Under the intense to a manufactured epidemic. An ex- sychotic medication to counteract scrutiny of capital litigation, areas of pansive interpretation of the diagnostic these side effects. There is evi- uncertainty and variations in informa- category of Bipolar Disorder to be dence that these types of medication tion gathering and interpretation of more inclusive of children has led to a combinations are becoming increas- diagnostic criteria are exposed. 40-fold increase in the number of chil- ingly common, particularly in vulner- (Footnote: The United States Supreme dren diagnosed with the disorder over able populations like children. For Court decision referred to both the the past decade and the doubling of the example, one study found that 74% of DSM and the American Association on use of antipsychotic medication in chil- children seen by a psychiatrist are on Retardation criteria in the Atkins opin- dren aged two to five (Olfson et al., a psychotropic medication; half of ion). 2010). these children are taking two or more Civil commitment is another foren- The problems of diagnostic hetero- psychotropic medications (Staller, sic setting in which to consider the lim- geneity, diagnostic overlap, and ex- Wade, & Baker, 2005). Zito and col- its and potential harms of psychiatric panding diagnostic categories, coupled leagues (2008a) found dramatic in- diagnosis. Civil commitment laws vary with a tendency to rely on pharmaceuti- creases in the off label use of antide- by state, but most states have a thresh- cal interventions, has led many in psy- pressants in children. Foster children old requirement that a person have a chiatry to use multiple psychotropic are especially at risk for polyphar- mental disorder before they can be in- medications in treating the same pa- macy (Zito et al., 2008b). Of foster voluntarily hospitalized. Some states tient. Polypharmacy may take the form children who had been dispensed specifically exclude some DSM diag- of a different medication for each diag- psychotropic medication, 41.3% re- noses, such as substance use disorders, nosis or symptom, essentially a pill for ceived at least 3 different classes of from their definition of mental disor- every ill. For example, a patient may these drugs, and 15.9% received at der. However, the potential expansion simultaneously meet criteria for Major least 4 different classes (Zito et al., of psychiatric diagnoses raises the pos- Depression, Attention Deficit Disorder, 2008b). Controlled scientific studies sibility of expanded eligibility for in- and Generalized Anxiety Disorder. evaluating more than two psychotro- voluntary hospitalization, with result- Such a patient may be prescribed an pic medications are virtually nonexis- ing risks to personal liberty. antidepressant, a stimulant, and an anx- tent (Antonuccio et al. 2008). Legal cases involving sexual iolytic even though there are no ran- crimes are another source of concern domized controlled trials to guide such Diagnostic Harms in Forensic regarding psychiatric diagnosis in the prescribing combinations in terms of Settings courtroom. An important example is safety or efficacy. Available data sug- the practice of civil commitment of a gest increased risk from combining In the courtroom, experts are sexual offender following the comple- medications. For example, systematic hired to present psychological and tion of a criminal sentence in some observations reveal increased side ef- psychiatric evidence about defendants states as set out in Kansas v Hendricks fects and medical risks (including risk and plaintiffs in many different types (Kansas v Hendricks , 521 U.S. 346.). of death) when SSRIs are combined of legal situations. Even though the In this case, Mr. Hendricks was a sex with other medications (Dalfen & DSM-IV includes a cautionary state- offender who became eligible for civil Stewart, 2001). The use of multiple ment regarding the use of the manual commitment because he had a "mental

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abnormality" or "personality disorder tioner do? Prudent practice behaviors analyses can guide informed consent [s]”—pedophilia. Since 1997, the lack include watching, waiting and data discussions so that clinicians and pa- of a psychiatric diagnosis that applied gathering during a period of uncer- tients may select scientifically sup- to some sexual offenders has invited tainty. Every prescriber encounters ported treatment choices. creativity (Zander, 2008). Is Antisocial diagnostic uncertainty and needs The Treatment of Adolescent De- Personality Disorder a qualifying men- more time in these situations or more pression Study (TADS, 2004) ex- tal abnormality, even if it is specifically data to confirm or disconfirm a diag- panded the data on potential risks and excluded from a state’s insanity law? nosis or a treatment response. There benefits to non-medical interventions. Can we look beyond the DSM and use are always urgent situations when The TADS authors measured the short- the non-DSM diagnosis of Psychopathy patients need immediate treatment. term relative risks of treating depressed for these civil commitments? Does There are also less urgent situations children with psychotherapy alone, “Paraphilia NOS” meet the requirement where an individual presents with medication alone, the combination, or a for a mental disorder in rapists or do mild to moderate symptoms that raise placebo. Despite the fact that suicidal- the civil commitment statutes for sex several diagnostic questions. Addi- ity decreased across all four arms of offenders require creation of new diag- tional data in the form of laboratory this study, the fluoxetine condition had noses used in civil commitment of sex tests, drug screens, collateral infor- a significantly higher rate of adverse offenders? A recent U.S. Supreme mants and the observation of symp- events (such as suicidal ideation), Court decision ( U.S. v Comstock, 650 toms over time should be a greater physiological side effects (diarrhea, U.S. (2010)) upholds earlier cases and part of the diagnostic approach. The insomnia, and sedation), and psychiat- references only “mental illness.” Critics DSM supports these practices with ric adverse events (irritability, mania, of the use of psychiatric diagnosis to clear rule-outs and time criteria. yet and fatigue) compared with placebo or indefinitely commit people convicted persistent questions about interclini- CBT alone. Using the global response of a sex offense question whether our cian diagnostic agreement of DSM measure from the TADS study, the legal system is using the psychiatric diagnoses suggest that clinicians have NNTB is about three in the combined diagnoses as a tool of social control not embraced these practices (Meyer, condition, five for fluoxetine alone, and instead of changing sentencing guide- 2002). twelve for CBT alone, all compared to lines to allow for indeterminate sen- Another characteristic of the rea- placebo. In terms of harm-related ad- tences for sex offenders. One might sonably prudent prescriber is the rare verse events, the NNTH is approxi- expect the Not Guilty by Reason of use of polypharmacy. Patient safety mately twenty in the fluoxetine- Insanity (NGRI) defense to be another calls for confirming the diagnostic containing conditions in comparison to major concern in the forensic area. This indication of each medication as well non-medication conditions. When con- defense is rare, however. Many state as the safety and efficacy of medica- sidering psychiatric-related adverse statutes have narrowed the NGRI crite- tion combinations. Medications that events, the NNTH is approximately ten ria to exclude many defendants with do not have clear efficacy are discon- in the fluoxetine alone condition com- significant psychiatric disorders and the tinued. In addition, a reasonably pru- pared with placebo and only about five success rate varies for this plea aver- dent physician includes areas of un- compared with CBT alone. Adding ages far below 50% (Borum, 2003). certainty, both diagnostic and thera- together the risk for psychiatric, peutic, into discussions of informed physiological side effects, and harm- Strategies for Reducing Diagnostic consent. related events reduces the NNTH even Harm One strategy for managing infor- further. Clinicians and consumers can mation on risk and benefit of medica- use information like this to inform their We suggest two general protec- tion treatment is to calculate NNTB treatment choices in a way that is con- tions to mitigate the potential harms of (number needed to treat to benefit sistent with their own values. psychiatric diagnosis: the emphasis of one extra patient compared with pla- In addition to adopting prescribing practice standards related to prudent cebo) and the NNTH (number needed practices that address ambiguity of care (with increased emphasis on the to treat to harm one extra patient diagnoses and risks of treatment, psy- NNTB/NNTH data) and the education compared with placebo). In an exam- chiatrists can educate others on the of our judges and legislatures on the ple from the childhood depression fallibility of psychiatric diagnoses. As limits of psychiatric diagnosis. literature, Whittington et al. (2004) psychiatry continues the self- Psychiatry has an opportunity with reviewed all of the available data examination and introspection stimu- the DSM to participate in the evolving (published and unpublished) from lated by Dr. Frances’ essays, we have a culture of patient safety. Psychiatrists, controlled trials of SSRIs in de- duty to share our concerns about the especially those who prescribe medica- pressed youth. This meta-analysis validity of psychiatric diagnosis with tions, can adopt the role of “the rea- concluded that the balance of risk and those who also need to understand the sonably prudent physician,” which may benefit based on NNTB and NNTH strengths and weaknesses of the DSM. represent a safer standard than some of calculations was favorable for This includes the medical students and the community standards described fluoxetine, but was unfavorable for residents who have entrusted their edu- above (Simon, 2005). What does the paroxetine, sertraline, citalopram, and cation to us as well as judges, legisla- reasonably prudent psychiatric practi- venlafaxine. The NNTB and NNTH tors, and consumers.

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Summary commitment of rapists. J Am Acad Psy- refined taxonomy of psychopathology chiatry Law . 36(4):459-69. in Beutler, L.E., & Malik, M.L. Most people using the DSM have 19. Zito, J.M., Derivan, A.T., Kra- the intention of advancing the well- (Eds.) (Eds). Rethinking the DSM. tochvil, C.J., Safer, D.J., Fegert, J.M., being of patients or the science of psy- Washington, DC: American Psycho- chiatry. A few use the DSM to assist logical Association. and Greenhill, L.L. (2008a). Off-label judges and juries. Dr. Frances and Dr. 9. Mojtabai, R. & Olfson, M. psychopharmacologic prescribing for Szasz remind us that the road to hell is (2010) National trends in psychotro- children: History supports close clinical paved with good intentions. If we hon- pic medication polypharmacy in of- monitoring. Child and Adolescent Psy- fice-based psychiatry Arch Gen Psy- estly face the risks related to diagnostic chiatry Mental Health. 2 (24). chiatry. Jan;67(1):26-36 creep, validity problems, polyphar- 20. Zito, J.M., Safer, D.J., Sai, D., macy, and the use of psychiatric diag- 10. Olfson M, Crystal S, Huang C, Gardner, J.F., Thomas, D., Coombes, noses for social control, we can begin & Gerhard T. (2010). Trends in antip- to put into place protections that safe- sychotic use by very young, privately Ph., Dubowski, M., & Mendez-Lewis, guard the well being of our patients and insured children. J Am Acad Child M. (2008b). Psychotropic Medication advance our science. Psychiatry. 49, 13-23. Patterns Among Youth in Foster Care. 11. Preda, A., MacLean, R. W., Pediatrics . 121 (1), pp. e157-e163. References Mazure, C. M., & Bowers, M. B. (2001). Antidepressant-associated *** 1. Antonuccio, D.O., Yury, C., mania and psychosis resulting in psy- Valenstein, M., and Matuszak, J. chiatric admissions. Journal of Clini- Diagnoses Can Be Bad for (2008). Common augmentation strate- cal Psychiatry. 62 , 30-33. 12. Rochon, P.A. & Jerry H Gur- your Health gies for depression: Findings show lack of evidence. Psychiatric Times. witz, J.H. (1997). Optimising drug treatment for elderly people: the pre- Allen Frances, M.D. 25 (3), 1-2. http:// www.psychiatrictimes.com/display/ scribing cascade. British Medical Journal . 315. 1096-1099. This is a really wonderful sum- article/10168/1147696. mary that should be required reading 2. Beutler, L.E., & Malik, M.L. 13. Simon, R.I. (2005) Standard-of- care testimony: best practices or rea- for every practitioner and trainee in the (2002). Diagnosis and Treatment mental health professions. I agree com- Guidelines: The Example of Depres- sonable care? J Am Acad Psychiatry Law . 33(1):8-11. pletely with everything said and wish I sion. In L.E. Beutler & M.L. Malik could have said it as well. I will offer a (Eds). Rethinking the DSM. (pp. 252- 14. Staller JA, Wade MJ, Baker M. (2005). Current prescribing pat- few reinforcements on the same themes 278) Washington, DC: American Psy- covering first the overuse of medica- chological Association. terns in outpatient child and adoles- cent psychiatric practice in central tions and then the forensic risks. 3. Borum, R. (2003). Not guilty by I agree completely that polyphar- New York. J Child Adolesc Psycho- reason of insanity, in Grisso, T. (Ed) macy has gotten out of hand- a point pharmacol. 15(1):57-61. Evaluating Competencies. Springer, made also by Dr Pinsker and in my 15. Szasz T. (2010). Commentar- NY, NY. response to him. Of course, polyphar- ies on Allen Frances’ critique of 4. CDC (2010). CDC’s Issue Brief: macy is often rational and necessary, DSM-V. Bulletin of Association for Unintentional Drug Poisoning in the particularly for bipolar disorder and for the Advancement of Philosophy and United States. http://www.cdc.gov/ some patients who respond only to cus- Psychiatry. (in press). HomeandRecreationalSafety/ tom tailored drug regimen. But poly- 16. Treatment for Adolescent De- Poisoning/brief_full_page.htm. pharmacy can never be studied well pression Study (TADS) Team (2004). 5. Dalfen, A. K., & Stewart, D. E. and so lends itself to extremely care- Fluoxetine, cognitive-behavioral ther- (2001). Who develops stable or fatal less, folk practice. apy, and their combination for ado- adverse drug reactions to selective se- Patients acquire a collection of lescents with depression. Journal of rotonin reuptake inhibitors? Canadian medications in different ways: 1) To the American Medical Association . Journal of Psychiatry. 46, 258-262. quote the author's well chosen words, 292, 807-820. 6. Frances, A. (2010) Opening Pan- "Polypharmacy may take the form of a 17. Whittington, C.J., Kendall, T., dora’s Box: The 19 Worst Suggestions different medication for each diagnosis Fonagy, P., Cottrell, D., Cotgrove, for the DSM-V Psychiatric Times. or symptom, essentially a pill for every A., & Boddington, E. (2004). Selec- 2.11.10. ill"; 2) Chasing non-response with an tive serotonin reuptake inhibitors in 7. Jerrell, J.M. & McIntyre R.S. additive approach that never sunsets childhood depression: systematic (2008) Adverse events in children and previous failed drugs; 3 )Excessive use review of published versus unpub- adolescents treated with antipsychotic of adjuncts; 4) The "prescribing cas- lished data. The Lancet. 363,1341- medications. Hum Psychopharmacol. cade" treating side effects with more 45. Jun;23(4):283-90. medications rather than stopping or 18. Zander, T.K. (2008). Commen- 8. Meyer, G.J. (2002) Implications of reducing the doses of the medications information-gathering methods for a tary: inventing diagnosis for civil the patient is already taking; 5) Too 17 Volume 17, Number 2 2010

little use of psychotherapy, too much of The Ideal and the Real: there is relatively little controversy in medication; and, 5) Mindless overpre- the claim that those conditions of great- scription because there are multiple How Does Psychiatry est interest to psychiatrists are doctors or one doctor who just keeps Escape The DSM-5 “mediated” by the brain. The concept throwing stuff in. of “mediation” gets me out of the fruit- The diagnostic system doesn't by “Fly-bottle”? less Cartesian conundrum of “mind” itself cause careless and excessive pre- versus “brain”, “mental” versus scribing habits, but it can facilitate it. Ronald Pies MD “physical” or somatic conditions, psy- DSM-III meant to divide the pie into SUNY Upstate Medical University; chological vs. biological theories of small slices to facilitate diagnostic and Tufts University School of disease, etc. My supposition is that— agreement. Some clinicians naively Medicine whatever the ultimate, ontological na- assume that the presence of multiple ture of what are now called “mental disorders implies the presence of multi- What is your aim in philosophy? To disorders”—the organ chiefly responsi- ple diseases. show the fly the way out of the ble for their manifestation is the brain, The drug companies have played fly-bottle. and not, say, the gallbladder. the largest role in promoting the use of Technically speaking, the particu- "adjunctive medication" , complex drug lar conditions listed in the MBMD combinations, and the excessive use of would be considered “instantiations of medications, recently especially in chil- disease”, rather than as “disease enti- dren. The drug company ads showing ties” or discrete “diseases.” I avoid the pretty pictures of exactly which neuro- ...Ludwig Wittgenstein term “diseases” because this term car- transmiter is not making it to exactly ries with it the connotation of reified which receptor best demonstrate how (Philosophical Investigations ) entities in the physical world, with the pseudoscience has become a marketing same ontological status as stones, trees, tool. Introduction or sodium atoms. I don’t believe dis- Our diagnostic system can be eas- ease entities sit in the same ontological ily misunderstood and misused by the We all have our fantasies, and I category as these objects; rather, dis- courts in what amounts to a psychiatric confess that one of mine is a tad gran- ease entities are essentially pragmatic hijacking of constitutional rights. The diose: I imagine being charged with constructs for making sense of human most flagrant current example is misuse creating a new system of psychiatric suffering. In this regard, my view is of the "diagnoses" Paraphilia Not Oth- diagnosis, starting from scratch. My closely related to that of Kendell and erwise Specified, nonconsent or he- strong belief is that American psy- Jablensky, who wrote in 2003 that “… bephilia to justify long term involun- chiatry has become trapped, much the mere fact that a diagnostic concept tary commitment of sexual offenders like Wittgenstein’s famous fly, in a is listed in an official nomenclature and after their prison sentence has been kind of conceptual fly-bottle, embod- provided with a precise, complex defi- served. DSM-5 would make the cur- ied in the DSM framework. Getting nition tends to encourage this insidious rent bad situation much worse and cries psychiatry out of that trap is the im- reification.” [1] out for a careful forensic review. De- petus behind my fantasy, and moti- To be clear: my position does not ciding the death sentence on the vaga- vates part one (“The Ideal”) of this deny that specific pathoanatomic le- ries of IQ measurement is the other essay. On the other hand, I am realis- sions or pathophysiological dysfunc- leading current problem at the bound- tic enough to know that we are likely tions may underlie many common in- ary between psychiatry and the law. to be saddled with some version of stantiations of disease. But my position The authors suggest the value of the present DSM framework for entails that such lesions or dysfunctions metrics to quantify the balance between many years to come. With that in are not disease itself . The latter— benefits and harms. The NNTB mind, I offer some specific comments derived from our subjective awareness (number needed to treat to benefit one on the DSM-5 framework, and on of “dis-ease”—is a pre-scientific con- extra patient compared with placebo) some of its prominent critics, in part struct, available to men and women and the NNTH (number needed to treat two of this piece. long before there were physicians, X- to harm one extra patient compared rays, or MRIs. (The English language with placebo). The “reasonably prudent The Ideal once had the term “diseasy” to describe physician” assess not just the benefits how people feel when experiencing dis- but also the harms of any intervention. So what’s my first move in creat- ease). The distinction I draw is one Watching waiting and data gathering is ing a new diagnostic framework? I based on Virchow’s apparent distinc- a good stance during a period of uncer- would drop the “DSM” designation— tion between Krankheiten (diseases) tainty-whether dealing with an individ- where were all those “statistics” any- and die Krankheit (disease in general) ual patient or the entire nosology. way?—and call my magnum opus the [2]. I also draw on the important claim Manual of Brain-Mediated Disease , put forth by Kendell; namely, that *** or MBMD. I choose the term “brain- “disease” is properly predicated of per- mediated disease” because I assume sons (“people”)—not of minds, brains,

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or bodies [3]. This is not a bad phenomenological hodge-podge of “…the beliefs of clini- My next move would be to sepa- starting point for the kinds of condi- cians, the wishes of patients, our gen- rate clinical descriptions of disease — tions we ought to let through our di- eral ignorance about many scientific embodied in what I call agnostic “door” to disease. Accord- facts, the limitations of our treatments, “prototypes” [see below]--from re- ingly, conditions like ego-syntonic [and] the needs of insurance reimburse- search-oriented criteria aimed at fos- “hypersexuality” or sociopathy—both ment.” [8] tering inter-rater reliability and uniform presumably lacking intrinsic suffer- 4. “Parsimony” refers to the goal selection of research subjects. These ing—would not be admitted as in- usually expressed in terms of Occam’s research criteria would be relegated to stantiations of disease. This is not to Razor; i.e., “entities should not be mul- one of the MBMD appendices, and say that such conditions should never tiplied beyond what is necessary". Ide- would not be of primary interest to be the focus of therapeutic interven- ally, this principle would reduce the clinicians. The research-oriented crite- tion , or of social and legal regulation total number of psychiatric diagnoses, ria would be quite similar to those now —but those thorny issues would take but without eliminating essential cate- used in the DSMs, and would consist of us far afield. gories. However, I would not prejudice symptom checklists that “define” a 2. “Prototypes” refers to the use the scientific enterprise by aiming for a particular condition, for research pur- of idealized models or archetypes of particular number of diagnostic catego- poses. These criteria sets would indeed disease, rather than of “categorical” ries, or even for the goal of increasing be “conservative”, as Dr. Frances or “dimensional” methods of classifi- or decreasing the total number of such would have it, to this extent: criteria cation. These prototypes are similar categories. would be altered from the previous to what Nassir Ghaemi has called 5. “Pluralism” refers to the use of DSM only if convincing scientific data “ideal types”, described as “… multiple types of evidence and levels of supported the change—an issue to be simplified version[s] of reality”[6]. understanding, in answering Prof. Tim determined by experts in research The use of disease prototypes is one Thornton’s question; i.e., “What is it… methodology, not just by experts in a way to navigate around the Scylla of for something to be a mental disor- particular area of study. By separating “nominalism” and the Charybdis of der?” [9] Or, in my terms, “What ought clinical from research-based descrip- “realism” [7]. In a sense, prototypes to count as an instantiation of brain- tions, I try, in a rudimentary way, to are the diagnostic equivalent of mediated (“psychiatric”) disease?” Plu- deal with the important distinction Dr. “fuzzy logic”, and would make up the ralism allows for, but does not require, James Phillips makes; i.e., “…the dis- core of the new diagnostic descrip- biologically-based criteria for specific tinction between utility in practice and tions. Each prototype would consist instantiations of brain-mediated dis- utility in research.” [4]. As Dr. Phillips of a richly-detailed, generic, clinical ease . Data on biological factors related rightly asks of the present DSM diag- case history, illustrating a particular to a particular condition would be ap- nostic criteria, “Who uses them?” clinical condition. The prototypes pended to the basic prototype, as The MBMD would be built upon would be compatible with , but not “Supporting Data.” Phenomenological six foundational principles, which I call identical to, the research-oriented data (see #6) would also “count” in the 6 “Ps ”: privilege, prototypes, parsi- criteria. Essentially, the research cri- identifying instantiations of brain-based mony, pragmatism, pluralism, and phe- teria would constitute a subset of fea- disease. nomenology. Roughly, these are de- tures within the surrounding “fuzzy” 6. “Phenomenology” –i.e., the con- fined as follows: construct of the prototype. tents and structure of the patient’s felt 1. “Privilege” refers to strict limi- 3. “Pragmatism” refers to the experience —would be an important tations on what conditions are permit- instrumental nature of the diagnostic part of the prototypical descriptions in ted into the diagnostic schema. If psy- schema; specifically, psychiatric di- the MBMD, following the work of chiatric nosology is conceived as a agnosis is seen fundamentally as a Husserl, Karl Jaspers, and various house with many rooms, only certain means to an ethical and humanitarian “existential” philosophers. Exemplary kinds of conditions would get through end —namely, the effective relief of in this regard are Arieti’s classic de- the front door; namely, only conditions certain kinds of human suffering and scriptions of the inner world of patients that entail substantial and enduring incapacity (“dis-ease”). Thus, my with schizophrenia [10]. suffering and incapacity. (To signal diagnostic categories would strive for forward a bit, I believe my position is “utility” in roughly the sense de- The Real: DSM-5 and its compatible with similar views ad- scribed by Kendell and Jablensky Discontents: Areas of Agreement vanced by Dr. Allen Frances). Further- [1] . Specifically: if the net amount with Dr. Allen Frances more, the “suffering” would need to be of psychic misery in the world were intrinsic to the condition, at least in reduced more by using prototype A I find many areas of agreement part—not merely the result of societal than prototype B, prototype A gets with Dr. Allen Frances’s positions, disapproval, punishment, or “bad stuff” priority, all other factors being equal. regarding the DSM-5. For example, I ensuing from a particular behavior [5]. I do not use the term “pragmatic” in agree with Dr. Frances that there is no In the Judaic tradition, the rabbis speak the debased sense that Nassir Ghaemi “paradigm shift” involved in the ideas of tiruf hada’at —“mental anguish”. MD rightly castigates; i.e., as a underlying the DSM-5. As several

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commentators in the AAPP Bulletin Indeed, on a purely ethical level, mines if condition X is, or is not, a have already pointed out, Kuhn’s con- I agree with Dr. Frances’s position. “disease”; or whether symptom X struct of the paradigm shift is in no way By way of analogy: in the Talmud, ought or ought not to be part of the commensurate with the tactical tinker- the principle of pikuach nefesh criteria for a disease, based on antici- ing proposed for the DSM-5, including (“danger to life”) overrides all reli- pated problems with physicians’ pre- the possible use of “dimensional” ap- gious laws except those involving scribing habits or the marketing strate- proaches to diagnosis. murder, idolatry, and prohibited sex- gies of pharmaceutical companies. I also agree with Dr. Frances that ual unions. [13]. In psychiatric there is a “threshold” problem with nosology, I would argue that demon- What is Harm Avoidance? several of the diagnostic categories strable “danger to life” (e.g., “harm to proposed for DSM-5; i.e., too many patients”) should also override virtu- Similarly, the issue of harm avoid- conditions that do not reach the level of ally all other concerns, if there is ance—often expressed by the maxim, “suffering and incapacity” seem to be strong empirical evidence of such a “First, do no harm”—also needs careful getting through the door. Specifically, I danger . For example, if we had analysis. As Dr. Ghaemi has noted in agree with Dr. Frances that “… the well-founded, empirical evidence— his discussion of the Hippocratic phi- difficulties people have in meeting so- say, from actual clinical experience in losophy, the complete quote attributed ciety's expectations should not all be Europe—that criteria set A for diag- to Hippocrates is, “As to diseases, labeled as mental disorders…” [11], nosing ADHD inevitably leads to make a habit of two things —to help , or absent convincing evidence of intrinsic substantial harm to patients, whereas at least to do no harm." [16] (italics suffering and substantial incapacity; criteria set B does not, the latter added). Note that the first Hippocratic that is, the presence of dis-ease [5]. If ought to be favored, all other things principle entails actively helping the society were suddenly to demand that being equal—even if criteria set A patient. Ghaemi goes on to observe we all function at the cognitive level of were directly linked with specific that, for Hippocrates, “ethics grows out Steven Hawking, and began to label as biomarkers, endophenotypes, etc. of science”, which for Hippocrates “mentally disordered” those who But it is a different matter meant knowledge of disease . “The ethi- couldn’t meet that expectation, some- when—despite persuasive scientific cal principle, standing by itself, is not thing clearly would be amiss. On the evidence to the contrary—we pre- at all what Hippocrates taught.” [16] other hand, it is pragmatically neces- emptively manipulate our diagnostic Thus, Hippocratic “harm- sary to specify certain (relatively) cul- categories, in order to head off some avoidance” begins with good science : ture-neutral , rudimenatry abilities as anticipated form of substandard i.e., deciding whether or not the patient defining the lower limits of functional medical care. In my view, this is actually suffering from disease; if so, capacity; e.g., the ability to get out of amounts to well-intentioned but mis- determining what kind of disease; and bed, feed oneself, maintain basic self- guided nosological gerrymandering. then offering the appropriate treatment. care, and perform certain essential cog- Thus, the fear that criteria set A will Hippocratic harm-avoidance is not a nitive tasks, such as remembering to harm patients, based solely on hypo- solicitation to “gaming the system” by turn off the stove. thetical scenarios of slipshod medical pre-arranging our disease criteria so as practice, should not be sufficient to to avoid certain feared socioeconomic Consequentialism in the DSM-5 overcome criteria set A’s scientific or behavioral outcomes. superiority to criteria set B . To be sure, Dr. Frances rightly As Dr. Alan Stone has noted For this reason, I am very uneasy calls attention to the risk of overmedi- (personal communication 12/24/09), with Dr. Frances’s speculation that cation that might very well accompany medical ethics partakes of both deonto- certain proposed changes in the “over-diagnosis” [11, 14]. But this is logical (duty-based) and consequential- DSM-IV criteria will lead to exces- merely one element of an overall, clini- ist (outcome-based) elements. Dr. sive prescribing of stimulants [11] or cal risk-assessment. The inherent mor- Frances espouses a largely antidepressants [14]. In this regard, bidity and mortality of a disorder must “consequentialist” ethos, in his urging both Dr. Sidney Zisook and I differ also be weighed in the balance. For that psychiatrists consider the possible with Dr. Frances on the issue of the example: Dr. Frances maintains that adverse effects that may flow from “bereavement exclusion” for major reducing the number of days required changes in the diagnostic schema. depressive disorder, which now ap- for the diagnosis of hypomania (from Thus, in a recent blog, he writes: pears likely to be eliminated in DSM- the current 4 to 2 days) will result in “Much has been written about the 5 [14, 15]. Zisook and I believe that over-diagnosis of bipolar disorder; "validators" of psychiatric diagnosis concerns regarding overzealous pre- over-prescription of atypical antipsy- and how they should influence scribing practices are best addressed chotic drugs; and adverse medical out- DSM...To my mind, by far the most thorough careful drug labeling infor- comes, such as metabolic syndrome important validator is how will any mation; and especially, through inten- [17]. This putative pathway to “harm” decision help or harm patient care , sive continuing medical education might or might not come to pass. But given the forseeable circumstances aimed at improving prescribing prac- assuming, as Dr. Ghaemi argues, that under which it will be used.” (italics tices. Indeed, I am not aware of any the 2-day hypomania criterion is scien- added) [12] medical specialty that routinely deter- tifically well-founded, its use could

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lead to robust societal “goods” that What is a “False Positive” in diagnostic criteria, that an increase in may well overcome the putative harm Psychiatry? the total number of cases of X neces- envisioned by Dr. Frances. sarily indicates an increase in “false For example, the suicide rate in I also find Dr. Frances’s use of positives” for X. To assert this is bipolar disorder is roughly 15-20 times the term “false positive” [14] in the merely to beg the question of what con- that of the general population [18]. It is psychiatric context deeply problem- stitutes a false positive; indeed, absent quite possible that by reducing the hy- atic. Indeed, some psychiatrists have a veridical biomarker for condition X, pomania criteria from 4 to 2 days, we appropriated this term from the fields the increase in cases may simply reflect would vastly increase bipolar patients’ of pathology or infectious disease, a legitimate increase in the identifica- access to lithium, which appears to without thinking through its episte- tion of the illness. Thus, if elimination reduce suicide risk substantially in bi- mological meaning in psychiatry. of the “bereavement exclusion” leads to polar populations [19]. To be sure, For example, when an infectious dis- an increase in the total number of diag- this is a pharmaco-epidemiological ease expert says, “False positive nosed cases of major depressive disor- prediction that depends in part on the FTA-ABS tests [for syphilis] can der, this does not necessarily point to behavior—and proper education—of occur in Lyme borreliosis ,”[21] the an increase in “false positives”[15]. physicians. We would need several expert is invoking a very different careful, medical-epidemiological stud- epistemological “deep structure” than Conclusion ies, analyzing, say, the risk of antipsy- that invoked, implicitly, by Dr. Fran- chotic-induced metabolic syndrome ces. Thus, when Dr. Frances ex- I have tried to look at the problems compared with the risk of missed bipo- presses concern that eliminating the of DSM-5 from the standpoints of the lar disorder and subsequent suicide. bereavement exclusion will increase “ideal” and the “real”. Ideally, in my My point is that merely positing iatro- the rate of “false positive” diagnoses view, the field of psychiatry would genic harm to patients should not, by of MDD [14], it is unclear to what scrap the basic “categorical” structure itself, overcome the scientific merits of veridical standard he is appealing. of the DSMs, and start from scratch. A refining our criteria for hypomania . What is our laboratory “test” for a new diagnostic system, in my view, Only well-documented, demonstrable true positive in MDD? Until we have would be guided by the six basic prin- harm to the public interest should a widely agreed-upon criteria set for ciples enumerated earlier: privilege, “trump” scientific data showing that a MDD, for which a specific biomarker prototypes, parsimony, pragmatism, change in criteria is justified. As Drs. or endophenotype has been identified, pluralism, and phenomenology. The Waterman and Curley persuasively the term “false positive” is, at best, a foundational principle of this idealized argue, we must consider “…the nega- wishful metaphor; and at worst, a system is that only those conditions tive consequences of leaving largely kind of Rylean “category mistake.” that entail substantial, intrinsic suffer- unchanged a taxonomy we know to be The term misappropriates, from the ing and incapacity “count” as instantia- inadequate at best and simply wrong at epistemic structure of the physical tions of disease . Disease descriptions worst.” [20] sciences, a term that has little if any would consist of “ideal As a very crude mathematical rep- “physical” meaning in psychiatry—at types” (prototypes)—not symptom resentation of these complex calcula- least, in the sense that an infectious check-lists specifying necessary and tions, we can write: disease expert would use the term sufficient conditions or “essential defi- J= S1B “false positive.” One hopes, of nitions.” S 2R course, that this situation will change In reality, we are probably stuck Where J is the justification for as neurobiological knowledge ad- with tinkering around the edges of our changing a specific criterion; S 1 is the vances [22]. present, seriously flawed diagnostic scientific evidence supporting the That said, the term “false posi- system. Even so, our tinkering should change; B is the known benefits of di- tive” can have a coherent conceptual at least be guided by the best available agnosing and optimally treating the meaning in psychiatry, when, for science. Absent convincing empirical condition (e.g., reduced suicide rates, example, it describes a problem with evidence that a change in criteria will disability, etc.); S 2 is the scientific evi- the application of specific diagnostic harm those we treat, our diagnostic dence arguing against the change, and criteria. For example, the statement, criteria should follow the principle, R is the known risk of over-diagnosis “Failure to recognize cocaine intoxi- “Go where the best science leads you.” and excessive or inappropriate treat- cation can lead to a false positive That direction just might lead psychia- ment. Obviously, this theoretical cal- diagnosis of DSM-IV-defined mania” try out of the diagnostic fly-bottle! culation would be exceedingly difficult is at least conceptually sound, since in practice. But it is equally evident we can point to cocaine as a con- References that retaining a dubious DSM-IV diag- founding factor in applying our pre- nostic criterion requires much more sent criteria for the diagnosis of ma- 1. Kendell RE, Jablensky A: Dis- justification than a mere prediction of nia. tinguishing Between the Validity and iatrogenic harm to patients. Finally, it is fallacious to assume, Utility of Psychiatric Diagnoses. Am J following a change in condition X’s Psychiatry 2003; 160:4-12

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2. Pies R: On myths and counter- 15. Pies R, Zisook S: Disentan- with no consideration for practical con- myths: more on Szaszian fallacies. gling Grief and Depression: Rejoin- sequences, we would cut the Arch Gen Psychiatry 1979; 36:139- der to Dr Frances. Psychiatric Times, (nonexistent) joints somewhat differ- 144. March 16, 2010. Accessed at: ently or try to number rather than 3. Kendell RE :The myth of mental www.searchmedica.com name. But the fact that the current sys- illness. In: Szasz Under Fire. Edited by 16. Ghaemi S: First Do No Harm tem is unlovely doesn't mean it bears JA Schaler. Chicago, Open Court, and DSM - Part I: An empty slogan? responsibility as the trap holding us 2004, pp. 29-48 What does First Do No Harm mean? back. Our bottle is much more difficult 4. Phillips J: The muddle that is Psychology Today blog, May 6, to escape than Dr Pies suggests. DSM-V. AAPP Bulletin, 2010; 17:10- 2010. Accessed at: http:// There are two reasons why replac- 12. www.psychologytoday.com/blog/ ing DSM would solve no problems, 5. Pies R: What should count as a mood-swings/201005/first-do-no- eliminate no traps. The first and lesser mental disorder in DSM-V? Psychiatric harm-and-dsm-part-i-empty-slogan problem is that were we to bench Times. April 14, 2009. Accessed at: 17. Frances A: Bipolar II Revis- DSM, there is no wonderful and uni- www.searchmedica.com. ited-Always Take The Experts With versally accepted pinch hitter ready to 6. Ghaemi SN: The Concepts of A Grain Of Salt. Psychology Today step up to the plate and hit the ball out Psychiatry. Baltimore, Johns Hopkins, blog, April 26, 2010. Accessed at: of the park. Many people offer alterna- 2003, p. 179. http://www.psychologytoday.com/ tive schemes (often passionately)—but 7. Coppleston FC: Medieval Phi- blog/dsm5-in-distress/201004/ all are about equally plausible and none losophy. New York, Harper bipolar-ii-revisited-always-take-the- has much scientific backing or offers Torchbooks, 1970. experts-grain-salt such compelling new insights as to be 8. Ghaemi SN: The secret of 18. Pompili M, Rihmer Z, In- clearly superior to any other. Better DSM-IV: The danger for DSM-5 .How namorati M et al: Assessment and methods of defining things descrip- DSM-IV attitudes could harm DSM 5. treatment of suicide risk in bipolar tively are much more likely to emerge Psychology Today blog, published on disorders. Expert Review of Neu- from a deeper understanding of psycho- April 28, 2010 Accessed at: rotherapeutics 2009; 9: 109-136 pathology than to be the vehicle for http://www.psychologytoday.com/blog/ 19. Tondo L, Baldessarini gaining this understanding. For the mood-swings/201004/the-secret-dsm- RJ.Long-term lithium treatment in the most part, changing the descriptions iv-the-danger-dsm-5 prevention of suicidal behavior in amounts to rearranging the furniture. 9. Thornton T: On wishing for a bipolar disorder patients. Epidemiol The second problem is probably paradigm shift. AAPP Bulletin, 2010; Psichiatr Soc. 2009;8:179-83. inherent and certainly more ominous. 17: 17-19 20. Waterman GS, Curley DP: Our stalled effort to understand psycho- 10. Arieti S: Interpretation of Doing no harm: the case against con- pathology most likely comes from its Schizophrenia. New York, Basic servatism. AAPP Bulletin, 2010; "chaotic" etiologic complexity, not Books, 1974 17:19-20 from our inability to describe it prop- 11. Frances A: DSM5 Plans To 21. Smith JL, Crumpton BC, erly. It is hard to predict weather be- Loosen Criteria For Adult ADD. Psy- Hummer J. The Bascom Palmer Eye cause so many variables influence it in chiatric Times, April 20, 2010. Ac- Institute Lyme/syphilis survey. J Clin such unpredictably complex and inter- cessed at: http:// Neuroophthalmol. 1990 Dec;10 acting ways, not because we have diffi- www.psychiatrictimes.com/depression/ culty describing it. The development content/article/10168/1556462 Sorry But No Easy Exit and maintenance of neural networks 12. Frances A: Should Practical may work the same way. The fly can't Consequences Influence DSM5 Deci- Allen Frances, M.D. escape the bottle because there may not sions? Yes, of course. Psychology To- ever be a simple and accessible way day blog, April 27, 2010, Accessed at: I very much enjoyed Dr Pies' out. http://www.psychologytoday.com/blog/ learned and graceful commentary and 2) Dr Pies accepts my pragmatic, dsm5-in-distress/201004/should- agree completely with him - except consequentialist view on how best to practical-consequences-influence- for the following: make diagnostic choices, but with one dsm5-decisions. 1) The fly metaphor is vivid, but important caveat—when the scientific 13. Kottek S: The practice of I think quite misleading. The implica- evidence is compelling, it should medicine in the Bible and Talmud. In: tion is that, but for the procrustean trump. Fair enough. But the practical Pioneers in Jewish Medical Ethics. bed imposed by the DSMs, descrip- point is that for the kinds of questions Edited by F. Rosner. Northvale NJ, tive psychiatry would overcome its being asked and answered in DSM de- Jason Aronson, 1997, pp. 7-2 disappointing failure to promote the liberations, the scientific evidence sup- 14. Frances A: How To Avoid deep understanding of pathogenesis. I porting one or another position is rarely Medicalizing Normal Grief In DSM5. agree wholeheartedly that the DSMs anywhere close to being compelling. Psychiatric Times March 16, 2010. are ungainly historical accretions. If On the very few occasions when the Accessed at:www.searchmedica.com. any of us were starting from scratch facts speak for themselves, there is no controversy—the decision is a no

22 Volume 17, Number 2 2010 brainer. But most often, and whenever there is controversy, the evidence is (4):255-60.remarkably incomplete, methodologi- Guze (1923-2000) of Washington Uni- cally 22. questionable, Maletic V, difficult Raison CLto general- Neuro- versity in St. Louis. Robins and Guze biologyize, and subject of depression, to very different fibromyalgia inter- clearly enunciated their position in their andpretations. neuropathic It almost pain. never Front grabs Biosci.you by *** 1970 paper, “Establishment of Diag- 2009;the throat 14:5291-338. in the way a "realist umpire" nostic Validity in Psychiatric Illness: would have you believe. Its Application to Schizophrenia” (the Indeed it appears*** that Dr Pies has The Past and the Future: precursor to Feighner). They asserted changed his umpire stripes. In his first What Constitutes a that by following the procedures they section, Dr Pies is a "second umpire" outlined, one could assure that any constructionist who strongly decries the Mental Illness given diagnosis was valid. Thus, before reification of descriptive categories. these procedures could be put in place, Here, we couldn't agree more. But in Hannah S. Decker, Ph.D. psychiatrists were to be limited to a these comments, Dr Pies suddenly re- University of Houston very few diagnoses. This was why the verts to a "first umpire" who can com- Feighner criteria were restricted to only Like Allen Frances, I had just fortably call the balls and strikes of 15 diagnoses. one philosophy course in college, so I diagnosis "as they are" because the The “Wash. U.” psychiatrists will try to comment only as an histo- science tells him so. Dr Pies is here (dubbed the “neo-Kraepelinians” by the rian of psychiatry, although like reifying what is still a very incomplete erudite and witty psychiatrist Gerald L. many people, (my guess), I am drawn scientific base that can be plausibly Klerman (1928-1992), argued that very to the philosophical issue of how to interpreted in contradictory ways and little was known about most mental conceive of a mental disorder. doesn't capture an elusive reality. The disorders and therefore psychiatry as a My first observation is that Dr. best way to diagnose grief or bipolar medical discipline had to be rigorous in Frances is not only a psychiatric disorder may vary dramatically de- its research to assure diagnostic valid- scholar but a sound historian as well. pending on whether you see the patient ity. The five methods they declared in a research clinic or in a busy primary Based on the fact that there were un- were necessary for validity of any diag- care setting and on your level of exper- intended negative consequences from nosis were (1) description of the clini- incorporating even small revisions tise. This is why it is so difficult to ap- cal picture, (2) laboratory tests, (3) ex- into DSM-IV, he is urging the leader- ply the Bayesian conditional probabil- clusion criteria to weed out patients ship of DSM-5 to move slowly and ity approach to psychiatric diagnosis- with other illnesses, (4) follow-up stud- carefully as they plan some signifi- the probabilities are so setting specific. ies in order to make certain the initial cant changes for the new manual. He There is no one, right, real way to de- diagnosis had been correct, and (5) is arguing that we have to learn from fine each diagnosis and we know far family studies. For the time being, they the past, a position with which I, like too little how any proposed criteria will pointed out, there were no laboratory any historian, would happily concur. work differently in different settings. tests for most mental disorders, so the Yet I imagine another question is— The DSM must be informed by the other diagnostic methods were essen- most balanced among the always con- for both sides of the ongoing contro- tial, never optional. Among these, fol- tradictory interpretations of the avail- versy—how large a vote should the low-up studies especially were deemed past have in any decision. I do not able science. But it is unwise to reify crucial. The neo-Kraepelinians reiter- intend to answer that at this point, but an incomplete and fallible scientific ated tirelessly the message that these perhaps my discussion will throw base or to assume that it can or should studies were indispensable in the mak- some light on the current debate. trump possibly terrible consequences, ing of a valid diagnosis. In two separate My second comment is that the when these are obvious. publications Donald W. Goodwin “epistemological game” is a game of And one must also factor in a uni- (1942-1999), a junior colleague of great consequence. Frances writes versal and systematic bias. Experts in Guze and Robins, quoted the words of any given area have a blind spot that that as editor of DSM-IV, he “had no Peter D. Scott, a well-known British has them overvalue the research find- grand illusions of seeing reality forensic psychiatrist: “The follow-up is ings in their area, especially their own. straight on or of reconstructing it the great exposer of truth, the rock on They are prepared to accept conclu- whole cloth.” There was no Truth which many fine theories are wrecked sions from very incomplete data sup- “out there.” By contrast, I am re- and upon which better ones can be porting their own pet suggestions that minded of the authors of the famous built; it is to the psychiatrist what the they would promptly shoot down were “Feighner criteria,” who seemed cer- post-mortem is to the physi- it from another area. The biggest flaws tain that with enough knowledge cian” (Goodwin, Guze, and Robins in the DSM5 process were allowing they, or their descendants, would be 1969, 182; Woodruff, Goodwin, and each work group to deliberate in rela- able to construct a totally valid classi- Guze 1974, x). tive isolation and then not to subject fication of all mental disorders. Truth Not surprisingly, Robert A. Wood- the proposals to a stringent and itera- is achievable. The principal figures ruff (another Wash. U. psychiatrist), tive external review. behind the legendary 1972 diagnostic Goodwin, and Guze were even stricter On all the rest, I agree with Dr Pies criteria of disorders, a short list which than Feighner in their 1974 textbook, and thank him for his comments. they were sure were valid, were Eli Psychiatric Diagnosis , where they of- Robins (1921-1994) and Samuel B. fered only 12 diagnoses. They wrote in *** 23 Volume 17, Number 2 2010

their Introduction: “Not every patient nostic classification. Spitzer wanted the conclusion that here the rational- can be diagnosed by using the catego- DSM-III to play a role in combating the ism of the Enlightenment and the ries in this book. For them, anti-psychiatry movement of the 1960s deconstructionism of Post-Modernity ‘undiagnosed’ is, we feel, more and early 70s and to refute critics such confront each other. appropriate than a label incorrectly as Thomas Szasz who said mental ill- My third comment has to do with implying more knowledge than ex- the definition of mental disorder, an ness was a myth. ists” (1974, ix). area of conflict in psychiatry. A defi- I would like to spell out briefly On this issue, Guze later recounted the obstacles that lay in the path of an nition of a “mental disorder” is in- to David Healy an amusing anecdote of agreed-upon definition of a mental dis- deed a tricky business, and many a meeting of the DSM-III Task Force, order. First, Spitzer encountered strenu- psychiatrists see no benefit in such a which he had attended. He had pro- ous opposition from psychologists to definition. Dr. Frances has acknowl- posed “that perhaps we should urge the notion that mental disorders were edged in his commentary that “many [the APA] that, until there had been at medical disorders. This was a turf is- crucial problems would be much less least two long-term follow-up studies sue, with the psychologists fearing that problematic if only it were possible to from different institutions with similar they would lose the right to treat mental frame an operational definition of results, we shouldn’t give the entity a disorders if they were defined as medi- mental disorder that really worked.” status in DSM-III. The alternative was cal. In June 1976, a conference was Nevertheless, he has concluded that to have a lot of undiagnosed cases. We held in St. Louis on “Critically Exam- thus far this has been impossible. could have a way of subcategorizing ining DSM-III in Midstream.” Dr. Dr. Frances’ discussion of this undiagnosed patients in which the label Maurice Lorr, representing the Ameri- matter brought three things to mind would indicate what the diagnostic can Psychological Association, which I would like to discuss: the problem was. That would put us on a “expressed the view that mental disor- vicissitudes of defining a mental dis- stronger scientific basis and it would ders (as medical disorders) should be order during the making of DSM-III constantly remind psychiatrists of our limited to those conditions for which a (a DSM about which I am currently ignorance and what kinds of questions biological etiology or pathophysiology writing), the anti-psychiatry move- needed to be studied...I couldn’t get ment—an unhappy era in the history could be demonstrated.” In addition, that group to vote in favor of my sug- of American psychiatry—and the role just two months earlier, a former presi- gestions. The answer that I was given of unsuspected motivation driving dent of the American Psychological was that they said we have enough Association had been quite blunt in historical events. When Robert trouble getting the legitimacy of psy- expressing his view that DSM-III was Spitzer began convening meetings of chiatric problems accepted by our col- the DSM-III Task Force in 1974, he “turning every human problem into a leagues, insurance companies and other emphasized that one of the things he disease, in anticipation of the shower of agencies. If we do what you are pro- wanted the Task Force to accomplish, health plan gold that is over the hori- posing, which makes sense to us scien- as part of a revolutionary construction zon” (Spitzer and Endicott 1978, 36). tifically, we think that not only will we of DSM-III, were definitions of However, even psychiatrists had weaken what we are trying to do but “medical disorder” and “mental dis- complaints about Spitzer’s attempts at we will give the insurance companies order.” These were to show that men- definitions. A month before the St. an excuse not to pay us” (Healy 2000, tal disorders were a subset of medical Louis meeting, at the annual meeting of 407). disorders, so when he first raised the the American Psychiatric Association, Before I leave the questions of the subject, he used the terms “medical Spitzer and Jean Endicott, a close col- nature of knowledge in psychiatry, di- league on the Task Force, had put forth illness” and “mental illness.” He agnostic criteria, and achievable cer- their definitions of medical and mental wanted to establish that, without any tainty, I should emphasize again the disorders. The reaction here too was doubt, psychiatry was a part of medi- fundamental tension between Frances’ quite negative. As Spitzer later re- cine. Spitzer had initially thought and the neo-Kraepelinians’ views of seriously about mental disorders even ported: “Some questioned the need and conceptualizing mental disorders. The before he was appointed the head of wisdom of having any definition. Many authors of the Feighner criteria seemed the Task Force. In 1973, he had bro- argued that the definition proposed was convinced that once enough was known too restrictive, and if officially adopted, kered the removal of the diagnosis of about any mental disorder, it could be would have the potential for limiting homosexuality as a mental disorder completely categorized. Frances, on the the appropriate activities of our profes- from DSM-II, and the controversy other hand, argues that “almost every- sion . . . they also felt that it was out of surrounding the event sensitized him thing in psychiatric classification is keeping with trends in medicine that to the subject of what constituted a overlapping, fuzzy, and heterogeneous . emphasize the continuity of health and mental disorder. He soon found im- . . The desirable goal of having a classi- illness” (Spitzer and Endicott 1978, pediments to his goal of establishing fication consisting of mutually exhaus- definitions in DSM-III. Still, at every 16). (This continues to be an important tive, non-overlapping mental disorders turn he persevered because he envi- question in current debates over what is simply impossible to meet.” Histori- sioned the issuance of the new diag- diagnoses should be in DSM-5. Fran- cally speaking (in addition to other nostic manual as having intellectual ces, in particular, has argued against aspects of the issue), I would venture pathologizing what he sees as aspects goals far larger than its being a diag- 24 Volume 17, Number 2 2010

of normality, “everyday incapacity,” in trate the complexities of arriving at and our interpreter. I will respond to his words.) In spite of disagreements, one that is intellectually satisfying, her three comments in turn: Spitzer, as was his wont, did not sur- clinically useful, and practically ac- 1) "How large a vote should the render easily. He returned the next year ceptable. It seems likely, however, past have in any decision." Dr Decker to bolster his arguments. This was at that individuals in each generation of raises this most fundamental of human the yearly meeting of the American psychiatrists will pursue this elusive questions, but modestly refrains from Psychopathological Association, an goal. voting on it. My authority is Thucy- organization of preeminent American These three subjects, the role of dides — who inconveniently voted psychiatrists dedicated to research on lessons from history, the extent of both ways. He wrote his history explic- human behavior. In 1977 it devoted its possible certainty in psychiatry, and itly as a cautionary tale to guide us in annual conference to “Critical Issues in the attempts at a definition of mental our current decision making — since Psychiatric Diagnosis.” Spitzer and disorder, have been prompted by my human nature is constant, the same Endicott not only presented retooled reading of Dr. Frances’ extensive dilemmas are inevitably recurrent and definitions of medical and mental dis- discussion of the issues facing the the unfolding of the past should be our orders, but Spitzer, as an editor of the authors of DSM-5. best blueprint for how to proceed into 1978 published proceedings of the con- the future. But Thucydides was a deep ference, now took the opportunity to References and tragic thinker who was also fully remind his readers of the blows psy- aware of the futility of his own didactic chiatry had endured in the 1960s and Goodwin, Donald W., Guze, ambitions. History repeats, but there early ‘70s: “The very concept of psy- Samuel, B., and Robins, Eli, “Follow- are so many interacting contingencies chiatric illness has been under consid- up Studies in Obsessional Neurosis,” that it never repeats exactly or predicta- erable attack in recent years. This at- Archives of General Psychiatry , Vol. bly or on time (instead it "rhymes" as tack has largely depended upon studies 20, February 1969, pp. 182-187. Mark Twain so perfectly put it). Peri- derived from the social sciences. Some Healy, David, The Psychophar- cles could be the most visionary of have taken the stand that what are macologists, Vol. III: Inter- Athenians and rightly predict that her called mental illnesses are simply those views. London: Arnold; New York: strength would come from her fleet— particular groups of behaviors that cer- Oxford University Press, 2000. but still miss the unpredictable point tain societies have considered deviant Robins, Eli and Guze, Samuel that the plague would also arrive on the and reprehensible.” Spitzer believed B., “Establishment of Diagnostic Re- very same ships. History provides no that this rejection of the legitimacy of liability in Psychiatric Illness: Its more than a rough guide, not a map. psychiatry was partly owed to the fact Applicability to Schizophrenia,” Which brings us to what we can that “no generally agreed upon defini- American Journal of Psychiatry , Vol. learn from the DSM past. I was a par- tion of mental illness has been pro- 126, No. 7, January 1970, pp. 983- ticipant observer in DSM-III and DSM- pounded that is not open to the criti- 987. III-R. I learned that Spitzer was a bril- cisms of cultural relativism” (Spitzer Spitzer, Robert L. and Endicott, liant and dogged innovator. He had the and Klein 1978, v). Jean, “Medical and Mental Disorder: insight that a criteria-based diagnostic In addition to his conviction that Proposed Definition and Criteria,” in system (developed originally as a re- DSM-III, with its new diagnostic crite- Robert L. Spitzer and Donald Klein search tool covering just a few disor- ria, would bring diagnostic reliability to (eds.), Critical Issues in Psychiatric ders) could be adapted and broadened psychiatry, Spitzer conceived of the Diagnosis . New York: Raven Press, for wide clinical use as the official di- DSM as a weapon that could repel psy- 1978. agnostic nomenclature. And he had the chiatry’s cultural challengers. The new Spitzer, Robert L. and Klein, determination and smarts to overcome manual would have a potential of his- Donald (eds.), “Preface,” Critical considerable opposition both within torical proportions. Nevertheless, al- Issues in Psychiatric Diagnosis . New and outside psychiatry. I also learned though Spitzer labored mightily to de- York: Raven Press, 1978, p. v. that, as with any extreme innovation, velop “mental illness” as a subset of Woodruff, Robert A., Goodwin, there were accompanying problems and “medical illness,” he was ultimately Donald, W., and Guze, Samuel B., excesses—too many rapid changes forced to bow both to the demands of “Preface” written by Good- (DSM III-R only 7 years after DSM- the psychologists that mental illnesses win. Psychiatric Diagnosis . New III); overselling descriptive psychiatry; be labeled “mental disorders,” and the York: Oxford University Press, 1974. reifying diagnostic categories; too opinions of his psychiatric colleagues, many unproven disorders, especially at who had philosophical and practical the boundary with normal; heterogene- objections to his definition. The upshot ity within and fuzzy boundaries be- was that mental disorders did not get to History Rhymes tween categories; pseudo-precision; be defined as medical disorders. The overestimating reliability in average attempts of Robert Spitzer—a psychia- Allen Frances, M.D. clinical settings, and so forth. What I trist of considerable accomplishment in concluded from this history was that many areas of the field—to establish a How wonderful for our field to DSM-IV needed to stabilize rather than definition of a mental disorder, illus- have Hannah Decker as our memory innovate—be careful, conservative, and

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evidence-based. The field needed time than way stations on the road to bio- structs we have made up . . .” But if to swallow, digest, and incorporate all logical understanding. It turns out this is true – if the standard for diag- the radical changes wrought by DSM- that this understanding will be long in nostic classification is not what exists III and III-R. coming and that the suggested “out there” but rather in “getting to The work on DSM-5 has been mis- "validators" are very poor substitutes. what works best,” if indeed “our mental informed by what is, in my view, a bad Robins and Guze did have a pre- disorders are no more than fallible so- misreading of the recent history of our scient understanding of the risks of cial constructs (but nonetheless useful field. The DSM-5 leadership, respond- diagnostic overreach. Their sugges- ones . . .)” – then Frances fits the type ing to all the wonderful advances in tion to limit the approved diagnoses of the third umpire perhaps even more neuroscience, developed an ambitious to those with a strong evidentiary cleanly than the early Szasz, whose taste for a producing its own "paradigm base was bound to collide with practi- foundational work in The Myth of Men- shift." They missed the fact that despite cal necessity. But they were dead tal Illness (1961) was premised on the its wondrous advances, the neurosci- right to be concerned about the uncompromising nosological realism of ence revolution has not yet at all in- spawning proliferation of new diag- the first umpire (the problem being, for formed psychiatric diagnosis. Descrip- noses, often based only on the fact Szasz, that mental illnesses were balls). tive changes that don't follow from that a few clinician/researchers de- It is the third umpire, not the second, causal understanding are now bound to clare them to "exist." My tease to Bob who best exemplifies Frances’ be arbitrary and likely to do more harm Spitzer was that he never met a new “utilitarian pragmatism.” than good. The DSM-5 leadership has diagnosis he didn't like. This applies To be sure, there are glimpses of also failed to learn from the mistakes even more to the DSM-5 work realism in Frances’ account. His obser- we made in the previous 3 DSM's— groups who are suggesting a plethora vation that the NIMH Research Do- that faddish, false "epidemics" can be of unproven and potentially danger- main Criteria (RDoC) project rather caused by overinclusive criteria ex- ous diagnoses that would have ap- than DSM might “lead the future ploited by drug company marketing palled Robins and Guze. charge in understanding psychopa- and that psychiatric diagnoses can be 3) Regarding the inability to op- thology,” along with his hope for a gravely misused in forensic settings. It erationally define the term "mental taxonomy of “true etiologically defined is too soon to draw any confident con- disorder": The only consolation is illnesses,” implies that psychopa- clusions about the historical meanings that the terms "illness" and "disease" thology is in some sense “out there” to of DSM-5, but the early returns are not are equally elusive. be analyzed and understood, even if promising. It will be fun to follow Dr discrete mental disorders are not. But 2) Regarding the Robins and Guze Decker's ongoing chronicle so that we this realism plays little if any role in his 1970 paper, “Establishment of Diag- may eventually learn what this DSM account of how diagnostic revisions nostic Validity in Psychiatric Illness: fuss has all really been about. should be made: DSM should be re- Its Application to Schizophrenia." vised not when new mental disorders When I read this paper as a second year *** “out there” are recognized (for how, resident, my reaction was "these guys after all, would we know a “mental are so amazingly simpleminded and The DSM and “Do No disorder” if we saw one?) but rather don't begin to understand how compli- Harm:” Is a Radical when the consequences of a revision cated psychiatry is." I felt the same way are likely to provide benefit to patients about Bob Spitzer, who was a favored Pragmatism Sufficient? and, above all, will do no (anticipated) teacher of mine, but seemed to see psy- harm. DSM, for Frances, serves and Warren Kinghorn, MD chiatry in terms that were far too naïve should serve as a regulatory and even Duke University School of Medicine for my sophisticated, sophomoric mind. disciplinary document demarcating

Then I grew up some and realized that limits for the appropriate extension of Dr. Frances, in a helpfully candid perhaps my elders were right after all. psychiatric technology and for the ap- glimpse into the politics of psychiat- The late seventies and eighties were propriate use of psychiatry by particu- ric diagnostic classification, classifies exciting times for biological psychiatry. lar interests (such as the state). himself as the second of the three The genetic and molecular and brain Frances is surely correct regarding umpires in the “epistemologic game.” keys to the psychiatric kingdom all the social function and power of DSM But is this borne out in his subsequent seemed within reach. Well, sometimes and regarding the need to approach discussion? The second umpire, like even ignorant sophomores turn out to potential revisions with extreme care. the first and unlike the third, is appar- be right. The psychiatric "disorders" But his insightful account begs the im- ently a realist, clearly holding that clearly are not simple "illnesses" ready portant question: who should decide? balls and strikes exist independently to be unmasked by our powerful tools. Who should decide what “mistakes” of the umpire’s judgment, which it- Instead, they are remarkably heteroge- and “problems” are, or what “mental self may or may not be accurate. But neous and complex, not only in presen- disorder” is, or what constitutes Dr. Frances appears to take a much tation, but also in etiology. The meth- “harm,” or what would render DSM more radical stance: “mental disor- ods of validation suggested by Robins “useful?” Should patients decide? ders don’t really live ‘out there’ wait- and Guze were meant to be no more Should individual psychiatrists decide? ing to be explained. They are con- Should the Task Force decide? And on 26 Volume 17, Number 2 2010

what grounds? And how would we Mental Illness: Foundations of a psychopathology, however complex, know if the judgments of any of these Theory of Personal Conduct. New resides in the solid world of everyday potential “deciders” were shaped, sub- York: Harper & Row. Newtonian reality, not the goofy, solip- tly and unconsciously, by particular sistic "(un)realities" of quantum phys- forces such as pharmaceutical market- *** ics which place inherent limits on our ing, consumer-driven ideals of beauty clumsy human capacity to measure and and success, gender stereotyping, and Pragmatism Meets Its to know. so on? Can psychiatric diagnosis ever 2) Dr Kinghorn's second critique is extricate itself definitively from Fou- Limits so telling I will quote its central por- cauldian and Szaszian critique? It is Allen Frances, M.D. tions again to provide the emphasis it difficult to see how Frances’ pragma- deserves: "But his insightful account tism can ensure that diagnostic revi- Dr Kinghorn makes two ex- begs the important question: who sions will “do no harm” if “harm” is tremely penetrating critiques of my should decide? Who should decide itself a contested category. position that cut straight to the heart what “mistakes” and “problems” are, or If, as Frances argues, efforts to of the matter. The first—that I am what “mental disorder” is, or what con- establish a consensual and non- really a disguised third umpire—I can stitutes “harm,” or what would render tautological account of “mental disor- answer, at least to my own satisfac- DSM “useful?” Should patients de- der” are likely to fail, there would seem tion. The second-that my pragmatism cide? Should individual psychiatrists to be no way around these questions. lacks normative values and a vouch- decide? Should the Task Force decide? Psychiatric diagnostic classification, safed method—is devastatingly accu- And on what grounds? And how that is, must be understood as a prag- rate and impossible to dispute. The would we know if the judgments of any matic and tradition-constituted enter- two points in turn: of these potential “deciders” were prise in which individuals and groups 1) Does my statement that men- shaped, subtly and unconsciously, by with particular interests interpret re- tal disorders are "fallible social con- particular forces such as pharmaceuti- search data (itself compiled and re- structs" mean there are no mental cal marketing, consumer-driven ideals ported by individuals with particular disorders til "I call them"- making me of beauty and success, gender stereo- interests) in such a way as to shape the a third umpire? I don't think so. As I typing, and so on?" use of psychiatry and psychiatric tech- conceive the third umpire, he believes The essential problem of utilitarian nology in accord with these interests. there is no underlying reality of balls pragmatism is that it often lives case by This recognition should, at the very and strikes and that construct is es- case, without clear external value least, provoke humility and non- sentially all. In contrast, I believe guidelines of the good or even the best defensive soul-searching among those there is a knowable underlying reality methodologies for establishing what tasked with revising the DSM, since to what we now call mental disorders, those guidelines should be. Suppose a biases and moral failures in the just that this reality is so remarkably drug for schizophrenia improves life, “deciders” would very likely become complicated and heterogeneous that it but in the process shortens it—who manifest in their nosological decisions, so far has successfully eluded our decides how the utilities should play and the ongoing cultural acceptance best efforts to "see" it at all straight out? In deciding whether to add a new and use of the DSM hinges on the on- on. As our scientific tools get more diagnosis for "psychosis risk syn- going public credibility of these sophisticated, we get ever clearer drome," one pragmatist may worry “deciders.” It is no wonder that the windows into that reality, but also more about the lost benefit for false DSM-5 architects, in the face of much discover evermore complexity that negatives of not having the diagnosis; work in the contemporary philosophy frustrates simple causal modeling. another (I think wiser) pragmatist of psychiatry, continue to speak in real- But that complexity doesn't mean that about the treatment burden on false ist terms about syndromes “actually brain/behavior relationships are positives if it is included. The Bentha- present in nature” and a nosology "unreal" or inherently impossible to mite utilitarians tried to solve this co- which “[carves] nature at its explain. And certainly there is an "out nundrum with "the greatest good for joints” (Regier et al., 2009, pp. 646, there" that needs explaining—I am the greatest number" and developing 648). In the absence of a narrative of just not sure that our current con- metrics for "good" is now part of be- progressive scientific discovery, would structs are all that close to explaining havioral economics. But as Kinghorn the social consensus regarding the use- it. puts it, the basic question is often fulness of the DSM continue to hold? In fact, as we plod along with begged—who decides the values, gradual scientific progress in the goals, and methods of utilitarian prag- References coming years, decades, and centuries, matism and how? it is conceptually possible the my Back to Dr Kinghorn's telling Regier, D. A., Narrow, W. E., second umpire will gradually merge words: "It is difficult to see how Fran- Kuhl, E. A., and Kupfer, D. J. (2009). into the first and become able to call ces’ pragmatism can ensure that diag- The conceptual development of DSM- this complicated game just as it truly nostic revisions will 'do no harm' if V. Am J Psychiatry 166:645-650. is. In other words, I think that the 'harm' is itself a contested category. If, Szasz, T. (1961) The Myth of relationship between the brain and as Frances argues, efforts to establish a consensual and non-tautological ac- 27 Volume 17, Number 2 2010

count of 'mental disorder' are likely to issues. So my choice would be NIMH ered the best we can do to describe and fail, there would seem to be no way supervision of a very inclusive and assist in understanding the world of around these questions. Psychiatric transparent process. psychopathology, that the prospects of diagnostic classification, that is, must None of this really answers Dr it being considered more favorably in be understood as a pragmatic and tradi- Kinghorn's fundamental point. Nor the future are even bleaker, and that tion-constituted enterprise in which can it be answered. Given the current continued employment of it in mildly individuals and groups with particular state of psychiatric knowledge, there altered forms can only impede much interests interpret research data (itself are rarely clearly right choices based needed progress in all of the areas of compiled and reported by individuals on a cut and dried science base, and psychiatric thought and practice on with particular interests) in such a way the proper course of pragmatism is which it has profound influence. as to shape the use of psychiatry and often in the eye of the beholder. The In this follow-up commentary I psychiatric technology in accord with safe play is to be aware of risks and will summarize very briefly the specific these interests. This recognition potential blind spots and to build in a changes to diagnostic practices David should, at the very least, provoke hu- lot of checks and balances. In an un- Curley and I (2010) recommended in mility and non-defensive soul- certain world, your worst critics are our previous piece, and then address searching among those tasked with often ultimately your best friends. what I assume to be Allen Fran- revising the DSM, since biases and ces’ (2010) objection to our approach. moral failures in the 'deciders' would *** Since our initial commentary presents very likely become manifest in their the opinion (in Dr. Frances’ words) nosological decisions, and the ongoing Doing No Harm Redux: “that the existing system is so bad that cultural acceptance and use of the DSM The Case For (Ultra) even the aggressively innovative DSM- hinges on the ongoing public credibility V is suggesting far too little change, of these 'deciders.'" Conservatism? not too much,” it seems very likely that Right on. But to where? The his diagnosis that this is “a naïve Carte- DSM's have come to assume enormous G. Scott Waterman, M.D. sian rationalist view that neglects the (probably too much) influence in University of Vermont College of deep roots and far flung branches of the widely diverse decisions that impact Medicine diagnostic system” applies to us. That greatly on public health, the distribu- conclusion is so far wide of the mark tion of scarce mental health and school Discussions and depictions of that we must take responsibility for resources, and even the protection of psychiatry in the news media rarely having failed to make our position suf- constitutional rights. The scope and fail to make me cringe. One scenario ficiently clear. I am, therefore, grateful strength of influence of DSM has guaranteed to produce that result is for this opportunity to correct that grown far beyond what anyone could reference to the DSM as “the Bible of shortcoming. have envisioned thirty years ago. The psychiatry.” As is so often the case In our previous commentary in American Psychiatric Association has in circumstances in which one feels these pages, Dr. Curley and I identified sponsored the DSMs for sixty years, embarrassment, though, perhaps that several specific features of the DSM taking on the task originally because no characterization is uncomfortably system that we believe must be elimi- one else wanted to be bothered with close to the truth. Many of the ele- nated: 1) multiaxial diagnosis as cur- anything so insignificant. It seems clear ments are there: a sizeable minority rently conceived, whose unmistakable now that the importance and scope of of its adherents take its words liter- but spurious implication of deep dis- the psychiatric diagnosis has outgrown ally and believe it to demarcate enti- tinctions between “mental” and its being comfortably nested within a ties that exist independently of their “general medical” conditions, and be- single professional organization. The descriptions, while others see it as a tween “clinical” and “personality” dis- sorting of different values and weight- heuristic device that prompts produc- orders, is misleading and destructive; ings in making tough pragmatic choices tive thought and action, but is more 2) definitions of some of the somato- require much wider consensus. of an approximation that necessitates form disorders that invoke the vague, If not the American Psychiatric interpretation and nuanced applica- non-specific, and misleading con- Association, then who should be re- tion. To the extent that the main con- structs of “psychological factors” and sponsible for future revisions in the testants in the most recent DSM wars failure to be “fully explained by a gen- diagnostic system? There is no clear seem to take much of the prevailing eral medical condition”; 3) adjustment right answer. My best (but far from framework of psychiatric diagnosis as disorders, which misleadingly imply perfect) choice would be the National a given, they may be viewed roughly that adversity in the social environment Institute Of Mental Health. NIMH as the modern analogues of the mo- is less etiologically relevant to other, would bring a far broader view to the nophysite and Chalcedonian factions more serious forms of psychopa- task and be less burdened by publishing of early Christianity. What I hope to thology; and 4) disorders “due to a gen- concerns. But NIMH also has limita- add to the mix is (in this extended eral medical condition,” a construct tions. It would tend to be too research metaphor) the atheist position: that that both unnecessarily deviates from focused, less sensitive to practice con- the DSM system – a development of the primary/secondary distinction that cerns, and not necessarily representa- undeniably immense historical sig- has served the rest of medicine well, tive of larger public policy and forensic nificance – can no longer be consid- and implies falsely that the etiopatho- 28 Volume 17, Number 2 2010

geneses of psychiatric syndromes fall thankfully given way to a more ma- chore, akin to procedure coding, that is into two distinct categories – “medical” ture – and, frankly, more genuinely divorced from actual clinical medicine. and otherwise. “biological” – framework in which If we reject Dr. Frances’ claim Beyond those particular sugges- phenotypes are recognized as results that, limited and problematic as it cur- tions for the cutting-room floor (some of the actions and interactions of mul- rently is, amending our diagnostic sys- of which are apparently shared by the tiple genes and environments. Most tem will bring more harm than good, editors of DSM-5), our general critique relevant to psychiatric phenotypes are how can psychiatric nosology be recon- of the DSM project and the error of its social environments, which exert ceived to help us accomplish our clini- neo-Kraepelinian underpinnings led us their influences via the mechanisms cal, educational, and scientific goals? I to recommend a radical overhaul of the of epigenetics, understandings of agree with him that forging ahead with diagnostic system. Given our emphasis which are progressing rapidly. My new categories, or fiddling with the on empiric findings that reveal myriad complaint that the framework of the definitions of old ones, are not the an- problems with DSM-defined pheno- DSM does not comport with this swers. The approach I am recommend- types, Dr. Frances (and likely other emerging conceptualization of psy- ing can be characterized as both a readers as well) may be forgiven for his chopathology, and that that has be- highly provocative and an ultra- mistaken impression that our approach come a fatal flaw, is seen by Dr. conservative one that acknowledges to nosology is an essentialist/naïve real- Frances as a naively realist objection explicitly that the DSM – despite the ist one. But one need not be an essen- which is therefore not compelling. best of intentions and methods of the tialist to recognize that some taxono- As I hint at above, however, recogni- time – took the discipline down the mies accomplish the goals they should tion of the necessity of classification wrong road, and that continuing on that be expected to achieve better than oth- schemes both to reflect and to support road or one of its branches will only ers, and Dr. Frances’ response to the scientific advance simply does not deepen the trouble we are in and make original commentaries in the Bulletin depend on the view that diagnostic it ever less likely that we will get where compellingly catalogues the DSM’s categories are what Dr. Frances calls we need to be. We must, therefore, many shortcomings and disappoint- “real entities.” Our increasingly turn around, return to a fork passed ments. He points out, for examples, sophisticated conception of the long ago, and consider our options “Descriptive classification in psychia- etiopathogenesis of psychopathology, from there. The steps I recommend try has so far been singularly unsuc- involving as it does multiple genes contemplating include: cessful in promoting a breakthrough interacting over time with multiple 1. Identification for possible reten- discovery of the causes of mental disor- environments, renders unsurprising tion of that handful of syndromes that der” and “It is not even clear that the the ubiquitous observation in clinical have performed well over time (in DSM categorical approach is the best psychiatry that the syndromes with some instances, such as mania and a research tool.” Ironically, he parlays which patients present and those de- few others, millennia). That list of these accurate (and, in the latter case, fined in the DSM often resemble one entities may overlap significantly with understated) observations into a case another only weakly. that for which the diagnostic criteria of for conservatism, and it is there that we From a practical standpoint, the Feighner and colleagues (1972), the part ways. I believe that the disconnec- domain of psychiatric endeavor for forerunner of the DSM-III, were for- tion between his realistically austere which changes to the diagnostic sys- mulated. view of what the DSM can accomplish tem are most urgently needed is the 2. Provisional elimination of the for us and his strong belief that we one in which I spend most of my pro- majority of the remaining DSM catego- should nevertheless stick with it is fessional life – that of education and ries, which neither capture nor help us traceable to an error in what he sees as training. It is widely recognized that understand or investigate adequately (at least my) philosophical motivation experienced clinicians use the DSM the phenotypes, etiopathogeneses, for scrapping it, and a limitation on only to the limited extent that they prognoses, or treatment responses of what he imagines are its alternatives. find it useful in any given circum- the patients ostensibly described by Dr. Frances is far from alone in his stance, and clinical investigators at them. assimilation of the DSM enterprise to least sometimes have the ability to 3. Study and implementation of the expression and construct employ other taxonomies that suit methods of documentation of clinical “biological psychiatry.” Although the their scientific purposes better. But findings that are reliable and systematic historical ties between the two are un- the felt necessity of students and resi- and thus lend themselves to standardi- deniable, they are also long-since ex- dents to learn the application of DSM zation and to teaching and research on pired, and with them the misguided diagnostic rules not only crowds out psychopathology. expectations that DSM-defined clinical opportunities to learn actual science; 4. Organization and funding of entities might turn out to be caused by it is creating generations of physi- investigations that link clinical presen- small numbers of genes that act autono- cians who adopt either what Dr. Fran- tations, natural histories, potentially mously from the social environment, ces would recognize as naïve realist/ relevant alleles and epigenetic markers, and treated effectively with drugs that essentialist misunderstandings, or and treatment responses that can inform are specific to them. That sort of anti- cynical conclusions that psychiatric proposals for bottom-up formulation of quated “biological reductionism” has diagnosis is a mere administrative diagnostic constructs – categorical,

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dimensional, or both, as indicated. A Psychiatry 26:57-63, 1972. it is desirable to radically change an similar hope was expressed in the In- Frances A. DSM in philoso- admittedly flawed system. The ques- troduction to A Research Agenda for phyland: curiouser and curiouser. tion I faced, on assuming responsibility DSM-V (2002). Though more modest Bulletin of the Association for the for DSM-IV, was whether to undo what in scope, a highly successful model for Advancement of Philosophy and Psy- I didn't like in what had been done pre- a bottom-up approach to the taxonomy chiatry 17:21025, 2010. viously to suit my own preferences or of emotional and behavioral problems, Kupfer DJ, First MB, Regier DA. whether it was wiser to settle for the the Achenbach (2006) System of Em- A Research Agenda for DSM-V. less ambitious goal of reducing addi- pirically Based Assessment, already Washington: American Psychiatric tional puffery (by introducing high exists. Association, 2002. thresholds for change in DSM-IV). The 5. Gradual adoption of official Waterman GS, Curley DP . Do- latter seemed to me then, and still does (and amendable) diagnostic nomencla- ing no harm: the case against conser- now, the smarter and safer choice. ture as data are judged to warrant it, vatism. Bulletin of the Association Ultraconservatives are always radical, without the need or expectation of en- for the Advancement of Philosophy never conservative. Whenever an ultra- compassing soon – or maybe ever – and Psychiatry 17:19-20, 2010. conservative acts upon his ideas, the every conceivable instance and permu- actions are inevitably risky and likely tation of human distress or dysfunction. *** to do much more harm than good. I The set of recommendations prefer the skeptical Edmund Burke briefly outlined above obviously re- Ultraconservatives Are conservative approach that eyes suspi- quires far more elaboration to be con- ciously any grand revolutionary de- sidered an alternative proposal. It is Radicals in Sheep's signs—whether to lurch progressively instead offered only to illustrate that a Clothing forward or fundamentally backward. radical change to our nosological ap- So I resisted any impulse to re- proach need not – indeed, should not – Allen Frances, M.D. make the diagnostic system in my own lead scientific, clinical, and educational image. I believed that the system advance, but instead must both reflect I too am an ultraconservative in should not oscillate wildly based on the and facilitate it. If the DSM system my personal preference for a smaller whims of any one person, who happens were capable of fulfilling that funda- and tighter diagnostic system. But, to be in charge at that given moment. It mental criterion, I would advocate its unlike Dr Waterman, I am a conser- is very hard to know which approach is retention. I understand that my sugges- vative in wanting to avoid radical best when none ( including my own tions may be seen as outlandish, rhe- changes and instability in the classifi- pets) seems particularly more proven or torical, irresponsible, or simply impos- cation. (Incidentally, being ultracon- promising than any other. When so sible – and thus unserious. I hope that servative and conservative in any way little is well established, there is no is not the case, and that psychiatry goes against my usual grain—I am a reason to feel confident even on ones strongly considers leaving the Bible hopelessly bleeding heart liberal in own best judgment. business to others. most other things). The bottom line is that I distrust all Perhaps Dr. Frances and I agree Dr Waterman and I do agree fancy ideas on how to improve our more than either of us realized. Per- about the limitations of the current admittedly flawed and possibly over- haps “doing no harm” is best served by system. I am as skeptical as anyone blown system, even my own. There has conservatism – in this case, by just get- can possibly be about DSM-IV be- to be a very good reason and strong ting out of the way. cause I know its shortcomings so up evidence to make every change. Radi- close. If I were starting from scratch, cal changes to the system shouldn't References I too would insist on a higher stan- come from armchair reasoning and dard for diagnosis that would elimi- personal whim - they should follow Achenbach T M, Rescorla LA. nate some of the existing categories only from compelling scientific evi- 2006. Developmental issues in assess- and raise the thresholds for many dence, even if this may be a long time ment, taxonomy, and diagnosis others. I felt, as I was watching it coming. My own personal experience of psychopathology: Life span and happen, that DSM-III and DSM-III-R in the different roles has been that it is multicultural perspectives. In Develop- were both puffed up with question- very much easier to criticize the system mental Psychopathology, 2nd Edition, able new diagnoses and low thresh- from the sideline than to actually find Volume 1: Theory and Method , Cic- olds. The high rates of DSM-IV di- compelling ways to make it better chetti D, Cohen DJ, eds. Hoboken, NJ: agnosis reported in community sam- when one is actually in John Wiley ples suggest that the system is very the game. & Sons, Inc., 2006. overinclusive (although the epidemi- Feighner JP, Robins E, Guze SB, ological study methods are also often ***

Woodruff RA, Jr, Winokur G, Munoz questionable). R. Diagnostic criteria for use in psy- But Dr Waterman and I disagree chiatric research. Archives of General in a fundamental way about whether

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Final Comment official diagnostic nomenclature be Proofs at that time: zero. Fides adopted gradually as evidence war- quaerens intellectum—a belief looking Scott Waterman, M.D. rants it, without the expectation that for understanding. I think it was histori- all conceivable clinical problems will cally simply a revolt against the domi- be codified soon, or perhaps ever. nance of psychoanalytic-Freudian I thank Dr. Frances for his re- Dr. Frances’ final point – that it thinking in the field at a time when sponse to my most recent commentary, is easy to “criticize the system from Freud’s influence in psychiatry was and I appreciate the opportunity to re- the sideline” – is no less valid for anyhow declining. It was also from the but it. This reply, however, is only being ad hominem . Unfortunately, beginning on clearly stated that the partly a rebuttal, since he and I appar- though, the ease with which dissatis- work should be a-theoretical (i. e. ently agree on so much. It is largely faction with the DSM has arisen re- stripped of the psychoanalytical ballast the conclusions we draw from our lates far more to its attributes than to and bias). shared premises that differ, though they those of its numerous critics. For What Allen Frances states about differ dramatically. what it is worth, I too confess my the importance of classification in the Dr. Frances acknowledges – life-long leftward leanings, making history of sciences in general as he has throughout this debate – that my ultra-conservatism (if that accu- (Kepler-Newton, Linnaeus-Darwin, the DSM is “flawed” with “limitations” rately describes my position) on this etc.) is highly convincing. Even if in and “shortcomings,” and that the stan- topic uncharacteristic. Persistence psychiatry the efforts in the domain of dards of inclusion of diagnostic catego- may be a virtue in many contexts, but categorization were not followed by ries have not been high, leading to our not in the face of evidence that the spectacular breakthroughs, there were current “puffed up” system. That is not status quo is an unacceptably poor without doubt some fundamental defi- an auspicious starting point for a call to alternative. nitions, such as the distinction between conservative inaction, but Dr. Frances neuroses and psychoses and the de- makes the best of it. He is more fearful *** lineation of the syndrome of schizo- of the effects of “instability” than he is phrenia which may prove the contrary. of the adverse consequences of retain- About DSM in As in the Bible: your words should be ing a diagnostic system that has failed Philosophyland yes-yes, no-no, what you add comes to serve any of its purposes or constitu- from the Devil. Big categories: yes ; encies well, and whose retarding influ- minutiae: no. ence on progress – to whatever extent André E. Haynal M.D. For the protection of a weak popu- the field will continue to treat it seri- Department of Psychiatry, University lation of suffering and handicapped ously – will only grow with time. He of Geneva (Switzerland) people, it remains nevertheless impor- puts great stock in the fact that the cur- tant to maintain these social constructs rent DSM system dates back 30 years, Allen Frances' all encompassing and not to deny their usefulness, e.g., in a period of time that (though a mere "DSM in Philosophyland..." touches the insurance system and perhaps also blink of an eye in historical perspec- fundamental problems that makes us permitting to scrutinize more or less tive) he sees as having committed us to think. As this reader is leaning toward homogenous groups in research work. this unfortunate course for the indefi- the position of the third Umpire, But their potential, especially for exclu- nite future. which has for long been defended by sion, should neither be denied. Dr. Frances and I agree on other Thomas Szasz, it may be that a patho- Reading this text is a great pleas- premises as well: that “grand revolu- logical mistrust concerning classifica- ure and stimulation and Allen Frances’ tionary designs” are to be viewed sus- tions plays a role in the leaning of utilitarian-pragmatic point of view can piciously, and that taxonomies should this reader. A memory emerges from be very well accepted, even by people not be the products of “armchair rea- ancient Greek, where for Aristotle, who, themselves, suffered from politi- soning and personal whim” but should e.g., the verb categorize meant not cal, ethnic, professional (!) or other instead “follow only from compelling only to put into categories, but also to categorizations. scientific evidence, even if this may be accuse. It seems that today’s common a long time coming.” Exactly! Those words stigma and stigmatization have *** principles should guide both the deci- a much nobler origin, which is the sion to scrap the current DSM system description of people who wore the The Power to Name is the (which ran afoul of them) and the wounds (stigmata) of the Christ. In Power to Harm means of formulating its successor. this respect, the DSM may have My proposal explicitly urges a process grown on dubious philosophical and that brings to bear empiric investiga- theological bedrocks in an emotion- Allen Frances, M.D. tions on a range of parameters (clinical ally loaded context... presentations, natural histories, poten- I personally don't think that We agree completely. tially relevant alleles and epigenetic DSM-III was a victory of biological 1) Professor Haynal's classical markers, and treatment responses) in psychiatry as it is stated by Allen references remind us that the power to the reformulation of psychiatric Frances. What might be biological in name is not always medicinal and be- nosology. It also recommends that it? Only the "myth" as Szasz called it. nign. Naming can also be misused or 31 Volume 17, Number 2 2010

misunderstood to accuse or stigmatize. DSM-IV, Hippocrates, source of disease, and that the physi- The egregious misuse of the concept cian (and surgeon) needs to fight Na- "paraphillic rape" in legal settings to and Pragmatism: What ture to effect cure. Even in ancient allow for the inappropriate (and often Might Have Been Greece, physicians had many potions lifetime) involuntary psychiatric com- and pills to cure ailments; Hippocrates mitment of sexual offenders is by far resisted that interventionist medicine, the most conspicuous and shameful S. Nassir Ghaemi, MD, MPH and his treatment recommendations current example. But the unintended Tufts University School of Medicine often involved diet, exercise, and wine potential risk of stigma is fairly ubiqui- – all designed to strengthen natural tous and must be calculated into the The main conceptual critique that forces in recovery. If Nature will cure, risk/benefit analysis for each new pro- Allen Frances, head of DSM-IV, ap- then the job of the physician is to has- posal. pears to be making about the DSM5 ten Nature’s work carefully, and at all 2) I don't mean to imply that DSM- process is as follows: “It fails to ad- costs to avoid adding to the burden of III represented some kind of victory for dress the most important questions illness. biological psychiatry. It was more an concerning the impact of proposed Based on this philosophy of dis- iconic marker of the already well ad- DSM-5 changes on prevalence rates ease, the Hippocratics divided diseases vanced changing of the guard from and on false-positive diagno- into three types: curable , incurable , psychodynamic to biological models ses.” (Psychiatric Times, June 2010) and self-limiting . Curable diseases and thought leaders. Although DSM-III He calls for external committees, require intervention, aimed at aiding was theoretically atheoretical, it lent beyond those on each subgroup of the the natural healing process. Incurable itself best to, and was a culmination of, task force, to review proposed criteria diseases generally were best left un- biologically oriented research methods. for these practical purposes. In our treated, since treatments did not im- The provision for each diagnosis of a previous discussion, he becomes ex- prove illness and, due to side effects, definitional criteria set ( the major in- plicit about his two apparent primary would only add to suffering. Self- novation of DSM-III) was a direct ap- conceptual assumptions, underlying limiting diseases also did not require plication of criteria based methods that the above critique: 1. First and fore- treatment, since they improved sponta- were just previously being developed most, that we should be guided by the neously; by the time any benefits of for (mostly) biologic research. DSM-III principle “Do no harm.” 2. That treatment would occur, the illness also helped bring American psychiatry “pragmatic” judgments should be the would resolve by itself, again leaving back into the mainstream of medicine, overriding principle in the final noso- only an unnecessary side effect burden. and thus toward an emphasis on medi- logical definitions for each DSM re- The concept of Primum non nocere, cation, not psychological, treatment. vision. thus, meant knowing when to treat and 3) The lag between description and Here I will critique those two when not to treat, based on what kind explanation is certainly not unique to assumptions. of disease one diagnosed . psychiatry and also applies at two of It is exactly this primacy of dis- psychiatry's boundaries—e.g., most of “First do no harm” ease, this special appreciation for the medicine is still empiric, and the social scientific importance of understanding sciences all do a lot better at describing This is obviously derived from disease, that cannot met due by the than at explaining. Explanations are the famous Hippocratic teaching. second claim above: the primacy of easier to come by in the somewhat sim- (The full original quote was in the pragmatism. pler worlds of astronomy, physics, and maxim of Epidemics I: “As to dis- chemistry than in medicine, psychiatry, eases, make a habit of two things – to “Pragmatism” or economics. The really interesting help, or at least to do no harm.”) It next question is whether the gap be- may be relevant to understand what it Pragmatism in its postmodernist tween description and explanation will meant in that Hippocratic tradition. flavor has become, in fact, the uncon- be crossed soon with our powerful sci- The Hippocratic tradition is often scious philosophy of the average 21 st entific tools or whether explaining mistakenly identified simply with a century American (and indeed the aver- mental disorders will be as tough as conservative approach to treatment. age Westerner). To appreciate what explaining the complexities of fluid While partly true, this popular simpli- this means, I will describe what prag- dynamics (which is what makes fication fails to capture the deeper matism originally was, what it has be- weather forecasting so problematic). I genius of Hippocratic thinking, for its come, and how it has become a phi- am betting that the complexity will ethical maxims were not abstract losophy of mental illness that under- give the science a very long run for its opinions but rather grew out of its girds DSM-IV, and destroys chances money. theory of disease (1, 2). for a beneficial evolution in future 4) I am indebted to Professor Hay- The basic Hippocratic belief is DSMs. nal for standing behind the third um- that Nature is the source of healing, As a philosophy, pragmatism in pire. Well informed philosophical skep- and the job of the physician is to aid the hands of its late 19 th century origi- ticism is a useful and rare commodity nature in the healing process. A non- nator, Charles Sanders Peirce, meant these days. Hippocratic view is that Nature is the

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that the truth of a concept could be tween you and me, only agreements clude that we should give up on diag- found in its results. If we have a hy- and arguments that reflect power, not nosing altogether. Either way – with pothesis in science, for instance, we do truth. arbitrary eclectic definitions or with the an experiment, and based on the results Those among our colleagues who refusal to define – postmodernist ap- of that experiment, we judge the truth claim never to read philosophy suffer proaches to mental illness are a dead of that hypothesis. In this way, from unconsciously imbibing their end for psychiatric nosology. Peirce’s pragmatism is simply equiva- philosophies from the larger culture. lent to science; it has nothing to do What Frances means by Bipolar disorder with “being practical.” Peirce knew “pragmatism” seems to be a postmod- that science involves hypothesis and ern Rortyean neo-pragmatism, one One sees this postmodernist ideol- that the process of science is not sim- which denigrates science as the ogy play out in some of the specific ple. The results of one experiment can power-plays of experts – a view that critiques made by Frances. For in- differ from another. Seeing pragma- only cares about what is practically stance, he strongly opposes the notion tism as the same as science entailed useful – truth be damned. This is a that the cut-off definition for hypoma- seeing the limits of science. But Peirce long way from Peirce’s original at- nia should be reduced from four days to did not draw postmodernist conclu- tempt to explain science. This degen- two days, even though the original defi- sions. His solution was to think of sci- eration of pragmatism is reflected in nition of four days was based on zero ence, as a whole, as a process of many the standard English usage of the scientific evidence, and there is reason- experiments and many experimenters, word as equivalent to being practical, able evidence to make a change to a constantly subjecting the truth to the not engaging in theorizing, focusing shorter number of days. For instance, scrutiny of research (he calls this proc- on what happens in the real world, Jules Angst published a review of this ess “inquiry”). Over time, the truth and the actual consequences of acts literature, including his half a century would display itself through this proc- or decisions. of research on this topic which also ess of inquiry. Then, the consensus of includes a 40 year outcome study from investigators would be the same as the Postmodernism Zurich, a psychiatric equivalent of the actual truth. Framingham heart study. His research So pragmatism, in its inception, It is but a short step from this was an important basis for the whole not only valued science, but pragma- simplistic neo-pragmatism to a dan- distinction in DSM-III in 1980 between tism was identified with science, prop- gerous postmodernism. All defini- MDD and bipolar disorder, so Angst erly conceived. Pragmatism is not a tions become arbitrary, not in a super- can hardly be criticized as someone means of devaluing and ignoring sci- ficial or transient way, but pro- who opposes the diagnosis of MDD. ence. foundly. All diagnoses represent Yet in his review of a lifetime’s work After Peirce, William James took a cultural and professional consensus. in the British Journal of Psychiatry , he few steps toward postmodernism by Now, homosexuality is a mental ill- provides evidence for a shortened dura- famously identifying truth with the ness; now, it is not. Neither view is tion of hypomania (3). I would like to “cash-value” of an idea. This would right or wrong. There is no right or see one citation that refutes Dr. Angst’s seem to identify pragmatism with utili- wrong, only our cultural preferences. data and supports a four day cutoff as tarianism – the truth of a concept is If I want to define depression, I more valid for hypomania than shorter what is useful. This step moves be- should do so based on awareness of definitions. If, as I believe is the case, yond Peirce and loses the connection the cultural powers that be, not just such data do not exist, one might hear with a real truth that would justify our first and foremost, but solely and instead the debating point that this is beliefs. John Dewey took a few more completely. What does society want? just the power-play of experts; science steps than James. By equating truth What are the relevant social forces is never definitive; there is always un- with “justified belief”, rather than real- (pharmaceutical and insurance com- certainty; the literature can be selec- ity, Dewey further distanced pragma- panies, the professions, advocates)? tively rendered, and so on. All true, but tism from truth. Where Peirce’s inquir- What produces the most useful re- this reduction of scientific knowledge ers gradually moved closer and closer sults? (Postmodernists do not stop to nothing but mere opinion, no differ- to the truth, Dewey’s justified believers much to justify their claims to utility, ent than any other kind of opinion, is could never know where the truth because their own philosophy under- the hallmark of antiscientific postmod- really was. They could only justify cuts them. Since there is no truth, ernism. what they believed at the time as best what is useful is a merely a relative In his blog, Frances writes: “The as they could. A half century later, matter of cultural preference. Utility, ratio of bipolar diagnoses at least dou- when French postmodernism began to as everything, is ultimately arbitrary). bled since the introduction of Bipolar II suffuse itself in Western culture, Rich- Without truth, the process of in DSM IV and the extraordinary drug ard Rorty and others took a few more arbitrariness degenerates into anarchy marketing campaign promot- leaps and jumps from Dewey, landing – a pure eclecticism of thoughts and ing antipsychotics and mood stabiliz- fully in the arms of Foucault: there afterthoughts, actions and reactions, ers. This has undoubtedly helped some should be no talk of truth, there is no consensus and debate, without end. people and harmed some others- the objective truth, only conversations be- Diagnosis is chaos, and some con- exact extent of each is unknown and

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perhaps unknowable. But my bet is that that our science is always so limited honest, faithful depiction of the signs this is a fad that has overshot- they al- that it is near useless in informing our and symptoms and course of most ways do. I would assume that anyone judgments. medical conditions. For the next 50 now presenting with anything suggest- years, in 16 editions ending in 1948, ing equivocal bipolar disorder is much What could have been Osler’s text, which outlived the man by more likely to be overdiagnosed and three decades, was the central descrip- overtreated than to be missed." One need not spoil for a fight be- tive nosology – the DSM – of internal Actually this matter has been stud- tween “biological reductionism” and medicine. In the 1920s randomization ied. The last statement has been proven whatever one wishes to label this was invented; in the 1930s antibiotics false. And it comes from a researcher, apparent mish-mash of neo- were discovered; in the 1940s the first Mark Zimmerman, who is quite a skep- pragmatism, postmodernism, and RCTs occurred for pneumonia; in the tic about bipolar disorder and is critical pure opinion. These are false op- 1950s hormone treatments saved the of its overdiagnosis (and thus cannot be tions. There is such a thing as medi- lives of those with diabetes and Addi- accused of simply having the power- cal humanism: one can be reduction- son’s disease. Over time, the motivation and bias of the “experts”). istic when it is correct to be so, with (reductionistic) science of modern In that very recent study (long after all many diseases of the body, and non- medicine made its discoveries, and the purported marketing of bipolar dis- reductionistic when it is correct to be Osler’s honest nosology proved quite order) (4), whose data I reanalyzed so, with problems of living that do useful as a map of how to apply and in the British Medical Journal not represent disease. And even advance those biological studies. The (5), 30% (27/90) of patients with un- when one faces diseases of the body, antibiotic revolution, for instance, was equivocal Structured Clinical Interview one still always needs to be humanis- effective in part because Osler’s for DSM-IV (SCID) diagnosed bipolar tic because we are always faced with nosology of pneumonia was mostly disorder had never been previously human beings, who may or may not correct. diagnosed with bipolar disorder by have diseases. It is a poor doctor who Imagine William Osler, sitting at clinicians in the community. fails to identify a disease, and a poor his desk for the third edition of his text These data directly contradict the profession that fails to care about circa 1900, and saying to himself: last quoted sentence stated above. All disease; it is the ultimate anti- Well, these doctors are rather ill- the pragmatism in the world is unhelp- humanism to fail, as a doctor or pro- educated; and the pharmaceutical ful if it is based on inaccurate opinion. fession, to identify and cure those houses will fool them (he wrote about To continue with that diseases which can be identified and this factor back then, by the way); let study: Evidence for overdiagnosis of cured. And yet, there is still more to me tinker with the definition of pneu- bipolar disorder indicated a lower fre- medicine, the human connection, the monia this way and that way, so as to quency than underdiagnosis. Bipolar personal relationship, which is espe- discourage the use of these ineffective disorder had been mistakenly diag- cially important when disease can be and harmful treatments of my day. nosed in the community in 13% ruled out, and life’s vexing problems If Osler had approached medical (82/610) of people in whom the gold ruled in. This medical humanist nosology this way, justifiably based on standard Structured Clinical Interview model has long existed, dating back the poor treatments of his day, his text- for DSM-IV (SCID) determined that to Hippocrates, indeed, those physi- book would have been out-of-date they did not have bipolar disorder. This cians who cared deeply to know within half a decade, rather than half a is why we can conclude that, as a mat- about disease – reductionistically and century, and future antibiotic studies ter of relative risks, bipolar disorder is biologically – and also cared deeply would have been hampered if applied more than twice more frequently under- about those persons, as persons, who to the consciously false definitions of diagnosed in those who have it than have disease (or not). In the modern pneumonia that our counterfactual overdiagnosed in those who do not era, this Hippocratic tradition was Osler would have devised in prior dec- have it (30% > 13%). The absolute identified and developed most clearly ades. frequency of bipolar disorder is low by William Osler (6, 7). But Osler took the honest ap- though, so, ignoring the denominator, My teacher the psychotherapist proach: he described diagnoses based more people were misdiagnosed who Leston Havens MD (8) used to say on the best scientific and clinical did not have it, than those who had that contemporary psychiatry exists at knowledge of his time. He then spent it. Yet this still does not entail general- the same level, scientifically and much of his career trying to convince ized "overdiagnosis" if by that phrase clinically, as general medicine in the doctors to use less drugs, and to engage we mean that almost all people who late 19 th century, i.e., Oslerian medi- in more research, in the belief that in have the diagnosis are diagnosed with cine. In Osler’s era, causes of most future years such research on those it, and many who do not have the diag- diseases were unknown; treatments honestly described diagnoses would nosis are diagnosed with it. This is not were legion, empiric, and ineffective bear fruit: causes would become the case with bipolar disorder. (though widely believed effective); known, and effective treatments devel- Obviously, science does not entail and diagnoses were unsystematic. In oped. absolute knowledge, but this should not 1892, Osler wrote the first edition of Time proved Osler right; medi- lead to the postmodernist conclusion his textbook, a magnificent, careful, cine’s advances in the past century can

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hardly be gainsaid, especially by those cently in his forties of a terminal many of us who would have suc- medical illness. His time was espe- cumbed to a mere infection of child- cially short. Now a new generation history of medicine, only this approach hood a century ago. is entering our field, as DSM-5 is has succeeded in moving us towards But psychiatry has not experienced about to come out, and other young that Hippocratic goal: to cure some- similar progress, despite major growth persons with great energy and com- times, to heal often, and to console in neuroscience, in the past two genera- passion will try to advance our always. tions. Could it be that it is not a coinci- knowledge, and perhaps help some dence that this stagnation in clinical patients. The current leadership in References progress coincides with DSM-III and our field, and the past leadership, has DSM-IV. Instead of the Oslerian an important responsibility to help, 1. Ghaemi SN. Towards a Hippo- model, the leaders of psychiatric and not hinder, this process. cratic psychopharmacology. Canadian nosology apparently have focused on Even under the best circum- Journal of Psychiatry . 2008; 53 (3): avoiding immediate pragmatic risks, in stances, the work of research is diffi- 189-196. their estimation. It is, perhaps, not sur- cult, success infrequent, progress 2. Jouanna J . Hippocrates . Balti- prising that their gerrymandering of slow, each human life inadequate. more, MS: Johns Hopkins University psychiatric diagnoses for contemporary Hippocrates famously remarked that Press, 1999. pragmatic purposes does not correlate life is short, art is long. It took Osle- 3. Angst J. The bipolar spectrum. with biological research or robust treat- rian medicine a century to make real Br J Psychiatry 2007; 190: 189-191. ment benefits. advances for its major illnesses. But 4. Zimmerman M, Ruggero CJ, Many blame the drugs, or disbe- if our nosology is consciously gerry- Chelminski I, Young D. Is bipolar dis- lieve in biology; but it could be that we mandered so as to make scientific order overdiagnosed? J Clin Psychia- have the biological tools, and even the progress well-nigh impossible, we try ; 2008: 69 (6): 935-940. drugs, we need, but our “pragmatic” are sacrificing entire generations to 5. Smith DJ, Ghaemi N. Is under- diagnoses blur our vision of the right wasted activity, and other generations diagnosis the main pitfall when diag- connections to be made. Osler’s un- of persons with mental illness will nosing bipolar disorder? Yes. Br Med compromising scientific realism, com- continue to suffer as our professional J 2010; 340-c854. bined with a therapeutic conservatism, ineptitude persists. 6. Ghaemi SN. The Rise and Fall hit the perfect balance for his own age, Nosology is not just about re- of the Biopsychosocial Model: Recon- and proved successful in the future. search, I know; it has many uses: ciling Art and Science in Psychiatry. His diagnostic realism (not pragma- there are the lawyers and the capital- Baltimore: The Johns Hopkins Univer- tism) produced spectacular practical ists and so on. But, at some level, we sity Press, 2009. results. In contrast, in the past two should care to know the truth, I 7. Bliss M. William Osler: A Life decades, few practical successes have would think. In fact, we should give in Medicine . New York: Oxford Uni- followed from a pragmatic DSM-IV. primacy to getting at the truth - versity Press, 1999. This “pragmatism” has proven useless unless we do not believe in truth of 8. Havens LL. The need for tests in practice. any kind, unless we view science as of normal functioning in the psychiatric just power, and its knowledge as interview. Am J Psychiatry 1984; 141 Conclusion mere opinion. (10): 1208-1406. I think of how many of my col- 9. Hegarty JD, Baldessarini RJ, I finished residency a generation leagues in the last 20 years – an entire Tohen M, Waternaus C, Oepen G. One ago, as DSM-IV was just published. generation, some of whom are al- hundred years of schizophrenia: a My closest friend, James Hegarty, was ready gone – had hoped to build on meta-analysis of the ourcome literature. an energetic and optimistic young man what we were given, including DSM- Am J Psychiatry 1994; 151: 1409-1416. with a strong interest in research; he IV, expecting that our leaders would conducted a classic study showing that care, first and foremost, not about *** outcomes of schizophrenia were de- pragmatism, not about their opinion pendent on its diagnostic definitions of what treatments were harmful, not over a century of changing nosologies about their social and cultural opin- (9). Jim, and I, and many others, hoped ions, but about the truth. "Do No Harm" Meets to contribute to knowledge in psychia- Let’s have the right priorities, "The Rule Of Thirds" try, naively, perhaps, believing that this trusting that in psychiatry as in medi- attitude was useful, and would help cine, seeking out the truth will prove patients. For a generation, we and oth- to be the most pragmatic course of Allen Frances, M.D. ers conducted our research under the action as well, and remembering that, aegis of DSM-IV definitions, looking millennia ago, our Greek teachers Dr Ghaermi is a first umpire who at treatments, genetics, biology. We knew this was the way, and the only makes the wrong calls on Hippocrates; have had some small successes, and way, to achieve a practice based on on Mark Zimmerman; on the strength many failures. Jim passed away re- First Do No Harm, and that, in the of the science supporting nosological

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decisions and the ease of its interpreta- cise, and wine – all designed to almost always tincture of time, watch- tion; and on the relation of pragmatism strengthen natural forces in recovery. ful waiting, education, encouragement, to reality. If Nature will cure, then the job of the and support. Let the illness declare physician is to hasten Nature’s work itself more clearly before starting what Getting Hippocrates Right carefully, and at all costs to avoid might be unnecessary and harmful adding to the burden of illness." treatment. Medications have very little When their heads weren't trapped It is curious that Dr Ghaemi advantage in efficacy over placebo in the Platonic clouds, the Greeks were would introduce Hippocrates into our when used is used in mild conditions the most remarkable of scientific ob- debate since Hippocrates was so (especially those of recent onset which servers and intuitors (e.g. witness their clearly the first and best advocate for have especially high rates of spontane- development of atomic theory and their caution in diagnosis and treatment. I ous remission). In these situations, accurate measurement of the circumfer- couldn't possibly ask for a better sup- medications are usually more likely to ence of the earth). Early on, the Hippo- port for my position or a clearer con- cause harmful side effects than extra cratic school made its own great dis- tradiction of Dr Ghaemi's. clinical improvement. So let nature covery - the "rule of thirds." This was Let's go deeper into the implica- have first crack at healing and follow the crucial triage observation that about tions of Hippocratic caution. The ever the treatment sequence of time and one third of patients can't be helped, elusive trick that has so far eluded support first, brief psychotherapy sec- about one third get better without help, psychiatry (and the rest of medicine) ond, and medication reserved as a third and the remaining third is the appro- is the ability to pick out which pa- line only for those who need it . And priate focus for active and potentially tients are likely to be in each of the nosologically, be cautious by keeping harmful medical treatment. This rule of three groups and to tailor specific subthreshold diagnoses in the appendix thirds was not the result of any theory interventions to their different needs. until they have proven themselves safe of disease; it was a prognostic tool that It is the great disappointment of sci- and useful. came from pragmatic empirical obser- entific medicine (and psychiatry) that Of course, this flies in the face of vation. we are still so far from achieving this the recent early interventionist dogma. The rule of thirds has turned out to goal. With just a few exceptions, psy- But suggestions for primary prevention be the most astoundingly robust finding chiatric and medical treatment re- in psychiatry have so far been based on ever to inform medicine- applicable mains an empirical, trial and error theory, hope, and hype rather than sci- across varying epochs, places, medical endeavor with many people treated entific evidence. None of the five sub- specialties, types of illness, medical who don't need it and many others threshold conditions proposed for theories, research knowledge, and receiving treatment that does them DSM- 5 has been well studied enough methods of treatment. It works best for more harm than good—just as was to be safe. All would lead to a frenzy of patients with moderately severe illness. observed so long ago by Hippocrates. drug company marketing and the use of When the illness is especially severe, "First, do no harm" was a bril- potentially harmful treatments for con- chronic, or fatal, the nonresponding liant recognition and a suitably hum- ditions highly likely to remit in the group expands beyond its allotted ble confession of the limitations of natural course of events. Hippocrates "third." When patients are mildly or medical art and science. It applied would certainly not be pleased. Early acutely ill, the spontaneous recovery then, it applies equally now. Cer- treatments for subthreshold conditions group expands. In psychiaty, the mo- tainly, we have better medications, need to establish themselves with sci- dal response rates over thousands of but haven't solved the age old prob- entific evidence before becoming a clinical trials is 60 -70% for active lem of how to use them with best risky public health experiment. treatment and 30-40% for placebo-ie effect and least risk. At the other end of the severity yet another confirmation of the rule of The question then becomes how spectrum, we have inflicted a scientifi- thirds. For the milder conditions in to deal with the interaction of "the cally unsupported, often useless, and psychiatry, the placebo response, spon- rule of thirds" and "do no harm" sometimes very harmful polypharmacy taneous remission rate approaches when we have no way of predicting on patients in third group of poor re- 50%-so that only a small proportion of prospectively who is in which third? sponders. Polypharmacy is inherently patients actually benefit from the active In their commentary, Drs Piasetky impossible to study systematically in treament. For schizophrenia, the pla- and Antonucio provide numerous the practical world because of the sam- cebo response rate is below 10%. wise counsels that bear repetition ple sizes required by the large number Dr Ghaemi and I both admire the here because they are so helpful and of permutations of possible treatment Hippocratic wisdom of “As to diseases, would warm the heart of a cautious combinations. It is an art more equiva- make a habit of two things – to help, or Hippocrates. lent to alchemy or dress designing than at least to do no harm.” Dr Ghaemi Let's start with the case for con- to science. Skillful clinicians treating goes on to state correctly that servatism in diagnosing and treating the more responsive patients of the "Hippocrates resisted that intervention- milder cases at the border of normal- third group are sometimes able to use ist medicine, and his treatment recom- ity. For this group of likely spontane- polypharmacy for a custom tailored mendations often involved diet, exer- ous remitters, the best first course is perfect fit with the patient showing a

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much better result than would other- paper that has examined both there is a "real" right answer to the wise be possible. Too often, however, under and overdiagnosis, which question and that he has it. Although a polypharmacy is an act of clinician he did not cite, found that the vanishing breed, first umpires serve a and/or patient desperation egged on by overdiagnosis rate was higher very useful function in the world as drug company marketing with little than the underdiagnosis rate. In producers of scientific data. It often rationale and much potential for harm. summarizing this study I recently takes a true believer to slog away at the Hippocrates knew that less is often wrote: Although other studies frustrating, and often disappointing, more. have reported overdiagnosis of day to day labor of conducting the re- bipolar disorder, we are aware of search studies. But first umpires are Pragmatics, Reality, and Science only one other study with data on very often not trustworthy guides to the both overdiagnosis and underdi- interpretation of the data—they often Dr Ghaemi and I have differing agnosis. Hirschfeld and col- set out selectively to prove a point and views on the strength of the science leagues[16]interviewed 180 de- miss the contradictory interpretations supporting nosological changes. Re- pressed primary care outpatients and larger issues. views of the literatures of the various receiving antidepressant drugs Dr Ghaemi also seems to believe DSM disorders are consistent in the with the structured clinical inter- that DSM-IV is an obstacle on the royal relative paucity of studies and their view for DSM-IV. Forty-three road toward scientific progress in psy- limited generalizability (because they patients reported a prior diagno- chiatry. If there is a simple and are usually conducted in university sis of bipolar disorder, and this straightforward "reality" of mental dis- hospital settings with highly selected diagnosis was not confirmed in orders and we are not finding it with all patients and evaluators). The 14 (33%). The overdiagnosis rate our powerful neuroscience tools, it "validators" of descriptive diagnosis are of 33% was higher than the 22% must be because of the obscuring veil usually disappointingly inconsistent underdiagnosis rate in the 137 of the incorrect, excessively pragmatic and uninformative. The findings are patients who had not had bipolar diagnostic system. Just get the diagno- almost always equivocal and refuse to disorder previously diagnosed. ses right and by golly we will figure submit to a single, unimpeachable in- Regarding the question of out what causes them. terpretation. Plausible arguments can the 2 day cutoff...Like you I am As we have discussed in many of always be made on both sides. There very concerned that lowering the the other responses, this naïve realism are no "real" balls and "real" strikes threshold will increase the fre- puts the cart before the horse. The ob- here—only a fuzzy picture that requires quency of false positives, and stacle to progress in understanding psy- a "call them as you see them" humility. subsequent overtreatment. I am chopathology is the complexity of the As an illustration of this issue, I not aware of any treatment stud- brain realities which inherently defy asked Dr Mark Zimmerman to com- ies of patients who meet the simple answers - not that we lack the ment on Dr Ghaemi's interpretation of lower (but not DSM-IV) thresh- right descriptions. There is nothing his research on the over and underdiag- old. Do I treat some individuals sacred about DSM-IV—it could be nosis of Bipolar Disorder. I will quote with 2 day episodes as having different and improved in thousands of his reply in its entirety because it sheds bipolar disorder? Absolutely, and ways. But none of these would provide a crucial light on differences in episte- I diagnose them with bipolar anything remotely like the keys to the mology between first umpires and sec- disorder NOS. The data may well kingdom of deeper understanding. The ond umpires. bear out the validity of the 2 day causes of psychopathology are obscure threshold. The question, though, to us because they are so complicated, Hi Allen., is how to balance the 2 potential not because we have not described it Ghaemi has the numbers harms—the false negative prob- well enough. right, but I do not agree with his lem of undertreatment due to a Dr Ghaemi incorrectly assumes the interpretation. Which is more im- clinician not using the bipolar peculiar notion that pragmatism repre- portant, rates or persons? He indi- disorder NOS diagnosis if the sents a denial of the underlying reali- cates that the rate of underdiagno- hypomanias only last 2 days ver- ties. In fact, pragmatism is a humble, sis is higher than the rate of over- sus the false positive problem flawed and limited—but altogether diagnosis. A rate calculation de- that is likely to increase if the necessary—place holder when there is pends on the denominator. When I duration requirement is lowered. no clearer path to truth or action. Prag- think of the over-under diagnosis Mark. matists believe in the reality that reality issue I think of persons. How is very hard to figure to figure out and many individuals are overdiag- We don't have space here to re- that, in the meantime, we must muddle nosed or underdiagnosed? We count all the persuasive reasons not to along as best we can trying to do the found 3 times as many individuals follow Dr Ghaemi in his idee fixe for most possible good and least harm. were overdiagnosed compared to a two day duration of hypomania. The debate is not academic. Many underdiagnosed (82 vs. 27). The point here is that Dr Ghaemi is a of the dangerous DSM-5 suggestions Of interest, the only other first umpire—he is very sure that are defended with the Dr Ghaemi's

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claim that "this is where the science has long, heated, and invariably (to para- cord is this: I am a scientific realist; I taken us". But reviewing the studies phrase Ambrose Bierce) confirmatory value facts and truths, though I know always shows (as it does for Dr of the errors of others. we fallibilistically approximate them, Ghaemi's prized two day hypomania) He engages in polemics, not in- and that truth is corrected error. Hav- that the science is weak while the risks quiry. Polemics are a game; one ing not read philosophy texts since col- to patient welfare are great. Reducing scores debating points, and rarely lege in the last millennium, my col- the required duration of a hypomanic admits error; like a boxing match, one league does not explicitly state any episode from four to two days will dodges and weaves, hoping to make it philosophy other than a claim to serve little useful purpose (any patient to the last round. In such debates, “pragmatism” which I philosophically who really needs the diagnosis can be truth is annihilated, as Montaigne critiqued previously. I argue that his covered by Bipolar NOS). But shorten- remarked. Inquiry seeks the truth; unconscious philosophy is postmodern- ing the duration will extend the Bipo- knowing that truth is corrected error, ism, a preference for tastes over truth, lar fad with consequent overuse of it readily admits error when present, his opinions over scientifically solid harmful antipsychotics and mood stabi- and it seeks to find those aspects of facts. My interlocutor’s view seems to lizers. The pragmatic verdict is a no truth that can be seen in most any be that pragmatism is that philosophy brainer. argument. Frances seems to say that in which one ignores scientific facts by Utilitarian pragmatics is certainly I am wrong in everything that I have insisting that facts are, after all, open to not the best method of developing a said; I did not find him to admit that dispute, while the common sense opin- psychiatric nosology—but it is unfortu- he was wrong in anything, even when ions of retired professors emeriti are nately the only option currently avail- clear facts refute specific claims self-evident. His method is consistent – able to us. For a good discussion of (such as his claim that almost all the standard postmodernist obfuscation this see the Kinghorn commentary those who have bipolar disorder are of facts as interpretations, setting eve- which provides a devastatingly accu- diagnosed with it). rything up as the disagreements and rate critique of the limitations of prag- Let’s try to revive what is true, or ideologies of experts, with himself as matics in nosology. I confess to the agreed upon, in all that has been said. ultimate arbiter. obvious dangers and limitations in my His claim, stated most powerfully, I Those appear to be the general response to him. . But when all is said believe, and most simply, is this: differences; since he courageously and done, there is no other viable ap- When our science is weak, then prag- identifies four errors in my commen- proach to pragmatism given our limited matic considerations about utilitarian tary, here are specific responses to scientific understanding of the psychi- outcomes are important in psychiatric those claims: atric disorders and the huge practical diagnosis and treatment. I agree impact the diagnostic system has on with this view as a necessary evil, On Hippocrates people's lives and public policy. i.e., when our science is weak. (Our If we had a stronger and less disagreements entail from his post- We both agree that the Hippocratic equivocal science base for making modernist rejection of science in tradition is important, but a key error – nosological decisions, we would use it. practice.) I agree with the Hippocratic fixable by actually reading the sources But the currently available results never approach of caution in treatment I previously cited - is that he thinks that reach out and grab you and (as the when our diagnoses are unclear or the Hippocratic tradition supports cau- Ghaemi/Zimmerman exchange illus- when our treatments are ineffective. tion in diagnosis and treatment. This is trates) are always subject to different (We disagree because he extends this simply wrong as a historical fact. The interpretations. Whenever there is a caution to areas where our science of Hippocratic tradition was aggressive in DSM controversy, the science probably diagnosis is more clear.) I agree with diagnosis, and cautious in treatment. It cancels out or there would not be a conservatism regarding treating mild, valued diagnosis highly, and viewed controversy. When the science does borderline, or subthreshold condi- itself as different from the empirical, cancel out, the best guide (however tions. (We disagree on whether this pragmatic approaches that preceded fallible and difficult to operationalize) should mean that we should not allow Hippocrates exactly in the value given is the practical common sense of Hip- them to be diagnosed.) If we are re- to technical praxis ( teknae iatrike), pocrates—Do No Harm. ferring to definitions of sexual disor- scientific knowledge, applied to under- ders or ADHD or MDD (which he standing disease. Disease comes first *** always ignores and whose diagnostic and foremost, and before anything else: realm he has expanded greatly), I Diagnosis matters most. Then one cau- Final Comment would agree with these cautions. We tiously treats those diseases which one DSM-IV-ever disagree because he extends it to understands and can treat, while not cases, like bipolar disorder, where his treating those which one does not un- “pragmatism” means ignoring legiti- derstand well or cannot treat. The out- Nassir Ghaemi MD mate science in favor of his personal come: Doing less harm than good. tastes. Since Frances likes the outcome as a Discussion with Allen Frances The crux of the conceptual dis- slogan, he really should study more becomes, unavoidably, disputation –

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carefully how it is achieved. Then he method: create an artificial contro- lowed halls of academe: “The duration may realize that his pragmatic gerry- versy based on pseudoscientific hand- of hypomania in bipolar-II disorder in mandering of psychiatric diagnoses waving, and then claim that since private practice: methodology and vali- produces the opposite result. Further, there is so much controversy, the dation.” It reads: “DSM-IV 4-day the “rule of thirds” is not an immutable science is too limited to use. minimum hypomania duration is not clinical fact, but a matter for scientific Also, Zimmerman’s claim that evidence-based. Epidemiologic data research, as all else. Certainly in the we can ignore the denominator, when suggest that briefer hypomanias are past century, major advances have been judging over vs underdiagnosis, is prevalent in the community. We sought made in reducing that third which is simply wrong, ignoring the impact of to find out the relative prevalence of untreatable in medicine. Lewis Tho- prevalence. (NB: I actually stated short (2–3 days) versus long (> 4 days) mas’ Youngest Science demonstrates Zimmerman’s argument in my com- hypomanias in private practice. Meth- this therapeutic revolution clearly. No mentary; his restatement in his email ods: 206 bipolar-II (BP-II) depressed such progress is possible when couch- was superfluous.) Most diseases are outpatients (group B) and a group of pragmatism consciously falsifies our low in prevalence; most of the popu- 140 remitted BP-II (group R) were as- best scientific knowledge to date. lation is healthy. Even the broadest sessed with the DSM-IV Structured definitions of bipolar disorder would Clinical Interview, as modified by the On Zimmerman lead to its diagnosis in no more than authors. BP-II with short vs. longer 5% of the population (versus 10-20% hypomania were compared on such (Previously, to respect word limits, for MDD in its current definition). bipolar validators as early age at onset, I refrained from extensively describing Imagine if 100 out of 1000 (10%) depressive recurrence, atypical feature study results. But since Frances exten- persons are misdiagnosed with dis- specifier, depressive mixed state and sively cites opinions from emails in ease X when they have disease Y, but bipolar family history. In addition, to place of facts, I provide the facts here 90 out of 100 (90%) persons are mis- ascertain the bipolar status of depressed at length). diagnosed with disease Y when they patients with brief hypomanias, we Dr. Zimmerman states the “only” have disease X, would we still say included a comparison group of 178 other study (besides his own, which that there is overdiagnosis of disease major depressive disorder (MDD) pa- proves underdiagnosis of bipolar disor- X? On that definition, all diagnoses tients assessed when depressed. Re- der) supports overdiagnosis. But he are always overdiagnosed (n=100 > sults: 27–30% of hypomanias ignored three other studies, one which I n=90). (depending on whether assessment oc- published a decade ago (1), and two curred when patients were depressed or more recently (one by our group (2), On the science supporting nosology: in remission) had 2–3-day duration; and one by a German group (3)), all of 72% lasted less than 4 weeks. Except which found bipolar underdiagnosis Regarding the “idée fixe” of 2 for the atypical feature specifier, BP-II compared to MDD. For instance, in days for hypomania, Frances seems with short vs. BP-II with longer hypo- our study, the average patient with bi- wedded to his overvalued ideation for mania were not significantly different polar disorder saw 3.3 psychiatrists the 4 day criterion he invented in on bipolar validators. Moreover, BP-II before getting the correct diagnosis, 1994. (One might call it a delusion with short, like its longer hypomanic with a delay of about 9 years. In con- since it has no basis in even a single counterpart, was significantly different trast, the average patient with MDD study, which he has not, and cannot, from the comparison MDD group on saw 1.5 psychiatrists before getting the cite; neither can any of his favored all bipolar indicators.”(4) correct diagnosis, with a delay of about experts). Zimmerman says he knows Then there is Dr. Jules Angst, who 3 years. In the German study, case of no such studies, which unfortu- as I said, has followed patients for over vignettes of DSM-IV mania and MDD nately suggests the inability to type 40 years in the Zurich cohort study, and were shown to 185 mental health pro- www.pubmed.com. Five minutes on was the person whose research was key fessionals, and 62% of bipolar cases Medline would have shown his error. to the whole definition of MDD as were misdiagnosed as MDD primarily, (Type “hypomania” and “duration” separate from bipolar disorder in DSM- while only 5% of MDD cases were and you will see 88 articles. Reading III in 1980. Here is what he found: misdiagnosed as bipolar disorder. In the abstracts takes about half an hour, “The Zurich cohort study identified a our recent study of 64 children in com- less time than it takes to send emails prevalence rate up to age 35 of 5.5% of munity practice (again not Frances’ and opine.) There are multiple stud- DSM-IV hypomania/mania and a fur- ivory tower), we found that 33% of ies that show that less than four days ther 2.8% for brief hypomania children meeting DSM-IV criteria for adequately picks out bipolar disorder (recurrent and lasting 1–3 days). The mania were diagnosed previously with from MDD based on the standard validity of DSM-IV hypomania and MDD (despite past manic episodes), diagnostic validators. For instance, brief hypomania was demonstrated by a while only 5% of children meeting here is one abstract from the late family history of mood disorders, a DSM-IV criteria for MDD were previ- Franco Benazzi, in an obscurely titled history of suicide attempts and treat- ously diagnosed with bipolar disorder. article conducted, as Dr. Frances be- ment for depression….The study sug- Here again is the postmodernist lieves all research occurs, in the hal- gests that recurrent brief hypomania

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belongs to the bipolar spectrum.”(5) specialists in the fields being studied) postmodernist flings the accusation, Why were Dr. Angst’s data – from the to review all the criteria created by however, assuming the motivations and exact same study by the exact same the experts. In this world-view, the knowledge base of others. researcher - central to making the less one knows, the more qualified Nescient disregard for facts, and an major changes of DSM-III in 1980, but one is to judge the views of those umpire metaphor, is another classic unworthy of being considered at all for who know. If this is the rationale, postmodernist move: all is interpreta- much smaller changes for DSM-5 now? forget the über-experts; let’s grab the tion, there is no fact. He is explicit first random person we see on the about it when he says that whenever It is perhaps superfluous to note street and ask him to give the final there is controversy, then the science is who in this discussion does not know word on our diagnostic criteria. weak. But there is controversy about the scientific facts, and then claims that everything in science, even when the there are not enough scientific facts to On the relation of pragmatism to re- evidence is strong (unless one wants to know the answers. The two studies ality believe that Darwinism was accepted above are easily accessible by Medline; placidly; leeching was dropped quietly; searching and reading them took me What should we be pragmatic hormone replacement therapy ended three minutes. Scientists are used to at about? It seems to me that some justi- effortlessly; and homosexuality was least looking at data; polemicists can’t fication exists for being pragmatic removed from DSM without fuss). In let facts get in the way of beliefs. about treatment, but not about diag- fact, epidemiologists have shown that In sum, the method of assessing nosis. This is what Frances continu- even after strong scientific evidence the scientific evidence expressed by my ally confuses. I consulted on this refutes certain notions, those ideas per- colleague appears to involve the fol- matter with another “expert” (a third sist for a long time in the medical lit- lowing procedure: first, avoid looking umpire I suppose), Dr. Jerome Kas- erature (6). at any scientific data; second, send an sirer, former editor of the New Eng- The last word on science and real- email to one who knows little about land Journal of Medicine, Tufts fac- ism might belong to another professor said data; third, refute said data with ulty, and co-author of the classic emeritus, Harry Frankfurt, the Prince- the uninformed opinions of said email medical text, Clinical Reasoning . ton philosopher, who wrote a slim best- correspondent; fourth, conclude that the There he uses pragmatic concepts selling book that shows that the vaga- scientific data for said topic are too (Bayesian) for diagnostic tests (as is ries of my colleague’s postmodernist weak to draw conclusions; fifth, return standard in medicine) and for thera- nihilism are widespread in our culture. to the philosophy of pragmatism de- peutics. We discussed the ideas of Frankfurt created a technical philoso- scribed above (especially the part Frances and the data of Zimmerman, phical term for the problem, which he where the opinion of the professor and what became clear to me is that put in the title of his book; he defines it emeritus is final). Move to the next they are making the mistake of apply- thus: “It is just this lack of connection diagnosis: Repeat, wash, and rinse. ing pragmatic notions to diagnostic to a concern with truth – this indiffer- criteria, which is an entirely different ence to how things really are – that I On science and expertise matter. In medicine, if one is going to regard as the essence of bullshit.” ( On use toxic chemotherapy, one wants a Bullshit , pp. 33-34) I will add here a major factor in highly reliable diagnosis of cancer. If my colleague’s erroneous belief- one is going to use aspirin, one does Postmodern polemics emeritus system. He views science as messy, not need as reliable a definition of with experts constantly disagreeing; headache. Fine. But this pragmatic Here are the options: the cynically hence the need for his humble pragma- approach does not mean that we humble pragmatics of 1994 DSM-IV- tism. In so doing, he makes the post- would alter the definitions of cancer ever, blocking us from getting to the modern move of equating science with so as to make it harder for clinicians truth, and disrespecting the lives that opinion, and reducing data to pure to decide to treat it with chemother- are spent and lost in the process; or the interpretation, so he can continue to apy. This is what Frances is doing humbler, more practically successful, believe what he wants. Let’s examine with bipolar disorder. Cancer is can- scientific inquiry after truth. Polemics, his assumptions: cer, and we need to be honest about it rather than inquiry, result in the verbal He acts as if all experts are equal, if we are to understand it better and equivalent of repeating oneself and or as if those experts with less expertise get better treatments. The same holds simply raising one’s voice, trying to (second umpires) are more objective for bipolar disorder. win the argument based on the superior than those with more expertise (first I will briefly add that it is naïve power of one’s lungs (Montaigne). The umpires), and those experts in diagno- to think that all realism is “naïve” next generation is no longer convinced sis, like himself, who have no expertise realism. There is such as thing, in by this rococo pastiche of postmodern in anything in particular, are the most philosophical terminology, as rhetoric. objective. (Call them über-experts). In “scientific realism”, as a philosophi- fact, he has proposed that we need a cal concept, which I uphold and have References whole slew of über-experts (non- studied in my graduate training. The

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1. Ghaemi SN, Boiman EE, Good- Many of the problems with chiatry as a clinical application of neu- win FK. Diagnosing bipolar disorder DSM-5 are not particular to this edi- roscience (Insel and Quirion, 2002; and the effect of antidepressants: a tion, but go back for decades. As Regier et al, 2009). This point of view naturalistic study. J Clin Psychiatry Frances notes, no one has ever come emphasizes genomics and neural cir- 2000: 61 (10): 804-808; quiz 809. up with a convincing definition of cuitry, and downplays life experience. 2. Chilakammaire JK, Filkowski mental disorder that separates it from It subscribes to a reductionist model in MF, Ghaemi SN. Misdiagnosis of bipo- normal experience. Over five edi- which mind is seen as reflecting brain lar disorder in children and adolescents: tions, the number of diagnoses in the activity, and does not allow for emer- A comparison to ADHD and major manual has increased, as has their gent properties of complex systems that depressive disorder. Annals of Clinical range. Epidemiological research on cannot be explained at a molecular Psychiatry 2010; in press. the prevalence of disorders in the level (Gold, 2009). 3. Bruchmuller K, Meyer TD. Di- community depends entirely on inclu- The leaders of DSM-5 seem unin- agnostically irrelevant information can sive DSM-based definitions. Thus it terested in, if not hostile to, psychologi- affect the likelihood of diagnosis of is not surprising that half of the popu- cal theories and therapies. This corre- bipolar disorder. J Affec Disord 2009; lation meet formal criteria for a men- sponds to the current zeitgeist of psy- 116 (1-2): 148-151. tal disorder sometime during their chiatry. But while such ideas claim to 4. Benazzi F, Akiskal H. The dura- lifetime (Kessler et al, 2005). It has be scientific, they do not correspond to tion of hypomania in bipolar-II disorder been argued that mild disorders evidence. As Frances points out, there in private practice: Methodology and should not be excluded from DSM-5 is not a single biological marker for any validation . Journal of Affec Disord (Kessler et al 2003). But almost every diagnosis. In spite of progress in under- 2006; 96: 189-196. problematic human emotion or be- standing the brain, we know little more 5. Angst J. The emerging epidemi- havior can be found in this manual. about the causes of mental illness than ology of hypomania and bipolar II dis- Sadness becomes depression we did 40 years ago. While drugs are order. Journal of Affec Disord 1998; (Horwitz and Wakefield, 2007), essential for severe mental disorders, 50: 143-151. moodiness becomes bipolarity they are not that effective for common 6. Tatsioni A, Borutsis NG, Ioanni- (Goodwin and Jamieson, 2007), and problems such as mild to moderate dis, JP. Persistence of contradicted uncontrolled anger becomes intermit- depression (Kirsch et al, 2008). A vast claims in the literature. JAMA 2007; tent explosive disorder (Kessler et al, literature supports the efficacy of psy- 298: 2517-2526. 2006). If DSM-5 goes on to describe chotherapies (Lambert, 2003), but is eccentricity as autism spectrum disor- largely ignored by psychiatrists. *** der or as risk psychosis, and labels Everyone agrees that DSM-IV people with normal declines in cogni- was, at best, a rough draft, and that the The Ideology behind tion with age, the process will go system that has endured since DSM-III even further. remains inadequate. I have taught diag- DSM-5 Like other professionals, psy- nosis to psychiatry residents for dec- chiatrists believe that many, if not ades, and I tell them that DSM provides Joel Paris, M.D. most, people can benefit from their a common language, but should not be McGill University services. They are happy to medical- viewed as a serious scientific docu- ize the human condition. But the con- ment. However, with time, these diag- Allen Frances has performed a sequences will be inappropriate treat- noses have become reified, and treated great service to his colleagues by high- ment. Fifty years ago, many normal as if they represent some absolute truth. lighting the many problems with DSM- people were encouraged to undertake At this point in the history of psy- 5. While far from a disinterested ob- psychoanalysis (Paris, 2005). Today, chiatry, almost any classification has to server, Frances frankly reports on his every human dilemma is managed be inadequate. But even biology, which own experience with DSM-IV, in with medication. Psychiatrists have has had 200 years to describe species, which minor revisions led to major (but turned away from psychological theo- still suffers from problems in defining unexpected) consequences. ries and treatment. They have em- such boundaries. So we have to be pa- Any DSM manual has multiple braced neuroscience (Paris, 2008), tient and humble. constituencies. Researchers who study while doing much less talking and Moreover, DSM-5 is much too patients are expected by journal editors much more prescribing (Mojitbai and complicated for clinical utility. Even to use its criteria. Lawyers, judges, and Olfson, 2008). DSM-5 will accelerate DSM-IV was hardly ever applied, at insurance companies will consult it. this trend. Stockholders in pharma- least as directed, in clinical practice. The general public can look up their ceutical companies may rejoice, but The manual will sit on everyone’s problems (or those of their friends and the rest of us should be deeply con- shelf, but many will go on doing what relatives). But the main purpose of a cerned. they have always done. diagnostic classification is to guide The leaders of DSM-5, as well as The crucial question is whether we clinicians. And that is where the most the leaders of psychiatric research, should make radical changes in a serious difficulties lie. are committed to the vision of psy- flawed system, without the theoretical

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advances and empirical data we need to try 54: 503-5 Press guide us to do so. To describe this di- Goodwin, F.K., & Jamison, K. Regier DA, Narrow WE, Kuhl EA, lemma as the opposition of conserva- (2007): Manic-Depressive Illness: Kupfer DJ (2009). Conceptual develop- tive vs. liberal agendas begs the ques- Bipolar Disorder and Recurrent De- ment of DSM-V. American Journal of tion. Societies and political systems pression, 2nd edition, New York, Psychiatry , 166: 645-650. often maintain anachronisms when the Oxford University Press consequences of alternatives are un- Horwitz, A.V., & Wakefield, *** known. One only has to look at the J.C. (2007). The Loss of Sadness: history of the 20 th century to see how How psychiatry transformed normal The Elusive Definition of readily well-meaning “progressive” sorrow into depressive disorder . New ideas can lead to disaster. York: Oxford University Press Mental Disorder and For this reason, while I am in favor Insel, T., & Quirion, R. (2005). Problems With Reification of some of the proposed changes in Psychiatry As a Clinical Neurosci- DSM-5, I agree with Frances that radi- ence Discipline. JAMA: the journal of Allen Frances, M.D. cal revision will be destructive. It is not the American Medical Association, just the changes that worry me. It is the 294, 2221-2224 I agree completely with Dr Paris' fact that psychiatrists want to catego- Kessler, R.C., Merikangas, K.R., elegant commentary and will just rize all of human experience. We are Berglund, P., Eaton, W.W., Koretz, elaborate on some of his points: already making too many diagnoses, D.S. & Walters, E.E. (2003). Mild 1) There is not now, and probably and treating too many patients who do disorders should not be eliminated never will be, a satisfying definition of not require our services. DSM-IV may from the DSM-V. Archives of Gen- mental disorder. If the boundary with be a mess, but DSM-5 could make a eral Psychiatry, 60, 1117-1122 normal can't be established with ab- bad situation worse. Kessler, R.C., Coccaro, E.F., stract concepts or scientific findings, it Where Frances is most clearly Fava, M., Jaeger, S., Jin, R., & Wal- must be set pragmatically—what does right on the mark is in noting that ter, E. (2006). The prevalence and the most good and least harm. Of DSM-5 consistently errs on the side of correlates of DSM-IV Intermittent course, the utilitarian calculation is expanding boundaries—out of fear of Explosive Disorder in the National itself inherently uncertain because the missing something. The result is that Comorbidity Survey Replication. problem comprises so many complex many people with normal variations in Archives of General Psychiatry, 63, and interacting variables and the data emotion, behavior, and thought will 669-678 are always woefully inadequate. What receive a formal diagnosis, leading to Kessler, R.C., Chiu, W.T., Dem- we can do is take into account the best inappropriate and aggressive treatment. ler, O., Merikangas, K.R., & Walters, available scientific evidence and at- This is what the military calls “mission E.E. (2005). Prevalence, severity, and tempt to extrapolate it to the real world creep”. And when biological processes comorbidity of 12-month DSM-IV settings in which the manual is used. A in normality and pathology are seen as disorders in the National Comorbidity searching risk/benefit analysis of each lying on a continuum, it becomes even Survey Replication. Archives of Gen- new proposal is crucial and has not more impossible to set any boundary eral Psychiatry, 62, 617-627 been done for DSM-5. that could define mental disorder. With Kirsch I, Deacon BJ, Huedo- 2) There is an unfortunate imbal- this system in place, psychiatrists are Medina TB, Scoboria A, Moore TJ, et ance between the use of medication vs very likely to do as much harm as good al. (2008) Initial severity and antide- psychotherapy in the treatment of to their patients. pressant benefits: a meta-analysis of milder conditions at the border of nor- Frances is particularly apt in point- data submitted to the Food and Drug mality. This is precisely where psycho- ing out on the arrogance and hubris of Administration. PLoS Med 5: e45 therapy is most likely to hold its own in modern “scientific” psychiatry. It takes Lambert, M. (2003). Bergin and efficacy and cost and have an edge in a really great mind to be humble about Garfield’s Handbook of Psychother- producing durable results with fewer lack of knowledge. Isaac Newton once apy and Behavior Change . New side effects and greater generalizability described his own contribution to sci- York: Wiley to the other life problems the person ence: “I was like a boy playing on the Mojtabai, R, Olfson, M (2008): may have. But there is an overwhelm- seashore, and diverting myself now and National trends in psychotherapy by ing pharmaceutical marketing force then finding a smoother pebble or a office-based psychiatrists. Archives that pushes drugs when they are not prettier shell than ordinary, whilst the of General Psychiatry , 65: 962-970 always needed and no comparable sup- great ocean of truth lay undiscovered Paris, J (2005): The Fall of an port for psychotherapy. before me.” Icon: Psychoanalysis and Academic 3) The Introduction to DSM-IV Psychiatry. Toronto, University of contains many efforts to reduce the References Toronto Press reification of the disorders covered in Paris, J (2008): Prescriptions for the manual - which efforts are, unfortu- Gold, I (2009): Reduction in psy- the Mind: The Struggle for the Future nately , largely ignored. chiatry. Canadian Journal of Psychia- of Psychiatry , Oxford University 4) Anyone interested in just how

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cumbersome and obscurely unreadable latter remarks by Frances seem sug- have proved extremely useful in both DSM-5 can be should review the post- gest otherwise. For example, he states research and clinical practice. The cri- ing of the personality disorders work that: teria for these illnesses evolved from group. We must accept that our diagnos- decades of experience in descriptive tic classification is the result of psychiatry (just as our understanding of *** historical accretion and accident all physical illness started with descrip- without any real underlying sys- tive medicine). I would surmise that, at tem or scientific necessity … least for the major axis one disorders The Illusion of Epistemo- Our mental disorders are not (major depression, bipolar disorder, logical Problems in the more than fallible social con- schizophrenia), the diagnostic criteria structs (but nonetheless useful if have proved useful precisely because Definition of Mental understood and applied properly) they capture correctly some part of the Illness (Frances 2010). underlying biological reality of mental This statement suggests that the natu- illness. Michael A. Cerullo, M.D. ralist perspective plays no role in how When discussing the reality of University of Cincinnati College of we define mental illness. Together mental illness it is often useful to step Medicine with the earlier baseball analogy this back and take a larger philosophical places Frances in the uncomfortable and pragmatic perspective. All of our The recent discussion of the DSM- position of being an umpire who be- mental states are ultimately a product 5 has raised interesting epistemological lieves there really are balls and of our brains. As neuroscience ad- questions about how best to define strikes but who feels his rulings have vances we will come to understand mental illness. Within the philosophical absolutely no relationship to them how the brain generates cognition, literature of the taxonomy of illness whatsoever, and who is OK with this! emotions, and moods. Thus we will there are two basic camps: naturalists I believe Frances backs himself come to understand how the brain and normativists (Boorse 1997, Nor- into this awkward position at least causes the symptoms of what we call denfelt 2007). Naturalists feel that dis- partly because of a rather extreme mental illness regardless of whether ease is an objective fact which can be pessimism about the etiology of men- mental illness is mostly normativist or defined by a breakdown of the normal tal illness. He states that: mostly naturalist. From a pragmatic biology. Normativists contend that dis- All normal brain functioning is standpoint the vast majority of people ease is subjective and depends on cul- normal in more or less the same seeking voluntary outpatient treatment turally relative judgments. Yet this de- way, but any given type of for mental illness have very objective bate is largely an academic exercise pathological functioning can symptoms that follow a specific illness where philosophers try to defend ex- have many different causes. course. Thus there is nothing intracta- treme positions declaring all disease is (Frances 2010). ble or mysterious about finding the either completely subjective or com- Following this statement there is a biological etiology of mental illness. pletely objective. Outside of this small discussion about the lack of a simple In the end Frances and I both share philosophical circle no one pays any genetic explanation for any mental similar concerns about premature and attention to this debate for the obvious illness and the worry that there are disruptive changes to the DSM-IV and reason that illness is a very heterogene- potentially “hundreds of paths to we agree that we are still far from un- ous concept and medicine a very prag- schizophrenia” (Frances 2010). While derstanding the etiology of any mental matic business. Some illnesses are best the above statement may be true the illness. Yet I would argue that, at least defined more from the naturalist or conclusion that we can never under- for the major diagnoses, this has noth- normativist perspective but the vast stand the etiology of mental illness ing to do with the normativist elements majority of illnesses are best under- (or perhaps the stronger statement of mental illness. There is a strong nor- stood using both perspectives. that there is no etiology) does not mativist element even in many physical In his discussion of how to define follow from this. Frances then seems illnesses but this doesn’t seem to im- disease Frances provides a nice base- to change course and acknowledges pede our colleagues in internal medi- ball analogy to illustrate the different that there can be progress in under- cine (e.g. when is blood pressure or epistemological positions available standing the etiology of mental illness cholesterol too high?). When defining (Frances 2010). Frances describes him- but worries that it will be painstaking diseases with strong normativist ele- self as most sympathetic to the second slow and that our current DSM dis- ments small subjective changes in the umpire who believes there is an under- ease categories may play no useful criteria can sometimes have vast conse- lying reality to balls and strikes yet role. quences. Thus I share Frances’ concern acknowledges there is also a large sub- While I agree that progress will about making changes to illnesses that jective element to being an umpire. At most likely be slow it seems prema- have serious consequences in forensics first glance this seems to be consistent ture to give up a link between our or the potential to create stigma. It is with the common notion of admitting current diagnostic criteria and etiol- better to acknowledge the normativist the importance of both the naturalist ogy. As Frances admits, the DSM-III elements in these cases and seek out- and normativist perspective. However, and IV definitions of many diseases side societal input and all potential con-

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sequences should be studied and de- exist and cause suffering in ways that ally of quite limited explanatory value. bated openly before making any are all too tangible. And they all have Dr Cerullo sees our mental disorders as changes to diagnostic criteria. This materialistic biological underpinnings being much closer to reality; I see them being said, I believe the vast majority that we will some day understand. as fragile, not necessarily capturing of the major mental illnesses We also don't accept the opposite much the elusive, underlying biological (depression, bipolar disorder, schizo- "realistic" extreme. Mental disorders reality. We are both second umpires, phrenia etc.) have only small normative are not preordained and simple but Dr Cerullo is ever so much more elements. These mental illnesses are "diseases" just waiting to be easily confident in his calls. mostly naturalistic and are about as decoded by our increasingly sophisti- Dr Cerullo titles his commentary normative as Parkinson’s disease or cated scientific tools. "The Illusion of Epistemological Prob- diabetes. For these illnesses we need to Dr Cerullo and I thus agree that lems in the Definition of Mental Ill- continue to study objective symptoms the best epistemogical stance is to ness". Of course, in a limited sense this and their biological correlates and there somehow split the difference. We is accurate. There is no inherent reason is every reason to be optimistic in the both expect to call them as we see to believe that the human race (if it long run. them as second umpires. But this lasts long enough) cannot unearth the brings us to our considerable quanti- numerous and heterogeneous pathoge- References tative disagreement. We are very dif- netic underpinnings of most, if not all, ferent second umpires and disagree the behaviors we now label as mental Boorse, C. 1997. A Rebuttal on on how easy it is to make the calls disorder. But the title obscures the Health, in What is Disease? , J. Humber separating the balls from the strikes. practical epistemological problems that and R. Almeder, Editors. Humana Dr Cerullo misstates my position to arise if my guess turns out to be right Press: Totowa, New Jersey. make me sound like a third umpire that schizophrenia (and the other major Frances, A. 2010. Allen Frances manqué when he suggests I might mental disorders) each have more than Responds. Bulletin of the Association even say that "the naturalist perspec- fifty (and perhaps hundreds of) differ- for the tive plays no role in how we define ent underlying causes. Would we still Advancement of Philosophy and Psy- mental illness." Of course, I don't call it "schizophrenia" and be so at- chiatry 17(1): 21-25. believe this. How could any sensible tached to this unsatisfying and hetero- Nordenfelt, L. 2007. The concepts person? There are naturalistic under- geneous melange of symptoms once we of health and illness revisited . Medi- pinnings to everything that happens knew all the things that are "really" cine, Health Care and Philosophy . in our little universe—and it could going wrong. Like Dr Cerullo, I also 2007. 10: 5-10. not be otherwise. There are always treasure the practical, everyday utility real balls and real strikes, whether or of our homely system. But I think that *** not it is within our poor powers to see he has an unwarranted complacency them or understand their meaning. Dr and offers false hope about its eventual Cerullo confuses my statements about explanatory power. Epistemological Problems difficulties discovering causal reali- I do thank Dr Cerullo for providing not so Easily Solved ties into thinking I am saying these a better summary of my position than I realities don't exist. did myself when he says, "Frances Allen Frances, M.D. Indeed, this is precisely where Dr describes himself as most sympathetic Cerullo and I have our quantitative to the second umpire who believes Dr Cerullo and I have a quantita- disagreement. He is much more con- there is an underlying reality to balls tive, not qualitative, difference of opin- fident than I am in the eventual ex- and strikes yet acknowledges there is ion on what Dr Cerullo calls the natu- planatory value of the mental disor- also a large subjective element to being ralist /normative divide. Let's start with ders described in our current diagnos- an umpire". the qualitative ways in which we con- tic system. He is a second umpire In summary, then, Dr Cerullo and I verge and then indicate the quantitative who believes we are close to seeing are both second umpires, but with very ways we part company. things as they really are and states different stripes. I am a very uncertain Dr Cerullo and I agree that when a confidently, "I would surmise that, at second umpire, never sure whether I debate has managed to maintain itself least for the major axis one disorders am calling the right balls and strikes— for twenty-five hundred years, there (major depression, bipolar disorder, nestled about equidistant from the first must be truth on both sides, absolute schizophrenia), the diagnostic criteria and third umpires. In contrast, Dr Ce- truth on neither. We are therefore both have proved useful precisely because rullo is an extremely confident second second umpires who reject the extreme they capture correctly some part of umpire quite sure of his calls and ready poles on the epistemology of mental the underlying biological reality of to become a first umpire if only there disorders. We don't accept the third mental illness." were just a little more light. If he is umpire view that mental disorders have In contrast, I regard our mental right, we should have some pretty been conjured up in some Bishop disorders as no more than superficial quick and dramatic findings to explain Berkeley, solipsistic sense. Certainly and heterogeneous constructs, of the major mental disorders. If I am mental disorders are not "myths". They great practical utility now but eventu- right, it will be, as it has been, an inher- ently slow and retail slog despite the 44 Volume 17, Number 2 2010

brilliant tools. system made by the APA. A 17th Kraepelinian movement took hold in century leader, Sydenham’s con- official APA classification, marked by *** ception of disease and its classi- its use of descriptrive operational crite- fication included several basic ria sets, its heuritistic nature, atheo-

points: reticity, and the use of reliability as its Nosology for Beginners: • Use of empirical observation measure. In their specific proposals DSM-5’s authors now propose some The Context of Psychiatric • Classification using the more departures from these tenets. The next botanico / categorical method Classification and section reviews tensions and problems • Diagnosis That the categories were applica- any classifier, such as those of DSM-5, ble across humans and across faces. places Avram Mack, M.D. Sydenham’s principles were inte- Recurring Philosophic Issues Georgetown U. School of Medicine grated into the medical profession in Nosology

that coalesced in Enlightenment Today, as in a few other previous France. There, the “Anatomic- Nominalism/Realism. One of the instances, our profession faces calls for Pathologic” method, which combined first questions that invariable arises is change or movement of the field either descriptive observation of illness with whether or not mental disorders exist at in or through its classification. When a pathologic findings, produced the all. Szasz argued that mental illness membership organization such as APA most terrific breakthroughs, espe- was a myth, which gave support to the engages in the creation of a classifica- cially in the conditions due to infec- anti-psychiatry movement. On the other tion there are risks that are shared by tious agents—gold standards for fur- extreme are those who assert that men- all who care about the field. The risks ther characterization of syndromes. tal disorders are entities that are tangi- of a problem-ridden official classifica- Like Sydenham, Kraepelin ble. Where one stands on this contin- tion include: viewed illnesses as valid or real enti- • uum informs one’s approach to classifi- Forensic Misuse ties, and his textbook for the most cation. DSM-IV did not assert validity • Clinical Disruption part included 17 main categories of except to the extent that the symptoms illness. In addition his scientific out- • Reduced Research Generalizability in its criteria sets were associated with • look was that ultimately classificatory each other. Confusion for Patients attempts based either on symptoma- Sui Generis/More Botanico . More • Deterioration of the Profession’s tology, course, or etiology would Botanico refers to Sydenham’s view Standing converge around the same valid that illnesses have typical features • Degradation of the professional groups. Finally, Kraepelin viewed his across humans and that they can, thus, association’s control over mental work as heuristic models with practi- be classified categorically as plants had health classification systems cal benefits, particularly towards been. On the other side, the Sui Generis As our professional association communication within the field. He concept refers to the concept that each continues to move toward a proposed would write in 1920, “I want to em- individual’s mental disorder is special classification, it is in all of our interests phasize that some of the clinical pic- or unique to himself. This latter per- to understand the historical context of tures outlined are no more than at- spective was germane to the psychobi- issues in psychiatric classification by tempts at presenting part of the mate- ology of Adolf Meyer as well as to focusing on several recurring problems rial in a communicable form.” psychoanalysis, and is antithetical to and issues in the classification of psy- It is notable that at this time in categorical descriptive psychiatry. chiatric conditions, and considering chemistry, the Periodic Table was Local/Universal Illness . Along the some proposals for DSM-5 in this con- developed—it was an analogous sci- same lines, many psychiatrists have text. entific method: continued description seen disorders as local—occurring only of atoms and their behavior did lead for a specific location. For example, Review of the Neo-Kraepelinian to the production of a valid classifica- George Beard’s neurasthenia was de- Movement : tion of atoms. This was a positivistic fined by the American environment and ideal. And between 1917 and World Industry. He called it “modern and • War II, the APA’s classification was originally American.” But this is in Notwithstanding the hope updated 10 times to provide the sec- of its authors that DSM-5 shall opposition to Sydenham’s perspective. tion on mental disorders in 10 edi- Charcot, too, saw hysteria as “valid for represent a “paradigm shift,” and tions of the American Medical Asso- all countries, all time.” DSM-IV’s co- with the exception of DSM-I and ciation’s “Standard” classification ordination with the WHO indicates its DSM-II, official American psychi- system. American psychiatry’s “cross cultural” intention—to be appli- atric classification has followed the nosology was psychologically ori- cable across nations and cultures. descriptive tenets of the Sydenham ented during the post-war period as The Range of Psychopathology. and Kraepelin model for nearly a psychodynamic principles informed All classifications have had to grapple century, starting with the 1917 the system until 1980, when the neo- with the range of the psychopathology

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defined by the system. Freud’s ex- achievement of Esquirol, Pinel’s Historical Context’s Application to planatory system could explain the protégée. However over the early DSM-5 Proposals psychopathology of everyday life, but 19^th century it was used so fre- this would be restricted by DSM-IV’s quently in courts in France that its There are many considerations that requirement of clinical significance or meaning became diluted, ultimately have constantly arisen in the production by restriction of clinical attention to the leading to a backlash by the French of psychiatric diagnostic classifica- institutionalized patients. A system’s judiciary, followed by a reduction in tions, and they would apply in the for- range of coverage—based much on its forensic and clinical use. Today’s mation of DSM-6. For example: how it is written or its criteria sets writ- PTSD is one such disorder that may 1. Splitting/ Lumping—In the ten (in an operational classification) has be misused—and misuse is possible lumping of the abuse and dependence a great effect on public health, stigma, in the whole range of forensic set- diagnoses of substance use. and treatment utilization. tings, including the administrative 2. Empirical/rational Epistemol- proceedings of Individualized Educa- ogy: The DSM-5 proposal for psycho- Specific Technical Issues in tional Plans for children and adoles- sis risk syndrome is wanting fo a gold Psychiatric Classification cents. standard for psychosis—but is there Empirical/Rational Classifiction . one? Splitting/Lumping . This is a ten- There have been no shortage of theo- 3. Dimensional/Categorical Diag- sion that arises in a categorical system. ries of psychopathoogy, and this has nosis: the proposal to create a contin- The ultimate perspective of the ranged from psychological to biologi- uum for the pervasive developmental “lumper” is that there is only one kind cal conceptions. In the 19th century, disorders in DSM-5 is welcome but of mental illness, and this cuts across Broussais claimed that all mental possibly not ready. theoretical backgrounds. Many leaders disorders had an etiologic basis in the 4. The range of Psychopathology: have asserted that there is solely one GI tract. But there have been many the range would be expanded in the mental disorder—in the 19^th century instances where others have called for alterations proposed for grief, mild both the neuroscientist Greisinger (who a “fallback” on a heuristic symptoma- cognitive disorder, and ADHD. proclaimed mental disorders are brain tology as the means to classification. disorders) and the early psychologist Pliny Earle, one of the APA’s foun- Conclusion Neumann both held this view. And in ders, said, “In our present state of the 20th century Karl Menninger held knowledge, no classification of insan- The anatomic-pathologic descrip- to the “Unitary Concept.” At the other ity can be erected upon a pathological tive method had led to some successes extreme, the 2400-item classification of basis…the pathology is unknown. We in psychiatry, but our frustration should Sauvages (who tried to replicate the are forced to fall back upon the symp- not lead us to once again prematurely binomial method of Linnaeus) was tomatology of the disease.” Or, Sam- abandon it as we had done in the actual rejected as impractical. uel Orton said in 1917, classification paradigm shift of DSM-I. Psychiatry Categorical/Dimensional . Dimen- by empirically-observable phenom- should proceed with caution and recall sional approaches are desirable for the ena was “a necessary result of our our predecessors, such as Charcot, or description of some aspects of mental limited understanding of etiology.” I.S. Wechsler who wrote in JAMA in disorders—specifically for continu- And this empirical perspective re- 1930, “It is no discredit to psychiatry to ously-distributed phenomena, ideally to sumed sway in DSM-III. acknowledge that it has barely emerged be converted into a numerical form. Description without Gold Stan- from the descriptive stage…” Except for the GAF scale, none exist in dards . A gold standard for a diagno- DSM-IV. They might be best suited to sis, whether an etiological agent or a *** personality disorders. distinctive pathological finding, can Fad . Excess levels of diagnosis at serve as a centerpiece while other a particular time may occur naturally, information is discerned about a par- but in some cases disorder levels are ticular syndrome. To date there are no artificially heightened either due to gold standard findings among psychi- Thesis/Antithesis/ popularity or the definition of the ill- atric disorders. The hope of the neo- Synthesis ness, or a combination of both. DSM- Kraepelinian model is that continued IV’s alteration of the definition of Au- improvements in reliability will coa- Allen Frances, M.D. tism and the Pervasive Developmental lesce around valid disorders for Disorders as well as ADHD each al- which gold standard findings will be Dr Mack has provided us with a lowed for sudden increases in the disor- discovered. However, one must also brief, lucid recapitulation of the history der. recognize, as did Kraepelin, that reli- of psychiatry and presents rich anec- Forensic Misuse . As far back as ability is important but it may not yet dotes illustrating the recurring, seem- Esquirol’s Monomania, there have been approximate validity, and that the ingly, insoluble debates in psychiatric disorders that were used inappropri- heurtistic process may, but may not, classification. Whenever a debate man- ately in forensic settings. The definition lead to success. ages to persist for decades or centuries, of monomania had been a celebrated the assumption should be that there is considerable truth on both sides. Let's 46 Volume 17, Number 2 2010

start with a brief note on the historical in a communicable form.” be much better at vivid naming than at context and then point at some poten- This is really all that can ever be more accurate numbering. Computers tial syntheses that could modulate the expected of a descriptive classifica- are better at numbers. Medicine has intensity of the debates. tion and Kraepelin knew it. There been almost exclusively categorical I think the most important para- have been only two important ad- (exceptions are hypertension, cancer digm shift in the history of psychiatry vances in nosology since Kraepelin: staging and in DSM-IV,severity ratings was the development by classic Greek 1) the extension of psychiatric diag- and the GAF). Categorical description medicine of the four humors theory of noses to less severe outpatient condi- loses information in describing con- personality and disease. The Greeks tions, which was stimulated mostly tinuous phenomena that lack clear intuited that behavior and illness were by Freud; and, 2) the introduction of boundaries—like mental disorders. the product of an imbalance in the biol- diagnostic criteria in DSM-III by Dimensional measurement can be cum- ogy of the body, discounting previous Spitzer. The diagnostic system has bersome and bloodless. It makes sense beliefs that they were caused by the not improved since DSM-III. It will to gradually combine both methods in gods or spirits or a curse or the place- not improve in DSM-5 and may get clinical work and to move more toward ment of the stars. The next paradigm worse. dimensions in our research efforts. The shift was delayed for two thousand Now for the attempted syntheses obstacle to a synthesis is the tremen- years until the development of system- of Dr Mack's pairs of recurring theses dous resistance to dimensions among atic descriptive classifications during vs antitheses: practitioners. DSM-5 will likely stiffen the age of enlightenment. We are now Realism vs Nominalism . For by offering ridiculously complex di- (hopefully) close to the end of this tired now, the nominalist, second umpire mensional proposals that no one will era and are impatiently waiting for the clearly rules. Our currently defined ever use. next paradigm shift that will replace mental disorders don't stand up as Lumping vs Splitting . There has to mere description with explanatory unified diseases and will be picked be a happy medium somewhere be- models. The understanding of brain apart as heterogeneous causal expla- tween the 1 mental disorder category of psychopathology may not be reached nations for psychopathology are the extreme lumper and the 2400 of the for many decades and certainly won't gradually discovered. In time and extreme splitter. Eventually, many dec- be achieved at the same time for all with accumulating scientific knowl- ades from now, 2400 may seem more disorders. It will doubtless be much edge, we will gradually get to see right when we have deciphered many more particular and less elegant than things more as they "really" are and of the mysteries of psychopathology the theory of evolution or the periodic will gradually become more like first and discovered its myriad interacting table. The brain is too complicated for umpires. causes. For now, with a classification simple, sweeping, causal explanations. More Botanico vs Sui Generis based only on description, DSM-IV Kraepelin's work was a solid job of (which includes Local vs Universal). seems a bit cluttered with its almost careful observation and of thorough To paraphrase Sullivan, everyone is 300 categories. It is a splitter's dream summation, but it did not represent a more simply human than otherwise. conceived with the purpose of enhanc- paradigm shift and he had the insight Psychiatric disorders tend to be ge- ing reliability. This is fine except for and modesty to know it. Kraepelin was neric—to present in more or less the the artificial comorbidity caused by the building upon and assimilating the doz- same way across times, places, and splitting of more complex syndromes. ens of diagnostic systems that had cultures. But the equivalence is only The best approach is to be mindful that been developed during the nineteenth "more or less." There is lots of "sui DSM disorders are no more than de- century, starting with Pinel's. His generis" too. First off, each of our scriptive building blocks and much less method was based on the painstak- defined mental disorders is remarka- than homogeneous diseases. . ingly systematic charting and collating bly heterogeneous in its presentation. Lean vs Full Coverage . There is no of symptoms, course, family history, Then there are the definite cultural clear boundary between normal func- medical history, and findings on au- variations, the changes in presenta- tioning and having a mental disorder topsy. (I have seen his patient charts in tion over time (whatever happened to and no operational program to decide Munich—his notes were voluminous catatonia and conversion disorder), which disorders are to be included in and remarkably neat—he used pens of and the fact that everyone is unique the diagnostic system, which to be left different colors for each category of on many variables that may count out. My intuition and reading of the information). Kraepelin wrote the most importantly, especially in planning literature tells me that DSM-IV is al- popular textbook of psychiatry and its treatment. The best synthesis here is ready far too inclusive and that DSM-5 table of contents became his classifica- to be equally sensitive to the common is likely to make things very much tion. patterns and to the individual varia- worse. Kraepelin's goals were appropri- tions on the theme. Empirical vs Rational Systems . I ately limited given the scientific infor- Categories vs Dimensions. I pre- love Dr Mack's Pliny Earle quote; “In mation on causality available in his fer dimensional measures for IQ, our present state of knowledge, no clas- time (and still in ours); “I want to em- height, weight, and the balance in my sification of insanity can be erected phasize that some of the clinical pic- bank account. I prefer categorical upon a pathological basis…the pathol- tures outlined are no more than at- description for colors, foods, and in ogy is unknown". We have learned lots tempts at presenting part of the material fact for most things. We evolved to of things, but the quote still stands 150 47 Volume 17, Number 2 2010

years later. No descriptive system proclaims “The Future of Psychiatric every step of which was shared with makes much more sense than any other Diagnosis” ..... ”One of the most an- the public, American psychiatry dem- in the absence of deeper understanding. ticipated events in the mental health onstrated that the diagnostic system, All current attempts at causal explana- field.” In the 1960s Community which originated in observations of tions are speculations. Psychiatry was described by leaders patients in 19th century German hospi- Forensic Use vs Forensic Misuse . of our Association as “the third psy- tals, was not engraved on stone tablets, The cautions in the introductory sec- chiatric revolution.” (The first was but was a body of work that should be tions of DSM-IV are meant to encour- Pinel’s releasing patients from their modified continuously in response to age the appropriate and necessary rela- chains, the second was the introduc- new information. The path to this tionship of psychiatry and the law and tion of Freudian analysis.) Today we event had been blazed a few years ear- to discourage misuse and misunder- remember Community Psychiatry as lier when the entire membership was standing in this relationship. The abuse an innovation in delivery of services asked to vote on the elimination of ho- of psychiatry in the involuntary com- that faded when Federal funding mosexuality as a category of mental mitment of sexually violent prisoners is ended. Lasting benefits of Commu- disorder. Awareness that the diagnos- a disturbing example of how delicate is nity Psychiatry were modest: outpa- tic scheme is transient is one of DSM- the balance and how fragile are both tient treatment became more accept- III’s major contributions to psychiatry. constitutional rights and professional able and available to a larger portion The use of criteria in DSM-III, a move integrity in the face of a serious societal of the public, and the professional intended to enhance reliability, was problem (see comments by Drs Szasz status of non-physician psychothera- acceptable because there was a growing and Piaseki). pists was enhanced. Two Nobel sense in our field that exactness was Loose vs Tight Standards For Prizes have been awarded for treat- preferred over vagueness. While de- Change . Absent a gold standard for ment of mental disorders. The most scribed by its authors as “atheoretical,” making decisions about change in the recent, in 1949 was for pre-frontal the repudiation of theory was focused classification, what standard should lobotomy, a procedure that helped on assumptions of causality based on apply. The purported "validators" of many patients, but is cited today by inferences about unconscious process. descriptive psychiatry have been disap- our critics as evidence that psychia- For example, Depressive Neurosis was pointingly uncompelling, inconsistent, trists are potentially evil. We should described in DSM-II as “an excessive and a poor guide to change. The drug do our work without awarding our- reaction of depression due to an inter- industry is ready to pounce on any selves medals or employing the su- nal conflict or to an identifiable event DSM change to promote false, faddish, perlatives of the entertainment indus- such as the loss of a love object or and risky epidemics. A high threshold try. “Paradigm shift” is a designa- cherished possession.” Physicians for change seems reasonable- one that tion to be made by historians looking diagnosed Depressive Neurosis when places a heavy burden of proof, an ex- back at the impact of a new program the patient had symptoms of depres- acting standard for evidence, and risk/ or idea, not by the program’s enthusi- sion, without regard for the physician’s benefit analysis before any change is astic proponents. belief in the unconscious or evidence of accepted. The popular press characterizes internal conflict. The diagnostic proc- DSM as “the psychiatrist’s bible.” ess usually consists of selecting a term *** Although “bible” is defined as “a that seems to explain the patient’s book authoritative in its field,” the problem or that seems appropriate for implication is that it is a book to be the intended treatment. revered. We should do what we can DSM is a policy and procedure to dispel this image. DSM-III occu- manual with an educational mission. pies a special place in our history Axis II was established to “ensure that A Grandfather Reflects on because it introduced important pro- consideration is given to the possible the Younger Generation cedural changes and ratified concep- presence of disorders that are fre- tual changes that had become wide- quently overlooked.....” Physical dis- Henry Pinsker M.D. spread in the American psychiatric orders were declared an axis because Mt Sinai School of Medicine community. With its successors, the psychologically-minded psychia- DSM has become an institution, an trists of that era tended to ignore them. When I had the privilege of partici- industry. Although the DSM process Evaluation of stressors, axis IV, was pating on the APA Task Force that has served psychiatry well, it is now intended to provide information rele- produced DSM-III, I was characterized time to begin planning for psychiatry vant to prognosis. The DSM-III Task by a colleague as “a clinician- to join the medical community and Force understood that many patients administrator.” Writing about planning use ICD as the official source of diag- with diagnosis of schizophrenia—the for DSM-V, I will maintain that pos- nostic terms. We would be better off diagnosis on most inpatient charts— ture rather than adhering to the disci- if the public thought of us as being really had mood disorder and conse- pline of scholarly writing which recog- guided by technical manuals rather quently, if properly treated, a better nizes and credits other people’s ideas. than by a “psychiatrists’ bible.” prognosis. Antidepressant medications The APA’s website for DSM-5 With the creation of DSM-III, had recently been introduced. Mood

48 Volume 17, Number 2 2010

disorders were declared trump, so in a “anxiety,” and other symptoms for used the same term were talking about number of places, the criterion (i.e. which patients seek care. Moving the same condition. The descriptions instruction) is: “not due to a distur- from DSM to ICD might lead to use and definitions of mental disorders bance of mood.” of diagnoses that are at times more follow the medical model of assuming When I was in medical school, the simplistic than what we are accus- that the diseases are real, although we classification of mental disorders was tomed to, but more realistic. Psychia- know that many are best understood as of little more import than classifying trists seem obliged to report they are constructs scarcely more accurate than beetles or butterflies. American psy- treating specific disorders, while the the old classification “fevers.” The chiatrists diagnosed schizophrenia rest of the medical profession, realis- problem with a “risk syndrome” is that whenever they found a little thought tically, is permitted to treat symp- it appears to be a construct created disorder. That some of the patients toms. The “Psychiatrists’ Diagnostic from a set of criteria, not from an at- might have been manic-depressive did- Manual” would be a companion pub- tempt to describe something that had n’t really matter because treatment lication, providing relevant instruc- been observed. choices were essentially analytically- tions for diagnosis and treatment. Bipolar II was added to DSM-IV oriented psychotherapy and sedating The word “statistical” as a major ele- because there appeared to be clinical medication. Fretting about formal ment of the title reflects DSM’s mis- evidence that it was as real as the other diagnosis was thought to be a denial of sion in 1952—to stabilize nomencla- constructs. “Psychosis Risk Syn- the patient’s individuality, and the di- ture and facilitate statistical coding of drome,” it is feared, will be over- agnosis would not affect the treatment. case records. Those who use the diagnosed and will be associated with The introduction of lithium in the late book today are seldom concerned excessive pharmacologic treatment, as 60s as a treatment specific for mania with “statistical” implications. We has been the case with Bipolar II. Con- and the introduction of antidepressants can find more meaningful ways to trolling physician behavior, however, in the 70s suddenly made diagnosis honor the past. is an educational or administrative mat- excitingly relevant. When DSM-III The problem of early diagnosis ter, and should not be addressed in the was written, it appeared that psychiatry illustrates how procedural rules have classification of disorders. If a condi- now had two major disorders and for become intertwined with the diagnos- tion is real enough to merit a place in each there was a specific treatment. tic classification. Because schizo- the classification, it should not be de- Correct diagnosis would lead to correct phrenia was often overdiagnosed, the nied on the grounds that physicians are treatment. We did not anticipate that creators of DSM-III elected to protect not skillful enough manage it. Physi- thirty years later, everyone would be patients from the social stigma asso- cians routinely decide when to initiate diagnosed with everything and would ciated with this diagnosis and from treatment for mild or subclinical condi- be receiving every medication. the harmful effects of the tions, weighing the risks and the bene- The first months of the Task [phenothiazine] medications likely to fits. Guidance about when to treat and Force’s work were devoted to an at- be prescribed. The diagnosis could how to treat comes from the textbooks, tempt to define the term “mental disor- not be made unless there had been manuals, and current literature—it is der.” I thought that this was an impos- “continuous signs of the illness for at not the function of the classification. sible task and proposed that the name least six months.....” Early diagnosis All areas of medical activity are of the book should be changed from of schizophrenia was no longer per- shaped by administrative and legal con- “Diagnostic and Statistical Manual of mitted. Now, “Psychosis Risk Syn- cerns, which may be more involving Mental Disorders” to “Psychiatrists’ drome” has been proposed for DSM- than scientific and therapeutic goals. Diagnostic Manual,” shifting the focus 5. What has happened? The medica- Students of disease were creating clas- from subject matter - Mental Disorders tions used to treat the condition are sifications as an intellectual and scien- - to the users - Psychiatrists. My idea not as likely as the old ones to cause tific challenge before administrative was speedily and unanimously rejected. permanent neurologic damage, and concerns required an interface between I was delighted to read Frances’s ob- new findings give hope that early classification and medication. In all servation that “Mental disorder is what treatment may reduce subsequent societies, people have ingested non- clinicians treat and researchers research disability. To allow (or justify, or food substances with the goal of reliev- and educators teach and insurance com- encourage) early treatment, the fram- ing distress, whether it be pain or infer- panies pay for.” His statement gives ers of DSM-5 have proposed a new tility or unhappiness. Because society me courage to suggest again that the disorder. It is well established in has placed control of certain agents in APA book be reconceptualized as a medicine that new findings may lead the hands of physicians, and because manual of clinical practice and that to drastic changes in treatment rec- we have a system of payment that is ICD become the official classification. ommendations. It should not be nec- oriented around treatment of diseases, When the first DSM was produced, in essary to change the classification of it is necessary that patients have named 1952, ICD did not provide adequate disorders in order to change treatment disorders. Pharmaceutical companies support for contemporary psychiatric plans. The diagnostic system and the are free to develop agents that may practice. Since that time, ICD has procedure manual should be separate alleviate distress. When they succeed, evolved, influenced, of course, by books. the new agent must be approved as DSM. ICD includes codes for The purpose of criteria in DSM- treatment for a specific condition, so if “headache,” “fatigue,” “depression,” III was to ensure that people who the condition does not have an accepted 49 Volume 17, Number 2 2010

name, one must be created. If the pa- generated—often these are most com- peared psychiatry might achieve a ra- tient has reimbursement-type insur- placently trumpeted just prior to be- tional and specific differential treat- ance, a disorder must be diagnosed. ing abandoned for the next ment selection based on a reliable sys- Even if the patient is in treated by sala- "revolution." The proof in real para- tem of descriptive diagnosis. "We did ried physicians, quality review proce- digm shifts is in the historical pud- not anticipate that thirty years later, dures monitor the appropriateness of ding—their lasting value, not the everyone would be diagnosed with prescribing. When, however, treatment drumbeating hype. Psychiatry, like everything and would be receiving does not involve a potent pharmaceuti- medicine in general, seems tantaliz- every medication." Clearly, things have cal product, or when insurance reim- ing close to the real paradigm shift of gotten out of hand. bursement is not requested, it is not scientific understanding. But like the I disagree with only one of Henry's necessary that the patient have a Tantalus myth, catching the fruit has points, but the disagreement is impor- named disorder. so far been elusively impossible—the tant. He is much less worried than I am Criteria are instructions to ensure more powerful the scientific tools we about making "Psychosis Risk Syn- that diagnostic terms are applied cor- develop, the more we learn just how drome" an official diagnosis. rectly. Criteria belong in the proposed complex are the problems they are "Controlling physician behavior, how- Psychiatrists’ Manual, not in the diag- seeking to solve. Psychiatry may be ever, is an educational or administra- nostic classification. Dimensional rat- decades away from a paradigm shift- tive matter, and should not be ad- ing scales offer a brilliant approach to ing revolution. dressed in the classification of disor- describing patients. Rating scales be- Like Henry, I have been troubled ders. If a condition is real enough to long in the proposed Psychiatrist’s and embarrassed by the description of merit a place in the classification, it Manual, not in the classification of DSM-IV as a "bible" and never felt should not be denied on the grounds disorders. It is clearly stated in the any reverence whatever for it. DSM- that physicians are not skillful enough introductions to both DSM-III and IV seems to me to be no more and no manage it." Henry temporarily be- DSM-IV, that the classification classi- less than a useful (but necessarily comes a first umpire who believes that fies disorders, not patients. makeshift and temporary) compen- conditions are demonstrably "real" so Changes in the classification of dium of current diagnostic assess- that untoward consequences should be disorders should be limited to those ment using limited descriptive meth- dealt with external to the classification made necessary by changing conditions ods. We tried to highlight the many system. I think that Psychosis RiskSyn- or made possible by solid new evi- fallibilities of the DSM approach in drome will become "real" in a real dence. The major changes introduced the Introduction and in presentations, sense only when it has a reasonable low by DSM-III, even if not a paradigm but many people place more faith in false positive rate and a safe and effec- shift, were appropriate because of the the manual than we do. H e n r y tive treatment. As it stands today, it gulf at that time between clinical prac- suggests that psychiatry "join the may have a false positive rate of 75- tice and the old diagnostic system. No medical community and use ICD as 90%, no effective treatment, and will such gulf exists today, so major change the official source of diagnostic promote the terrible side effects of an- is not called for. Change is appropriate terms" and " that the APA book be tipsychotic medications. The makers of as a response to new information or to reconceptualized as a manual of clini- the classification cannot responsibly remedy deficiencies in the current man- cal practice and that ICD become the take a hands off attitude toward the ual. Eliminating Axis II and changing official classification." Actually, we way their decisions are likely to be personality disorders to personality already use the codes of ICD, and misused. Physician and patient educa- types is such a remedy. Change is pretty much the same terms. Regard- tion is no protection since so much of it potentially disruptive, so it should not ing official status, DSM is really just is influenced by the drug industry. be done for the purpose of being “one an (admittedly mammoth) American of the most anticipated events in the Psychiatric Association sponsored *** mental health field.” gloss on ICD. The fact that the gloss is often given such independent au- Final Comment *** thority places great responsibility to do it competently, consensually, and Henry Pinsker, M.D. The Wisdom of the Ages cautiously—standards I feel that the

work on DSM-5 has so far failed to My comment about the proposed Allen Frances, M.D. meet. The larger question is whether Psychotic Risk Syndrome was limited

the APA (or any one professional to the somewhat libertarian position Henry Pinsker was my first teacher association) should be permitted to that education about good practice is of psychiatry and has remained a great retain such an important franchise, not the function of the diagnostic clas- influence. He always has a clear eye for especially when it has not provided sification. This does not mean that I the strike zone and calls them just as he nearly enough quality control. APA endorse the inclusion of this diagno- sees them. has treated DSM-5 more as a publish- sis. Until we adopt a different system, Henry begins by pointing out the ing asset than a public trust. several of which have been described tendency of psychiatry to have recur- Henry also nostalgically recalls in this series of comments, our diagnos- ring "revolutions" that ultimately fail to the time not so long ago when it ap- tic scheme continues to be based on the live up to the enthusiasm they initially 50 Volume 17, Number 2 2010

notion that the disorders we diagnose In the section titled “Descriptive As for the arguments forwarded by exist out there somewhere, even though psychiatry gets long of tooth” Allen Mender I would like to indicate that the their nature has eluded discovery and Frances places current psychiatry new non-linear taxonomy is already many agree that they are constructs within its historical scientific per- here, insights from nonlinear systems, more than they are phenomena. It is a spective, the premise of the DSM as a and mathematical neural network and convention that underlies much of descriptive method is that “any do- neural-computation models provide for medical practice. main receiving systematic observa- an initial conceptual framework to re- From this perspective, a risk syn- tion and classification would eventu- formulate mental disorders as distur- drome is a contrivance, not a disorder. ally display causal patterns. This ap- bances to optimal brain organization. Medical practice includes prescribing proach was enormously successful in Mender eventually argues that for conditions which, in the physician’s each of the major paradigm shifts in these "hopeful beginnings cannot be judgment, are latent, early, or incipi- science." productively leapfrogged by premature ent. It is enough that we continue to Also According to Allen Frances taxonomic efforts." I would argue that split off new entities based upon patient descriptive psychiatry has done as changing the taxonomy and conceptu- behavior. We don’t need to open the much as it can to further our field, alization is productive. An old Chinese door for new entities that give names to etiology based psychiatry is the para- saying states that wisdom begins by treatment decisions. digm shift needed. Descriptive psy- calling things by their correct name; chiatry has offered reliability; we instead of "psychosis," "disconnection *** now need a diagnostic system with syndrome" (Friston & Frith 1995) has a validity. brain-related orientation that will lead The Paradigm Shift for In this regard James Phillips future psychiatrists to research it in Psychiatric Diagnosis is (2010) indicates that “not only don’t patients and eventually validate it and we have a so-called paradigm shift to develop "re-connecting" interventions Already Here ! make the nosology more valid, we to cure it. As Mender properly indi- don’t even know how will that occur, cated, it has the potential to fuel un- Avi Peled M.D. or even if it will in fact ever occur.” precedented insights not thought of Technion: Israel Institute of Donald Mender (2010) asks, “Do before. Technology we have the conceptual means to mo- The morphology of the neuron bilize unified predictive principles in tells us that what the neuron does best, I have no training in philosophy the service of a rigorous psychiatric i.e. connect; each neuron is capable of and I will address the issues relevant to nosology?” he goes on to state that connecting to hundreds of thousands of psychiatric diagnosis from a practical “living things as physical systems other neurons via its elaborate axonal- medical approach which assumes that demonstrate emergent properties be- dendritic structures with their numer- curing patients is the bottom line in any yond those of their particular micro- ous synaptic spines. Thus the funda- medical discipline. constituents.” It is clear that single mental function of the brain made up of In this regard I am fond of some of neurons and even entire neural cir- billions of neurons is CONNEC- the definitions of mental disorders de- cuits do not demonstrate characteris- TIVITY. scribed by Allen Frances in the section tics such as consciousness, aware- As early as the end of the 19th of “The Elusive definition of mental ness, feelings and personality, such century Theodor Meynert (1885) ad- disorders,” for example that mental characteristics arise as emergent dressed the relevance of connectivity to disorders are such because of properties from whole brain organiza- higher mental functions; he stated that “accretion and practical necessity,” and tions. when we have a thought, an idea or an that they are “what clinicians treat and Mender goes on to indicate that experience it is represented by activa- insurance companies pay for.” In sum, scientists are beginning to develop tions of neuronal ensembles in our mental disorders relate to human suf- the taxonomy from non-linear sys- brain. Accordingly associations are fering and disability, are dysfunctions tems analysis linking the levels of interconnections forming among re- that bring people to clinicians, and “molecular biology and behaving lated ideations, i.e., neuronal groups. most seek medical insurance to guaran- mentating organisms.” He argues that According to Meynert each individual tee treatment, and resolve the disorder. “those links have the potential to fuel has his personal experiences and The major issue concerning the unprecedented future insights regard- thoughts, thus develops his personal debate about future psychiatric diagno- ing psychopathogeneses.” brain connectivity configuration. ses relates to the idea of a “Paradigm I agree with Allen Frances Meynert called this individual brain shift.” This is because intuitively most (2010) in his rightful positioning of connectivity organization " Ego ." Later psychiatrists feel there is a need for a psychiatry in its historical and scien- on Freud developed this concept unre- revolution so that we will really know tific coordinates. Our descriptive sys- lated to the brain and thus shifted our what is wrong with our patients and tem precedes the next phase of dis- field away from neuroscience. will actually be able to cure them. For covering the causes of mental disor- Today we know that physical sys- this to happen we need major new ways ders and generating a valid brain- tems like the brain can embed informa- of thinking as defined by Thomas related taxonomy for psychiatry. tion within their connectivity organiza- Kuhn. 51 Volume 17, Number 2 2010

tion. Hebbian dynamics (Hebb 1949; of everyday life. Object relations psy- atrophy (Yasuda et al 2009). This indi- Rumelhart, & McClelland 1986) chologists talk about internal objects cates that depression is associated with causes repeatedly activated neuronal that create the internal reference ac- impaired neuronal resilience and re- ensembles to strengthen their intercon- cording to which, we perceive our- duced neural plasticity, while increase nectivity and strongly interconnected selves and others. These descriptions in neural plasticity and resilience is neurons to become more active in com- ultimately explain how we react and associated with anti-depressive effects parison to weakly connected units. behave in psychosocial contexts and (Pittenger, & Duman 2008). There are enough neurons and connec- thus explain our personality traits and The brain system as a whole is tions in the brain to form internal brain development. more flexible and adaptable with syn- configurations of the human experi- We can now begin to define per- aptic genesis and dendritic-spin- ence; and in effect, if we apply state- sonality as the result of evolving genesis. This flexibility enables better space description to such a system. we flexible ever-changing neural- matching between internal and external can conceptualize topological mapping networks constructs and organiza- representational constructs resulting in that forms internal maps or representa- tions in the brain that provide for the optimization dynamics that as an emer- tion of the outside world within the adaptable interactions and behaviour gent property that improves mood and physical brain. with the environment and other be- is antidepressant. In a "state-space" formulation, the having brains. With this definition we According to this theory any meta- "state" of the system is its current in- can now begin to approach personal- bolic, hormonal or other factor that stantaneous neural activation pattern, ity disorders from a brain-related inhibits neuronal reliance results in and the "space" comprises all the possi- perspective. reductions of flexible matching to ex- ble combinations of all patterns of acti- If during development, for some ternal stimuli causing mismatch and de- vations. When patterns of activations reason, markedly unusual, erratic and optimization that emerges as depres- are strengthened they form "attractors." unbalanced experiences occur, then sion. This is probably the mechanism Those are the patterns the system read- Hebbian neural organization would of endogenous depression. ily activates, i.e., those states that the be impaired and experience- Environmental stressors typically system is readily "attracted" to, that is dependent-plasticity processes would involve some radical change of incom- why they are called attractors. reflect biased experiences creating ing external stimuli; for example the "Matching Complexity" (Tononi internal representations that can be loss of a loved person (or a function) 1996) and "Free Energy" (Friston markedly removed; i.e. mismatching will result in the loss of external sets of 2007) are concepts relevant to the way of real-world occurrences. Such a stimuli that belonged to that person or the brain creates an internal model of mismatch would cause non-adaptive function. The discrepancy is between the world, one that is concordant, flexi- attitudes or responses and behaviour the internal representations that still ble and adaptable with the ever- due to the disparity between what an hold the missing person or function, changing occurrences in the real world. individual perceives (according to his and the actual incoming information in "Matching Complexity" describes how internal representations) and what is which the function no longer exists. the statistical configurations in patterns actually occurring. This discrepancy and mismatch is ex- of inputs create statistical correlates of At this point we see that by using pressed by de-optimization dynamics neural activations by forming input- the connectivity system approach, a and depressed mood. With this formu- related synaptic connectivity strength- complicated phenomenon such as lation we can now explain how envi- ening among neural ensembles in the personality disorders can begin to be ronment stressors trigger depression brain. "Free Energy" describes Bayes- reformulated as brain-related altera- (Peled 2008). ian statistics in the brain responsible for tions. While plasticity and resilience dy- ongoing reductions between internal Connectivity is also a dynamic namics occur during long periods of activations of the brain and sets of in- phenomenon that can help explain days and weeks, connectivity dynamics put patterns. Based on these insights we other mental disorders such as those have very-fast millisecond range dy- can begin to understand how the brain of mood and psychotic clinical pic- namics. Today, it is recognized that creates and maintains a flexible up- tures. The dynamics of connectivity nervous systems facing complex envi- dated adaptable model of reality. can be explained with concepts such ronments have to balance two seem- Carl Rogers (1965) suggested that as neural-plasticity and neural- ingly opposing requirements. They the best vantage point for understand- resilience, defining the changes in need to quickly and reliably extract ing behaviour is from an “internal neural connectivity over time and the important features from sensory inputs frame of reference” of the individual ability of each neuron to dynamically and the need to generate coherent per- himself. He called this frame of refer- interact with other neighbouring neu- ceptual and cognitive states allowing an ence the “experiential field” that en- rons. We know that these properties organism to respond to objects and compasses the private world of the in- are related to mood changes. Anti- events, which present conjunctions of dividual. According to Rogers, depressive treatment has been found numerous individual features. “organismic evaluation” is the mecha- to correlate with synaptic genesis and The need to quickly and reliably nism by which a “map” (i.e., the inter- dendritic-spin-genesis (Kapczinski et extract important sensory features is nal configuration) of the experiential al 2008), while depression has been accomplished by functionally segre- field assesses the psychological events found to relate to neuronal death and gated (specialized) sets of neurons 52 Volume 17, Number 2 2010

(e.g., those found in different cortical dynamics, where neuronal ensembles negative signs in schizophrenia. How- regions); the need to generate coherent act in a statistically-independent man- ever the repeated activations of neu- perceptual and cognitive states is ac- ner result in fragmentation of experi- ronal ensembles for OCD are enough to complished by functional integration of ence and mental functions and lead to create a certain amount of de- the activity of specialized neurons loose associations, illogical refer- optimization dynamics, to cause emer- through their dynamic interactions ences i.e., delusions and hallucina- gence of depression and anxiety. (Tononi et al, 1994). tions. Typically psychosis arises from Another example is Anorexia Ner- The mathematical concept of fragmentations of neural network vosa, where delusional or perceptual “neural complexity” (Tononi et al, organizations (Yoon et al 2008; ideation is limited to body representa- 1994) captures the important interplay Volpe et al 2008; Williams 2008). tion and perception and is not extended between integration (i.e., functional Over-connectivity dynamics result in to full blown clinical manifestation of connectivity) and segregation (i.e., overly constrained information proc- psychosis. functional specialization of distinct essing, reducing neural-computation, In effect the combination of all of neural subsystems). Neural complexity resulting in poverty of thought per- the above perturbations to brain organi- is low for systems whose components severations, and a clinical picture of zation participates to various extents in are characterized either by total inde- deficiency, negative-symptoms as all forms of mental disorders. Clinical pendence or by total dependence. Neu- those described for residual schizo- experience teaches us that it is rare to ral complexity is high for systems phrenia (Peled 1999) find a pure form of clinical manifesta- whose components show simultaneous Perturbed connectivity balance tion; for example psychosis can fre- evidence of independence in small sub- may cause the system to oscillate quently manifest with mood changes sets, and increasing dependence in sub- between disconnectivity and over- resulting in a schizoaffective clinical sets of increasing size. Different neural connectivity dynamics as occurs in manifestation. It can be concluded that groups are functionally segregated if the course of schizophrenia between most mental disturbances can be de- their activities tend to be statistically psychotic episodes and increased fined in a 3 dimensional space of brain independent. Conversely, groups are deficiency periods. These oscillations disturbances: that of disturbances in 1) functionally integrated if they show a probably perturb the hierarchy by neural-complexity organization, 2) in high degree of statistical dependence. eliminating higher-levels of transmo- neural resilience optimization dynamics In order to adapt to the shifting dal organizations and causing the and 3)in connectivity constructs for paradigms required by high mental elimination of higher- level functions context and internal representations. functions such as attention and working such as motivation and volition Such definition can be given the title of memory, it is likely that brain function (Mesulam 1998). Clinical Brain Profiling (CBP) (Peled requires integrative as well as segrega- Using formulations of disturbed 2008). tive capabilities. The balance between neural complexity and small wordi- CBP involves describing mental integrative and segregative functions in ness we can now begin and reformu- disorders as brain disorders and brings the brain is achieved when neural com- late schizophrenia spectrum disorders psychiatry back to the realm of neuro- plexity is optimal. as disturbances in fast dynamic con- science where it belongs. Psychiatrists Small World Network organization nectivity balances in the brain (Peled await neuroscientific discoveries before describes neighboring closely related 2008). advancing and proposing a novel brain- networks that are linked by many Based on the formulations so far, based diagnosis for psychiatry, but by densely connected pathways, far apart 1) schizophrenia spectrum, 2) mood doing this they miss the opportunity to networks that have less connections spectrum and 3) personality spectrum contribute to a much needed paradigm and distant regions that are sparsely disorders can be reformulated as shift for psychiatric diagnosis connected. This type of organization disturbances in 1) neural-complexity (McHugh 2005). was termed “small world” as shown in organization, 2) neural resilience op- Validating CBP has a ground- internet web networks where this or- timization dynamics, and 3) connec- breaking relevance for psychiatry, not ganization enables the transfer of infor- tivity constructs of internal represen- only by providing an etiological diag- mation in relatively few steps and junc- tations, respectively. nostic system, but by offering to de- tions around the globe. Small world Other clinical descriptions can velop effective curative interventions. network organization has been de- result from combinations of these Few examples involve medications that scribed for many biological systems three disturbance patterns. For exam- boost neuronal resilience and devices that have multiple interacting units, ple in obsessive compulsive disorders that can act as "brain pacemakers." including the brain with its interacting (OCD), intrusive ideations can be Experience-dependent-plasticity neuronal ensembles (Micheloyannis et described by repeated activations of can be enhanced by medications that al 2006; Liu, Y. 2008). neuronal ensembles representing the boost neuronal resilience to the extent Perturbations and disturbances to repeating ideations; this is a result of of offering brain plasticity similar to the neural complexity and small-world increased connectivity for those neu- childhood developmental plasticity. network organizations result in specifi- ronal ensembles, but it is an increased This provides unlimited possibilities to cally defined brain-dysfunctions and connectivity that does not reach the reorganize brain disturbances and ef- cognitive disturbances (Micheloyannis extreme magnitude and extension of fectively correct developmental disor- et al 2006). For example disconnection over-connectivity characteristic of the ders. Technology of neuronal stimula- 53 tion (e.g., DBS, TMS, Optogenesis) offers opportunities to intervene and control neuronal network activity in the Volume 17, Number 2 2010

brain,;for example if hallucinations Cognition. Brain 121, 1013-1052 Yoon, J.H., et al. Association of emerge from disconnectivity dynamics (1998). dorsolateral prefrontal cortex dysfunc- between the temporal cortex and the Micheloyannis, S, et al. Small- tion with disrupted coordinated brain rest of the brain, then designing a re- world networks and disturbed func- activity in schizophrenia: relationship connecting "brain pacemaker" can res- tional connectivity in schizophrenia. with impaired cognition, behavioral titute the normal connectivity needed to Schizophr Res 87, 60-66 (2006). disorganization, and global function. cure the patient of hallucinations. Peled, A. Multiple constraint Am J Psychiatry 165 , 1006-1014 Metaphorically, just as a cardiac pace- organization in the brain: A theory (2008). maker corrects cardiac arrhythmias for serious mental disorders. Brain differences in schizophrenia. Neuroi- curing hurt failure, so will the brain Res Bull 49 . 245-250 (1999) mage 42 ,1560-1568 (2008). pacemaker correct perturbations to Peled, A. NeuroAnalysis, Bridg- Volpe U, et al. Cerebral connec- brain organization, curing brain insuffi- ing the Gap between Neuroscience tivity and psychotic personality traits : ciency, i.e., mental disorders. Psychoanalysis and Psychiatry A diffusion tensor imaging study. Eur (Routledge, New York, 2008). Arch Psychiatry Clin Neurosci 258, References Phillips J. The muddle that is the 292-299 (2008). DSM-V. AAPP Vol 17 Number 1 Williams, L.M. Voxel-based mor- Cajal, S.R., Histologie du Système 2010 phometry in schizophrenia: implica- Nerveux de L'homme et des Vertèbres, Pittenger, C., Duman, R.S. tions for neurodevelopmental connec- (Instituto Ramon y Cajal, Madrid Stress, depression, and neuroplastic- tivity models, cognition and affect. 1952 ; ed., Vol. 2. Madrid: Instituto ity: a convergence of mechanisms. Expert Rev Neurother 8,1049-1065 Ramon y Cajal, 1911). Neuropsychopharmacol 33 ,88-109 (2008). Frances A. DSM in Philophyland: (2008) . Curiouser and Curiouser. AAPP Vol 17 Rogers, C.R. Client Centered *** Number 1 2010 Therapy, its Current Practice Impli- Friston , K. Klass, E.S. Free- cations and Theory (Houghton Mif- Only in the Eyes of energy and the brain . Sythese 159, 417- flin Company Boston, 1965). 458 (2007). Rumelhart, D.E., McClelland the Beholder Friston, K.J., Frith, C.D. Schizo- J.L., Parallel Distributed Processing: phrenia: a disconnection syndrome? Exploration in the Microstructure of Allen Frances, M.D. Clin Neurosci 3, 89-97 (1995). Cognition , PDP Research group ed., Hebb, D.O. The Organization of Vol. 1 and 2. (MIT Press, Cambridge, Dr Peled is a clear thinker who Behavior (John Wiley & Sons, New 1986). has developed an elegant and inspir- York, 1949). Schloesser, R.J., Huang, J, Klein, ing model. In contrast, the DSM clas- Edelman, G. M. Neural Darwin- P.S., et al; Cellular plasticity cascades sification is messy, inconsistent, and ism : The Theory of Neuronal Group in the pathophysiology and treatment uninspiring. Why don't we junk the Selection ( Basic Books, New of bipolar disorder. Neuropsycho- DSM and get with the exciting find- York, 1987). pharmacol.2008; 33:110-133. ings from neuroscience by substitut- Kapczinski F, Frey BN, Kauer- Sun, D., et al. Brain surface con- ing for it a new, improved, consistent, Sant'Anna M, et al. Brain-derived neu- traction mapped in first-episode and rational model? The rub is that rotrophic factor and neuroplasticity in schizophrenia: a longitudinal mag- there are too many candidate models bipolar disorder . Expert Rev Neurother netic resonance imaging study. Mol and none have proven themselves 8, 1101-1113 (2008). Psychiatry 14 , 976-987(2009). ready for prime time. Kim, D., et al Hybrid ICA- Tononi, G., Sporns, O., Edelman, Every few months, someone Bayesian network approach reveals G.M. A measure for brain complex- (usually very smart and passionate distinct effective connectivity ity: relating functional segregation like Dr Peled) sends me a proposal for Liu, Y. Disrupted small-world and integration in the nervous system. a new diagnostic system offered as an networks in schizophrenia. Brain 131 Proc Natl Acad Sci USA. 91 , 5033- alternative to the jumbled, pedestrian, (Pt 4), 945-961(2008). 5037 (1994). atheoretical, and purely descriptive McHugh P. "Striving for Coher- Tononi, G., Sporns, O., Edelman, method used in DSM. The new sys- ence, Psychiatry's Efforts over Classifi- G.M. A complexity measure for se- tem is invariably theory driven, cation" JAMA, May 25, 2005 Vol 293 lective matching of signals by the clever, neat, and plausible. Surely, it No20 brain. Proc Natl Acad Sci U S A 93 , is quite easy to be more coherent than Mender D. DSM, Groups and 3422-3427 (1996). a DSM that consists of a jumble of phases: Beyond the Laundry list. AAPP Yasuda, S., Liang, M.H.,, Mari- disorders gathered together largely Vol 17 Number 1 2010 nova, Z., et al. The mood stabilizers through a historical accreting process Meynert, T. Psychiatry (Hafner, lithium and valproate selectively acti- based mostly on clinical observation New York, 1968) [First published in vate the promoter IV of brain-derived and descriptive research—without a 1885]. neurotrophic factor in neurons. Mol unifying theory or deep knowledge of Mesulam, M. From Sensation to Psychiatry : 14 , 51-59 (2009). causality.

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The new systems come in 3 types: Functional First: “real.” They may not have quite the 1) Brain biology—these used to be Creating a Pragmatic expansive vision of the elemental real- based on correlates with neurotransmit- ists since knowledge need not fit into a ters, but recently (as with Dr Peled) and Progressive Diagnos- grand model, but they have constructed neural networks of various kinds are tic System their theoretical and empirical build- much more popular; 2) Psychological ings on the common sense idea con- dimensions; and 3) Evolutionary psy- Steven C. Hayes, PhD tained within human language itself, chology. University of Nevada that is, that we “understand” when we Unfortunately, none of these ap- can consistently and unambiguously proaches, however interesting or prom- In Allen Frances’s charming and name preexisting events and their at- ising, is remotely ready to replace or be telling analogy, there are three um- tributes. And there we are back to on- included in the official system of psy- pires playing a marathon epistemo- tology. chiatric nomenclature. DSM must by logical game with the balls and What if we adopted a view of truth its very nature be a conservative docu- strikes of diagnosis. Each sees the that was more humble, pragmatic, and ment that follows and never leads the role differently: call them as they are, local? Yes, we live in a real world (or field. The problem with all of the sug- call them as I see them, and there are at least the one world, whatever you gestions to replace the admitted DSM none until I call them. There is a may choose to call it). Fine. And in that jumble is that there are so many con- fourth however. Call them in a way world we have work to do. Let’s get tenders, none of which has been proven that advances the game. about doing it. or has attained wide acceptance from These three umpires are not just This is what our patients want the field. Proponents of rival systems arguing about epistemology. They are from us. This is what busy clinicians can make about equally valid claims arguing about ontology: about what is want from applied scientists. This is for their respective pet methods. More- real. Once umpires are drawn in a what the funders and payers want. over, most clinicians have absolutely game of determining what is real, What would happen if we as research- no interest in any of them. however, the game can go on virtu- ers and theoreticians started there as I feel sure that our clumsy descrip- ally forever without thinking to ask or well? tive classification is not the only, or answer a central question: So what? If we want to empower umpires optimal way, to sort things for future Decades can go by, each happily interested in advancing the game, we research. But I feel equally certain that named by NIH committees, and bil- would have to start by specifying what DSM remains necessary to carry forth lions can be spent. In defense of this the game is and what we mean by ad- the current, everyday, practical clinical work nothing really need be said vancement. Allen Frances’s article con- and administrative work that are its other than “we are making progress tains a number of positive and prag- first priority. Once we have attained a in our understanding (of what is matic positions. In his view, mental widely accepted, etiological under- real).” The part in parentheses is of- disorders are social constructs that standing of at least some forms of psy- ten not said aloud, but it is a powerful should help us treat patients success- chopathology, the new insights will organizing assumption. Unfortunately fully. They should not lend themselves gradually replace our clumsy, but none- “progress in understanding what is to medicalizing everyday actions and theless now still useful system. real” is far too flexible a criterion to issues. They should not run afoul of At this stage in this arena, the wis- determine whether the game is ad- real world consequences in the areas of dom of the philosopher Vico trumps vancing or not. As a result, anything a insurance, forensic issues, and medica- the much greater and better known powerful research group is studying tions. Descartes. Descartes sought to use can be put into the diagnostic system, This is a good list, and I agree with what we now call Cartesian rationality whether or not it makes good sense it. In the context of DSM-5 they make and mathematical order to sort what and advances the discipline or its particular sense because so many prag- were previously seemingly disorderly practices. matic outcomes are threatened by the phenomena. This turned out to be a Most of science is built on ele- expansionism it contains. The DSM –5 screaming success in the mathematical, mental realist (i.e., mechanistic) as- work group [1] rightly pointed to the physical and chemical worlds, but has sumptions: what are the preexisting current situation: “All these limitations (as Vico predicted it would) much less parts, relations, and forces in the in the current diagnostic paradigm sug- purchase in understanding the sloppy world and how do they go together to gest that research exclusively focused complicatedness of human affairs- create complexity? That view of sci- on refining the DSM-defined syn- including psychiatric diagnosis. ence gives a bear hug to ontology dromes may never be successful in because finding these preexisting uncovering their underlying etiologies. *** parts and organizing them into com- For that to happen, an as yet unknown prehensive models is the very defini- paradigm shift may need to occur.” (p. tion of scientific truth. Likewise, sci- xix; italics added). Unfortunately, para- entific theories that are built on Pla- digm shifts cannot be ordered up like a tonic formism, a favorite of nosolo- plate of spaghetti and the DSM-5 itself gists, are intensely focused on what is looks more like a mishmash than a

55 Volume 17, Number 2 2010

course ahead. mental health disciplines. Pragmatism frequency or form of unwanted private While I like Allen Frances’s list, it provides another way forward. If we experiences, including thoughts, does not go far enough to change direc- are willing to let “truth” refer to how memories, emotions, and bodily sensa- tions. Pragmatism can do more than we well are playing the game and tions, even when doing so causes per- hold at bay the hubris of researchers nothing else we can respectfully leave sonal harm [3]. The attempt to suppress wanting to name categories because ontological claims behind, since they or avoid difficult emotions, bodily sen- they believe them to be real regardless add nothing functional beyond what sations, sensory experiences, memo- of their functional impact. It can reor- we already know, pragmatically ries, or thoughts, is an incredibly toxic ganize the research agenda in front of speaking. process. There is a vast and growing us. One of the best ways to play the literature that suggests the harmful im- Functionally speaking, what do we game pragmatically is to cheat. Let pact of many if not most of the symp- want? What is the game we are play- me explain. My young son likes to toms commonly focused on in our di- ing? I would argue that we need con- play mazes. He’s quite good at it, but agnostic system comes not from their cepts and models that are empirically he can get bogged down. When he presence but from the avoidant re- based, systematized, and as simple as does he’s recently started cheating in sponses they evoke. For example, expe- the goals of diagnosis will allow. Con- a creative way: he puts his little fin- riential avoidance does a better job cepts need to be precise, so that they ger at the end of the maze and works predicting who will develop chronic can be applied with rigor, but they need backward. pain and be disabled by it than does to have broad scope so that a small If we stay focused on the game pain intensity or the degree of injury [4, number of key ideas apply to a range of we are playing we can cheat in the 5, 6]. Experiential avoidance does more phenomena. They need to cohere same way. There are a growing num- to determine whether traumatic experi- across levels of analysis, that is, they ber of transdiagnostic processes that ences such as sexual abuse [7, 8], com- need to have depth. Nothing that is are already known to help explain the bat violence [9], or interpersonal vio- known in psychotherapy should contra- development and course of multiple lence [10] leads to PTSD than does the dict what is known in neuroscience; problems currently viewed as distinct severity of the trauma. Over 25% of the nothing that is known in the social ba- disorders [2]. Some have already variance in depression and quality of sis of pathology should contract what is been shown to function as moderators life for persons suffering from com- known in evolutionary biology. Indeed, or even mediators of treatment out- mand hallucinations despite medication we need concepts that actively support come. Examples include memory compliance is determined by avoidant productive research across levels of processes such as selective memory coping applied to the voices [11]. Pro- analysis. They need to be demonstrably or over general memory; attentional spective studies [12] show that depres- useful in organizing the complexity of processes such as selective attention, sive symptoms are more likely to human suffering into treatment and or self-focused attention; emotional emerge from stressors in those who are prevention responsive units. They need regulation processes such as thought experientially avoidant. to facilitate discovery of the biopsycho- suppression, behavioral escape, or We could continue with a listing social processes of change that func- experiential avoidance; and cognitive like this for quite a while because expe- tionally explain the etiology and course processes such as interpreting am- riential avoidance is associated with an of disorders and the processes responsi- biguous stimuli, or rumination. amazingly broad array of mental and ble for treatment outcomes. They need Especially as these become sys- even some physical health outcomes, to lead us toward new treatment meth- tematized, explained, and clustered, accounting for 16 to 25% of the vari- ods that maximize benefits and mini- they can provide processes of some ance in most behavioral health areas mize costs and side effects. In sum- known importance—functional end [13]. We know that experiential avoid- mary, the scientific game of diagnosis points—that can then be traced back ance is key to treatment and is modifi- is to develop concepts with precision, to help develop functional dimen- able because it moderates [14] and me- scope, and depth that help us over time sional diagnostic systems. Instead of diates [13] treatment outcome. Neuro- in identifying etiology and course, and starting with lists of signs and symp- biological studies shown that people the moderators and mediators of treat- toms in hopes that functional proc- who are highly experientially avoidant ment impact, and that help us innovate esses will emerge, we can start closer respond to aversive stimuli in a more in treatment and prevention. to the end of the maze now, identify- lateralized way [15], suggesting that In the history of medicine, purely ing functional processes we now this is in part a verbally / cognitively descriptive approaches have bogged know about, and then backing up into mediated process. down when core processes can give the biological and psychological un- Experiential avoidance is a good rise to an array of outcomes, when derstanding of these processes. example, but I’m making a more gen- processes interact in a complex and If I were to nominate a single eral point. We can today reduce a wide systemic fashion, or when a single out- example of what I mean it would be variety of topographically defined come can be produced by a wide vari- experiential avoidance. It is a concept problems into a much smaller set of ety of processes and their interactions. from my own research program, known functional processes. Such proc- After decades of effort in the modern which I apologize for, but the science esses right now can provide demonstra- era, it appears more and more likely is fairly well developed. Experiential bly more information about course and that this is the situation we face in the avoidance refers to efforts to alter the response to treatment than our current 56 Volume 17, Number 2 2010

diagnostic categories. They seem far 4. McCracken, L. M. (1998). 14. Masuda, A., Hayes, S. C., likely to be a useful focus of attention Learning to live with pain: Accep- Fletcher, L. B., Seignourel, P. J., Bun- for studies of the etiology and underly- tance of pain predicts adjustment in ting, K., Herbst, S. A., Twohig, M. P., ing neurobiology of mental problems. persons with chronic pain. Pain, 74 , & Lillis, J. (2007). The impact of Ac- The point is not to create new cate- 21-27. ceptance and Commitment Therapy gories such as “experiential avoidance 5. McCracken, L. M. & Ec- versus education on stigma toward peo- disorders” and the like. Rather my cleston, C. (2003). Coping or accep- ple with psychological disorders. Be- point is that if diagnosis is going to be tance: What to do about chronic pain. haviour Research and Therapy, 45(11), progressive we need to do more to lay Pain, 105, 197-204. 2764-2772. the foundation for a functional dimen- 6. McCracken, L. M. , Vowles, 15. Cochrane, A., Barnes-Holmes, sional diagnostic system. Dimensional K. E., & Eccleston, C. (2004). Accep- D., Barnes-Holmes, Y., Stewart, I., & systems built on issues of severity, tance of chronic pain: Component Luciano, C. (2007). Experiential avoid- chronicity, topography, broad personal- analysis and a revised assessment ance and aversive visual images: Re- ity styles, and the like will either method. Pain, 107, 159-166. sponse delays and event-related poten- quickly morph into incredible complex- 7. Marx, B. P. & Sloan, D. M. tials on a simple matching task. Behav- ity or be yet another topographical cul (2002). The role of emotion in the iour Research and Therapy, 45, 1379- de sac. psychological functioning of adult 1388. Diagnostic distinctions that focus survivors of childhood sexual abuse. on what is “really there” while forget- Behavior Therapy, 33, 563-577. *** ting functionality are like trying to de- 8. Rosenthal, M. Z., Rasmussen- termine the perfect ball without throw- Hall, M. L., Palm, K. M., Batten, S. Forced Choice: Be Prag- ing it. Pragmatism can help correct that V., & Follette, V. M. (2005). Chronic matic OR Progressive- error because pragmatism contains avoidance helps explain the relation- Usually Hard To Be Both within it a call for a different kind of ship between severity of childhood science. We can build an alternative sexual abuse and psychological dis- Allen Frances, M.D. approach based on high quality con- tress in adulthood. Journal of Child cepts (i.e., those with precision, scope, Sexual Abuse, 14, 25-41. Dr Hayes and I are both practical and depth) that tell us some of what we 9. Plumb, J. C., Orsillo, S. M., & people and agree on everything con- want to know now . For example, while Luterek, J. A. (2004). A preliminary ceptual. We both favor "a view of truth detailed knowledge of etiology appears test of the role of experiential avoid- that is more humble, pragmatic, and to be in the distance, we can reasonably ance in post-event functioning. Jour- local?". Where we disagree is on the insist that researchers provide us with nal of Behavior Therapy and Experi- practical question of what to do next concepts and distinctions that link mental Psychiatry, 35, 245-257. with the diagnostic classification. Dr tightly to the course of mental health 10. Orcutt, H. K., Pickett, S. M., Hayes sees all the impracticalities of problems and to the moderators and & Pope, E. B. (2005). Experiential the current system and suggests a much mediators of treatment. By demanding avoidance and forgiveness as media- more elegant alternative. "I would ar- functionality first, we can establish a tors in the relation between traumatic gue that we need concepts and models pragmatic filter that will keep the um- interpersonal events and posttrau- that are empirically based, systema- pire’s eyes on what advances the game. matic stress disorder symptoms. Jour- tized, and as simple as the goals of di- nal of Social and Clinical Psychol- agnosis will allow". References ogy, 24, 1003-1029. I agree in principle, but I also see 11. Shawyer, F., Ratcliff, K., all the impracticalities of changing sys- 1. Kupfer, DJ, First, MB & Regier, Mackinnon, A., Farhall, J., Hayes, S. tems and also the failure so far of alter- DA. (2002). A research agenda for C., & Copolov, D. (2007). The native models (however attractive) to DSM-V. Washington, DC: American Voices Acceptance and Action Scale: gain wide acceptance. Dr Hayes and I Psychiatric Association. Pilot data. Journal of Clinical Psy- part company immediately with his 2. Harvey, AG, Watkins, E, chology, 63, 593-606. subtitle "Creating a Pragmatic and Pro- Mansell, W, & Shafran, R. (2004). 12. Shallcross, A. J., Troy, A. S., gressive Diagnostic System." I regard Cognitive behavioural processes across Boland, M. & Mauss, I. B. (in press). this as a contradiction in terms. For me, psychological disorders: A transdiag- Let it be: Accepting negative emo- an official diagnostic system that is nostic approach to research and treat- tional experiences predicts decreased pragmatic can never expect simultane- ment. New York: Oxford University negative affect and depressive symp- ously to also be progressive. An official Press. toms. Behaviour Research and Ther- nomenclature must follow the field, it 3. Hayes, S.C, Wilson, KW, Gif- apy. cannot possibly lead it. It must be the ford, EV, Follette, VM., & Strosahl, K. 13. Hayes, S. C., Luoma, J., culmination of consensus. It cannot a (1996). Experiential avoidance and Bond, F., Masuda, A., and Lillis, J. new research agenda to "advance the behavioral disorders: A functional di- (2006). Acceptance and Commitment game." The game has to be advanced mensional approach to diagnosis and Therapy: Model, processes, and out- on its own steam until it is gets in- treatment. Journal of Consulting and comes. Behaviour Research and cluded by general consensus. Clinical Psychology, 64, 1152-1168. Therapy, 44, 1-25. 57 Volume 17, Number 2 2010

This is the same issue discussed some point, if we are to make a deci- long been recognized to form the cor- previously in my response to Dr Peled sion on whether to proceed with nerstone of medical ethics. The vulner- who was suggesting his own elegant changes in the DSM, the process ability and concomitant ethical demand model of a very different sort. My re- must become closed. Just how the spill over into the development of a marks there apply here as well. process becomes closed is a matter of nosology of mental disorders. Inter- no small importance. I think that preting the best interests of patients *** instead of lamenting the intrusion of points to the difficulties inherent in a politics into the science of nosology, practical scientific task such as devel- it is more productive to carefully con- oping a nosology. Certainly patients Weighing the Evidence sider just what kind of politics will have an important and irreplaceable guide the development of nosology. level of expertise in determining their and Rendering Judgment Will the political process favor the own interests. But complications arise on the DSM: arbitrary assertion of power or a fair because we are determining those inter- Do We Need a Supreme hearing of conflicting arguments? ests in light of scientific evidence. This Perhaps if, after a requisite period of requires a level of scientific expertise, Court? due process, intractable and signifi- but one that should never become de- cant conflict of opinion persists: a tached from the first person experience Douglas Porter, M.D. “supreme court” of the DSM should of illness that grounds the meaning of New Orleans, LA render decisive judgment. the entire endeavor. I am afraid that I speak of such a So, there you have it. The compo- Reading through the variety of “supreme court” only half jokingly. sition of the court requires, if not first- responses to proposed changes in the While the donning of long robes may hand experience of mental illness, at DSM contained in the recent bulletin be considered optional, conceptualiz- the very least sensitivity to the distress of the AAPP, I was struck by the real- ing the criteria for such a court does caused by such illness and a commit- ity and depth of the discord on how provide further opportunity for reflec- ment to prioritize a concern for this we should proceed. Even if we all tion on criteria for fair judgment in distress in any decisions rendered. The agreed on the scientific validity of these matters. Allen Frances notes composition also requires a level of pertinent empirical claims, and I don’t that Work Group members are “too scientific expertise such that the merit think that we do, we would still dis- attached…to be objective” about the of various technical arguments may be agree about what those scientific facts risks of their suggestions. It appears measured. The merits of scientific ar- mean for a nosology of mental disor- that a degree of impartiality is re- guments should be judged without un- ders. This is because of our differing quired to judge fairly about proposed due prejudices toward particular theo- theoretical assumptions about what a changes. It may be impossible to retical orientations but with all due nosology should accomplish. I be- make atheoretical observations, but it prejudice toward any practical reper- lieve this is why some authors could does seem only fair that judges cussions various theoretical assump- confidently claim that “science” should not be so prejudiced by theo- tions may have upon patient welfare. clearly dictates a conservative ap- retical commitment as to be unable to One thing is for certain. Should the proach and other authors could just as hear arguments that stem from con- justices decide to don long robes, they confidently claim that “science” trasting theoretical assumptions. will certainly have earned them. clearly dictates a liberal approach to While fairness may require a sense of change in the DSM. Perhaps it is the impartiality when it comes to theo- * American Psychiatric Associa- belief that the scientific facts should retical assumptions, it requires a high tion 1998. Constitution and Bylaws . be clear-cut and overwhelmingly per- degree of partiality in another impor- Washington DC: American Psychiatric suasive that leads to an expectation of tant sense. Insofar as the supreme Association as referenced in Sadler, J consensus in scientific matters. But, court of the DSM is sworn to uphold (2005). Values and Psychiatric Diag- given the reasonable room for dis- the constitution of the American Psy- nosis. Oxford University Press, Oxford: agreement about the proper goals of chiatric Association then it is sworn p. 381. nosology, it should come as no sur- to “promote the best interests of pa- prise that, when it comes to the DSM, tients and those actually or potentially *** instead of “science” and consensus, making use of mental health ser- we have a plurality of “sciences” and vices”. * Yes Surely, More Now dissensus. While consensus would There is an ever present danger Than Ever have deemphasized the importance of that the practical significance of judg- the political process used to determine ments regarding nosology for the Allen Frances, M.D. whether or not to make changes in the concrete lived reality of vulnerable current DSM, the reality of discord patient populations will be lost in the Dr Porter raises three crucial highlights the importance of this proc- abstractions of scientific argument. points: 1) there is disagreement on the ess. We may all agree on the impor- That the vulnerability of patient strength of the science supporting the tance of an “open process” for the populations demands the prioritiza- suggested DSM-5 changes and also on objectivity of our science. But, at tion of patient interests in practice has how much weight to give to other fac- tors and risks that haven't been (or can't 58 Volume 17, Number 2 2010

be) scientifically measured; 2)there is been no lower courts to provide re- Who’s on First? Mental no psychiatric Supreme Court for the view along the way. Dr Porter does final adjudication of differences of not indicate how the "Supreme Disorders by Any Other opinion; and, 3) the best interests of our Court" should be constituted. There Name? patients should always come first. are no easy answers. I am close to At the risk of getting into the an- losing faith in the American Psychiat- Aaron Mishara, Ph.D., Psy.D. noying "this is how we did it" routine, ric Association as the final arbiter of Yale University School of Medicine there are some useful lessons from past the DSM system. Their governance Michael A. Schwartz, M.D., DSMs. The first has to do with moni- and quality control mechanisms have Austin State Hospital, Austin Texas toring and governance. Realizing that so far failed badly and show no signs workgroup members always overvalue of self correcting even now. It seems In response to Allen Frances’ DSM the science supporting their pet sugges- likely that future DSM's should be in Philosophyland: Curiouser and Cu- tions, we developed an obstacle course prepared under the auspices of the riouser , we agree that diagnostic classi- to curb their enthusiasms. First off, we NIMH- but with extensive input from fication must steer between the Scylla conducted a series of methods confer- clinicians to balance the likely bias of of naïve biological realism and the ences to train everyone in a "consensus a research institution. Charybdis of social constructionism, or scholar" method of doing literature As Dr Porter elegantly demon- alternatively, logical empriricism and reviews that was meant to reduce bi- strates from the words of the APA post-modernism (Frances’ First and ases and result in as thorough an constitution, it is the patients who Third Umpires). But in what way does evaluation of risks as of benefits. Next, count most when making decisions Frances’ pragmatic compromise (his the DSM-IV Task Force was encour- about the diagnostic system. And to Second Umpire) provide a solution? aged to shoot down all low flying work quote his own wise words, "There is Perhaps merely asserting that psychia- group suggestions. The DSM-IV lead- an ever present danger that the practi- trists should be driven by consensus, ership was ever alert to the risks in new cal significance of judgments regard- reliability in diagnosis, or a common diagnoses and eagerly disposed to find ing nosology for the concrete lived language (“calling them as I see them”) their fatal flaws. Then there was a deep reality of vulnerable patient popula- is not enough. The pragmatic definition and expert external reporting chain. tions will be lost in the abstractions of of mental disorders (“forging a com- The DSM-IV Task Force reported to scientific argument. That the vulner- mon language rather than a common the Committee on Diagnosis and As- ability of patient populations de- truth”) as ““what clinicians treat” in- sessment, which reported to the Re- mands the prioritization of patient vites circularity. After all, it still begs search Council, which reported to the interests in practice has long been the essential question, what kind of APA Trustees. The process all along recognized to form the cornerstone of entities are mental disorders? As Mis- the way was completely transparent medical ethics," I have heard the fol- hara (1994) argued, to the extent that and open to wide interchange and cor- lowing disturbing statement repeated DSM-III and the following DSMs base rection from a large circle of advisors numerous times in one form or an- their putatively reliable descriptions of and from the field at large. other by people working on DSM- mental disorders on everyday language, DSM-5 took the opposite (and 5—"I have I am following the sci- then folk psychological and other kinds much more dangerous) path in every ence, I can't predict or be responsible of assumptions, including metaphysical regard. Work groups were encouraged for possible misuse of my sugges- assumptions, creep into the classifica- to innovate, with no guidance on how tions.” This statement is epistemo- tion system. In their neo-Kraeplinian to do literature reviews and risk/benefit logically naïve and medically irre- zeal for reliable diagnosis, DSM-III analysts and little or no supervision sponsible. The "science" of diagnosis advocates (Umpire I) had overlooked from the Task Force or DSM-5 leader- is far too weak and equivocal to lead that the Hempelian approach they ship. The Task Force until recently anyone anywhere unless he starts adopted was only one approach that reported directly to the Trustees, with with a preconceived notion of where neglected more phenomenologic ap- no intermediary groups that are more he wants to go. The risks to patients, proaches (Schwartz and Wiggins, expert in psychiatric classification. In though impossible to quantify, are 1987), e.g., Jaspers, Conrad and Ey effect the work groups posted raw, un- often far more tangible and should (see below). edited, unmoved suggestions that often settle all the many scientific tie scores Even Gerald Klerman, “the high- present a biased and overvalued inter- in favor of the caution: Do No Harm. est-ranking psychiatrist in the federal pretation of a very limited and equinox government at the time,” who had at science base. And they have in many *** first appraised the movement from the cases been inhibited by confidentiality DSM-I and II to the DSM-III as a agreements and by working in relative “victory for science,” later revised his isolation from the field, with input only view that DSM-III was largely “a po- from a very small circle of like minded litical document” (cited by Mayes and advisers. The products are predictably Horwitz (2005). That is, by adopting problematic. Hempel’s logical empirical approach to We desperately need a Supreme science, the neo-Kraeplinians’ presum- Court now only because there have able “revolution” in conceptualizing 59 Volume 17, Number 2 2010

and classifying mental disorders actu- cism by posing (falsely) that this pre- serve as both the standard for clinical ally pre-empted alternative approaches, liminary work is already done (as in researchers who attempt to explain the which were philosophically informed, the DSM-5 reluctance to develop a disorders (find and treat the underlying but in a manner different than Conceptual Issues Work Group pro- mechanisms) and for clinicians who Hempel, that is, the German tradition posed by Kendler et al., 2008, and see attempt to understand and treat the per- of philosophic phenomenology. In fact, below). In contrast, when an earlier sons suffering from the disorder. the German phenomenologic psychia- work group put together a volume on Schwartz and Wiggins (1987) had trist, Jaspers (1963) had written that to the conceptual issues involved in argued that clinicians in their practice the extent that psychiatry ignores phi- diagnostic classification (Sadler et al., use a different approach than that out- losophy, it is inevitable undone by it in 1994), Allen Frances (Chair of the lined by the neo-Kraeplinian embrace one way or another. DSM-IV Task Force) graciously of Hempelian nomological science: the For example, although DSM-III agreed to write the preface. He wel- clinician's experience is already per- and the later DSMs ultimately rely on comed the volume by stating that it is vaded by typifications which help to the patient’s reports of their own sub- to be “congratulated by having as- structure the clinicians diagnosis mean- jective experience of symptoms and the sembled an especially comprehensive ingfully. In fact, Husserl had indicated clinician’s observations of signs that probing analysis of the theoretical that perceptual meaning is itself based the patient may not directly experience, issues that inform psychiatric classifi- on such a typification process: That is, there is little or no effort in DSM to cation… DSM-IV is a manual of we never perceive the individual them- formalize and/or operationalize subjec- mental disorders but it is by no means selves but always in terms of the type tive experience itself. Despite this lack clear just what is a mental disorder that implicitly subsumes it. We per- of precise conceptual relationship to and whether one can develop a set of ceive the not yet known in terms of the what it presumably and ultimately tar- definitional criteria to guide inclu- known, i.e., in terms of the general type gets (the patient’s subjective experi- sionary and exclusionary decisions that is activated in the particular per- ence, i.e., suffering in self and/or oth- for the manual...The failure of defini- ception. With each view, there is built ers), DSM-III and its successors pose tion of a mental disorder or disease a reference to the next anticipated view the dangers of a “hegemony” (Schwartz which reduces to what clinicians treat based on past experience of this and and Wiggins, 2002), a co-opting of is tautological and potentially self- similar objects. The references between clinical practice and clinical research serving is probably the best of a bad aspects are anticipatory constraints, such that research grants, publications, lot of ways of defining these neces- which are nevertheless open to revision conference presentations, insurance sarily imprecise terms” (p. viii-ix). or cancellation in their structure so that reimbursement and the like are com- We are delighted by Allen Frances’ each aspect prefigures its successor in pelled to make use of reliable DSM conceptual openness to the issues but seamless transition as belonging to the diagnoses (despite DSM’s own initial think there may be more productive same perceptual object (for Husserl’s caveats that the categories are only ways of philosophically grounding concept of “type” as pervading the per- provisional and therefore, still lack how to proceed in the systematic phe- ception of both things and persons, see conceptual foundation). Nevertheless, nomenology of the patient’s experi- Uhlhaas and Mishara, 2007). for reasons that provoke speculation — ence. Even if we are wrong, others The two phenomenological psy- loss of credibility in courtrooms, insur- may suggest better ways and we chiatrists, Klaus Conrad (1958) and ance companies and the Halls of Gov- would not want to close the door. Henri Ey, employed the nineteenth ernment? fear of “anti-psychiatric” or One problem is that rather than century neurologist, Hughlings Jack- like-minded “philosophic” critics? Cre- bridging clinical practice and clinical son’s approach to classification in dulity—many of DSM-5’s adherents research, DSM-III’s logical empiri- terms of describing and formalizing the currently posture that all questions cist agenda inserted a wedge between subjective experience of the patient as a about conceptual foundations have al- clinician and clinical researcher field of consciousness which is dis- ready been discussed, solved and put to which still has not been appropriately rupted in its organizing activity pre- rest. Their “naïve realism” permits their addressed. In their historical analysis, cisely in response to the degree of se- leapfrogging over major conceptual Mayes and Horwitz (2005) write: verity of the underlying neurobiologic problems, including the problem of the "Spitzer selected a group of psychia- disturbance. Therefore, Klaus Conrad human person, the mind body problem, trists and consultant psychologists compares the disruption of psychosis to the so-called hard problem of how to who were committed primarily to the organization of conscious experi- map conscious experience (qualia) onto medically oriented, diagnostic re- ence to dreaming: “In sleep, there is underlying putative neurobiologic search and not to clinical practice" radical dismantling ( Abbau ) of higher mechanisms (see Mishara, 2009 for one That is, there appears to be a divide functional levels… this characterizes approach to this problem), and finally between DSM-III and later DSM's the negative side of the phenomenon. the definition/reification of mental dis- prescriptive diagnostic practices for At the same time, we find in dreaming orders (as entities, types, dimensions, the researchers and what the clinician the expression of the release of deeper etc.). These DSM-5 protagonists em- actually does in practice. At the very …levels of functioning as positive ploy what is essentially a rhetorical least, the DSM’s following DSM-III symptoms of this occurrence.” How- strategy to obviate any conceptual criti- have been burdened by a dual role: to ever, psychosis is not simply a form of

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dreaming or sleep. Rather, “the differ- classification, we have the danger of activity, reveal anything about resting ence lies in how quickly the everyday allowing this to replace the phenome- perfusion or whole-brain activity which meanings are broken down, i.e., the nology of the patient’s subjective nevertheless may differ in clinical tempo of their dismantling. In psycho- experience. populations. Moreover, the two groups sis, the dismantling is incomplete. The Now we would like to raise the may be employing different components or aspects of the field of following questions: is it possible that “strategies” during task. That is, to consciousness are not impacted so uni- you, Dr. Frances, have not gone far claim that our “tool box” is so ad- formly and radically as in sleep… enough in your critique on two mat- vanced that we can replace descriptive [Referring to his French contemporary ters (ones that we suggested in our psychopathology with cognitive meas- and phenomenological psychiatrist contributions to the “Philosophic Per- ures is precipitous. friend, Henry Ey] Without previous spectives” book (Sadler et al., 1994)): On the other hand, recent findings knowledge of Henri Ey’s efforts, I re- 1) precipitous optimism with regard in the rapidly developing field of social peatedly referred to the dream as a typi- to finding biologic markers for neuroscience support the view that the cal state of protopathic transformation disorders which would pre-empt human brain evolved to be a “social of Gestalt-meaning of the total mental or at least guide our descriptive brain.” This approach confirms the field.” (1953, our trans). Indeed, the classifications previously philosophic phenomenologi- similarities between Conrad’s and Ey’s 2) the continued neglect of the sys- cal view that the human brain or mind work are noteworthy. Ey’s classifica- tematic study of the patient’s never works in isolation, i.e., as an iso- tion of the different mental disorders subjective experience to guide lated Cartesian subject, but in relation according to the depth of both our classificatory systems to others (in what some recent re- “dissolution” (Jackson) of conscious- and our measurement of treat- searchers call the “grounding problem,” ness resembled Conrad’s own efforts to ment outcome i.e., how to ground cognition in terms describe psychosis as a progressive For example, the clinical researcher, of an embodied self that is already in- “deformation” of the field of conscious Mary Phillips (see First, 2006) pro- tersubjective, or a so-called “two- experience, which affects greater and poses a “psychiatric toolbox” (i.e., person” psychology). To the extent that greater portions of this field depending neuropsychological tests, neuroimag- neuroscience, descriptive phenome- on the severity and/or course of the ing, genotyping) to develop disorder nologic psychopathology, and diagnos- disturbance. Conrad (1958) finds that “biomarkers” that are persistent, tic classification work together in the the Jacksonian “release” of pathologi- rather than state-dependent. This future, it is possible that many of our cal behaviors of the earlier stage of would obviate the phenomenological current diagnostic categories will have perceptual-meaning cannot be said to research of the patient’s subjective to be reconceptualized as disorders of be merely a component of the later experience of the disorder. The dan- an embodied, intersubjective human process but is its own productive or ger will be, however, that we will self embedded in interactions as social positive transformation. (Since the phe- define disorders in terms of what agent. nomenologic application of the Jack- technologies we have available. A Despite Allen Frances’ concern sonian concepts is relatively compli- problem with clinical researchers that DSM-5 may promote “a wholesale cated, and not well known, we provide defining the categories that they have medicalization of everyday incapacity” a more detailed description of this ap- themselves helped to validate has the that could have real-world conse- proach and its relevance for diagnostic inevitable by-product that even the quences in how disorders are diag- classification in future publications). best scientists are nevertheless still nosed, Kendell (2000) expresses a Following these efforts, Mishara (1994) guided by their human bias to pro- view that could lead to such prolifera- proposed that psychiatric classification mote what they most believe (or the tion: “If physical disorders are so com- could be reconceptualized in terms of real need to provide positive findings, mon, there is no reason why psychiatric the patient’s subjective experience of or at least positive pilot data, for fu- disorders should not be equally com- the disorder according to what extent ture grant funding). As a result find- mon and it would be a big mistake both the phenomenological categories of ings are often interpreted over- scientifically and politically, to change space, time, embodiment, intersubjec- optimistically (see Farah, 2005). our definitions in order to reduce their tivity and self are disrupted (see the Neuroimaging studies, which merely apparent prevalence” (p. 6). Similarly, discussion of the current impact of so- compare statistical differences of Kendell writes, “The only reason most cial neuroscience in both clinical neu- activation of certain regions of inter- mental disorders are still defined by roscience and psychiatry, below). est when samples from clinical popu- their clinical syndromes is that the hu- However, we would like to ask lations and healthy individuals per- man brain is infinitely more complex whether current diagnostic classifica- form the same cognitive task, over- machine with a much wider range of tional efforts may be too precipitous in look a host of methodological prob- functions that the heart, kidney, or still other directions than those outlined lems (Mishara, 2007). These include liver” (p. 13). But is this the only rea- by Dr. Frances? To the extent that we the fact that the blood oxygenation son? Have we as neuropsychiatric re- allow current genetic results, results level-dependent (BOLD) effect in searchers or neuroscientists overcome from neuroscience in so-called bio- fMRI does not, without absolute the explanatory gap proposed by phi- markers to organize our descriptive quantification of resting metabolic losophers? Is there not something of

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the explanatory gap in those mental Interestingly, for much the same rea- Hamilton, Trans. 7 th Ed). The Johns disorders in which we have not as yet son, DSM-III pioneer George Saslow Hopkins University Press. found unequivocal etiologies? Our cur- (Kanfer and Saslow 1969) had unsuc- Kanfer, F.H., Saslow, G. (1969) rent medical model views illness in cessfully advocated for an analogous Behavioral diagnosis. In Franks, C.M., terms of underlying physiological proc- solution for psychiatric classification. (Ed.) Behavior therapy: Appraisal and esses, not acknowledging that they are In this regard, it is also helpful to status (pp 417-444) McGrawHill: New inseparable from the person’s life. The remember that the original criteria York; pp. 417-444. symptom indicates both organic change used as the initial basis for the speci- Kendell R.E., (2002) Five criteria but also what this means for the per- fied diagnostic criteria for the major for an improved taxonomy of mental son . These are mutually exclusive, but diagnostic categories of DSM-III disorders. In: Helzer, J.E., Hudziak J. also inseparable processes (v. were regarded exclusively as (Eds). Defining Psychopathology in the Weizsäcker, 1950). Insofar as the em- “research diagnostic criteria” (RDCs; 21st Century: DSM-V and Beyond bodied human brain clearly mediates see, for example, Williams and American Psychiatric Publishing: experience and functioning and re- Spitzer, 1982). Our inclination, given Washington, DC; pp. 3–18. mains the substrate of our interven- the current state of psychiatry, is to Kendler, K.S., Appelbaum, P.S., tions, our target remains the subjective view such a dual tiered framework as Bell C.C., Fulford K.W.M., Ghaemi experience of the embodied individual an advance. Perhaps there are better S.N., Schaffner K.F., Waterman G.S., who experiences these symptoms, defi- ways, but surely the topic commands First M.B., Sadler J.Z. (2008): Issues cits, anosognosia (lack of insight), etc. interest. Grist for the DSM-5 (or 6, or for DSM-V: DSM-V Should Include a With regard to the problem of what ICD-12 or 13) Conceptual Issues Conceptual Issues Work Group. Am J we are classifying when we classify Work Group, already proposed by Psychiatry 165, 174-5. mental disorders, phenomenology Ken Kendler et al. (2008) and others Mayes, R., Horwitz, A. (2005) “brackets” ontological claims about the – a proposal that has so far fallen on DSM-III and the Revolution in the reality of entities while examining the deaf ears. This absence of response Classification of Mental Illness, Jour- meaning that contributes to their con- hardly exhibits the “openness” for nal of the History of the Behavioral struction. That is, the phenomenologic discussion and debate supposedly Sciences Vol. 41, 249-267) approach requires that we must be sure tendered by DSM-5 enthusiasts. Al- Mishara, A.L. (1994) A Phenome- that our operational constructs actually ternatively, we propose that using the nological Critique of Commonsensical capture what they claim to in the pa- patient’s subjective experience of Assumptions of DSM-III-R: The tient’s experience of symptoms or the “symptoms” as standard, there should Avoidance of the Patient's Subjectivity. clinician’s descriptions of the signs of a be ongoing studies of bi-directional In Sadler, J., Schwartz, M. and Wig- disorder before being operationalized/ feedback between clinical practice gins, O. (Eds) Philosophical Perspec- quantified for their further scientific and the diagnostic classifications op- tives on Psychiatric Diagnostic Classi- study. erationalized by researchers to further fication , Baltimore: Johns Hopkins To return to Dr. Frances’ theme, refine these classifications. We will Series in Psychiatry and Neuroscience, how can we put all of this together in a demonstrate how this is done con- 129-147. format that is valid yet sufficiently cretely in future publications. Mishara, “pragmatic” for myriad psychiatric A.L. (2007) Missing links in phenome- purposes: for the interests of our pa- References nological clinical neuroscience? Why tients, their families, society at large, we are still not there yet. Current clinicians, researchers, the courtrooms, Conrad, K. (1953) Über moderne Opinion in Psychiatry 60, 559-569. and other third parties? To achieve this Strömungen der französichen Psychi- Mishara, A.L. (2009) Human bod- goal, we return to Hughlings Jackson, atrie. Nervenarzt 25. 114-118 ily ambivalence: Precondition for So- medical researcher and clinician par Conrad, K. (1958) Die begin- cial Cognition and its Disruption in excellence. Working with the categori- nende Schizophrenie . Stuttgart, Ger- Neuropsychiatric Disorders. Philoso- cal diagnoses of his day, Jackson was many: Thieme Verlag. phy, Psychiatry & Psychology 15, 234- able to appreciate their utility in his Farah, M. J. (2005) Neuroethics: the 7. daily clinical work, while at the same practical and the philosophical. Sadler, J., Schwartz, M. and O. time he could see their limitations Trends Cogn. Sci. 9, 34–40. Wiggins (Eds) (1994) Philosophical when it came to scientific investiga- First, M. (2006) Deconstructing Perspectives on Psychiatric Diagnostic tions. His proposed solution was a two- Psychosis (February 15-17, 2006) Classification , Baltimore: Johns Hop- tiered system for diagnosis – with one http://www.dsm5.org/research/pages/ kins Series in Psychiatry and Neurosci- tier reserved for clinical practice and a deconstructingpsychosis(february15 - ence. second for research: “There are two 17,2006).aspx Schwartz, M.A., Wiggins, O.P. kinds of classification of diseases: one Hughlings-Jackson, J. (1879) (1987) Typifications. The first step for scientific, generally called theoretical, Lectures on the diagnosis of epilepsy. clinical diagnosis in psychiatry. J Nerv for the advancement of knowledge; one The British Medical Journal 1, 33-36. Ment Dis 1987, 65-77 empirical or clinical, for prac- Jaspers, K. (1963) General psy- Schwartz, M.A., Wiggins, O.P. tice” (Hughlings Jackson 1879, p. 33). chopathology (J. Hoenig & M. W. (2002) The hegemony of the DSMs, in

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Sadler, J.Z. (Ed.) Descriptions and tion to DSM-IV tries to undercut rei- Final Comment: Prescriptions: Values, mental disor- fication, but few people read it and ders, and the DSMs. Baltimore, MD, follow this advice. In my reply to Dr Phenomenology and Opera- Johns Hopkins University Press, pp Phillips, I take up the prototype/ tionalism: Not Opposites but 199-209. criteria set issue. Uhlhaas, P.J., Mishara, A.L. People probably expect too much Mutually in Need of (2007). Perceptual anomalies in schizo- from the DSM's. DSM-III was di- One Another phrenia: Integrating phenomenology rected at what was then the major and cognitive neuroscience. Schizo- problem facing psychiatry—the in- Aaron Mishara, Ph.D., Psy.D. phrenia Bulletin 33, 142-156. ability to deliver reliable diagnoses. Michael A. Schwartz, M.D v. Weizsäcker, V. (1950) Funk- It helped to greatly improve reliabil- tionswandel und Gestaltkreis . In: ity in research settings and probably Dr. Frances, thank you for your Deutsche Zeitschrift für Nerven- improved reliability ( although much kind and thoughtful response, entitled, heilkunde 164, 43-53. less so) in clinical settings as well. “Phenomenology vs. Operationalism.” Williams, J.B.W., Spitzer, R.L. We don't have a basis at this point to In this reply, we take this opportunity (1982) Research diagnostic criteria and expect more from our diagnostic clas- to clarify some frequent misunder- DSM-III. An annotated comparison. sification than that it be reasonably standings about phenomenology’s con- Archives of General Psychiatry reliable, reasonably representative, tribution (at least, our view) to diagnos- 39, 1283-1289. and reasonably safe and useful. tic classification. In fact, our argument DSM- IV meets these minimal goals. will be that the phenomenology is not *** I was never a first umpire and the antithesis to operationalism but instead always had a healthy skepti- precisely the step required to translate Phenomenology vs cism that biological psychiatry was the patient’s subjective experience of being oversold. But the last twenty symptoms, etc., into workable opera- Operationalism years of psychiatric (and more gener- tionalizable hypotheses which can be quantifiably measured using the experi- Allen Frances, M.D. ally of all medical) research has been disappointing beyond anyone's expec- mental methods of clinical neurosci- ence (see Mishara, 2007). That is, I am certainly no expert on Jas- tations. We are learning amazing qualitative description and quantitative per's, but my vague and uninformed things about the normal genome and measurement are not opposites but are memory is that his phenomenological the normal brain, but very little about ultimately inseparable (von approach doesn't lend itself very well to the mechanisms that underlie psycho- Weizsäcker, 1950a), working together Hempelian operationalism. Human parthology. Everything is much more in both clinical judgment (e.g., the pa- experience is so personal and ideo- complicated than anticipated and tient’s depressed mood is more or less graphic that ot is hard to reduce to there are no clear breakthroughs in severe) and in its scientific study (e.g., nomethetic categories. Following Jas- the pipeline. I take this as a reason to operationalizing this “more or less” pers can help us be sensitive to fine avoid dramatic changes in the de- into a clinical rating scale). and individualized distinctions, but it is scriptive classification until we know By appealing to phenomenological not clear to me how these could be- much about the basic pathways. psychiatrists such as Jaspers, Conrad or come the basis of a diagnostic system. The lack of a reasoned concep- Ey, we are not referring to the idio- Perhaps Drs Mishara and Schwarz tual base is the original source of graphic-nomothetic opposition which could do a reply to this reply spelling DSM-5 problems—then this bad start comes precisely with the realist as- out in more detail what they have in was exacerbated by excessive ambi- sumptions of the nomologic approach. mind. I know that they plan to present tion, secrecy, and sloppy methods. Rather, as in our previous contribution, their thoughts in future papers, but a bit Rather than the several-year futile we paraphrased Husserl (founder of the of a teaser here would be nice. exercise of attempting prematurely to phenomenological approach), the per- The tautological circularity of my establish biological markers, the ceived individual (whether object or half joking definition of mental disor- DSM leadership should have spon- person) is already perceived in terms of ders as "what clinicians treat and re- sored a freewheeling discussion of a type which subsumes the perception searchers research" is indeed an ab- the appropriate goals of the diagnos- as a meaningful unit. More recent ex- surdity and an embarrassment, but I tic system and the means available to perimental findings have demonstrated have not yet seen or thought up a better meet them. Without the clarity that the rapidity and automaticity of these definition. could have come from a conceptual processes in decision-making and eve- I agree that the “hegemony” of work group, DSM 5-has often been ryday social cognition. DSM-IV has unduly co-opted psychiat- flying pretty much blind and usually There is of course a certain way ric research. Granting agencies and in the wrong direction. that phenomenologic psychiatric ap- journals should be open to other diag- proaches have traditionally emphasized nostic approaches. But I think DSM-IV *** the importance of the patient’s is an appropriate tool for clinical and “uniqueness” in the “encounter” be- administrative purposes. The Introduc-

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tween patient and doctor, i.e., the pa- still defined by their clinical syn- ing sense. If we are able to describe tient’s person as a “thou” transcends dromes is that the human brain is and verbally capture everyday each of the clinician’s provisional diag- infinitely more complex machine “healthy” consciousness in terms of nostic judgments. As we wrote in our with a much wider range of func- its “field” organization, then we are previous contribution: “ The symptom tions that the heart, kidney, or able to model disorders by seeing indicates both organic change but also liver” (p. 13). But this view that how this “field of consciousness” is what this means for the person [as] all disorders, as we have defined specifically disrupted in a particular mutually exclusive, but also insepara- them, will resolve as diseases mental disorder (as we currently ble processes” (von Weizsäcker, with unequivocal biologic causes classify it) by disabling this or that 1950b). This call for the clinician’s remains at best a guiding “idea,” component of consciousness. To empathy in taking into account in each or what Kant called a “regulative elaborate on this analogy. Neural case the patient’s narrative history, i.e., idea.” As Jaspers (1963) puts it: network models, for example, simu- ways of making sense of, coping with “We have classes of disease in late mental disorders by the symptoms, may be the reason that mind although their definitive “damaging” this or that part of the Dr. Frances and certainly others mis- causes and nature are not known, network. Similarly, animal models perceive phenomenology’s main contri- but in fact one is always confined lesion a crucial part of circuitry and bution as accenting the individual, as to types” (Max Weber’s types) drug models alter neurotransmitter concerned only with the idiographic, (see Schwartz and Wiggins, signaling. In each case, the mental without seeing that phenomenology 1987). Here, the notion of “ideal disorder is “modeled” by systemati- systematically provides a bridge be- type” provides a certain flexibil- cally removing or altering some tween subjective experience and more ity in the interplay between clini- aspect of healthy functioning general operationalizable hypotheses cian’s diagnosis and its opera- thought to be implicated in the dis- about mental disorder. In this brief re- tionalization in scientific study order. Similarly, these phenomenol- ply, we indicate two ways that the no- which we hinted at in our previ- ogical psychiatrists begin with mothetic-idiographic opposition does ous contribution, elaborate be- healthy waking consciousness and not apply to phenomenology’s contri- low, and discuss further in future by “damaging” or “removing” bution to the current debate: the first publications. We will merely healthy components of this con- concerns Jaspers; the second concerns emphasize here that conceiving sciousness (in as it were introspec- Conrad, Ey and other like-minded phe- psychiatric diagnoses as “types” tive, phenomenologic thought ex- nomenologic psychiatrists who were provides psychiatry with a flexi- periments, what Husserl called more influenced by Husserlian phe- ble nomenclature that is descrip- “imaginative variation”), attempt to nomenology than Jaspers. tive and operationalizable yet at produce the subjective experience 1) Jaspers is often cited for applying the same time far more open to of symptoms until they arrive at a explanation-understanding opposi- broad-ranging inquiry – hence plausible model. In this way, we tion (having achieved its heyday far more “atheoretical” - than are suggested in our previous contribu- during Jaspers’ time) to psychiatry. the descriptive diagnostic catego- tion, “Who’s on First? Mental Dis- This does not mean that he re- ries of DSM-III and IV. Such orders by Any Other Name?” that mained restricted to Windelbrand’s openness allows us to move both Conrad and Ey apply a Jack- well-known idiographic-nomothetic much more adeptly between the sonian hierarchical approach to distinction, which he overcomes two levels of clinical practice nervous functioning in the organiza- precisely in his use of ideal types. and clinical research (described tion of the patient’s “field of con- Here, Jaspers describes three do- by Hughlings Jackson and out- sciousness”: “Psychosis is not sim- mains of mental disorder: lined in our previous contribu- ply a form of dreaming or and Ey, I. Somatic processes. These tion). to phenomenologically model include mental disorders in which III. Variations of human life many aspects of the subjective we know the etiology unequivo- that are far from the average and experience of schizophreni sleep. cally. General paresis of the insane qualify for treatment because Rather, ‘the difference lies in how (GPI) is a good example. Once we they cause psychic distress. quickly the everyday meanings are learned the cause (i.e., syphilis 2) There is a way that the more broken down, i.e., the tempo of their infection), the clinical phenome- Husserlian minded phenome- dismantling. In psychosis, the dis- nology reduces in importance. nologic psychiatrists, Conrad, Ey mantling is incomplete. The compo- II. Unfortunately, the GPI but certainly others go beyond nents or aspects of the field of con- model (biologic reductionism) has Jaspers on this point. These phe- sciousness are not impacted so uni- not worked for most psychiatric nomenological psychiatrists an- formly and radically as in disorders, where the etiology con- ticipated the kind of modeling of sleep…’” (from Conrad, 1953, our tinues to remain unclear. There- mental disorders later done by trans). As we will demonstrate in a fore, Kendell’s (2000) pronounce- neural networks, animal models, subsequent publication, it is possi- ment remains wishful, “The only and drug challenge studies with ble, following Conrad a by reason most mental disorders are healthy individuals in the follow-

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“disabling” the subject’s Miscellany Past and that is not what AAPP and the philoso- “intentional mental activity” in the phy of psychiatry are about. For me, same way that it becomes reduced Present the value in Bob’s and Allen’s critiques while sleeping or dreaming. is not whether they are “conservative” John Z. Sadler, MD. We emphasize again that such or “progressive”, but whether their in- UT Dallas School of Medicine modeling (as any other modeling) does sights and experience give us reason- not replace the operationalization re- able pause and valid cautionary histori- This second cycle of discussions quired for experimental research. cal experience. I think they do, though of Allen Frances/DSM-5 develop- Rather, it generates useful hypotheses I don’t agree with all they say. Sec- ments is another good opportunity for this research (Mishara, 2007). We ondly, as a person who applauded Fran- because of several coincident oppor- hope in this and other contributions to ces’ contributions in Psychiatric Times , tunities that were not available (or indicate the power of Jaspers’ vista on I was starting to wonder whether I was quite as visible) at the time of the psychiatric nosology. Furthermore, we a “conservative” or “liberal”, then real- AAPP Bulletin original solicitation: hope to indicate how an appreciation of izing that these encompassing labels most pointedly the DSM-5 draft crite- the phenomenology of the patient’s simply distort viewpoints and lead peo- ria, a series of literature reviews in subjective experiences can contribute ple down premature-closure paths. My various areas address DSM-5 pro- to diagnostic classification through views are complex (as you will see a posed changes, and remarkably, an proposing provisional classifications of sample of below), as are others’, and explosion of discussion in the Psychi- this experience and also through pro- they don’t belong in pigeonholes. atric Times online and print editions, viding hypotheses for their neuroscien- Third, I devoted a whole chapter about as well as Medscape online and (as tific study. politics in classification for Values and well as others I haven’t yet found), Psychiatric Diagnosis (VAPD), point- about DSM-5. Thanks to Jim Phillips References ing out “good” and “bad” politics for a for the opportunity to discuss DSM-5 DSM, and indeed, as those who read it and Allen Frances’ critiques again. Conrad, K. (1953) Über moderne and remember, the labeling of positions My apologies for those AAPP mem- Strömungen der französichen Psy- as “conservative” or “liberal” best fits bers who do not find the DSM-5 as chiatrie. Nervenarzt 25. 114-118 into a Politics move—rhetorical per- endlessly fascinating as I do (there Jaspers, K. (1963) General psycho- suasion not philosophical argument. In are many of you) and are already fed pathology (J. Hoenig & M. W. Hamil- my view this is not “good” politics for up with DSM-5. You’ll have to suf- ton, Trans. 7 th Ed). The Johns Hopkins a DSM. Let’s debate the issues not the fer along at least until 2013, and per- University Press. labels. haps longer! Kendell R.E., (2002) Five criteria 2. Impoverished diagnostic crite- I would like to organize my for an improved taxonomy of mental ria. One of my prior observations on points into separate topical sections. disorders. In: Helzer, J.E., Hudziak J. DSM-IV/TR is the marked discrepancy Some are new issues/questions and (Eds). Defining Psychopathology in the in what might be termed descriptively some revisit earlier topics. 21st Century: DSM-V and Beyond rich vs. impoverished diagnostic crite- 1. Against politicization. I American Psychiatric Publishing: ria sets. The issue persists in the DSM- would like to speak out against the Washington, DC; pp. 3–18. 5 draft criteria, with some exceptions. (unhelpful) politicization of the Mishara, A.L. (2007) Missinglinks Consider the diagnostic criteria for DSM-5 discussion. The politicization in phenomenological clinical neurosci- Schizophrenia, which are phenome- is symbolized neatly by some of my ence? Why nologically rich with multiple symptom friends’ characterization of we are still not there yet. Current sets, stipulations, and qualifiers. On “conservatism” and “liberalism” in Opinion in Psychiatry 60, 559-569. the other hand, consider the DSM-IV/ characterizing DSM-5 critiques, but Schwartz, M.A., Wiggins, O.P. DSM-5 diagnostic criteria sets for dis- extends elsewhere in the emerging (1987) Typifications. The first step for orders like the Paraphilias, Kleptoma- debate. For AAPP and philosophers clinical diagnosis in psychiatry. J Nerv nia, Pyromania, Pathological Gam- of psychiatry I think this is a dire Ment Dis 1987, 65-77 bling, and Intermittent Explosive Dis- mistake. Early in the debate, spear- v. Weizsäcker, V. (1950a) Der order. These criteria sets represent headed by Bob Spitzer (and including Gestaltkreis. Theorie der Einheit von little more than single symptom clus- me and others) regarding the Wahrnnehmen und Bewegen 4. Aufl. ters embedded in standard DSM lan- “openness” issue in DSM-5, Robert Stuttgart, Georg Thieme Verlag;1950. guage with stipulations like “not due to Freedman (editor of AJP) was push- v. Weizsäcker, V. (1950b) Funk- another disorder” or the clinical signifi- ing back on American Journal of Psy- tionswandel und Gestaltkreis . In: cance criterion. I’d like to hear Allen’s chiatry “Issues for DSM-V” editorial Deutsche Zeitschrift für Nerven- response if “impoverished criteria sets” submissions on the grounds that some heilkunde 164, 43-53. were identified as an issue in the DSM- were too “political.” This is how con- IV era or in DSM-5 today. I think it is ceptual work gets a bad name. Dr. *** an issue in that monosymptomatic dis- Freedman’s response reminded me orders have a rich history (the how easily conceptual critiques are “monomanias” of Esquirol), and pro- perceived as political jockeying, and mote, to repeat a DSM-IV era phrase, 65 Volume 17, Number 2 2010

“artifactual comorbidity”. It’s not hard problems, disorders or not, are very DSM-5 I mean it in the simple Edmund to figure out why. If I invent a descrip- common in (outpatient) clinical prac- Burke sense of conserving the past in- tive category based on a single relevant tice today. If not in the DSM, then stitutions, not necessarily because they descriptor (like “mammals are four- where? V codes? If the criteria can- are terrific or inherently deserving of legged animals”) then you will get a lot not be written well to address false particular loyalty or affection, but of false positives (alligators) as well as positive/negative concerns, then rather because of skepticism that pro- a lot of false negatives (humans). If that’s an issue, but doesn’t mean the posed changes will be more beneficial this was identified as an issue, why did condition is necessarily a non-starter. than harmful. I’ve said more on this in so many criteria sets end up as impov- B. I may have missed it, but I my reply to Dr Waterman. erished? I recognize the knowledge think Allen has not said much yet The introduction of the term base may not be there to provide di- about the DSM-IV “appendix” for "politics" into DSM debates is usually verse kinds of validators or descriptors. proposed disorders and criteria. Do part of a purist's polemic and is almost But is that all there is to it? The DSM- you think this DSM-IV innovation a always derogatory as in "I happen to 5 draft criteria for Pedophilia have at success, and if so, should DSM-5 know the real scientific truth and you least partially addressed the issue consider placing these new proposals are just talking politics here." Heated through adding, in the case of Pedo- (like hypersexual disorder) in a simi- debates about diagnostic decisions arise philia, a criterion item on viewing child lar portion of the DSM-5? precisely because there is little compel- pornography (as an example). C. I’m curious to Dr. Frances’ ling science to decide them. As noted 3. A related area is the issue of response to the new NIMH RDoC by many of the commentators in this what counts as a primary disorder ver- (Research Domain Categories) issue, the casting vote must always be sus a primary disorder with “features [http://www.nimh.nih.gov/research- pragmatic common sense about what is of”. Some of the monosymptomatic funding/nimh-research-domain- likely to bring most good and least DSM-IV diagnoses had notorious co- criteria-rdoc.shtml] and their relation- harm to patients. Aristotle would morbidity with other disorders ship to/ reaction to the DSMs? Any probably include this as "politics," but (firesetting/Pyromania) being a prime insights into the genesis of the Re- that was before politics got such a bad example (Geller 1992). The problem search Domain categories? name. with the criteria of tension-mounting D. A and B above raise an en- 2) Re descriptively rich vs. impov- and release in Pyromania is they are compassing question. Allen, do you erished diagnostic criteria sets: the easily fulfilled, in that even angry think the DSMs could be (have been, DSM is a historical hodgepodge. Some criminal arsonists may get tension re- will be) in any way effective in stem- diagnoses are complex, heterogeneous, lief from their fire-setting, and ration- ming the tide of medicalization and well established by long usage, and the ales for fire-setting are easy to contrive mental disorder expansionism? Why/ subject of tens of thousands of papers. or deny. Was fire-setting ever consid- why not, and how/how not? Others are simple and relatively un- ered as a complicating feature of other studied. There is no overarching defini- disorders (psychotic, antisocial, con- References tion of mental disorder that governed duct disorder, etc)? When a symptom their inclusion in the diagnostic manual complex repeatedly appears as comor- Geller JL. 1992. Arson in re- and no complexity threshold that had to bid with other diagnoses, did the DSM- view. From profit to pathology. Psy- be passed. IV leadership seriously consider mak- chiatric Clinics of North America 15 DSM-III was created with a split- ing these symptom complexes compli- (3): 623-45. ters mentality. The effort was to im- cations of other Axis I disorders? For Sadler JZ. 2005. Values and prove diagnostic reliability by dividing instance, “schizophrenia with fire- Psychiatric Diagnosis. Oxford/New categories into convenient component setting” or “personality change due to a York: Oxford University Press. parts that clinicians might more easily general medical condition, with pedo- agree upon. More complex notions philic features.” Why/why not? *** ("anxiety neurosis") have been divided 4. Some DSM-5 draft categories/ into simpler modular units. This of criteria and implications. Politics; course created "artificial comorbidity," A. Allen has railed against hyper- Lumping vs Splitting; particularly troubling among those who sexual disorder and “behavioral addic- regarded a DSM diagnosis as a real tions” as false-positive playgrounds What Place For entity rather than as descriptive build- (forgive the pun), and on the basis that Conceptualizing ing block. they represent, in my interpretation of I am personally a lumper, but Allen’s comments, as invalid, poorly- Allen Frances, M.D. (following the conservative discipline chosen medicalizations of human foi- already discussed) was unwilling to It is always interesting to have a bles. The philanderer becomes a sex impose this preference on DSM-IV. If dialog with John Sadler. addict. The video gamer who under- we were starting from scratch, a num- 1) Re labels: "conservative" is a goes negative consequences, even ex- ber of the simpler categories might currently much misused term and one treme ones, for excessive play becomes have been nested in larger ones, consid- that I would not normally adopt as a a gaming addict. On the other hand, I ered only as subtypes or cross cutting self characterization. In regard to can’t speak for all clinicians, but these symptoms, or dropped altogether. 66 Volume 17, Number 2 2010

3) "What kind of efforts go into the practical problems facing the di- ethical. It seems to me odd that I find imposing uniform or coherent ap- agnostic system. This would then myself agreeing with his two premises proaches to cross-cutting conceptual lead to a specific and guiding charge yet in complete disagreement with his issues? How successful were they? to the task force chair and colleagues. conclusion. How do cross-cutting conceptual issues The DSM should reflect the general His metaphysical premise rests on 'rise to the top' of the list to be ad- will of the field, not the personal three related empirical facts with which dressed?" preferences of its leaders. I certainly concur. The first fact is the My experience with the last three 4) Why not have "diagnoses" like genesis of all psychiatric taxonomies to DSMs was that the APA governance "hypersexuality" or "internet addic- date from a gradual historical accretion structure had no idea what it wanted or tion" or "binge eating" since clini- of practical, historically conditioned interest in discussing conceptual issues. cians sometimes see such presenta- imperatives. The second fact is the The Chair of the Task Force is ap- tions and want to help the patients? demonstrable failure of current neuro- pointed with no conceptual restraints The problem is that we know very and molecular biology to short circuit, and has free rein to pursue his own little about the diagnosis and treat- through an epistemically powerful path. Spitzer's main concern was to ment of such problems and the conse- breakthrough, this pattern of gradual provide a needed legitimacy to psychi- quences of medicalizing them by pragmatically fueled nosological evolu- atric diagnosis by making it reliable. including them within the diagnostic tion. The third fact is the continued My main concern was to provide a system. The reach of psychiatry has imprecision of psychiatric disease cate- needed stability to psychiatric diagno- already expanded dramatically in gories by way of both mutual overlap sis by making it evidence based. The recent decades-perhaps beyond our and internal incoherences. The meta- DSM-5 main concern has been to be grasp. NIMH estimates that twenty physical stance supported by these innovative. In each case, the direction five percent of the population quali- three facts is the idea that mental ill- was set by the DSM leadership unen- fies for a mental disorder in any given nesses as we have conceived them so cumbered by external discussion or year. A prospective study found that far are not definable in any clear one- restraint. This is a serious mistake. by age thirty two, fifty percent of the to-one correspondence with natural Anything as important as the diagnostic general population had experienced objects existing in the "real" world but system should be guided by a thought- an anxiety disorder, forty percent a rather emerge as constructs reflecting ful, inclusive discussion of the underly- depression. We are expanding the the workaday utilitarian and culturally ing issues and the status of the field. boundaries of mental disorder too far hegemonic agendas of its architects. Decisions that will so consequentially and too fast, without adequate re- Dr. Frances rests his ethical prem- impact on the profession and our pa- search and clinical experience. The ise on yet another empirical observa- tients should not be left to the personal best solution for new and untried dis- tion: small changes in DSM, in the di- preference of one individual. orders is current diagnosis under the rection of either greater sensitivity or Once established, the DSM-IV most appropriate NOS or V code ru- greater selectivity, have too often had goal of stability and evidence-based bric and inclusion in the Appendix to incommensurately massive, unantici- decision making was effected through a encourage future study. pated, and often harmful impacts, i. e. series of methods conferences. These 5) The NIMH RDOC project is a excessive or inadequate intervention, had both an information gathering and novel attempt to integrate its enor- on patients. This assertion is also cer- an educational function. We wanted to mous resources in the search for the tainly true. create uniformity and quality control to neural network underpinnings of cer- Why, then, might one differ with guide and monitor the individual work tain important dimensions of psycho- Dr. Frances in his conclusion, which groups. The problems with DSM-5 can pathology. It is early days but this is a advocates cautious conservatism rather be traced in part to a failure at the out- promising approach. than massive overhauls of psychiatric set to discuss the implications of an nosology? The problem with this infer- innovative approach and how best to *** ence from the above premises is his implement it in a way that would be additional but unwarranted assumption safe for patients and convenient for that scientific progress is inductive in clinicians. The work groups have pretty De-Centering the nature. much fended for themselves without Subject of DSM As he portrays the process, since theoretical, practical, or editorial guid- the beginning of the Enlightenment ance—resulting in a remarkably incon- most successful branches of maturing sistent product. Donald Mender, M. D. science have advanced through two Yale School of Medicine How can this be done better in the stages: first comes a cataloging of future? The Chairs of future revisions Allen Frances, if I correctly un- many observed facts, and then, from should not receive a blank check as in derstand the arguments of "DSM in these data, clear causal patterns the past. Before her or his appointment, Philsophyland: Curiouser and Curi- emerge. Examples mentioned by Dr. the mental health field as a whole ouser," invokes two premises in order Frances include the extrapolation of should have a mechanism for thrashing to justify his conclusion opposing Newton's physical laws from Kepler's through the conceptual issues, evaluat- radical changes in DSM. His first observations, Darwinian biology from ing the science base, and considering premise is metaphysical, his second Linnaean classification, and Bohr's 67 Volume 17, Number 2 2010

atomic model from Mendeleyev's peri- through the tractable heliocentricity I Don’t Believe in Magic odic table of the elements. Mental ill- of Copernicus and Kepler to the rela- nesses, however, are said to resist tran- tivities of Galileo, of Newton's reac- Allen Frances, M.D. sition from the first stage of the empiri- tive law, and of Einstein's electrody- cal catalog to the second stage of namics traced a progressive demotion I thank Dr Mender for restating my clearly patterned causal inference. of the scientific observer's locus from views more precisely and poetically Dr. Frances seems to believe that the navel of the cosmos to no univer- than I was able to do in the original. the reason for this resistance lies within sally absolute place, time, or velocity. We agree completely on what he calls the metaphysically non-objective na- Hence, the human biologist's illusory my "metaphysics" and "ethics" and also ture of psychodiagnostic concepts as throne fixed atop the pre-Darwinian on the value of a decentering point of outlined above. Yet another possibility tree of life yielded to a fungible ad- view in any endeavor - although he exists: that "revolutions" advancing the dress on a twig configured by expresses much more hope for its po- sciences of celestial mechanics, evolu- "fitness" contingent upon shifting tential than I do. We disagree on this tionary biology, and the physics of the selective pressures. Hence, the very one latter point because Dr Mender microcosm have entailed something presumed equivalence of causality, believes in the possibility of a "magic more than mere induction, and that this order, and rationality on which the ingredient" that may lead to a great leap added component may yet bring clarity originators of classical mechanics forward - while I am a skeptic who to future psychiatric thinking. prided themselves crumbled in the simply doesn't believe in magic. Dr What might that magic ingredient face of quantum theory's irreducible Mender awaits the future psychiatrist/ be? Not mere political power shifts as probability amplitudes, non- messiahs able somehow to climb out of Kuhn conjectured, or else the direction- distributive logic, and non-unitary our self centered observational cave in ality of scientific “advance,” including opacity to the scientist's measurement order to see things as they really are. If the demonstrated augmentation of the of canonically conjugate observables. psychiatry has not yet enjoyed a Coper- classical physicist's explanatory and Perhaps some similar humbling nicus, Newton, Einstein, or Bohr, it is predictive power by the today's Stan- disruption, not yet apparent, awaits still early days. New and powerful ob- dard Model, would have no meaning. psychiatrists. One can only guess at servational tools used with genius (and Not mere formalistic substitution of what guise it might take, but we as a decentered perspective) may help find inductive verification by experimental agents of psychiatric praxis can ex- simplifying regularities that explain the falsifiability, or else elegance and syn- pect that the revolutionary shift in seeming surface confusion. optic simplicity, i .e. "algorithmic perspective, which may finally un- This is where Dr Mender and I part depth," would have no intuitive scien- mask at least some clear "joints" in ways. Although I hope he turns out to tific appeal. Not mere cataloging of psychiatry's underlying intrinsic ar- be right, my best guess is that the prob- objective data according to any system, chitecture, will be a traumatic blow to lem lies less in the observer and much insofar as Quine's "web of belief" will our sense of our own professional more in the "chaotic" complexity of always search out alternative theoreti- centrality in the universe of the mind. what is being observed. My pessimistic cal sophistries that minimize the need This might seem at first glance a prediction is that psychopathology is for revising theoretical orthodoxies in terrible vocational price to pay for not just heterogeneous at the surface the face of anomalous experimental progress, but it could also bestow level - it is also bewilderingly complex findings. many ethical blessings. "Sensitivity in the large variety of underlying eti- The Talmudic quotation, "We don't to initial conditions," as non-linear ologies that can cause the very same see things as they are….We see things dynamics might describe the outsized presentation. I expect there is no low as we are," cited by Dr. Francis him- and unintended consequences of even hanging fruit, even for the best in- self, provides a clue to the solution of small changes in DSM's currently formed and most decentered observer this mystery. Great leaps forward in hazy formulations, would likely give wielding the most powerful tools. the coherence of science's encounters way to much more linear proportion- What is the evidence for my pessi- with natural objects have required revo- ality relating informational input in- mism? Thus far, the most interesting lutionary changes in scientific subjec- crements to operational output jitter. findings on the complex "diseases" in tivity's view of itself. These changes That kind of improvement in ballis- medicine and in psychiatry wind up have been wrenching and painful in tics followed the Newtonian revolu- explaining just a few percent of the proportion to their profundity, because tion; similar precision in population variance. Most likely, there will not be they have de-centered the subject of genetics issued from the theory of one type of breast cancer or schizo- science by challenging particular his- natural selection; technologies cali- phrenia—more likely there will be hun- torically situated orthodoxies that had brated at the nanoscale were born dreds of "causes" of each (and of most nourished institutionalized narcissistic from quantum insights. Why can we "diseases" which unfortunately seem to illusions of the relevant epoch's scien- not expect similar benefits in psychia- have no simple causes). This suggests tists. try, if we are willing and able to that scientific advances will be more Hence, for instance, the path of shoulder whatever epistemic self- trench warfare than blitzkrieg —steady, advance that led celestial mechanics sacrifices might be needed? but agonizingly slow; retail, bit by bit, from unwieldly geocentric epicycles rather than wholesale great leaps for-

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ward as per Newton or Einstein. serving many useful practical func- duce the crucial concrete evidence, in If I turn out to be right, the next tions. I don't see any magically better the form of Jupiter's orbiting moons question is why is it that psychopa- alternatives for the moment—and and the phases of Venus, that precipi- thology is so hard to crack? A possi- regrettably for quite a while. tated development of a new, widely ble paradox might explain why accepted Newtonian cosmology. (inherently?) there is no magic ingre- *** What evolving forces of economic dient to make everything clear. The production relevant to possibly a future normally functioning brain is a tri- Final Comment leap forward in psychiatric thinking are umph of non-chaotic development. in play today? One such impetus, I Our DNA is a superb engineer, some- Donald Mender, M.D. suspect, may be the nascent emergence how orchestrating the most complex Dr. Frances and I agree that of quantum computers which, though interactions with so few errors that the prospects ahead for a sweeping, they at present are still not practically we develop from a single cell into a massively simplifying, and paradig- exploitable, may eventually overwhelm run of the mill human-all achieved matically clarifying revolution in digital technology through sheer com- with remarkably little variance. Tril- psychiatric disease taxonomy pres- putational power. Just as intellectual lions of things that could go wrong, ently remain uncertain. Hume's fork fashion during the 19th century era of don't. When everything works out, we makes predictions about the future of steam engines conceptually framed get the nonchaotic miracle of the science shaky on the basis of past mind/brain relations in neurally hydro- more or less normally functioning historical patterns. However, to the dynamic and libidinally thermody- person. But having a complex system, extent that upcoming scientific revo- namic terms, and just as Boolean spins however fine tuned and self correc- lutions may be able, as in the past, to on information processing now occlude tive, is always a gamble with the "renormalize" into coherently finite normative holes in our current neuro- probability gods. If something can go convergence the infinite divergences cognitive models, so with the dawn of a wrong, sooner or later it occasionally of apparent chaos, a cautious opti- future economy dominated by radically will. When complex systems go mism might be justified. probabilistic qubits we may come to wrong, they do so in complex ways I do very much disagree with Dr. see consciousness as necessarily linked that are impossible to predict and Frances regarding his apparent take to quantum brain dynamics. extremely difficult to track down. on the term "magic," which in my If so, whole paradigmatic frame- Figuring out how the normal brain view is a wholly relativistic concept. works, including mechanistic causality works is turning out to be much eas- At least in the past, great leaps for- itself along with its problematic ier than anyone could have imagined- ward from less to more adequate ex- "variances," may reveal themselves as once we got the magic ingredients of planatory paradigms have repeatedly moot, having been grossly misapplied molecular biology, genetics, and im- transformed what had formerly by our contemporaries to psychobiol- aging. By comparison, figuring out seemed magical into pristinely ra- ogy, whether normatively simple or the crapshoot of the intricate and tional science. An agent of such complexly pathological. probabilistic causes of psychopa- revolutionary change should not be thology will likely be the painstaking understood a priori as some mysteri- *** and pedestrian work of generations. ously genial and unique "messiah"; No Newton. No Einstein. no single mastermind prestidigitated Another DSM on I could be dead wrong. It may the entire shift from Newtonian to turn out that there are much simpler quantum physics, which in fact suc- the Shelf? high order regulators that go wrong in cessfully engineered the goals of al- much less complex and more easily chemy from muddled incantation into James Phillips, M.D. understood ways. For fifty years the the protocols of particle accelerators. Yale School of Medicine neurotransmitter models were the It may well be that, as Marxists prime candidates to provide explana- While we have the ear of the archi- have argued, the most definitive fuel tory power, but they have failed to tect of DSM-IV, I want to question him for foundational scientific progress deliver on early hopes. The vogue further about a point I addressed in the flows, albeit through channels carved previous issue of this Bulletin: the now is neural networks (see Dr Pe- by individual innovators, from the question of utility of the DSMs for led) and certainly this is a fascinating collective demands and historical practitioners. I noted in my previous window. But the incurable skeptic in dialectics of economic production. me suspects that we are dealing with commentary a disjunct between, on the For example, though Copernicus and probabilistic, multimultivariate, com- one hand, a statement of purpose in the Kepler tried to revive an ancient he- plexities that will always elude grand DSM-IIIs and IVs that the manuals liocentric alternative to medieval geo- unifying schemes. were designed to be useful for clinical centric epicycles, only Galileo's im- Skepticism breeds conservatism. use, and on the other hand, the seem- proved telescope, created in response Our current diagnostic classification ing reality that the manuals are de- to the navigational needs of seafaring is creaky at its non joints and cer- signed primarily for reliability in the merchants from the city states of tainly not a very clear mirror to na- research community, not for clinical Renaissance Italy, was able to intro- ture. But it does its workaday job usefulness. The evidence for this argu- 69 Volume 17, Number 2 2010

ment is that experienced clinicians ten: “The single most important pre- U.S. psychiatrists and 1984 graduating don’t in fact use the DMSs in the man- condition for moving forward to im- psychiatric residents. Am J Psychiatry . ner directed by their authors: that is, prove the clinical and scientific utility 143:148-153. clinicians don’t check diagnostic crite- of DSM-V will be the incorporation Jampala VC, Sierles FS, Taylor ria to make a diagnosis; rather, they of simple dimensional measures for MA. 1988. The use of DSM-III in the rely on syndromal prototypes which assessing syndromes within broad United States: A case of not going by they have learned and integrated into diagnostic categories and supraordi- the book. Comprehensive Psychiatry . their diagnostic evaluation. My evi- nate dimensions that cross current 29: 39-47. dence is primarily anecdotal - my own diagnostic boundaries. Thus, we have Jampala, VC, Zimmerman M, experience and that of colleagues, who decided that one, if not the major, Sierles FS, Taylor, MA. 1992. Con- tell me they rarely take the DSM-IV off difference between DSM-IV and sumers’ attitudes toward DSM-III and the shelf. It is hard to find empirical DSM-V will be the more prominent DSM-III-R: A 1989 survey of psychiat- evidence for this opinion, since no one use of dimensional measures in ric educators, researchers, practitioners, seems to study the actual use of DSM- DSM-V” (Regier et al 2009, 649). and senior residents. Comprehensive IV. Searching for such studies will get Again, a promise to improve clinical Psychiatry . 33: 180-185. you many manuals on how to use the utility linked to a program of dimen- Regier DA, Narrow WE, Kuhl EA, DSM, but no studies on how it is actu- sional measures that will surely be Kupfer D. The conceptual development ally used. The limited empirical evi- perceived as tedious and unnecessary of DSM-V. Am J Psychiatry . 166: 645- dence I could find (Cantor et al 1980; for clinical work, and will be summa- 650. Jampala et al 1986, 1988, 1992) sup- rily ignored. Working clinicians al- ports the impression that practitioners, ready give scant attention to the GAF if they use the manuals at all, use them in DSM-IV. We can hardly expect Using Clinician Proto- in a loose, informal manner and are that they will pay attention to still comfortable ignoring diagnostic criteria more dimensional scales in DSM-5. types vs Criteria Sets In and making their diagnoses following It’s hard to disagree with Michael Making Diagnoses an informal prototypal pattern. While First, who had already argued for researchers may use diagnostic criteria using clinical utility as a criterion for Allen Frances, M.D. carefully to insure homogeneity across any change in the existing manual research subjects, clinicians are com- (2004), that the dimensional scales James Phillips is probably right fortable with prototypal, syndromal will corrode clinical utility in DSM-5 that most clinicians base their diagno- diagnoses, usually a mix of biomedical (2005). Will DSM-5 be one more ses of most patients on a mental syn- categories and, in some cases, psycho- manual gathering dust on the clini- dromal prototype rather than doing all dynamic factors. cian’ book shelf? the extra work of performing a system- My question then is the following: atic checklist of the pertinent DSM Allen, the first paragraph of the Intro- References defining items. But I disagree that this duction to DSM-IV contains the fol- means the manual could usefully dis- lowing statements: “The utility and American Psychiatric Associa- pense altogether with criteria. credibility of DSM-IV require that it tion. 2000. Diagnostic and Statistical First off, I would argue that psy- focus on its clinical, research, and edu- Manual of Mental disorders , 4th Edi- chiatric diagnosis would be much more cational purposes and be supported by tion. Text Revision. Washington, DC, reliable and accurate if indeed it had to an extensive empirical foundation. Our American Psychiatric Association. be justified and documented based on highest priority has been to provide a Can- the systematic checklist approach. helpful guide to clinical practice. We tor N, Smith E, French R, Mezzich J. Much of the unreliability of diagnosis hoped to make DSM-IV practical and 1980. Psychiatric diagnosis as proto- comes from clinicians reading off dif- useful for clinicians by striving for type categorization. J Abnormal Psy- ferent scripts. This uniformity would be brevity of criteria sets, clarity of lan- chology . 89:181-193. impossible to mandate in office prac- guage, and explicit statements of the First MB, Pincus HA, Levine JB, tice, but would probably be a useful constructs embodied in the diagnostic Williams JSW, Ustun B, Peele R. requirement in clinic, hospital, and criteria. An additional goal was to fa- 2004. Clinical utility as a criterion for training settings. And even in office cilitate research and improve communi- revising psychiatric diagnoses. practice, my guess is that DSM-IV does cation among clinicians and research- American Journal of Psychiatry . 161: come down off the shelf to assist when- ers” (2000, xv). What were you (as 946-954. ever there are more confusing and un- well as the DSM-III task force) think- First M. 2005. Clinical utility: A familiar diagnostic decisions. ing? Did you really think that busy prerequisite for the adoption of a di- Second, even if clinicians are not clinicians would spend their time re- mensional approach in DSM . Journal faithfully using the DSM with every viewing diagnostic criteria before mak- of Abnormal Psychology. 114: 560- patient, the prototypes they form of ing a diagnosis? And what do you think 564. each mental disorder are probably of the prospects of DSM-5 in this mat- Jampala VC, Sierles FS, Taylor mostly derived from the DSM criteria ter? The available hints are not promis- MA. 1986. Consumers’ views of sets. In bridging the clinical/research ing. Regier and colleagues have writ- DSM-III : Attitudes and practices of interface, it is desirable that clinicians 70 Volume 17, Number 2 2010

and researchers all have the same start- ments. I’m aware that one of the …Still, I Wonder ing point, even if their ultimate adher- much-trumpeted triumphs of DSM-III ence to the criteria sets varies widely. was the banishment of psychoanalytic Claire Pouncey, M.D., Ph.D. I do agree that, unless corrected, assessment from the DSM. But in the U Pennsylvania School of Medicine DSM-5 will be most cumbersome and real world in which we live and work, difficult to use. The writing is impre- people don’t leave their psychody- How disappointing that we cannot cise and inconsistent across sections. namics at the door when they enter move our discussion of nosologic merit The dimensional approaches suggested our offices. past a basic framework of realism ver- are so complex and user unfriendly that Second, he responds that sus empiricism versus constructivism. they will bury dimensions in unde- “psychiatric diagnosis would be And how disappointing that Dr. Fran- served infamy. DSMs cannot ever be much more reliable and accurate if ces doesn’t see where metaphysical and an easy or fun read, but they should indeed it had to be justified and docu- epistemological commitments have strive for simplicity, clarity, consis- mented based on the systematic already been made, and thus where tency. checklist approach…And even in they are no longer under debate. In office practice, my guess is that DSM psychiatry, we are already committed *** IV does come down off the shelf to to empiricism. The more pertinent assist whenever there are more con- question is what sort of empiricism we fusing and unfamiliar diagnostic deci- can commit to, why we do so, and how Final Comment sions.” Yes to part two of this state- we overcome its limitations. No one in ment. Or at least, it comes down off this conversation about DSM-5 is a Not so Fast my shelf in moments of diagnostic Platonic realist: we all agree that we James Phillips, M.D. unfamiliarity. But regarding the first know the world via our sensory abili- part of his statement, I’m tempted to ties (both direct and technologically- First, inasmuch as I complained say, are you kidding, you want to pull enhanced), and we agree that although about lack of empirical evidence for down the manual every time I see a we strive for intersubjective agreement actual use of the DSM by practitioners, depressed or anxious patient (the bulk about those perceptions, the percep- let me thank my eagle-eyed colleague, of my and most colleagues’ prac- tions themselves do not necessarily Ron Pies, for pointing to a recent study tices)? reveal a truth that exists beyond us. by Zimmerman & Gallione (J Clin Psy- But there is a much larger issue That said, we need to elaborate what chiatry. 2010 Mar;71(3):235-8) on use lurking is this latter point that, I hum- sort of agreement we seek. We all of the DSM-IV criteria in diagnosing bly submit, Dr. Frances misses. It agree with Frances’s second umpire depression. As Pies summarizes: “As it again has to do with the difference that we “call them as we see them”, but stands, nearly one-quarter of psychia- between research and clinical work. any empiricist worth her ivory tower trists indicate that they usually do not Researchers need diagnostic criteria knows that doesn’t get us very far, use the DSM-IV DMM criteria when and reliability. They are interested in since we have no direct insight into diagnosing depression, and nearly half diseases and correct diagnoses. Clini- whether what we perceive represents of nonpsychiatrists physicians indicate cians operate with a quite different anything apart from our own biases and that they rarely use the DSM-IV MDD set of assumptions. They deal with expectations. We need to articulate criteria to diagnose depression” (http:// living, breathing, individual patients. reasons for endorsing our ontological, www.psychiatrictimes.com/blog/ Their first order of business is, how epistemological, and theoretical com- couchincrisis/content/ do I approach this patient, not how do mitments in a way that freshman year article/10168/1601688). I get the most reliable diagnosis. To philosophy classes do not teach us to More to the point, let me half agree make this point in the most provoca- do. We know that sociopolitical values and half disagree with Allen Frances on tive manner, diagnostic criteria are and settings influence the outcomes of two of his points. First, when he re- clearly necessary and good for re- the most basic scientific investigations. sponds that “even if clinicians are not search, but often bad for clinical care. This does not mean that our scientific faithfully using the DSM with every I hear my critics screaming, how can ontologies are “mere constructions” patient, the prototypes they form of you claim good clinical care if you that should be dismissed as works of each mental disorder are probably haven’t secured the correct diagno- fictions. Rather, this means that we mostly derived from the DSM criteria sis? Yes, if I’ve diagnosed the bipolar must go beyond the observations them- sets,” I think he is largely right. At least patient as schizophrenic, my critics selves to justify our beliefs. This is that is true of me. What he leaves out, has a point. But for every such lapse especially important in medicine, however, is that when working with there will be a multitude of others in where we intervene in potentially patients clinically, our lack of rigid which this objection is bogus, in harmful ways based on our studies. It adherence to the criteria sets allows us which the formal diagnosis will rep- is more important in psychiatry, where to be flexible in our diagnostic assess- resent only a limited window on the the intersubjectivity of perception itself ment, to include, for instance, bits and rich complexity of the individual I am often is the object of study. pieces of psychodynamics, family proc- treating. Frances does seem to appreciate ess, and other factors in our assess- the ubiquitous uncertainty that per- *** 71 Volume 17, Number 2 2010

vades all empiricist approaches to leave behind all the tired baseball But the nature of brain functioning may knowledge (though why he localizes metaphors). offer neuroscience no slow, easy, this to quantum physics is unclear). pitches right down the middle of the Yet he does not follow this awareness *** plate. to the logical conclusion that psychiatry 3) Descriptive psychiatry as em- has a tremendous responsibility (1) to Afterword bodied in the DSM is enormously use- articulate our ontological commitments ful (really indispensable) in everyday Allen Frances, M.D. (i.e., mental disorders and neuropsy- clinical practice, but it is fallible in chiatric theory); (2) to give reasons for So what has DSM learned from many ways and perhaps not the best maintaining or altering them; (3) to its brief adventure in philosophyland. (and certainly not the only) guide to defend our characterizations of those I can't be sure that I am a fair judge future research discovery. commitments with intersubjectively and that we have a fair sampling of 4) Elegant theory driven (and par- appreciable reasons; (4) to make ex- opinion. It is in the nature of learning tially empirically supported) substitutes plicit our methods and history of theory and of knowing that different people for the DSM approach are an important development; and (5) to justify our will perceive the dialogues differently vehicle for advancing the game of re- contemporary interventions based on and take home different lessons. search, but are not yet major leaguers that existing theory. His articles cir- These, then, are no more than my ready for inclusion in an official no- cumvent these fundamental questions; own impressions—doubtless biased menclature. his response to the commentaries in the by my own preconceived notions and 5) It is a great misfortune that there Bulletin ignore them entirely. Good by the fact that the commentators are is no operational definition for the con- philosophy requires criticizing one’s a small and very select group. The cept—“mental disorder"—that is at the own position and challenging oneself to field at large may continue to see very core of the diagnostic manual. We reason. Frances describes an irrelevant things quite differently. have no bright line telling us which historical debate and engages with his 1) The second umpire rules. As conditions should, or should not,be own empiricist commitments not at all. psychiatric diagnosticians and classi- included; who needs a diagnosis and fiers, there seems to be almost uni- who should be spared one. These deci- *** form consensus that we call them as sions—both on categories and on peo- we see them, not as they are or as we ple—can be made only case by case on An Apology For Dumb make them up to be. There was a practical, utilitarian grounds unin- surprising unwillingness to defend a formed by conceptual clarity and only Utilitarianism pure umpire one approach. Assuming very partially informed by scientific that this is not just selection bias, the evidence. Allen Frances, M.D. acceptance of a nominalist position 6) The decisions made for DSM-5 may represent a departure from the must consider the potential practical I am used to disappointing people majority epistemological opinion consequences and cannot claim an im- (including myself) and I accept Dr during the heady, early days of bio- munity from responsibility because Pouncey's criticism that I haven't even logical psychiatry when everything they are "following the science." The attempted to articulate a systematic, seemed so simple and real and a deep available "science" underlying DSM consistent way to decide which empiri- understanding of causality was only a decisions is never very deep or genera- cal position is most defensible on any matter of time. lyzable and is always subject to widely given question in psychiatric diagnosis. 2) The scientific enterprise in varied interpretation. The most impor- I am not sure to what degree this repre- psychiatry has an extremely bright, tant guide to decision making must be sents my ignorance or my intellectual but extremely difficult future. The the ancient, practical dictum- First, Do laziness (both lively contenders) or powerful tools at our disposure guar- No Harm. whether psychiatric classification is an antee a steady succession of remark- 7) The huge advances in the neuro- inherently messy activity that would able finds in psychopathology. The sciences have thus far had no impact on defy even clear and energetic thinkers complexity of the problem guarantees psychiatric diagnosis. Until we know like Dr Pouncey. I wouldn't know how that each will explain a small percent- more, there is no justification for major to begin to develop an approach that age of the variance. The only possi- changes in the diagnostic system. would "go beyond the observations bility for a quick walk or grand slam Changes, when they come, will likely themselves to justify our beliefs." The home run would be the finding of be retail and piecemeal, each explain- usual organizing principles—or valida- higher order nodal regulators that ing only a small portion of the presen- tors—of descriptive diagnosis have provide a final common pathway tations in any of the existing categories. certainly not proven to be very compel- channeling the complexity of basic The best hope for more wholesale un- ling guides. If there is anything better causes into more manageable patho- derstanding is the NIMH RDOC pro- than ad hoc, "do least harm," case by genetic units. Neurotransmitters theo- ject. case, rough and ready utilitarianism, I ries were once promising, but now 8) The reach of psychiatry should have not yet stumbled across it. So Dr seem to be disappointing, candidates. not exceed its knowlege base. We must Pouncey, the future work in this area is Neural networks are next up to bat. avoid the temptation to medicalize both your wicket (at long last, we get to 72 Volume 17, Number 2 2010

normality and criminality. If we don't out of assumptions and values that useful one…)’—then Frances fits the know how to treat something, it is render the field of psychiatry inaccu- type of the third umpire perhaps even probably not a great idea to make it an rate and sometimes damaging, is no more cleanly than the early official diagnosis—particularly if it small task. It is a project that we phi- Szasz…” (ibid). Frances resists this will result in the diagnosis and possible losophers, psychiatrists, and others charge, affirming that there are ball and mistreatment of millions of people. We can and should continue to work col- strikes out there, a “knowable underly- should not create categories that can be laboratively on. ing reality to what we now call mental misused in the legal system to promote disorders, just...remarkably compli- preventive detention via involuntary *** cated and heterogeneous…” (p 27). psychiatric commitment. (Continued from page 1, Editor) Michael Cerullo enters this discus- 9) Our dilemmas are not ours sion with a naturalist/normativist dis- alone. Most of the above applies almost years prior to publication in 2013— tinction, arguing that most illnesses equally well to all of medicine. There is work within the official chambers of involve a combination of both perspec- no clear and universal definition of the DSM-5 Work Groups, and work tives. He concludes from another state- medical illness and no simple path of going on in parallel outside the offi- ment of Frances that “Together with pathogenetic understanding. The body cial chambers. the earlier baseball analogy this places is not as complicated as the brain, but it In the remaining space I have Frances in the uncomfortable position is pretty complicated. allotted myself, of the many topics I of being an umpire who believes there Finally, a huge thank you to James could comment on from the ensuing really are balls and strikes but who Phillips for conceiving, organizing, and discussions—umpires, pragmatism, feels his rulings have absolutely no editing this exercise. It has been an diagnostic conservatism, alternative relationship to them whatsoever, and illuminating illustration of the central models, clinical utility vs research, who is OK with this!” (p 43). Frances role that conceptual discussion should etc.—I will choose the first, since I again asserts misunderstanding, insist- play (but hasn't ) in the development of find that, while serving us richly and ing that he takes naturalistic under- our psychiatric classification. It is charmingly, the umpire metaphor has standing for granted, but adding about never wise to build an edifice on shaky also led to some confusion—and I Cerullo, “We are very different second conceptual foundations. The DSM-5 don’t just mean for our non-American umpires and disagree on how easy it is process could have avoided many of its readers to whom baseball is probably to make the calls separating the balls mistakes had it begun its efforts by as comprehensible as cricket is for from the strikes” (p 44). appointing a "Philosophy Workgroup" me, i.e., not very. It begins to look as if our problem under the leadership of Dr Phillips. The point of possible confusion is in clarifying what exactly are balls Hopefully this issue will stimulate fur- is umpire #2, with whom Dr Frances and strikes? To be quite concrete, I take ther discussion toward getting the diag- identifies himself, and whom Mishara Frances to mean the following. Balls nostic system back on track. and Schwartz describe as steering and strikes are symptoms and symptom “between the Scylla of naïve biologi- clusters/syndromes: I can see them and *** cal realism and the Charybdis of so- you see them. ‘Diagnoses’ are con- cial constructionism, or alternatively, cepts/constructs that formalize these logical empiricism and post- syndromes. ‘Balls’ and ‘strikes’ may (Continued from page 1, President’s column) modernism.” Calls of alarm regarding temological and ethical responsibilities also refer to these diagnostic constructs umpire #2 come from Kinghorn, Ce- (thus the confusion). There is a poten- in terms of patient values and voices is rullo, and to a lesser extent, Ghaemi, not to strip each person of his or her tially knowable naturalistic, biologic Pouncey and others. underpinning to the symptoms and syn- embeddedness in culture: we are indi- Frances describes the second viduals, yes, but always also living in dromes, but it may not match up at all umpire as : “There are balls and there the midst of social categories, organiz- with the diagnostic constructs. In the are strikes and I call them as I see absence of further knowledge, we ing principles , and more or less oppres- them” (p 3). He adds later: “[M]ental sive societies. We are individuals, yes, should not assume that the diagnostic disorders don’t really live ‘out there’ construct tells us anything about the but we are also members of humanity waiting to be explained. They are together—and whatever else that underlying reality of the respective constructs we have made up—and symptoms or syndromes. means, it is a call for us to work toward often not very compelling ones at mutual flourishing in the eudaimonistic I am left with one question for our that” (p 4). So what is a second um- second umpire. Taking a note from sense. And we are also gendered, ra- pire? Kinghorn remarks that Frances cialized, raised in ethnic and religious Cerullo regarding naturalistic under- at first appears to be a realist of some standing, and Kendell and Jablensky and political communities; we form kind, but then quotes the above cita- perspectives based, in part, on the good (Am J Psychiatry 2003; 160: 4-12) in tion and remarks: “But if this is their discussion of conditions that meet or bad luck of our lives and the cultural true—if the standard for diagnostic meanings we ascribe to that their standard of validity (Down’s syn- classification is not what exists ‘out drome, Huntington’s disease, etc.), ‘luck’ (Was that merited? Was that there’ but rather in ‘getting to what deserved?) Combining EBM and pa- would Frances agree that, say, in the works best,’ if indeed ‘our mental case of Huntington’s disease, we have tient values, not to mention the identifi- disorders are no more than fallible cation, critique, and necessary weeding an adequate understanding of the con- social constructs (but nonetheless dition and that for this diagnosis he 73 would declare himself an umpire #1? Volume 17, Number 2 2010

The Association for the Advancement of EXECUTIVE COUNCIL Administrative Secretary Philosophy and Psychiatry was estab- Linda Muncy lished in 1989 to promote cross- Department of Psychiatry Louis Charland, Ph.D. disciplinary research in the philosophical UT Southwestern Medical Center aspects of psychiatry, and to support edu- Alfred M. Freedman, M.D. 5323 Harry Hines Blvd. cational initiatives and graduate training K.W.M. Fulford, D.Phil., MRCPsych. Dallas, TX 75390-9070 programs. Phone (214) 648-4959 S. Nassir Ghaemi, M.D. Fax (214) 648-4967 OFFICERS Jennifer Hansen, Ph.D. E-mail [email protected]

President Douglas Heinrichs, M.D. Bulletin Editor Nancy Nyquist Potter, Ph.D. Loretta M. Kopelman, Ph.D. James Phillips, M.D. Vice-president Paul R. McHugh, M.D. 88 Noble Avenue David H. Brendel, M.D., Ph.D. Milford, CT 06460 Marilyn Nissim-Sabat, Ph.D., M.S.W. Founding President Phone (203) 877-0566 Michael A. Schwartz, M.D. Christian Perring, Ph.D. Fax (203) 877-2652 E-mail [email protected] Claire Pouncey, M.D., Ph.D. Past Presidents George Agich, Ph.D. Louis A. Sass, Ph.D. Philosophy, Psychiatry, & Psychology Jennifer H. Radden, D. Phil. K.W.M. Fulford, D.Phil., MRCPsych. Jerome L. Kroll, M.D. Deborah Spitz, M.D. G. Scott Waterman, M.D. Founding Editor Secretary John Z. Sadler, M.D. Osborne P. Wiggins, Ph.D. James Phillips, M.D. Co-Editor Treasurer J. Melvin Woody, Ph.D. John Z. Sadler, M.D. Peter Zachar, Ph.D. AAPP Web Site www3.utsouthwestern.edu/aapp

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