Advancing DSM: Dilemmas in Psychiatric Diagnosis

Abstract

KATHARINE A. PHILLIPS M.D., MICHAEL B. FIRST M.D., AND HAROLD ALAN PlNCUS M.D., EDS.: Advancing DSM: Dilemmas in Psychiatric Diagnosis. American Psychiatric Press, Washington DC, 2003, 264 pp., $39.00, paperback, ISBN 0-89042-293-1. Clearly something special happened with the introduction of DSM-III in 1980. For a number of years, an APA task force had been working on the third revision, the previous one dating to 1968. DSM-II was widely considered out of date. Indebted to ideas derived from Adolf Meyer and Freud, it used language like manic-depressive reaction, depressive, which now seem quaint. The 1960s and 1970s had seen the growth of psychopharmacology and an apparent specificity of treatments, at least according to the government. Tricyclic antidepressants treated depression, neuroleptics treated schizophrenia, and lithium treated mania. Emil Kraepelin's nosology, scorned for so long by leaders of American psychiatry for being therapeutically nihilistic, seemed vindicated after all. In the revolutionary city of St. Louis, a not-so-secret cabal began to resuscitate Kraepelin's nosology. It deleted the master's commitment to infectious/physical etiologies, and added a therapeutic optimism that the asylum superintendent from Munich lacked. Gerald Klerman, surveying the scene from his perch at Massachusetts General Hospital, realized that change was afoot, and he gave this change a name: neo-Kraepelinianism. Klerman and others, like Robert Spitzer, a talented methodologist from Columbia, joined forces with the St. Louis group (headed by Eli Robins), and the task force to update DSM was born. Sitting on an APA task force at present to update the APA ethics guidelines, I can say from experience that such committees are not simple affairs. They are essentially appointed by the APA president, and then produce a document, often with peer review from academic experts who read the next to final draft. The document then may need ratification from the APA congress of representatives, before it receives the final imprimatur of the organization. Thus, the work of the DSM-III task force was not conducted in clandestine darkness. Besides the neo-Kraepelinian group, efforts were made to include representatives of other approaches, the strongest of which was of course the psychoanalytic school. There were compromises: the categories of dysthymia and generalized anxiety disorder were added, for instance, primarily due to concerns among psychoanalysts about not having insurance codes (and thus a way of being paid) for neurotic depression. There was no doubt, however, that the thrust of the document was neo-Kraepelinian: the key new categories were major depression, bipolar disorder, and schizophrenia. There was no talk of Meyerian reactions, and Freudian concepts were mostly relegated to the personality disorders on a separate axis of diagnosis than the primary psychiatric disorders. Commitments to etiology were dropped; an emphasis on descriptive reliability (Let's at least agree on what we call things) was emphasized. The hope was expressed, nowhere better than in a wonderful debate in the 1982 APA meeting in Toronto (1), that future revisions could build on the major changes in DSM-III. The big achievement, all agreed, was reliability. By giving up theories about etiologies, none of which were proven, we could at least agree on how to describe signs and symptoms objectively. This reliability would allow research to proceed more effectively, and hopefully data regarding etiology would eventually be obtained in a scientifically accurate manner. In other words, reliability would pave the way for validity. Future revisions of DSM-IV would change as research showed the way, with perhaps major changes in the initial formulations of DSM-III. This is how Spitzer and Klerman described their hopes in 1982. Has this happened? The fourth revision, published in 1994 and headed by Alien Frances, then chair of Duke University's department of psychiatry, was billed as incorporating empirical advances. …