Thursday, February 11, 2010

The Draft DSM-5 - Rip It Up and Start Over: Part I

Yesterday, the American Psychiatric Association’s DSM-5 Task Force released its much-anticipated draft to the next DSM, scheduled for completion in 2013. The document is available for viewing and comment on the APA’s website.

Where to start? Let’s go with my diagnosis - bipolar - as well as the bane of my life, depression. First some background:

Written observations on depression and mania go back to ancient times. How could Plato, for instance NOT notice Socrates acting weird? But observations do not equate to understanding, and, crazy as it sounds, what was beyond the grasp of ancients continues to elude today’s experts, namely:

How do depression and mania relate? Part of the same phenomenon? Or separate? A bit of both?

How do depression and mania fit into the human condition? Natural temperament? Or outside force that takes over the mind? A bit of both?

By the last half of the nineteen century, medical science had connected depression to mania. “Folie circulaire,” the French called it. In the early twentieth century, the pioneering German diagnostician, Emil Kraepelin (pictured here), coined the term manic-depression. But here’s the rub - manic-depression to Kraepelin and generations to follow was not synonymous with what we now call bipolar. Manic-depression also embraced what we now call unipolar depression.

Kraepelin saw depression as a “recurring” phenomenon. Some individuals cycled up into raving mania, then back down into depression (often with long periods of remission). Others simply cycled up into milder states.

In essence, Kraepelin saw depression and mania as occupying opposite ends of the same spectrum, different but closely related, with the same underlying cyclic features. Kraepelin also viewed manic-depression as a biological illness, but nevertheless occupying a spectrum that embraced the temperaments that influence our personality.

Kraepelin’s model proved to be a bit too overreaching. In the 1960s, Jules Angst and others identified “chronic” depression and parsed it out from “recurrent” depression. But the Kraepelin model still held. During the 1970s, Frederick Goodwin and others regarded recurrent depression as a close cousin to bipolar rather than a sibling of chronic depression.

This bears repeating: The leading investigators of the day viewed manic-depression as embracing both bipolar and recurrent depression. Chronic depression was seen as a separate phenomenon.

Another way of viewing the spectrum, pioneered by Angst, is by conceptualizing “pure” mania at one end and pure depression at the other, with a lot of mixing it up in the middle. Thus, severe depression with a bit of mania might look like this - Dm - while hypomania with some depression would be represented as - md. And so on. Under this view, “mixed” states (think agitated depression or dysphoric mania) are seen as closer to the rule rather than the exception.

Meanwhile, we had Freud to consider. Freud’s followers saw depression and mania (and other states) as not necessarily biological, but as maladaptive reactions to one’s environment. Freud was the dominant mindset of psychiatry when the APA published the DSM-I in 1952, replete with its inclusion of “manic-depressive reaction.”

Oddly enough, “manic-depressive reaction” embraced Kraepelin’s wide view of the illness, but as an outward expression of underlying psychosis. Since Freudian psychiatrists wrote off those they saw as “psychotic” as hopeless and uncooperative, there was little interest in working with these patients. Their fate was institutional neglect.

“Neurosis” and “behavior” by contrast, defined psychiatry’s walking wounded as well as its meal ticket. The DSM-I made provision for both depression, and manic-depression lite (cyclothymia) as either a manifestation of anxiety-driven neurosis or as embedded in one’s personality. This accorded with the Freudian mindset of rooting out the underlying neurosis or behavioral quirk rather than helping patients manage symptoms. Hence there was little professional interest in depression and other ills as entities unto themselves. Hence, there was little interest in the DSM.

The DSM-II of 1968, largely a rerun of 1952, met with the same underwhelming response. But change was in the air. First-generation psychiatric meds, coupled with the realization that not many patients actually got better under Freudian therapy, give rise to a new era of diagnostic psychiatry, with Kraepelin as its inspiration. Leading the charge was Robert Spitzer, with a modest brief to tweak the DSM so it harmonized with international standards.

Spitzer had other ideas. With a strong supporting cast of psychiatric researchers who valued science over dogma, Spitzer set about producing a document that would allow professionals worldwide to communicate in the same language. A major innovation was the “symptom list” that represented a giant leap forward from Freud and his neurotic muck.

What was widely understood by those working on what was to become the DSM-III of 1980 was that their efforts would represent a work-in-progress. With psychiatric science in its infancy, it was a given that new data and new insights would supplant the best guesses that Spitzer and his team were coming up with. Mistakes were inevitable, but you had to start somewhere. Just so long as you could correct them later.

Just so long as you didn’t cement yourself into a corner for the next 30 years.

Next: The DSM cements itself into a corner for the next 30 years ...

Further reading:

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