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

Allow me to explain the title to this piece and to a recent piece:

“Creative destruction” is a term popularized by Joseph Schumpeter in the 1940s to explain the necessary and typically heart-breaking disruption and chaos that gives rise to economic progress. Think changing times. The advent of the automobile put buggy whip manufacturers out of business. In turn, the likes of GM grew at the expense of smaller auto manufacturers. And the process continues today with GM fighting for its life in a new global economy.

It’s a never-ending cosmic dance of destruction and creation, exemplified by the Hindu diety Shiva.

A post-GM world, followers of Schumpeter would argue, promises to be a better one: Imagine a leaner and greener auto industry responsive to consumer needs and environmental realities. Yes, the transition is bound to be devastating, but indiscriminately trying to soften the pain, they would say, only leads to stagnation and decline.

In the field of psychiatry, the exemplar of creative destruction was Robert Spitzer, who boldly took on the cult of Freud and ushered in a new era of psychiatry. The ground-breaking DSM-III of 1980 and its follow-up DSM-III-R of 1987 were his great achievements. Thanks to Spitzer and his contemporaries, we seek out psychiatrists and therapists to treat our depression rather than undergo analysis to root out our neurosis.

Ironically, though, the unprecedented success of Spitzer's DSM spawned its own problems. Suddenly, we had “stakeholders” in the form of the insurance industry, the drug industry, the research establishment, not to mention psychiatry and its related professions. Oh, yes, patients too, but who listens to us?

Overnight, the DSM became entrenched, incapable of correcting even its most obvious faults, incapable of folding in new insight. Take the current DSM’s view of depression - please! - which is virtually unchanged since the DSM-III. Yes, the DSM-III version is an improvement on the DSM-II of 1968, but at least the older view recognized the complexity of the condition and its context, namely:

The DSM-II viewed depression as both separate from (in the sense of “depressive neurosis”) and as part of manic-depression (in the sense of “manic depressive illness, depressed type”) and tied into anxiety (in the form of “involuted melancholia” and as the driving force of “neurosis”) as well as embedded into personality (as in “cyclothymic personality disorder characterized by depression”).

Moreover, the DSM-II distinguished between depression seen as a result of the mysterious biology of the brain (“endogenous”) and depression seen to be caused by a reaction to events (“exogenous”).

The DSM-III replaced all that with a monolithic view of unipolar depression, separating it out from manic-depression and anxiety and personality and doing away with the endogenous-exogenous distinction. Instead, for the first time, we were treated to the famous and extraordinarily arbitrary nine-item symptom checklist.

Viewing depression as a single and non-complex entity offers the advantage of clarity in a world where clinicians and other interested parties need to be speaking the same language. The problem occurs when this simplistic view encourages equally simplistic treatments.

(Yes, the current DSM distinguishes the likes of melancholic from atypical depression and makes room for depression with psychosis and the like, but only if the full criteria is met for a depressive episode.)

In my book, "Living Well with Depression and Bipolar Disorder," I cite a 2004 article by Gordon Parker MD, PhD of the University of New South Wales in support of the proposition that this one-size-fits-all view of depression results in clinical trials that indiscriminately lump all patients together, with no regard to critical distinctions that may spell the difference between success and failure.

We know for instance that an SSRI such as Paxil gets 50 percent of patients with “major depression” 50 percent better over a period of about six weeks. This is good enough for the drug companies, who now have a license to print money, but what about the patients? Who wants a 50 percent chance of success? And who wants to be just 50 percent better?

What do we know about Paxil, anyway? Does it work better on a patient whose depression is marked by sadness? If so, is it possible to target this group of patients? Maybe then we would be seeing 80 percent of these individuals getting 80 percent better.

And try this on for size. Maybe a patient whose main feature is lack of motivation (about which the DSM has nothing to say) would benefit from something else, as would depression brought on by stress (the type of “exogenous” depression axed from the DSM-III). Maybe these drugs don’t exist. Maybe Pharma would be encouraged to develop them. As Dr Parker in a 2007 piece concludes:

Depression is a diagnosis that will remain a non-specific "catch all" until common sense brings current confusion to order. As the American journalist Ed Murrow observed in another context: "Anyone who isn't confused doesn't really understand the situation."

In other words, never mind what is convenient to the industry-professional-research establishment. To move forward, first we need to journey back to the naive and confusing DSM-II and acknowledge that the real world of depression is highly nuanced and complex. Then, maybe we could deploy our modern knowledge to develop a new and sophisticated, but no less confusing, understanding.

Instead, the DSM-5 Mood Disorders Work Group in a report from April 2009 signaled it was using the DSM-III (upon which the DSM-IV is based) as its starting point, noting that a subgroup was reviewing “whether there is sufficient data to support adding or removing symptoms” to or from the major depression checklist.

Often, the results justify working off an existing document. But no changes? With no explanation? After all we have learned since 1980? With our lives at stake?

A little creative destruction, please. Time to rip the thing up and start over.

Much more on the DSM-5 draft to come ...

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV

Spitzer and the DSM - Part IV

In Part I, I introduced Robert Spitzer, architect of the ground-breaking DSM-III of 1980 and what psychiatry was like when Freud ruled the roost. Part II described the Spitzer's triumph in unseating Freud, and Part III recounted Dr Spitzer's boorish behavior at the dinner table at the 2003 APA in San Francisco. To pick up where I left off ...

Yet when I surveyed all that my hands had done
and what I had toiled to achieve,
everything was meaningless, a chasing after the wind;
nothing was gained under the sun.

- Ecclesiastes 2:11

Nearly two years later, the Spiegel profile in The New Yorker gave me an insight into Dr Spitzer’s table manners. According to the piece:

Despite Spitzer’s genius at describing the particulars of emotional behavior, he didn’t seem to grasp other people very well. Jean Endicott, his collaborator of many years, says, “He got very involved with issues, with ideas, and with questions. At times he was unaware of how people were responding to him or to the issue. He was surprised when he learned that someone was annoyed. He’d say, ‘Why was he annoyed? What’d I do?’ ”

Then, following the runaway success of the DSM, things apparently went to his head. According to the New Yorker, “emboldened by his success, he became still more adamant about his opinions, and made enemies of a variety of groups.”

And again:

“A lot of what’s in the DSM represents what Bob thinks is right,” Michael First, a psychiatrist at Columbia who worked on both the DSM-III-R and DSM-IV, says. “He really saw this as his book, and if he thought it was right he would push very hard to get it in that way.”

This sense of ownership cost Spitzer his chance to head up the DSM-IV. The new chair, Allen Frances MD of Duke University, put his committees on notice to cut back on “the wild growth and casual addition” of new mental disorders. In a piece published in the June 29, 2009 Psychiatric Times, Dr Frances appeared to be bragging about how little the DSM-IV task force actually accomplished:

“In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III ...”

This is one hell of an admission. Basically, Dr Frances is telling us that the diagnostic psychiatry of 2009 is based on a book that was published in 1980, back when psychiatric science virtually didn’t exist.

It is speculative to ponder on the “what-if’s,” but that’s my job. So, suppose Dr Spitzer hadn’t fallen in love with his 1980 opus. Suppose he possessed some rudimentary people skills. Suppose he had been able to combine his innovative brilliance with a sufficiently level head to guide the DSM into its next critical phases - to fill in the blanks from the earlier editions, correct obvious errors, and realign content in accord with new scientific discovery and clinical insight.

Imagine, in effect, if you could pick up a current DSM right now and open the pages to an accurate description of your clinical reality. That book doesn’t exist. The DSM-IV is a dinosaur, and any clinician who relies on it as an authority is endangering his patients.

Things could have been a lot different. But the man who - through his superhuman efforts - unseated that twentieth-century icon Freud, through his own mortal foibles, wound up unseating himself. His personal disappointment turned out to be our huge loss.

To be continued ...

Robert Spitzer and the DSM - Part III

In Part I, I talked about finding myself at a dinner table at a symposium at the 2003 APA annual meeting with Robert Spitzer, who masterminded the ground-breaking DSM-III of 1980. Part II touched on the history of the conflict between diagnostic and Freudian psychiatry, and the triumph of Spitzer’s DSM-III. To continue ...

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. And here I was looking up from my salad trying to think of something to say.

Out of deference, I waited for the psychiatrists at the table to open the conversation. I would just be a fly on the wall. But no one spoke. Silence. Just the clinking of glasses and the rattling of plates. I always knew psychiatrists were a bit weird, but this was ridiculous.

I introduced myself to Dr Spitzer as a bipolar patient who was at this particular conference as a journalist. These days, I simply introduce myself as a journalist. Back then, I over-identified with being an entry in Spitzer’s diagnostic schema.

Let’s put it this way, if you are in a constant life-and-death struggle with testicular cancer you are understandably thinking about it every second of your life. But then comes a time when you need to forget that you have one testicle and start focusing on your own personal Tour de Life.

But, yes, I still wear a yellow and blue DBSA rubber wristband, not unlike the yellow cancer band that Lance Armstrong made famous.

Anyway, I had a few thoughts of my own about the DSM, I told Dr Spitzer. Would he be interested in hearing them?

This is like telling Einstein that I had a few thoughts about relativity, but Dr Spitzer indicated that I proceed.

What motivated me to ask in the first place was that I naively assumed that the very last person to regard the DSM to be cast in stone would be the person who broke the mold in the first place. Think of Robert Spitzer as the great auto designer Harley Earl, and the DSM-III of 1980 as the 1955 Chevy and the DSM-III-R of 1987 as the 1957 Chevy.

By contrast, the post-Spitzer era - the DSM-IV of 1994 and the DSM IV-TR of 2000 - merely played around with the fins. So now, here we were in a new millennium driving around to the mechanics of a bygone era

Mind you, at the time I lacked the both the standing and the knowledge to challenge Spitzer on this, so I decided to stick to the one aspect of the DSM that I had put some thought into. This concerned the issue of gender and depression. Here, I was on fairly solid ground, as many experts were pushing for changes to the DSM on this matter. My view, and the view of these experts, is that the DSM symptom list is biased toward picking up depression in women while men suffer in silence. According to conventional wisdom, twice as many women experience depression as men. But a bit of tweaking to that symptom list, I argued, could even out that equation.

I waited for the go-ahead, then proceeded down the list. Symptom one is “depressed mood most of the day,” and the unfortunate example is “appears tearful.” Men, by contrast, express themselves in other ways or else fail to express themselves at all. Number three concerns weight gain or loss. Think of what women go to the fridge for when feeling low. Now think of what men reach for. Symptom seven is about worthlessness and guilt, but men tend to lash out and blame others. Last but not least is suicidal thinking. Men fall victim more often than women, but women make far more attempts, and so are more likely to come to the attention of the profession and be treated.

Dr Spitzer pondered my comments, then, as psychiatrists are wont to do, said nothing. By now, the main course had come out. Any further conversation was light and inconsequential. Soon the first of several speakers started talking. It was time to go to work, to take notes.

Two hours later, the last of the speakers wrapped up. Question time was just ahead. Most members of the audience use this brief interval to leave, and so it was that Dr Spitzer got up to make his exit, but not before addressing me.

“I thought about what you said,” he told me, or words to that effect. And then his verdict: “And I don’t go along with any of it.”

Then he rose from his chair and was gone.

Hey, what did I know? He was Robert Spitzer, founder of modern psychiatry. I was just a male bipolar patient who had to deal with depression every day of my life.

Robert Spitzer and the DSM - Part II

In Part I, I mentioned how I found myself seated next to Robert Spitzer, the architect of the ground-breaking DSM-III, and the inadequacies of the earlier versions. To pick up where I left off:

In an article published in Science in 1973, Stanford University psychologist David Rosenhan described dispatching eight healthy associates to various mental hospitals, each claiming to have heard voices. All eight were admitted, seven with the diagnosis of schizophrenia, one with manic-depression.

Following admission, all eight behaved normally. Although many of the real patients suspected a ruse, hospital staff interpreted even routine behavior on the part of the impostors as pathological, such as “writing behavior.” To obtain release, the “patients” had to acknowledge their diagnosis and agree to take meds. The “patients” were held on average for 19 days.

In the second part of his experiment, Dr Rosenhan let it be known at a particular hospital that more fake patients were on the way. The hospital was aware of the results of the first experiment, and were confident they could weed out the impostors. Out of 193 patients, 41 were singled out as phonies and another 42 were considered suspect. In reality, no bogus patients had been dispatched. All the patients were genuine.

According to Dr Rosenhan: “Any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.”

A year later, Robert Spitzer MD of Columbia University drew the assignment of leading a new revision of the DSM, the so-called diagnostic Bible that no one paid any attention to at the time.

Dr Spitzer drew his inspiration from the pioneering German diagnostician, Emil Kraepelin (pictured here), who was born the same year as Freud. It was Kraepelin who coined the term, manic-depression and separated out the illness from schizophrenia, thus giving psychiatry a basic navigating system. Kraepelin believed that mental disorders were best understood as analogues of medical disorders.

In other words, you don’t treat a heart attack as if it were cancer, or as if the two were somehow related. For one, an individual in the throes of cardiac arrest and someone with a specific organ system under siege have entirely different symptoms.

But psychiatry, which back in the seventies was still in thrall to Freud, viewed things totally differently. To Freud’s followers, symptoms (such as depression) were merely maladaptive reactions to inner turmoil. You didn’t treat the depression; you dug deeper to root out the underlying neurosis. To a Freudian, diagnostics didn’t matter.

The old-timers have no end of horror stories. At the 2004 APA in New York, I heard Jack Barchas MD of Cornell University - the man who pioneered research into serotonin’s connection to behavior - relate how an early mentor actually challenged one of his ideas on these grounds: “How is this justified in the writings of Freud?”

Dr Spitzer lined up support from the one university of the day not under the spell of the Wizard of Id, Washington University (St Louis), an outpost of intellectual sanity fairly crawling with Kraepelinians. In 1972, John Feigner, then a resident there, came up with a classification scheme that Spitzer adopted as the template to block out a first draft, which was completed in a year. In addition, Spitzer used his unlimited administrative control to establish 25 committees peopled with psychiatrists who despised Freudian dogma and who viewed themselves as scientists.

The catch was that there was precious little that could pass for psychiatric science at the time. Meetings often degenerated into free-for-alls where the loudest voices tended to prevail. Nevertheless, a working draft was thrashed out, which was tested by the NIMH for reliability. In other words, if presented with a basic set of symptoms, could different psychiatrists agree on the diagnosis? Or, at least, kinda come close?

One problem in the past was that one psychiatrist’s view of depression could be very different from that of another psychiatrist. Dr Spitzer’s solution was the “checklist,” something we all take for granted these days. (For instance, a diagnosis of major depression requires checking off at least five of nine listed symptoms.)

Something else we take for granted: ADD, autism, anorexia nervosa, bulimia, panic disorder, and PTSD - these illnesses and others debuted during Spitzer’s watch, and no one these days seriously challenges their legitimacy.

Finally, a “multi-axial” system separated out major mental illnesses (such a depression, bipolar, anxiety, and schizophrenia) from personality disorders such as borderline personality disorder (which made its debut in the DSM-III).

The draft copy that got circulated amongst the profession totally eliminated that Freudian article of faith, “neurosis.” To Spitzer and his task force, neurosis was an emperor with no clothes. Basically, if depression were a reaction to neurosis, then show me the neurosis. The depression was visible, tangible, treatable. But what was this underlying neurosis crap? Where was the scientific evidence?

By the end of the seventies, Freudians were in retreat, but they still had the clout to sabotage Spitzer’s efforts. The term, neurosis, was restored, but relegated to parenthesis. In 1979, following some more strategic compromises, the DSM-III came up for approval before the APA. According to an eyewitness account from an article by Alix Spiegel in the Jan 3, 2005, New Yorker:

“People stood up and applauded. Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts, and instead he gets a standing ovation.”

The DSM-III became an instant runaway success worldwide. Finally, no more Freudian muck. Clinicians, researchers, and other stakeholders had a common language, could actually talk to one another. Patients for the first time could enter a clinician’s office with the reasonable expectation of an accurate diagnosis and the appropriate treatment. Imagine that.

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. What do I say?

To be continued ...