by Ahmed Aboraya, MD, Dr.PH
Dr. Aboraya is Chief of Psychiatry, William R. Sharpe, Jr. Hospital, Weston, West Virginia; Clinical Professor of Psychiatry, West Virginia School of Osteopathic Medicine, Lewisburg, West Virginia; and Director of World Health Organization (WHO), SCAN Training and Reference Center, West Virginia University, Morgantown, West Virginia.
Psychiatry (Edgemont) 2010;7(11):32–36
Funding: There was no funding for the development and writing of this article.
Financial Disclosures: The author has no conflicts of interest relevant to the content of this article.
Key Words: DSM-V, psychiatric classification, validity criterion, causal specifiers, definite etiopathogenesis (DE), factors contributing to manifestations of mental disorders (FCM_MD)
Abstract: The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is anticipated in May 2013 with many new additions and changes. In this article, the author summarizes the phases of psychiatric classification from the turn of the 20th century until today. Psychiatry 2010 offers a DSM-V Scientific Forum and invites readers to submit comments, recommendations, and articles to Psychiatry 2010 and DSM-V Task Force.
Introduction
As the time of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) publication nears (now May 2013), serious debates and minor conflicts have erupted centering on the DSM-V process, including openness versus secrecy, the fear of influence of pharmaceutical industries on the DSM-V revision process, and the new proposed diagnostic criteria.[1–8] The DSM-V task force announced ambitious plans, such as adding a dimensional component to the DSM-V[9,10] and shifting to a more etiologically based classification system.[6,11] In order to appreciate the different points of contention regarding the DSM classification system, I will summarize the different phases of psychiatric classification from the turn of the 20th century until today.
Phase I: Unproven Theories Phase (from the turn of the 20th century until 1952)
Psychiatric nosology was founded by expert diagnosticians.12 At the turn of the 20th century, Kraepelin[13] conceptualized his famous “dichotomy theory” that divided mood and psychosis broadly into two diseases—schizophrenia and bipolar disorder. His theory was enshrined in Western psychiatry for more than a century, even though Kraepelin himself revoked his theory in 1920.[13] Another important figure in psychiatry was Adolf Meyer,[14] an influential psychiatrist who trained several generations of psychiatrists and British acolytes at Johns Hopkins University, Baltimore, Maryland, between 1910 and 1941. Meyer conceptualized psychiatric disorders as maladaptive reaction patterns rather than discrete disease entities.[14] Meyer opposed adopting a formal nosology in psychiatry because he feared diagnoses would distract researchers and clinicians from environmental factors, which he thought were the most significant elements in the etiology of mental illness. Meyer eventually resigned from the committee responsible for developing new classification.[15] As psychoanalysis gained ground in American psychiatry, psychiatric nosology was put on the back burner as psychoanalysts believed that psychiatric diagnosis was largely irrelevant for making psychotherapy treatment decisions.[16,17] In general, this half century was a continuation of the 19th century. RE Kendell[18] described the era as follows: “For a long time confusion reigned. Every self-respecting alienist, and certainly every professor, had his own classification…” This era can be summarized as the era of untested theories and therapeutic claims.
Phase II: Pre-DSM-III Phase (from 1952 to 1980)
As clinicians and researchers began to realize the importance of classification, the American Psychiatric Association Committee on Nomenclature and Statistics developed and published in 1952 the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), followed by the second edition, DSM-II, in 1968.[19,20] DSM-I and DSM-II were primarily used for record-keeping purposes, and their descriptions of mental disorders were so brief and general that their influence on psychiatric education, research, and clinical practice was minimal.[16] Theories mostly derived from psychoanalysis and Myers’ ideology influenced the writings of DSM-I and DSM-II. The lack of scientific evidence to support these theories of mental disorders continued, and mental health researchers and clinicians expressed dissatisfaction with the DSM-I and DSM-II because of this.
Phase III: Atheoretical Phase (from 1980 to present)
As the American psychiatric community was dissatisfied with DSM-II and the International Classification of Disease (ICD 9),[21] Robert Spitzer spearheaded the effort to develop and publish the DSM-III in 1980.[22] The DSM-III publication represented a benchmark in the history of psychiatric nosology because it included the long-awaited, detailed, explicit, specific criteria for many psychiatric disorders.[23] The DSM-III was designed to be descriptive and avoid theories with the hope that all clinicians, regardless of their orientations, could use the DSM system. Revisions of the DSM continued with the publications of DSM-III-R, DSM-IV and DSM-IV-TR,[24–26] and all maintained the descriptive approach of DSM-III. Because DSM-III provided psychiatrists with a standardized, diagnostic nomenclature, their enterprises flourished as geneticists, pharmacologists, and brain imagers became research partners with investigative psychiatrists.[17] Regardless of what the DSM critics say, the widespread use of DSM-III and subsequent editions all over the world is a phenomenal success.
Nevertheless, the widespread and slavish adoption of the DSM categorical descriptive approach resulted in several problems. First, as Kupfer et al[27] described, despite more than 30 years of using a descriptive approach to mental disorders, the goal of validating these syndromes and discovering common etiologies has remained elusive. Kupfer et al[27] went further to opine that the current DSM system may have hindered research on the etiology of mental disorders. Second, it is my personal opinion that the widespread use of the descriptive approach of the DSM system led clinicians to overuse medications and de-emphasize the social and environmental factors of mental disorders. A common theme in psychiatric practice today is that psychiatrists prescribe medications and psychologists and therapists do the psychotherapy. Third, several authors rejected the DSM classification to be atheoretical (i.e, mostly based on shared phenomenology only) because phenomenology is only one of many ways to organize psychopathology.28–30 Even strong advocates of the descriptive system, such as Frances,[31] asserted that “the descriptive system is only a temporary way station to be replaced, probably disorder by disorder, with more incisive pathogenetic and etiologic models of classification.”
Are we ready for an etiologically based classification system as advocated by Darrel Regier and the DSM-V Task Force?[6,11] This ambitious plan drew criticism from prominent clinicians and researchers because they believe that there was insufficient evidence to justify making the DSM more etiologically based.[6,7,32] I think that as long as scientific evidence supports the change, psychiatric classification needs to move gradually toward etiology. It is true that we are far from knowing the etiology of most mental disorders. It is also true that the exact etiology of psychiatric disorders is limited to a few disorders, such as Alzheimer disease and vascular dementia,[33] and will continue like that for generations to come. At the same time, we cannot be held back by a rigid descriptive system that might hinder progress in understanding the causes of mental disorders. We must start somewhere. Having said that, I would like to introduce and define the following terms: validity criterion and causal specifiers, which can be definite etiopathogenesis or factors contributing to manifestations of mental disorders.
Validity criterion. I define validity criteria as any knowledge, method (e.g., rating scale or structured interview), or procedure (e.g., blood test, lumbar puncture, or magnetic resonance imaging [MRI]) that can improve the accuracy of the disease, syndrome, or disorder measurement; help to rule out other diseases, syndromes, or disorders in the differential diagnosis; or validate a provisional diagnosis of the disease, syndrome, or disorder.[34] The use of validity criteria by clinicians improves the validity of psychiatric diagnoses[35] and leads to the knowledge of factors contributing to manifestations of mental disorders (i.e., contributing factors) and definite etiopathogeneses.
Causal specifiers. Causal specifiers are potential causes of mental disorders and can be biological, genetic, environmental, developmental, social, psychodynamic, behavioral, cognitive, or characterological. Depending on the clinical judgment of the degree of certainty, a causal specifier can be a definite etiopathogenesis or a factor contributing to manifestations of mental disorders.
Definite etiopathogenesis. A definite etiopathogenesis refers to a factor that is deemed with good evidence to be the cause of a mental disorder. For example, consider the case of a 45-year-old man who had no psychiatric history until he suffered head trauma in a car accident. MRI after the accident showed a subdural hematoma. Mental status evaluation and neuropsychological testing showed significant memory deficits. The final diagnosis was amnestic disorder due to head trauma. The head trauma or the subsequent subdural hematoma is a definite etiopathogenesis in this case. In this oversimplified example, the following four validity criteria were used: 1) history of head trauma, 2) mental status examination, 3) neuropsychological testing, and 4) MRI imaging. Remember, definite etiopathogeneses are rare in medicine and psychiatry.
Factors contributing to manifestations of mental disorders. These are factors (e.g., biological, environmental, social, developmental) that the clinician judges to be contributing to the manifestations of illness, but they fall short of being definite etiopathogeneses. These factors are very important in case formulation, differential diagnosis, and treatment decisions. As our understanding of these contributing factors improves, a contributing factor can be upgraded to a definite etiopathogenesis. For example, one patient is diagnosed with bipolar disorder and he has an uncle on his father’s side with bipolar disorder. Today, we can say genetics is a contributing factor. Tomorrow, geneticists may discover the specific gene for bipolar disorder. At that time, genetics can be upgraded to a definite etiopathogenesis. Also, it is important to note that one factor can be a contributing factor in one patient and a definite etiopathogenesis in another patient. For example, a 45-year-old man was diagnosed with schizophrenia, paranoid subtype at the age of 20 and had had 10 psychiatric admissions for delusions and hallucinations. At the age of 40, the patient suffered head trauma, which resulted in a new onset of violent episodes. In this patient, head trauma was a contributing factor, whereas case example of the man mentioned previously, head trauma was a definite etiopathogenesis. Finally, clinical judgment is crucial in deciding whether a factor is contributing to manifestations of mental disorders or a definite etiopathogenesis.
I am of the opinion that psychiatric nosology is moving from “expert-based classification” to “scientifically based classification,” whereby clinicians and researchers are called on to refine diagnostic criteria based upon phenomenology, validity criteria, and new statistical and scientific methods. A good example of new scientific methods is the process of epistemic iteration. Chang[36] defined epistemic iteration as a historical and scientific process in which successive stages of knowledge in a given area build in a sequential manner upon each other and lead toward a better approximation of reality. Kendler[12] proposed using the epistemic iteration process in psychiatric nosology where new diagnostic criteria proposed are expected to improve upon the performance of their predecessor using an agreed upon set of validators.
Regardless of whether we are ready for etiologically based classification or not, one fact is clear: the era of concocting theories without scientific evidence, such as the schizophrenogenic mother hypothesis of Fromm-Reichmann in the 40s, is over.[37,38] On a related issue, the division of general psychiatry into “biological psychiatry,” “social psychiatry,” “psychodynamic psychiatry,” “Anglo-Saxon psychiatry,” and other subdivisions is outdated and obsolete.[39–43] Proper case formulation of a psychiatric patient requires knowledge of the patient’s history; personal experiences in life; developmental, social, cultural, and genetic factors; medical conditions; symptoms presentations at different stages; and other relevant factors. These pieces of information must then be put together to understand the patient as one unique individual. Can any of the “biological psychiatrists” deny the role of social and environmental factors? Can any of the “social psychiatrists” deny the high bipolar disorder concordance rate in identical twins, even when raised in different households? When a theorist postulates a theory, he or she should demonstrate the scientific evidence to back up the theory. That is the hallmark of evidence-based psychiatry.
Invitation to readers to participate in a DSM-V Forum
Renato Alarcon, a member of one of the 13 working groups of the DSM-V Task Force, advised critics of the DSM-V process to offer specific suggestions about specific groups of disorders or clinical conditions in journals, periodicals, or in any other medium.[44] Psychiatry 2010 takes his advice and announces DSM-V Scientific Forum. Psychiatry readers, whether they are DSM fans or critics, are invited to share their views in Psychiatry 2010 DSM-V Scientific Forum.
For information on the DSM-V, readers are encouraged to visit the APA DSM-V Development website.
Guidelines for participation. The guidelines for participating in this forum are simple:
1. If the reader likes or agrees with a current DSM diagnosis or criteria, he or she should tell us why and suggest ways to improve the current DSM system.
2. If the reader does not agree with a current DSM diagnosis, criteria, or other issue, he or she should tell us why and advise and provide alternatives to improve the current DSM system.
3. Readers can comment on the new proposed diagnostic criteria for DSM-V.
4. Readers are expected to provide a thorough review of literature and use scientific data to support their views.
Psychiatry 2010 DSM-V Scientific Forum will kick off with my article, “Recommendation for DSM-V: A Proposal for Adding Causal Specifiers to Axis I Diagnoses,” which will be published in the December issue of Psychiatry 2010.
Instructions for participation. Reader participation in this forum can take place in the following manner:
1. Online. Readers can post their opinions and comments by using the “comment” feature at the bottom of this article. Comments should be concise, on topic, and evidence based. Please include your name with your comment. Off topic or anonymous comments on the website will NOT be posted. Please refer to the guidelines for participation.
2. In the journal. Readers can submit brief commentaries to the journal for consideration and possible publication in an upcoming issue of the journal. All commentaries should be evidence based, concise, and on topic, 500 to 1,000 words, with references. All commentaries will be reviewed by the editors and will be accepted or not accepted based on that review. Revisions may be required. Please refer to the guidelines for participation above, as well as the author guidelines for submission instructions. Anonymous or off topic commentaries will not be considered.
3. Anonymously. Anonymous comments will NOT be published in the journal or on the website. Readers can submit anonymous comments directly via email to eklumpp (at) matrixmedcom (dot) com. Indicate in the email that the comment is to be anonymous. Anonymous comments that are considered constructive by the editors will be labeled “anonymous” and included with the other accepted comments and commentaries sent to the DSM-V task force.
Deadline for submissions. All comments and commentary submissions should be via the journal website or email by May 15, 2011. Accepted commentaries will be published in upcoming issues of the journal. Accepted comments made to the website will be posted on a daily basis.
We hope Psychiatry 2010 readers will contribute to the DSM-V Scientific Forum. Your voice is the voice that counts, so let it be heard. All responses will be compiled and submitted to the DSM-V task force.
Questions. For submissions and/or questions, please e-mail Elizabeth Klumpp, Executive Editor, eklumpp (at) matrixmedcom (dot) com or call (484) 266-0702.
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