Imagining a new DSM

What would I do?

Posted Aug 11, 2010

Prof. Lane flatters in asking me to take a scalpel to DSM, especially since I was too young to be on DSM-IV, and no one asked me to be involved with DSM-5, and, I fear, after all these blog posts, I may be pre-empting any potential role in DSM-6.  But as William James said, the academic profession has its heroic obligations.  

To begin,  let's clear up some assumptions and preconceptions. I begin by describing two ways of looking at diagnoses:

The first way is to see diagnoses as diseases; the second is to see them as "clinical pictures." Clinical pictures are replicated, well-described, common conditions that clinicians see; alcoholism is an example. Sometimes clinical pictures represent diseases; sometimes they do not. One cannot prejudge this question; it is an empirical, not a philosophical question.

As to what is disease, specifically psychiatric disease, I am quite familiar with the philosophical questions, but I do not think the concept is one to be avoided. There is mental disease; it involves abnormality of the brain, expressed through psychological symptoms. Neurosphylis is a classic example where the etiology is now known; the etiologies of schizophrenia and manic-depressive illness are clearly not as simple as a single infectious agent, but this does not mean that they are not diseases. Much is known, in fact, about the biology of these conditions, and they seem quite similar to other polygenic diseases with important environmental aspects, like other common chronic illnesses without single known etiologies, such as coronary artery disease, diabetes, stroke, hypertension, migraine, epilepsies, and on and on.  This is a brief comment on a large topic, but one worth expanding if desired. (I have written extensively on it elsewhere.)

I would say that a good place to start with the diseases that deserve to be seen as such in future DSMs is the classic textbook Psychiatric Diagnosis, written in the Kraepelinian tradition. In that book, there is a list of about ten diseases, which I would revise as follows: schizophrenia, manic-depression, melancholia, panic attacks, obsessive-compulsive disease, delirium, and dementia. Then there are a few clear clinical conditions, described for at least a century or more, that are clear clinical pictures (though not diseases in the sense of the other conditions): alcoholism, drug abuse, sociopathy, hysteria, PTSD, anorexia, bulimia, borderline personality, phobias. This makes a list of sixteen conditions. The number 50 is not sacred, but I think future DSMs could derive a consensus based on clear clinical experience for other well-replicated clinical pictures: Some people seem to have sexual problems that are not explainable by the above diseases, "paraphilia" is a clinical picture. Another is neurotic depression ( a better term in my view than generalized anxiety disorder). There also is biological and scientifically valid diagnostic evidence for abnormal temperaments, which are essentially extremes of normal personality traits, and genetically related to mood conditions: cyclothymia, dysthymia, hyperthymia. In addition to these temperaments, I would support inclusion of normal personality traits - instead of personality "disorders" - to explain extremes of personality; eg, the Neuroticisim, Extraversion, Openness to Experience (NEO) model.

(An aside: Prof. Lane is correct I agree with the concept of temperaments, as recently advocated by Akiskal, but I do not agree with the removal of the notion of neurotic depression, as I have recently published, in contrast to some of the past articles of leaders like Akiskal and Winokur. In contrast, I think Sir Martin Roth had it right when he warned that the removal of neurotic depression from DSM-III was a major mistake. My experience is that some anti-Pharma and anti-bipolar critics are confused: they want to pigeonhole me based on their preconceptions, but they find I sometimes agree with some of their opponents, and sometimes I do not; the reason is that I am not pursuing an ideology to its logical consequences; I simply am trying to find out what is true.)

So in summary, this does not add up to 50 conditions; it seems it is about 20 conditions, supplemented by the normal dimensions of personality. But I could see adding ten or so more based on good clinical consensus for clinical pictures.

As for the rataplan about Pharma, I have already written about this topic, and presumably Prof. Lane has read and knows what I think about it. I will only add here the following brief comments:

Regarding the Pharma relationship with DSM-III, Prof. Lane points out Isaac Marks; I stand corrected if his point is that Marks was instrumental in instituting the diagnosis of panic disorder in DSM-III, if that is what he has found. However, that is one person and one disorder. The major revolution of DSM-III was in narrowing (not broadening) the most common major mental illness diagnosis in the US - schizophrenia. How did Pharma aid and abet that process, at a time when antipsychotics were the major drug class being marketed by Pharma? Major depression was invented broadly, but show me the connection between the DSM-III task force and the Pharma makers of antidepressants before 1980. I have not seen such evidence. I don't believe it exists. As for bipolar disorder, lithium was a generic drug from the start.

More generally, on the tired tantivy about doctors getting paid by Pharma, tell me something I don't know. And tell me how this matters for the future.  Some of the major Pharma players, including ones that produced useful drugs (like Glaxo), are completely pulling out of CNS activity altogether. Explain to me: How does this help people with psychiatric diseases? Unless you think there is no such thing as disease in psychiatry, and that none of them need drugs. Again the spirochete, and that most effective psychotropic drug, penicillin, beg to differ. To those who claim that there is no psychiatric disease and that drugs are just useless in psychiatry, I have a one word answer: Penicillin. No, I have two one-word answers: Lithium and penicillin

When some writers started describing some of these relationships over a decade ago, it was new and interesting. Now it is as stale and old as another diatribe against communism. Okay, we get it. Believe me, I know it in much more personal detail than Professor Lane. I saw all the corruption and I fought the biased views of some of my colleagues for the past two decades, in private and in public. Read some of my scientific articles in clinical psychopharmacology. As a journal peer reviewer, I also prevented publication of many biased papers, probably costing pretty pennies to many companies in the process.  I have actually fought this fight, not watched from the outside. These revelations are as novel as the Pentagon Papers. I can think, off the top of my head, of over a dozen anti-Pharma books written by doctors and proto-doctors of one stripe or another; I can think of hardly any pro-Pharma books. The commercial book industry is compensating the anti-Pharma crowd nicely, as are the trial lawyers, in many cases, with far more money than most academics made from Pharma. (Did I ever mention that an anti-Pharma trial lawyer once offered me $3 million to join a lawsuit?). There are major changes in conflict of interest rules; the promotional speaking has declined sharply, and is now much more provided by no-name private practitioners than by major academics; the New York Times publishes an article a week on the topic; the Senate investigates. Let's not fight yesterday's battles while ignoring the problems of today and the risks of tomorrow.

The anti-Pharma chorus have argued for years now that our drugs are not as effective as the companies claim. I agree. But now what? There are not going to be newer, better drugs on the horizon if Pharma leaves the business. (Don't be fooled; Marcia Angell is wrong:  Academia and the NIH have hardly ever developed any new drugs, especially in psychiatry).  How does this help sick people again?

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