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Can Validity and Pragmatism Go Hand in Hand? Yes? No? Sometimes?: Page 2 of 3

Can Validity and Pragmatism Go Hand in Hand? Yes? No? Sometimes?: Page 2 of 3

I would like to discuss two diagnoses in DSM-III—Borderline Personality Disorder (BPD) and Schizoaffective Disorder, both having no “hard” evidence to determine their validity, but arrived at by a series of thoughtful and even dogged approaches.

At the time DSM-III was constructed, BPD was not in DSM-II and was considered a “soft” diagnosis by some researchers who were opposed to it. But if we look at its history since 1980, it is clear that it has become a widely recognized disorder and one for which there is new understanding and specific treatment. Spitzer had declared at the outset of the revision of the manual that he would not include a diagnosis in DSM-III unless clear and unequivocal descriptive diagnostic criteria could be developed for it. He was always cognizant that he served two constituencies, researchers as well as clinicians, and that he had to make the diagnostic criteria accurate and specific enough so the researchers could form reliably homogeneous disease groupings with which to conduct studies and then do follow-ups.

When a psychoanalyst at the Menninger Clinic suggested BPD be added to the new manual, Spitzer wrote back to ask whether he could supply specific descriptive criteria that would capture the concept of “borderline personality organization.” The APA Archives contain no response from the analyst, but ultimately Spitzer made the decision that it would be “useful” to include this disorder but that it should be used only if no other personality disorder could be diagnosed. One of the first matters Spitzer addressed was whether “borderline” should be used as a noun or an adjective. Did it describe a full-fledged disorder or did it merely mean a level of severity? Actually, he asked, could there be “borderline” anything? Another issue that Spitzer had to untangle was whether there were episodes of psychosis associated with BPD; the profession did not agree on this question.

Spitzer also wished to make BPD a clearer, firmer entity. To this end, he sought to elucidate two conceptions of “borderline” as put forth by researchers who worked in this area. To start with, he proposed that the “borderline” diagnosis most closely conceived of as “borderline schizophrenia” in DSM-II be called Schizotypal Personality Disorder in DSM-III. Spitzer was attempting to rid the nomenclature of excessive and unwarranted schizophrenia diagnoses. He was heavily influenced by a disquieting US/UK study which had found that both countries’ diagnosing patterns for schizophrenia and affective disorders were alarmingly out of kilter. In the US schizophrenia was over-diagnosed—there were 10 different schizophrenia diagnoses in DSM-II and so-called “latent schizophrenia” contained 4 subtypes. Affective disorders were under-diagnosed. The exact reverse was the pattern in the UK.7 In the US, the diagnosis of borderline schizophrenia did not call for a psychotic episode, which made Spitzer question the diagnosis.

Then Spitzer turned to another conception of “borderline,” this one envisaged as borderline personality “organization.” The notion was the creation of the psychiatrist and analyst Otto Kernberg (b. 1928), and Spitzer corresponded with him. It was Kernberg’s conception that Spitzer wanted to make into BPD, but with a different, more descriptive and meaningful name than “borderline.” In this pursuit, he totally failed. The “borderline” name was so deeply entrenched that other designations were soundly rejected.

Spitzer also sought clinical validation for his plan. He sent out a questionnaire to 4,000 APA members “to help firm up our criteria” for “borderline” individuals. The APA members’ answers to the questionnaire on rating these individuals yielded data on 808 patients and 808 controls that Spitzer and a colleague subjected to a variety of statistical measurements.8 To be sure, this was no double-blind study. But with the information he had, he concluded that it was possible to find diagnostic criteria to describe both BPD and Schizotypal PD and that there was a measureable difference between the two personality disorders.

Yet Spitzer did not rest. He was determined to answer the question of whether psychosis was a part of BPD, and for help with this he turned to John G. Gunderson, a psychiatrist at McLean who had established a name for himself with a 1975 article, together with Margaret T. Singer. They had reviewed the literature on borderline patients and proposed 6 features that could be used to diagnose borderline patients in the initial interview.9 Still on the trail for accurate diagnostic criteria for BPD, Spitzer wanted to know if he should include “brief psychotic experiences.” He asked if Gunderson would please “provide several specific descriptions of such experiences.” The level of detail Spitzer went on to ask for is striking: samples of 6 to 10 such incidents, information on whether the experiences were “limited to therapy or transference distortions, whether delusions or hallucinations were involved, and how long such episodes lasted.”

While it is certainly true that psychoanalysts found personality disorders useful to their interests in character pathology—BPD was first enunciated by an analyst in 193810—it is not true, as Dr Ghaemi states, that I “document well” that personality disorders “were almost completely based on psychoanalytic opinion, with hardly any scientific validity literature to support them.” I could not conclude this because there is nothing in the Archives to indicate this. Spitzer and the DSM-III Task Force hardly discussed most of the Personality Disorders, and Spitzer’s meticulous efforts to define BPD do not support Ghaemi’s assertions.

Furthermore, of the 10 members of the DSM-III Personality Disorders Advisory Committee, at least 5 were openly antagonistic to psychoanalysis, and one scathingly so. Aiding the analysts was the last thing on their minds. Also, one member of the committee, Allen Frances, was very dubious about BPD and published a number of papers with the personality disorders expert Thomas Widiger that reflected this. And Spitzer, a research psychiatrist who had left his psychoanalytic training far behind, dumped 4 PDs and then added 5 new ones. There is no evidence that he did this to please the analysts. And further, whenever Spitzer showed signs of meeting some of the psychoanalysts’ concerns, the Task Force always overruled him. (These episodes are in the Archives.)

The second diagnosis I want to discuss is Schizoaffective Disorder. We can all agree that the delineation of this disorder has not primarily come about through rigorous testing, but because it is pragmatically needed. Someday, when the APA’s classification shifts to one based on etiology, perhaps it will disappear. But in the meantime, we need something when the formal division of schizophrenia from bipolar breaks down. (And even Kraepelin wondered towards the end of his life if his division of dementia praecox and manic-depressive illness was sound.) Modern neuroscience has already provided us with tantalizing indications that aspects of the two are closely linked.

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