Can Validity and Pragmatism Go Hand in Hand? Yes? No? Sometimes?: Page 3 of 3
Can Validity and Pragmatism Go Hand in Hand? Yes? No? Sometimes?: Page 3 of 3
Although Spitzer and the Task Force could not construct a hard case for the existence of this disorder, they did the next best thing: debate—nay, wrestle—with the thorny question of whether the diagnosis belonged under Schizophrenia or Affective Disorders and what its diagnostic criteria should be. In this short article there is no possibility of recapitulating the lengthy and informed discussions that went to the heart of diagnostic issues in psychiatry. Readers interested in examining this issue further can consult my book.
In DSM–II, Schizoaffective Disorder had been placed under Schizophrenia and indeed, in the first draft of DSM-III (April 1977) that is where it remained, with 2 sub-types—Depressed and Manic, and diagnostic criteria for each. But in the next draft (January 1978) it was placed in its own separate category with just 1 list of diagnostic criteria, but with an elaborate sub-typing of 9 forms, this latter intricacy being a clear indication of a struggle to describe the disorder. There it did not rest either because William T. Carpenter, on the Multiaxial Diagnosis Advisory Committee, (in 2013 on the Task Force of DSM-5 and also on its Psychosis Work Group) proposed that the diagnosis be situated under “Psychosis Not Elsewhere Classified” along with Schizophreniform Disorder, Brief Reactive Psychosis, and Atypical Psychosis.
The result was the creation of an increasingly heated debate over what had appeared shortly before to be a settled question. Highly intense discussions went on for several months with extremely specific and sophisticated confrontation of the issues involved in further describing the disorder. There were urgent memos and meetings, but a resolution did not emerge. One result though, of the robust examination of where Schizoaffective Disorder belonged and how to describe it, was the decision to strengthen the criteria for Major Depressive Episode, Manic Episode, and Schizophrenia, and this was done.
Ultimately the decision was made to retain Carpenter’s proposal for placement of the disorder but to abandon sub-typing it or developing diagnostic criteria for it. In earlier drafts of DSM-III the description of Schizoaffective Disorder had occupied several pages. It now appeared on a mere ¾ of a page without diagnostic criteria, in spite of Spitzer’s vow never to allow that to happen. The manual contained the statement that future research was needed on whether there is a need for the category, if so how it should be defined, and what is its relationship to Schizophrenia and Affective Disorders. Spitzer dutifully informed the APA’s Council on Research and Development, to which he reported, about the decision and eventually received word that the Council was in agreement with the general approach that had been taken.
In DSM-IV the disorder was categorized under Schizophrenia and Other Psychotic Disorders with a lengthy description and diagnostic criteria. It appears in DSM-5 under Schizophrenia Spectrum and Other Psychotic Disorders with more specific criteria than in DSM-IV in the hope this will increase reliability and reduce the overutilization of the diagnosis. Perhaps it can be said that the history of the placement and description of Schizoaffective Disorder illustrates usefully some of the challenges involved in constructing a psychiatric classification and the approaches that may be involved if lab tests and other studies are not available. It can even be argued that Kraepelin himself would have appreciated the dilemma of the makers of the DSMs.
BPD and Schizoaffective Disorder entered DSM-III not on the basis of laboratory evidence or double-blind studies, but with thoughtful and determined efforts to meet the medical needs of researchers and clinicians and to revise the APA’s classification system in order to achieve specific goals. The Task Force and Advisory Committees members took their charge very seriously, belying a common criticism that DSM-III was created by a group of people who insouciantly tossed around opinions. One may agree or disagree with the DSM-III resolutions of the BPD and Schizoaffective Disorder quandaries. But one cannot easily attribute the eventual outcomes to wheeling-and-dealing. And as Dr Pearlman has pointed out, the DSM Task Forces were “spurred towards seeking a truthful classification of psychiatric illnesses for . . . research and treatment,” mindful that the endpoint for their diagnoses was the succor of human beings with “a level of malfunction causing clinically significant distress or impairment in social, occupational or other important areas of functioning.”11
Far more important as to whether all DSM-III diagnoses were arrived through a “scientific” method was the fact that once constructed they became reified as sharply delineated categories. The makers of DSM-5 were able to partially break down categorization in 2 instances: Autism Spectrum Disorder and Schizophrenia Spectrum and Other Psychotic Disorders. However, the attempt to conceptualize certain aspects of Personality Disorder in dimensional terms ultimately failed. Here I agree most strongly with Dr Ghaemi’s criticism of the APA’s Board of Trustees for rejecting the Personality Disorders Work Group’s recommendation on this score. As all clinicians know, personality disorders run the gamut from mild to severe, and assessing where a patient falls on the continuum helps in prognosis and treatment. Yes, it is time-consuming for the clinician to make a dimensional diagnosis, but such a diagnosis is more valid, a reflection of real life circumstances. On the other hand, dimensional diagnoses may decrease reliability. No one ever said it is easy to be a psychiatrist.
I appreciate having the opportunity to add my remarks to this very focused discussion of psychiatric diagnoses and the DSMs, currently a topic of great controversy.
Acknowledgement: I want to thank Dr Norman Decker for his close reading of this paper. However, the views expressed here are my own.
Dr Decker is a Professor of History at the University of Houston and an Adjunct Professor of Medical History in the Menninger Department of Psychiatry, Baylor College of Medicine, Houston. She has written widely in the histories of psychiatry and psychoanalysis. In 2007 she received the Eric T. Carlson Award for “Extraordinary Contributions to the History of Psychiatry and Psychoanalysis” from the DeWitt Wallace Institute for the History of Psychiatry, Weill Cornell Medical College, New York City.
1. Decker HS. The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry. New York: Oxford University Press, 2013.
2. Pies RW. Science, Psychiatry, and Family Practice: Positivism vs. Pluralism. Psychiatric Times. October 14, 2013. http://www.psychiatrictimes.com/articles/science-psychiatry-and-family-practice-positivism-vs-pluralism. Accessed October 31, 2013.
3. Kroenke K. Diagnostic testing and the illusory reassurances of normal results. JAMA Internal Medicine. 2013;173:416-417.
4. Robins E. Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psych. 1970;126:983-987.
5. Ghaemi N. Book Review, The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry. Acta Psychiatrica Scandinavica. In press.
6. Ghaemi N. Why DSM-III, IV, and 5 are unscientific. Psychiatric Times. October 14, 2013. http://www.psychiatrictimes.com/blogs/couch-crisis/why-dsm-iii-iv-and-5-are-unscientific. Accessed October 31, 2013.
7. Cooper JE, Kendell RE, Gurland BJ, et al. Psychiatric diagnosis in New York and London. Maudsley Monograph Series, No. 20. London: Oxford University Press, 1972. Also see Kendell RE, Cooper JE, Gourlay AJ, et al. Diagnostic criteria of American and British psychiatrists. Arch General Psych. 1971;25:123-130; Kendell RE. Psychiatric diagnosis in Britain and the United States. Brit J Psych. 1975,9:453-461.
8. Spitzer RL, Endicott J. Justification for separating schizotypal and borderline personality disorders. Schizophrenia Bull. 1979;5:95-104.
Also see Spitzer RL, Endicott J, Gibbon M. Crossing the border into borderline personality and borderline schizophrenia: the development of criteria. Arch General Psych. 1979;36:17-24.
9. Gunderson JG , Singer MT. Defining borderline patients: an overview. Am J Psych. 1975;132:1-10.
10. Stern A. Psychoanalytic investigation of therapy in the borderline group of neuroses. Psychoanalytic Quarterly. 1938,7:467-489.
11. Pearlman T. In defense of DSM. Psychiatric Times. October 14, 2013. http://www.psychiatrictimes.com/blogs/couch-crisis/why-dsm-iii-iv-and-5-are-unscientific. Accessed October, 31, 2013.