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Can Validity and Pragmatism Go Hand in Hand? Yes? No? Sometimes?

Can Validity and Pragmatism Go Hand in Hand? Yes? No? Sometimes?

I am pleased to be able to join the dialogue on science, psychiatric diagnosis, and the DSMs that Dr James Knoll initiated with the posts of Drs Ronald Pies, S. Nassir Ghaemi, and Theodore Pearlman in Psychiatric Times on October 14, 2013.

I come to this exchange via my recent book, The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry, where I consider (1) The manual’s historical background (American psychiatry after World War II; the work of Emil Kraepelin, the master describer; and the neo-Kraepelinians at Washington University in St. Louis); (2) DSM-III’s prime movers (Robert Spitzer, the Editor, and his Task Force); (3) The construction of the manual and the development of many of its diagnoses. The history of DSM-III (1980) enables us to understand how we got to where we are today with DSM-5, which has aroused so much controversy.1

I would like to begin by expressing my appreciation of many of the points enunciated by Dr Pies.2 Pies’ article is a clear and carefully nuanced profession of the overdetermined—Freud’s useful term—nature of medical science and psychiatry. The issue at stake is the manner in which the physician goes about arriving at a diagnosis and whether certain frequently used processes produce a scientifically valid diagnosis. To this end, Pies asserts, quite correctly, that language matters. “Science” is a problematic word and can be used to mean different things. “Scientific process” is a more useful term, but even it does not always guarantee validity. The scientific process can produce what appears to be a valid diagnosis, but that diagnosis may turn out to be false. The scientific process then produces an alternate diagnosis that may remain valid or may be replaced in its turn. For psychiatrists, “diagnostic validity is always provisional [Pies’ emphasis] and probabilistic.”

Can a valid diagnosis be arrived at if laboratory tests are not available? Of course it can. Pies trenchantly cites the observations of Dr Kurt Kroenke who points out that usually the patient’s history contributes 75% of the information used in making a helpful diagnosis—lab tests generally furnish no more than 10%.3 Pies concludes that total reliance on lab tests to the exclusion of other factors when seeking validity is not science but “scientism.” Interestingly, Eli Robins and Samuel Guze, in their influential 1970 paper on diagnostic validity and its application to schizophrenia, came to their conclusions about “good prognosis” schizophrenia and “bad prognosis” schizophrenia relying mainly on a meta-analysis and family studies, with no laboratory information.4

Contrary to what Dr Ghaemi declares, not all revisions of the DSMs have been unscientific if one conceives of psychiatry as a “medical science” that relies on a multitude of factors in order to make a diagnosis. Here I must agree with Pies’ conclusion that psychiatry is not a natural science like physics.

Before I go any further, I want to mention that in a review of my book, Dr Ghaemi emphasizes my “neutrality” in interpreting the development of DSM-III.5 I bring this up only as background because at times in his October 14 post, he has made it seem that my work is at one with his critical views of how DSM-III came about.6 While there is much to criticize about the negative effects DSM-III has had on psychiatry—which I amply document in my book—I cannot accept his judgment that the manner in which DSM-III was constructed rendered it virtually worthless as a useful classification.

Let me draw on my work on DSM-III to make the argument that a valid diagnosis (ie, one helpful for prognosis and treatment) could be achieved by conscientious and careful investigation alone. This is not to say that the Task Force’s personal opinions never held sway nor that a member’s determined will to produce a diagnosis never occurred. (No classification has ever totally escaped the pressure of personal bias.) But one cannot conclude, as does Ghaemi, that all the work on DSM-III can be reduced to “political wheeling-and-dealing,” words I never use and a judgment I never make. Although the Task Force of DSM-III made many mistakes and created serious problems for the future, I have a healthy appreciation of their efforts to tackle knotty and unavoidable aspects of psychiatric diagnosis, often without laboratory authentication and decisive studies at their disposal.

Moreover, it is impossible to avoid the influences of non-scientific factors on scientific decisions, however desirable it would be that the former should not play a role. In 1973 the APA Board of Trustees at an emergency meeting mandated that DSM-II (1968) be speedily revised in order to show that psychiatry was a part of scientific medicine, as well as to combat the anti-psychiatry movement that was so prominent in the 1960s and ‘70s. The challenge of these two charges was so great as to defy any one verdict on the nature of the process whereby DSM-III was developed. To these two goals must be added the pressure on Robert Spitzer to produce a manual that would improve diagnostic reliability, which everyone acknowledged was abysmally low; on this score psychiatrists were often held in derision. Furthermore, the APA had to satisfy US treaty obligations to make its classification compatible with that of the WHO’s International Classification of Diseases (ICD.) DSM-III carried a weighty historical load of high expectations, difficult tasks, and lofty aims. History forces us to acknowledge the multiplicity of factors involved in the making of DSM-III.

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