Irwin Feinberg, MD

One cannot but be impressed at the ingenuity of our DSM-5 mavens at conjuring up new diagnostic syndromes. However, they risk unnecessarily fragmenting our nomenclature. To avoid this I propose a new, overarching diagnostic syndrome: LIFE or 

nvironments. This is the true premorbid condition; it antecedes (and encompasses) all the other the premorbid states now being considered.  Moreover, it has a virtue that contemplated premorbid conditions sadly lack: perfect inter-rater agreement, which falters in only really extreme environments like committee meetings (all fields) and - - more prominently -- psychiatric conventions.

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One cannot but be impressed at the ingenuity of our DSM-5 mavens at conjuring up new diagnostic syndromes.

A Unifying Premorbid Diagnosis

A vital consideration we learn in medicine is that continuing life support for a moribund patient past a certain point is harmful to the lives of all concerned. We have reached that point with DSM5. 

 has outlined compelling clinical arguments against many of the new disorders DSM5 proposes and he has shown how their adoption could have far-reaching, unintended, and damaging consequences for the patients we have pledged not to harm, and for society generally.

I write from the vantage point of 50 years of psychobiological research. Most of it is in the field of sleep neuroscience. However, as often happens in science, one thing leads to another and my observations enabled me to propose that the human brain undergoes a profound reorganization during adolescence driven by synaptic pruning and that some cases of schizophrenia might be caused by errors in this process.

My association at NIMH with Edward V. Evarts, one of the great neurophysiologists of the last half century, stimulated me to propose that the hallucinations of schizophrenia result from a failure of feed-forward mechanisms that distinguish self-initiated neural activity from that produced by external stimulation, resulting in auditory hallucinations and other first-rank symptoms.

It is difficult and time-consuming to produce reliable new knowledge; it cannot be accomplished by committee fiat, as Drs Kupfer, Schatzberg and Regier seem to be believe. Dr Frances has mentioned the damage to psychiatric research that several new, ill-conceived categories in DSM5 could inflict. He also pointed out that changing nomenclature and diagnostic standards in the absence of compelling scientific justification will severely damage psychiatric research as well as clinical practice. Many of these changes would make it impossible to compare decades of epidemiological results with new findings. Moreover, the sloppy thinking and language in the proposed revision will be apparent to any educated layman. The “field trials” and timetables proposed for new categories are laughable to any statistically trained psychologist. The inevitable public exposure of the gross defects in DSM5 will bring our entire field into disrepute and diminish public support for the research we need. 
 
There have been no research advances that demand new diagnoses and syndromes. Despite many intriguing findings, no psychiatric disease can be diagnosed by a biological or psychological test. If the DSM5 committee believes that new genetic or imaging findings justify a revised nomenclature, they should indicate which ones. Instead of creating dangerous new categories, let us discontinue DSM5 development and use its funding to make strong bridges between DSM-IV and ICD 11. We should also work to diminish or eliminate the huge differences between the US and the UK in the incidence of diagnoses like ADHD and pediatric bipolar disorders. These differences make it impossible to compare cross-national biological research on the same diagnostic categories, even in countries with similar cultures and medical traditions.

The proposed DSM5 would be a giant step backwards for psychiatry. American psychiatrists should petition the APA to drop this ill-conceived and badly executed project. 
 

1. Feinberg I. Schizophrenia: caused by a fault in programmed synaptic elimination during adolescence? J Psychiatric Research. 1982/1983;17:319-334

2. Feinberg I. (1978). Efference copy and corollary discharge: implications for thinking and its disorders. Schizophrenia Bulletin. 1978;4:636-640.

A vital consideration we learn in medicine is that continuing life support for a moribund patient past a certain point is harmful to the lives of all concerned.

Let's Call the Whole Thing Off

I am writing to commend Flavie Waters, PhD, for her recent article on 

auditory hallucinations in psychiatric illness

She covers the topic well. Her article is timely and I hope it will contribute to a badly needed reorientation of our field toward the positive symptoms of schizophrenia. However, I am compelled to point out an error of citation that is not the author’s fault.

Dr Waters attributes the theory that hallucinations are due to a failure of self-monitoring to Christopher Frith. In fact, the notion that hallucinations in schizophrenia result from a failure in the brain’s self-monitoring (feed forward or corollary discharge) systems was first put forward by me in 1978 in the Schizophrenia Bulletin.

 Frith subsequently promoted this idea as his own. In his 1992 volume on “The Cognitive Neuropsychology of Schizophrenia,”

 he outlines as original the argument that schizophrenics suffer from a defect in feed-forward systems more or less exactly as I had 10 years earlier. He states: “I will now introduce a concept that is very central to my own account of positive symptoms: self monitoring.” (p73). He then goes on to restate the arguments I had put forward 10 years earlier, citing many of the same references I used, including Helmholtz, Sperry, and von Holtz and Mittelstead. Frith was fully aware of my paper. Toward the end of his self-monitoring section he states, in his sole reference to my work: “Feinberg (1978) has suggested that monitoring mechanisms like corollary discharge apply not only to overt movement of the limbs and eyes but also to covert actions such as thinking.” (p81). Frith does not point out that, in this paper, I applied these ideas to the first-rank symptoms of psychosis, including auditory hallucinations, ideas of mind control and autochthanous delusions.

In the ensuing years, Frith has regularly promoted my basic idea of a failure of self-monitoring as his own, occasionally citing my paper but never its contents. I published an extensive review of my ideas in the 

 hoping it would lead Frith to correct his citations. Alas, it did not. I urge our field to read my papers and Frith’s and to render scholarly judgment.

The point is not solely one of scientific priority although this is important. My model points to a vital question on the neurophysiology in mind: how do we know that our thoughts, most of which arise spontaneously (“unwilled”), are our own? Many spontaneous thoughts are bizarre and even hateful. The patient with obsessive-compulsive disorder is plagued with tormenting thoughts. Yet we, and our obsessive patients, recognize that these bizarre and tormenting thoughts are our own.

This demonstrates the operation of systems that distinguish self-generated neural activity that produces conscious experience from that which arises from external stimulation. These are the corollary discharge or feed forward systems that have long been known in sensorimotor control. I postulated that similar systems operate in the motor mechanisms of thought. It is these systems that are defective in schizophrenia (and, often, in other psychoses). Hughlings Jackson emphasized that the process of thinking is simply our most complex motor act .

I hypothesized that successful sensorimotor control mechanisms are conserved through evolution and operate in this complex act. When they fail, perhaps because of errors in the massive brain reorganization of adolescence,

 the first rank symptoms of schizophrenia emerge.

1. Waters F. Auditory hallucinations in psychiatric illness. Psychiatric Times 2010;27:54-58. 

2. Feinberg I. Efference copy and corollary discharge: implications for thinking and its disorders. Schizophrenia Bulletin 1978;4:636-640.

3. Frith CD. The Cognitive Neuropsychology of Schizophrenia. Hove, UK: Lawrence Erlbaum Associates; 1992.

4. Feinberg I, Guazzelli M. Schizophrenia -- a disorder of the corollary discharge systems that integrate the motor systems of thought with the sensory systems of consciousness. Br J Psychiatry 1999;174:196-204.

5. Jackson JH. Selected writings of John Hughlings Jackson. New York: Basic Books; 1958.

6. Feinberg I. Schizophrenia: caused by a fault in programmed synaptic elimination during adolescence? J Psychiatric Res. 1982/1983;17:319-334.

I am writing to commend Flavie Waters, MD, for her recent article on auditory hallucinations in psychiatric illness.1 She covers the topic well. Her article is timely and I hope it will contribute to a badly needed reorientation of our field toward the positive symptoms of schizophrenia. However, I am compelled to point out an error of citation that is not the author’s fault.

Author | Irwin Feinberg, MD

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