Psychiatry, the DSM and the disease concept
There’s been much brouhaha in APA over the DSM 5 Workgroup product. Passionate attacks from DSM IV chair Al Frances, DSM III chair Bob Spitzer. Grumbling from others. Ardent defense from APA top leadership, the President, the Medical Director, the Board. Some accusations imply venality. Why all this? I have a different take. I feel sorry for the DSM V Workgroup and the terrible problem they face. Insoluble? I don’t believe so if we have patience and persistence, and here’s why:
Over 2 ½ millennia ago, physical and psychiatric illnesses were felt to be due to magical, supernatural and animistic factors, possession by spirits, demons and gods, that sort of thing. Then came the Greek Enlightenment in 600 BC, ushered in by Thales of Miletus, and naturalistic explanations entered the picture in all the sciences. In medicine a disease model emerged based upon a proposed psychophysiology of the four humors (blood, phlegm, green bile, black bile). Epilepsy was not “the sacred disease;” was not possession by a god, was no more sacred than any other disease. An excess of blood and one might have a fever, or a sanguine temperament, or maybe even hypomania. Too much phlegm made one phlegmatic. Too much bile and one was choleric. Too much black bile and one was melancholic (melanos is black). Thwarted entelechy might produce a womb (hysteron) that, “frustrated by remaining unfruitful long beyond its proper time, gets discontented and angry and wandering in every direction of the body closes up the passages of the breath and by obstructing respiration drives them to extremity, causing all variety of disease,” i.e., hysteria. Treatment? “Light the lamps of Hymen” (the god of marriage). Freud two millennia later will quote a teacher as prescribing for a woman with an impotent husband and hysteria: “penis normalis in dosem repetitur”, and later Freud himself will say that “in the last resort we fall in love in order not to fall ill and we are bound to fall ill in consequence of frustration if we are unable to love”. Although the matter contained some quite fanciful moments it did also contain somr potentially valuable ones as well.
Grecian rationalism and naturalism, however, succumbed to the rising Judeo-Christian world view with its religious and non-rationalistic, non-naturalistic world view, and there occurred then a return to supernatural explanations: magic, witchcraft and possession by demons and spirits (incubi, succub), etc.). It took another 1½ millennia for the Enlightenment and naturalism to rise again. Then medicine further developed the disease model (e.g., consumption, tuberculosis) on the basis of sign and symptom presentation (fever, night sweats, weakness, weight loss, cough with bloody sputum, etc.) and a descriptive picture of the disease emerged that included the history and course of the illness. The disease concept was medicine’s greatest gift to humankind for it led to scientific understanding and progress and ultimately to triumphs over illnesses. Developments in technology led us to go beyond pure description and projection to actual discoveries in pathology that helped to better define and understand the disease (e.g., the tubercle) although at that point all we could do was still to try to manage the illness, its manifestations and
its symptoms. With further development of technology the specific etiology was ascertained (e.g., the tubercle bacillus) and then other treatments and ultimately streptomycin and other antibiotics, directed specifically at Koch’s bacillus. the ultimate, specific etiology. Patients were not merely managed; now they were treated and cured. Preventive measures had been developing during the
descriptive-management phase (nutrition, sanitation, sunlight, rest, etc.) and they were continued, still of value.
Similarly, antibiotics and vaccination work strongly against the bacillus vibrio cholerae in cholera but sanitation is an indispensible tool in our therapeutic armamentarium for cholera and may even be enough at times.
I was present at one of these magical moments of scientific discovery. I was in medical school when penicillin came in. It was magic. Alexander Fleming had transferred a culture of staphylococcus onto a plate of agar and when the colonies appeared a spore of the mold, penicillium notatum, apparently riding on a dust particle, had inadvertently landed on the plate and grown as well. Fleming looked closely and saw that at the edges of the mold the colonies of staph had died. Science is not only the body of knowledge but the method one uses to achieve and verify that knowledge. Fleming made an hypothesis, tested it for falsifiability and proof, and a world of antibiotics flowed from that discovery. It was an event similar to and as precious and miraculous as Edward Jenner observing that milkmaids who had recovered from cases of cowpox, a mild, cutaneous disease, didn’t get smallpox. Vaccination was similarly tested and his hypothesis was proven true and invaluable. People stopped dying of smallpox and it was later eradicated from the world. Similarly, the scourge of my childhood, poliomyelitis, succumbed to the same process with Salk’s and Sabin’s vaccines. But we in psychiatry haven’t seen our Jenner, Fleming, Salk or Sabin moments yet.
That’s what we in psychiatry are waiting for too, no? With us some things have been done but we are not there yet. Oh, how we physicians envy the rest of medicine! How we lag behind! We have tried developing a disease model in psychiatry, as medicine did earlier on a descriptive basis of sign and symptom patterns,
presentation and history and course of illness: Pinel, Morel and others in France; Griesinger, Kahlbaum, Hecker in Germany. Kraepelin developed his overall model, ascribing what he called dementia praecox to general cortical atrophy, widened sulci, deepened gyri, enlarged ventricles. Eugen Bleuler saw that the pathology and the clinical picture were not necessarily that of dementia and he produced a much more nuanced picture of a disease process causing loosening of the associational pathways, after which psychosocial adaptation factors came into play producing the epiphenomena of the underlying disease, epiphenomena but not essence. In this the picture was greatly influenced by Sigmund Freud and Adolf Meyer with
their adaptational formulations that helped with the understanding of the epiphenomena. DSM I and II emerged influenced by all this, with the concept of a disease being a reaction to the presence of an internally driven illness in a psychosocial setting.
But it was loose and the edges were unclear. There was no clean and clear pathology or etiology. How does one then understand these things and diagnose, treat and reimburse for treating them? How do they fit into a Resource Based Relative Value Scale and have Relative Value Units assigned to them? And why does America differ so much from Europe in all this? Bob Spitzer’s DSM III emerged modeled on the categories in the rest of medicine. It didn’t work so well so in DSM III-R we tinkered with the edges. Then DSM IV came along with the same paradigm and there was more tinkering in DSM IV-TR. But the field was still filled with a lack of clarity and there were a host of diagnostic NOS’s (not otherwise specified), and no clear, useful
neurophysiological or neuroanatomical markers have emerged as yet from our rapidly developing technology.
This is what the DSM V Workgroup has to grapple with. One can well understand their attempt to use dimensions and spectrums in an effort
to be inclusive of all of that which is not so easy to include in a clearly defined categorical disease model. We are like Cinderella’s older stepsisters trying to fit our fat feet into the Prince’s delicate slipper so we can go off with him to the ball, but we’re not there yet and we’re not going to the ball right now. Not there yet we hope for more, and there are hopeful signs. Some emerge with
developments in the philosophy of science. The philosopher Immanuel Kant postulated in his Critique of Pure Reason two centuries ago the existence of a number of aprioristic “categories”, conceptions existing prior to experience, not learned from but imposed upon experience as the world of perceptions enters into us and forms our Vorstellungen, the internal representations of the world outside. We are not born with a “blank slate”, a tabula rasa . We have a mental set that organizes our perceptions into Vorstellungen and includes the factors of prior experience, personal, familial, social, cultural, etc. but also Kant’s aprioristic categories of time, space, morality, causation, etc. Much but not all is derived from experience (i e, my mother taught me this, or I was treated so at home so I developed that attitude, or my culture in which I was raised is such and such, etc.), but Kant had postulated that his categories did not come from these experiences but were there from the beginning, innate, inborn and imposed upon experience.
The ethnologist Konrad Lorenz, in a mid-20th century paper entitled “The Kantian A Priori in the Light of Modern Biology”, pointed out what an inestimable advantage a species with these a priori categories such as causation would have in the evolutionary struggle for existence if a mutation had resulted in the development of genes creating these categories. As a result they would be naturally selected in. In Science June 19, 2010, vol. 328, p. 1487-8, in an article entitled “A Kantian View of Space”, L. Palmer and G. Lynch discuss two experimental reports in that issue and their implications as to how the brain represent space, which representation is not entirely the result of learning from experience but seems to relate to Kant’s theory that includes two a priori pure forms of space and time, regarded as constraints of thought rather than results of investigation or experience. And if not only time and space what about other cognitive and affect laden matters such as those leading to cognitive distortions in schizophrenia, mood and anxiety disorders, autism, O.C.D., the different personality disorders, etc.?
The articles in that issue of Science by Langston et al. and by Wills et al. report on their working with electrodes placed in
the hippocampal formations of freely moving two week old rat pups, recording electrical impulses. The results “refer to…..[Kantian] theory…..that critical components of the brain’s spatial representation systems are already in place when an animal first encounters an extended environment. This supports the view that spatial representation indeed includes an innate component prior to experience.” Such factors govern cognition so perhaps we are getting closer to our hope that there may be, in time, the discovery of neurobiological markers that might denote a medical type of disease element in psychiatric disorders, the full content and management of which may involve psychosocial factors on top of the underlying neurobiological disease which are also present and need to be be addressed. This model is quite similar to Bleuler’s model of “the group of schizophrenias” and not too dissimilar to Freud’s own model. But so far no such neurobiological markers have emerged, although that is certainly not to say they won’t. It took the rest of medicine a long time too. But that contributes to DSM V’s problems now.
As to epistemology, John Hughlings Jackson, the 19th century neurologist who applied Darwin’s ideas to his evolutionary neurology and then to his, Jackson’s, similarly derived evolutionary psycholinguistic concept of aphasia, believed that monisms ultimately tend to break down in the real world to dualisms, and he postulated his doctrine of concomitance where psychology and physiology are not the same thing but are concomitant, albeit the former being a dependent concomitant of the latter. i.e., not an “either/or” but more an “either/and” model. A green leaf is never what is going on in a nerve cell, he stated, and what is going on in a nerve cell is never a green leaf. Freud in his On Aphasia derived much of his psychoanalytic model from Jackson but had to abandon his reductive neurobiological model in his “Project for a Scientific Psychology”as being most premature. Instead he adopted the psychological concomitant model in Chapter 7 of The Interpretation of Dreams. But Freud always hoped for a return to “the bedrock of biology” as he called it in his next to last paper, “Analysis Terminable and Interminable”, with his psychoanalysis more like a Naturwissenschaft, which it is not at the present time and may not be able to fully become.
The Workgroup has a tough row to hoe. We have come a long way but are nowhere near the finish line. DSM V will only be part of the waiting game until science catches up with our hopes. But what do we mean exactly by the word “science”? The word is derived from the Latin, to know, and to the knowledge itself, and it refers both to the process of reaching that knowledge as well as the content in the end point. In German “science” is Wissenschaft, and, unlike our tradition, there are in German two kinds of Wissenschaften — the Naturwissenschaften, the natural sciences, the sciences of nature, including what Ernst Mayr called “the exact sciences” of physics and chemistry where the language is mathematics as Gallileo stated; and the
Geisteswissenschaften, where Geist means “mind” and whose disciplines include sociology, philosophy, the humanistic disciplines, and the like, even the arts at times, where the language is not so exact or precise, not mathematics but more often metaphor. The problem is that in the Anglo-American tradition only the Naturwissenschaften are really recognized as true sciences, the Geisteswissenschaften not really. Which is why Strachey, and others when they translated Freud’s German terms into English changed them, trying to “scientificize” them and acclimate that middle European tradition to the Anglo-American tradition. So Deutung became “interpretation”, but that’s really much too exact and precise, and Besetzung became “cathexis”, which sounds something like an electric charge. Etc. The patient tells Freud, “I have trouble with my sexual passion (or anger or such) but I control it”, so Freud writes a book, “Das Ich und das Es”, the “I and the It”. This has to be “scientificized” too so it is translated into Latin, into “ego” and “id”, but if you call the “I” an “ego” you give an “itness” to it and you objectify, dehumanize and systematize it, and all changes. And we Americans, given to systematizing things anyway into crafts to be learned, transmitted and passed on, but not to be played with the way the Europeans who invented it were inclined to feel they could, we go along with that.
Then does psychoanalysis fit in as a Geisteswissenschaft? Not really. Psychology is the overall discipline, one of the Geisteswissenschaften in great part, and psychoanalysis really seems much more of a Weltanschauung within that discipline, a “world view”, albeit a rich. powerful and dramatic one, to be included in the discipline of psychology along with other psychological world views. I think we can also see that psychoanalysis is subjective rather than objective and is not scientific in the strict sense either in its method or end product. We saw that in our colleagues’ erudite and comprehensive reviews of the psychiatric, psychological and psychoanalytic literature where various highly intelligent colleagues stated their
different points of view, but, when you think about it, none were or even could be put in a form so as to be tested for falsifiability and proof, nor did they seem to be interested in that. Not the way the other examples in medical science that I described here were. But we must consider the science factor, as Jenner, Fleming, Salk and Sabin did, for our work, when you come down to it, is a matter of practical human interest, not just developing and discussing world views. As Einstein said, after all our theorizing (he was speaking of theoretical physics), we must always return to the world of perception. Our task, our validation, is not in making theories but helping our suffering patients, which is what it ia all about.
What exactly is the psychoanalytic world view? The French philosopher Paul Ricoeur stated with Gallic elegance that that aspect of human beings that Freud was interested in was “the viscissitudes of desire in its eternal debate with reality”. Desire, originating in the biology of the organism and serving the evolutionary necessities, emerges in phases and as it unfolds in its different phases and in interaction with culture, the microculture of the home or the macroculture of the world out there, is condemned in each phase forever to be thwarted and turned aside, but in renouncing its end point and moving on to another phase, it develops a building block in the self. One wants the breast forever, wants to be fed, clothed, cared for; well, one just cannot have that forever, so it ends up as a matter of “very well, I shall take care of myself and not be a baby any more.” One may then want to do whatever one wants, whenever and however one wants; well, one cannot do that forever even if one wants to, for humans must live and work in communities with others, so one cannot go in one’s pants when one is 21, not even when one is 3 or 4 and in pre-K, if one wants to be accepted and get along there and work and live with others. In that phase one wants freedom but freedom cannot be absolute absence of restraint; one cannot shout “fire!” in a crowded movie theater or go through a red light. The Greeks recognized the limitations of defining freedom as absence of restraint and redefined freedom as “perfect obedience to perfect law,” freely choosing to do what one, recognizing necessity, knows one has to do, and not just submitting and complying and resenting it. It is a matter of, “Well, I shall discipline myself and no longer be a sloppy pig.” The next phase, Freud’s pet phase, had to do with how one, a small creature in a big world, with all that power and authority and ambiguity out there, can learn to assert oneself nevertheless and not have to retreat into passivity and neurosis. And so on with the next unfolding phases as described by Erik Erikson. This is a powerful Weltanschauung, something in a way like Marxism was in sociology and economics when it similarly burst upon the scene a little earlier. It too appealed to the intellectuals, entered into academia and the arts, was picked up by the Marxist labor and political groups, and in Freud’s case by psychiatry, professional societies and mental health
groups. Each flourished for a while and then began a retreat from the heights. While up there they did some good and also some damage, both. Yet analysis, with its accusations of “schizophrenogenic mothers” and “icebox parents” causing autism and its at least implicitly blaming and intimidating patients’ families, never did anything comparable to the murdering, slaughtering and human suffering that Lenin, Stalin and Mao caused. We must always be careful when embacing even the most attractive of our ideologies.
Once, years ago, while talking about the Marxian influenced sociologist C. Wright Mills with Gerard Piel, publisher of Scientific American, he said to me, “You know, since Marx we are all Marxists.” And so we are. Not the slavish kind, not the dangerous kind. But we have been touched by his world view that humankind is deeply motivated by the need for food, clothing and shelter and these overwhelming needs affect all other human activity, are humankind’s fundamental drives, and all else is the superstructure of society, decisively influenced by those economic factors. We can never go back and forget that. The same is true of Freud. Since Freud we are all Freudians in the same way, and we cannot go back and forget that The world will never be the same again. But that does not make psychoanalysis a science. It remains a world view.
That brings us to the question of what is the place of management of illness and talk therapy. As with those other medical disorders where we have learned to understand the illness, see the pathology, the etiology, treat and cure, there is still a large place for the descriptive-management approach. In diabetes the pathology lies in the Islands of Langerhans in the pancreas and the etiology involves insulin’s role in carbohydrate metabolism, but attention must also be paid to diet and exercise. Even in General Paresis where we have uncovered the pathology and learned the specific etiology of tertiary neurosyphilis, the spirochete, and discovered the treatment and cure by penicillin and antibiotics, we can still use management techniques. And even where our present psychopharmacology is so helpful with our seriously and persistantly mentally ill it is still directed towards the symptoms: depression, mania, delusions, hallucinations, etc. and not the etiology. We continue to need a recovery model with the teaching of interpersonal and occupational skills and work with their families and others. So with our managment and talk therapy we must be humble, must understand our deep limitations. In comparison with the rest of medicine we cannot yet describe the underlying pathology to correct it or isolate out the specific etiology and cure it. Yet we can deal with what we have, managing things and remembering to keep close to the reality of the patient in his or her situation, with our eyes on the here and now and not get lost in speculations we cannot pin down and prove, and that are not useful. Often such speculations can seem more to aid the patient’s defenses against his or her having to recognize the need to change and do something, and instead just rummaging about in the past with speculations about its effects. We mustn’t let those theoretical speculations get in the way of our touch with and understanding of the patient in his/her actual situation in life. As AA says, “don’t analyze, utilize”. Theory and speculation may unnecessarily substitute for reality, may take us away from our primary task and evade what has to be done.
I recall how one day in my own analysis I entered the office, lay down on the couch, and said, “Doctor, I think you sleep during my sessions.” “Nod durink your sashions, Doctuh,” he said, “My fife o’clock patient, maybe, but nod durink your sashions.” Indignantly I replied, “That’s typical of you, Doctor. With your wit and cleverness you turn aside my statements and ignore them, but I can tell from the rhythmical quality of your breathing that you are sleeping.” He said, “Vy don’t you turn around and ketch me?” Indignantly I drew myself up to my full height, at least as much as one could do while lying supine on a couch, and I said, “Why, I wouldn’t do a thing like that!” (Against the sacred rules, you know.) He responded, “It’s bedder to do a zhing like zhat zhen it iss to make a neurozis out of it.” I left the office confused, mulling this over. This, I thought was not analysis. This is supportive therapy. Maybe I’m not worthy of real analysis, not up to it. For analysis would be for him to say something such as, “taal me about zhe breathing,” and I would talk about my father’s breathing after his sinus operations, or maybe about the heavy breathing in the next room with my mother when the door was closed. Or he might say, “Maybe, Doktuh, you zhink so little uf yourself that you zhink you are just boring.” Or maybe, “Perhaps, Doktuh, you haff some zhings on your mind you are not ready to talk about so you substitute some ozher zhings that you’re not really interested in so we are both bored.” Or any, or all of the above.
But the real question is what is the most useful to the patient? As opposed to the word “client” that some use and that means in Latin “leaning on”, dependent, a retainer, the word here is “patient”, from the Latin and Greek for “suffering” and it has been the
physician’s obligation for more than two thousand years, from when we were priests of Aesculapius, to alleviate that suffering and do no harm. That is our primary obligation. The development of our theory and world view is quite secondary, only a byproduct of our work. We must keep our eyes on what helps the patient in the world in which he or she is living. My analyst, I came to see, was focussing on my excessive idealization of the process just as I had idealized my uncle, a most distinguished and famous internist, and had bought into his idealization and philosophy of life, for good and for ill, and was still doing that. I had to learn to challenge that idealization within me and reexamine it to gain my freedom and autonomy. I had to challenge that not just in words but in action, and challenge my ego ideal, as Stanley Milgram showed in his experiment, “Obedience to Authority”. I must learn to think for myself, heading towards the day that my analyst will say to me, “Yes, it iss true, Doktuh, you are doing fine, aren’t you? And it iss time for me to giff you back your
freedom.” Which he finally did. And isn’t that what it’s all about?
In one of Robert Frost’s poems he writes about some people sitting in their beach chairs on a beach and gazing out at the ocean, and he writes, “They cannot see out far, / They cannot look in deep; / But when was that ever a bar / To any watch they keep?”
We must continue our watch as our technology continues to advance and our science and understanding develop further, and remember too that the DSMs are not at all final but just steps in a process, one after another, as we proceed toward our goal. The great physicist Max Planck wrote about this in his 1959 book The New Science, in the part entitled “Where is Science going?” There, using the analogy of the scientist as a traveler crossing an uncharted territory and climbing a peak and not seeing the peak beyond until it too comes into view and then climbing that one, and then the next, and so on, he stated, “The value of the journey is not in the journey’s end but in the journey itself,…..in the striving to reach the goal that we are always yearning for, and drawing courage from the fact that we are always coming nearer to it….. Health is maintained only through work…… We are always struggling from the relative to the absolute.”
Herb Peyser, MD, DLFAPA
December 2010