by Hunter Yost MD

Overview

Welcome to the site where I hope to build a case for returning psychiatry to its historical roots in the medical model as formalized in the late 19th century by Kraepelin and other European psychiatrists, as well as trace time-honored descriptions of clinical pictures such as classic melancholia and mania from antiquity to present-day patient care.

Concepts of the medical model missing from the current practice of psychiatry are that of Diagnostic Hierarchy and Diagnostic Validators, neither of which are components of the DSM, but will be discussed in detail in future blogs.

When psychiatry is viewed through the larger lens of history (see sources: Hannah Decker, Edward Shorter, Nassir Ghaemi, Ann Herrington, and others), we see that our current view is severely limited by the DSM at a cost to our patients.

The intent of this website is to provide information (generally not taught) to mental health professionals, primary care providers, as well as to the interested public, about the DSM history of psychiatric diagnosis, especially from the 1980 DSM-III to the 2013 DSM- 5.  In order to elucidate some of the misunderstandings that have resulted from the DSM non-disease based approach to diagnosis and treatment, the following issues and others will be covered:

• The difference between the DSM Bipolar and the classic Manic-Depressive Illness.
• The origin of the term “disorder.”
• The absence of the term “disease” or “illness.”
• The absence of blood tests for bio-markers in psychiatry, even though other specialties (i.e., cardiology, endocrinology, oncology, rheumatology) have constantly introduced revised tests over the past 40 years.
• No other medical specialty has its own DSM.
• Every “depressive” presentation may not be a Major Depressive Disorder, i.e., “MDD.”
• The origin of “GAD” (generalized anxiety disorder).
• The ubiquitous use of the PHQ-9 at the expense of the Mood Disorders Questionnaire.
• The de-emphasis in training programs over the last quarter century of lithium, one of the two most effective drugs in the history of psychiatry.
• The historical bias of not diagnosing children under 12 with Bipolar Illness even though there is a wealth of pediatric Bipolar studies over the past 30 years.
• The addition of DMDD (disruptive mood dysregulation disorder) to the DSM-5.
• The origin of “borderline personality” in the DSM.
• Why personality traits are more scientific than “personality disorder.”)
• The reason the chapter on personality traits 761-781 in the DSM-5 was supposed to replace the personality disorders chapter.

What was left out of your training program?

Professional training programs based on the DSM over the past 40 years (from DSM-III to 5) have significantly limited our understanding of diagnosis in clinical mental health.

For example, programs emphasizing that symptoms are the sine qua non of a diagnosis as promoted in the DSM, ignore the more important diagnostic validators of course and family history which are not part of official DSM criteria.

 Another central concept absent until the DSM-5, is that of “mixed symptoms” aka “mixed states” of depression and mania, which have been described for over a century and confirmed by more recent research to constitute up to 60% of all so-called “depressive” presentations in clinical practice.  These states respond poorly to antidepressants which may increase suicide attempts.

It has been over a decade since the National Institute of Mental Health (NIMH) said it will no longer use the DSM defined “disorders” for research since they are not considered valid and they confound studies.

In a 2013 blog just before the release of the DSM-5, Thomas Insel MD, then director of NIMH, said the DSM is “at best, a dictionary, creating a set of labels and defining each” and that “its weakness is its lack of validity.” He said that NIMH will “reorient” its research away from the manual. (bold added)

 He continued, “Unlike our definitions of ischaemic heart disease, lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” Insel said. “In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain, or the quality of fever.”

Insel said that “elsewhere in medicine this type of symptom-based diagnosis been abandoned over the past half-century as scientists have learned that symptoms alone seldom indicate the best choice of treatment.”

Insel was right, and that bell could not be unrung, but the pushback from the grandees of the American Psychiatric Association was swift: “the DSM remains the gold standard for clinical diagnosis, but what may be realistically feasible today for practitioners is no longer sufficient for research.” This sentiment abandons science for tradition.

Insel was advocating emphatically for a return to the medical model consistent with other specialties of medicine, but the psychiatric establishment clearly said it was not ready.

In every other specialty of medicine, decisions on criteria to define a “disease” are based on science i.e., rigorous clinical studies, conducted predominantly by the clinicians and researchers who perform and publish those studies.

In contrast, the decisions about psychiatric diagnosis are made less by researchers and their publications and more by “consensus committees” composed primarily by non-research-based academics.

In Psychology Today over the past decade and elsewhere, Nassir Ghaemi, MD has criticized the DSM process from the DSM-III to the DSM-5 as being overly concerned about how psychiatry is perceived socially i.e., “pragmatic” (political) concerns, rather than what clinical studies show or enduring clinical pictures such as Kraepelin’s original comprehensive disease concept of Manic-Depressive Illness of which “Bipolar” is a smaller category. (to be discussed in a future blog)

The best example of a psychiatric textbook based exclusively on clinical studies is the 2007 2nd edition, epic two-volume 1000-page tome, Manic-Depressive Illness – Bipolar Disorders and Recurrent Depression by Frederick K. Goodwin (1936-2020) and Kay Redfield Jamison PhD, consisting of literally thousands of research citations. (Available on Amazon).

Many notable collaborators include Nassir Ghaemi, MD, Hagop Akiskal, MD (1944-2021), and Myrna Weissman, Ph.D.

This is clinical psychiatric science at its best. Unfortunately, there is unlikely to be a third edition due to the Herculean task of putting together such a prodigious publication, and sadly, this is a loss for psychiatry. 

This excellent resource is an example of valuable information hiding in plain sight. Additionally, there is over 40 years of worldwide research on the validation of the historical concept of mood temperaments (Cyclothymia, Hyperthymia, Dysthymia) first described in the late 19th century but not included in any DSM. (Cyclothymia was initially included as a personality disturbance in the DSM-I and more recently as a “disorder” in the DSM-III through 5, but never as a mood temperament).

If the DSM was based primarily on this empirical research, our profession would be practiced very differentially today.

I suspect not many psychiatric residents were encouraged or required to study these two volumes, or were taught about the prevalence of mixed symptoms or the mood temperaments during their training, or that many board exam questions were based on these proven concepts.

I do not mean to imply that psychiatric diagnosis be based primarily on the brain as promoted by the current NIMH Research Domain Criteria. The time-honored diagnostic validators of course of illness and family history/genetics cannot be ascertained in the brain.

As in other fields of medicine what counts as a disease entity, it’s criteria and diagnosis is determined by many types of studies, including double blinded randomized placebo clinical trials (primarily for new medications), observational studies, longitudinal studies, preferably over years or decades, cohort, case controlled, epidemiological studies and the concept of Diagnostic Validators of course, family history, symptoms and biomarkers, (to be discussed in a future blog).

No one type of study, however, gives “the truth, the whole truth and nothing but the truth.” Clinical pictures can also coalesce over the years to become accepted diagnostic entities i.e., Parkinson’s disease for which there is no diagnostic test, or classic Manic-Depressive Illness, also with no diagnostic test.

Education in Mental Health at all Levels and Primary Care Providers

In the training programs in the broad area of mental health at any level whether MD/DO, Ph.D, psychiatric physician assistants or PA’s, psych nurses or masters level therapists and primary care providers, there appears to be a lack of historical education about the diagnostic process ignoring the how and why various diagnoses appear in the DSM.

That process, when viewed closely through historical analysis (Decker, Shorter, Harrington, and Ghaemi to name a few), is much more like sausage-making than science, evidenced by the fact the DSM has ever included references or citations to any clinical studies like standard medical textbooks.

From the 1952 DSM-I to the 1968 DSM-II there was little interest in the field of psychiatry related to diagnosis due to the hegemony of Freudian theory of the time, a theory which used only two diagnostic categories: neurosis and psychosis. That would change in 1980 with the DSM-III which intentionally removed any implication to etiology or causation from psychiatric diagnosis (i.e., Freudian concept of neurosis), and improved diagnostic reliability in the hope that better validity would follow in time with research… a backward approach to clinical practice seen in no other medical specialty.

Important discoveries in research were lost or ignored, even though they were available to the Mood Disorders committee prior to the DSM-5. For example, the half-century, longitudinal research of Jules Angst’s Zurich cohort study shows there is actually no genetic reason to separate severe, recurrent, clinical depression from Bipolar illness (as was thought to be the case prior to 1980 when the classic disease unity of Manic-Depressive Illness was broken into “MDD” and Bipolar Disorder, more on this later). Despite Angst’s contraindicated results, which were based on long-term family studies, the separation between MDI and Bipolar Disorder is continued in the DSM-5.

Intention and Sources for this site

The sources for this website are drawn from historical figures in psychiatry, from 19th century figures such as Kahlbaum, Hecker, and Kraepelin, to 20th and 21st century researchers such as Frederick Goodwin and Kay Jamison, Hagop Akiskal, Athanasios Koukopoulos, Jules Angst, Nassir Ghaemi, and others. For various reasons to be discussed in the future, the prodigious research of these experts has not made its way into many training programs or exams over the past 30-40 years. More importantly, their research has not influenced much needed changes in the DSM.

I intend to update this site with new perspectives and lost historical information as it becomes available. I will include research-based treatments that have been largely ignored. There will be a comment section to welcome constructive contributions and opinions to the overall theme of this site. If you find anything that is factually incorrect, please let me know so it can be corrected. 

The goal is to create a community of like-minded professionals who provide mental health care, and if you are so inclined, to contribute content (approximately 800-1000 words) to this blog in the overall theme of Returning to the Medical Model, as well as in the context of:

• what was left out of the DSM that should be included?
• what is in the DSM that should be left out?
• do we really need a DSM?
• what is a true “mental illness”, i.e. a disease, and what is not?
• what are the treatment implications of these inclusions and exclusions?

…and to provide references for your contribution(s).

Welcome to a pathway for returning the profession of psychiatry to the medical model as originally elaborated by the classic European psychiatrists of the late 19th century and rejoining our colleagues in other specialties of medicine.

This medical model also includes the Medical Humanistic Psychiatry as espoused by Karl Jaspers and William Osler, emphasizing empathy and a focus on the individual while diagnosing a disease, if present, and treating it if a cure is available.