Tuesday, June 30, 2009

Dr. Warren’s “DSM-Minus-IV”: Lessons for DSM-V?

The compelling article, "A Warning Sign on the Road to DSM-V," by Dr. Allen J. Frances,
inspired me to pull a brittle, yellowed old tome off my bookshelf. Warren’s Household Physician, based on the work of Massachusetts physician, Dr. Ira Warren, was first published in 1859 as a “brief description, in plain language, of all the diseases of men, women and children . . .”. The chapter titled, “Diseases of the Brain and Nerves”—what I call, the DSM-Minus-IV—is a gem of holistic thinking. Dr. Warren essentially unifies afflictions often called “neurological disorders” with those nowadays considered the domain of psychiatry. Thus, Dr. Warren addresses various types of brain inflammation, chorea, and neuralgia in the same chapter that addresses “derangement of mind” or “insanity.” Indeed, the good doctor seems uncomfortable with Cartesian dualism, noting that:

“Some have supposed insanity to be a mental disorder merely, having nothing to do with the body. They might as well suppose the delirium of fever to be a disease of the mind only.”

Under the general rubric of “insanity”, Warren includes only 5 main types: melancholy, monomania (“insanity on one subject”); mania, dementia, and idiocy. (This last category - in which “the brain is not large enough to be the organ of intelligence” - is similar to what neurologists would call anencephaly). Closing out his “DSM,” Warren discusses hypochondria—apparently not a cause of insanity, but nevertheless a brain disease characterized by “. . . constant fear, anxiety, and gloom.”

Now Dr. Warren’s classification is far from perfect. For example, Warren did not clearly distinguish bipolar disorder (or manic-depressive illness) from schizophrenia, as Emile Kraepelin would do about a quarter century later. (Then again—some recent genetic studies have challenged this dichotomy; see, e.g., Craddock et al, Schizophr Bull. 2009 May;35(3):482-90. Epub 2009 Mar 27.) And, let us be clear: we need more than 6 major disorders to capture the range of psychopathology we have delineated since 1859. But Dr. Warren’s pared-down classification—has Occam’s Razor ever shaved so close?—seems at one with the spirit of Dr. Frances’s critique.

Indeed, I suspect that Dr. Warren would agree that we must avoid expanding the DSM beyond what is absolutely necessary—and scientifically supportable. I, too, share with Dr. Frances the fear that extending the DSM’s reach in the absence of convincing data will further undermine psychiatry’s already battered credibility. For example, I have argued against reifying such proposed “disorders” as “Pathological Bigotry” and “Internet Addiction.”

The issue of “sub-syndromal” or “pre-clinical” conditions poses further conundrums. In psychiatry, as in all of medicine, there is always a tension between the sensitivity and specificity of our disease criteria—in essence, between how large a descriptive “net” we cast and how fine we weave its mesh. Ideally, both current and proposed disease categories should be built on a firm base of epidemiological, biological, observational, and phenomenological data . Absent this foundation, Dr. Frances rightly cautions us against building castles in the air.

And yet, we should view the task of the DSM-V directors with some empathy. “Objective science”—if there is such a thing—can take us only so far. Ultimately, the disease categories we create reflect complex existential decisions, not mathematical equations. We should be guided not by a need to increase or decrease the number of DSM diagnoses nor merely by a desire to safeguard psychiatry’s reputation. Our pole star must remain the healer’s ancient charge: to reduce human misery and enhance the blessings of health.

Ronald Pies, MD


  1. Ron,
    I agree wholeheartedly. Any paradigm shift that's not based on robust evidence does not fit Thomas Kuhn's definition. This is what made the evolution from DSM-II to III so revolutionary - it was a step back from theory and doctrine to a focus on data.

    DSM evolution should codify and organize robust data rather than drive a paradigm shift. Research is the appropriate arena for questioning our current thinking.

  2. Many thanks for your comments, Edward. We certainly agree on the foundational value of robust and reliable research data, for DSM-V.

    I would add that--while biomarkers, genetic patterns, and related "observable" data would be valuable indeed--the "phenomenological" data of the patient's inner world should also be a part of our diagnostic thinking. Dr. Alarcon picked up on this point in his recently-published piece on our website, as well.

    So, for example, it ought to count as "data" when the patient with a putative psychotic process tells us, "My brain is crumbling into little pieces...it's falling apart because of the evil forces arrayed against me." This sort of phenomenological information--emphasized by the philosopher Husserl and several existentially-oriented psychiatrists, ought to be part of our comprehensive "data base".

    In the best of all possible worlds--perhaps DSM-VI or VII?--this kind of experiential information will be used to enhance and even validate biochemical, genetic, and neuroimaging studies. This is why psychiatry exists, in my view: to knit the diverse strands of data into a rich and variegated fabric of diagnostic meaning. --Best,
    Ron Pies MD