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Fall 2012

The Last Word?

By: Mat Edelson
Date: September 1, 2012

The Last Word
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It is a book both revered and mocked by those within the profession—a 943-page diagnostic tome that was never intended to be a bible, yet nonetheless has been elevated to Final Word status by the majority of the nation’s practicing psychiatrists. It is not apocalyptic to state that the future status of the profession, its perceived capacity to help versus harm, may well rest on the book’s next chapter…

So perhaps it’s only appropriate that, with the Fifth Edition of theDiagnostic and Statistical Manual of Mental Disorders (a.k.a. DSM) on the verge of descending from the mountain top, a former DSM acolyte-turned-heretic is leading his disciples away from the dogma, and toward what he envisions as a promised land where mental illness and its sufferers will be seen and treated in a healing new light.

TO understand Paul McHugh’s love/hate relationship with the DSM is to understand the history of the book itself. Actually, it was more of a short synopsis in its first two incarnations, circa 1952 and 1968—nascent attempts to categorize and nomenclate the expressions of mental distress. But by the early-70s, it was becoming clear that psychiatrists, depending upon their particular schooling and inclinations, couldn’t agree on diagnoses; their infighting was reminiscent of the Islamic parable of the Six Blind Men and the Elephant, who, depending upon what part of the creature they touched, concluded that the animal definitely was either a wall, spear, snake, rope, fan, or a tree.

There was nothing amusing about the diagnostic inconsistencies then facing psychiatry. A landmark study in 1971 showed that, when evaluating patients with identical symptoms, American psychiatrists generally concluded the patients had schizophrenia, while British psychiatrists leaned toward a diagnosis of major depression. Two years later, a study in Science went a step farther; researcher David Rosenhan sent volunteer “pseudo-patients” claiming audio hallucinations into a dozen psychiatric hospitals across the U.S., where they were all admitted, some for weeks, with a schizophrenia diagnosis. The hospital’s diagnostic criteria never ferreted out the fakers among their general schizophrenic population, leading Rosenhan to conclude, ominously, “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.”

Similarly, depending upon whether one landed upon the doorstep of a Freudian, Jungian, behaviorist, or neurobiologically-oriented psychiatrist, one could be diagnosed with a myriad of mental conditions requiring a plethora of different treatments. This lack of agreement on diagnosis—“reliability” in medical parlance—was rapidly becoming an embarrassment to practicing psychiatrists.

“The field was riven by ideological factions,” recalls McHugh, who directed the department from 1975 to 2001 and is now University Distinguished Service Professor of Psychiatry. “We had to come up with a classification system, to get the psychiatrists to all agree on what disorders looked like so they could at least call them the same thing.”

Enter DSM III. Released in 1980 by the American Psychiatric Association (APA), it was staggering in scope: The work of hundreds of psychiatrists yielded symptoms for 265 diagnoses—for illness ranging from borderline personality disorder to catatonic type schizophrenia. Yet hardly any of the diagnoses had established scientific “validity,” i.e., a verifiable base set of causes, notes McHugh. This initially greatly concerned him.

 “I told [DSM-III editor] Bob Spitzer, ‘Gee, Bob, I don’t know; you’re starting off by naming stuff whose nature you don’t know,’” recalls McHugh. “And he said, ‘Nope, Paul, this is the way to do it.’ And for the first 10 years after, I thought, ‘he’s right!’”

McHugh, who was always fascinated by methods—he calls them “perspectives”—for helping to determine causation for mental illness, hopped on the DSM III train because of its implied promise: If psychiatrists, regardless of training and practicing philosophy, could agree on which symptoms led to the same diagnosis, then researchers would have a standardized field of patients to study, and begin to uncover the base causes of different mental illnesses. This was vital, for while different methods of psychological therapy had long been studied, the root causes of what made people mentally ill in the first place, and how best to choose between medications, therapy, and perhaps social services for treatment options, had received far less attention.

DSM III was supposed to fill this research Q and A void, but that’s not what happened in the wake of its launch; psychiatric research still lagged as few diagnoses proved easy to pin to a single biological cause. Furthermore, the intentionally atheoretical underpinnings of DSM III meant that “by rule, the APA’s editors wanted to stay away from thinking about causes,” says Hopkins psychiatrist Kostas Lyketsos.

Meanwhile, the simplified “checklist” system of DSM III—which, critics say, tried to quickly nail down a symptom/diagnosis match using leading questions, without deeply investigating the patient’s bio/psycho/social history—was radically transforming psychiatry. As an example, McHugh mentions grief. In the wake of DSM III, it became classified as major depression, “so instead of [doctors] talking with the person about the meaning of their loss, they just started popping pills into them. They lost touch with the humanity of this most basic human emotion.”

Still, the checklist concept was proving irresistible: Within a decade the APA found itself with a multimillion dollar bestseller on its hands, as both psychiatrists and physicians outside the field became fascinated by this elaborate diagnostic menu.

“DSM III was meant as a tentative guide to diagnosis. Instead, it was treated like a bible,” says McHugh contemporary Allen Frances, who was editor of the 1994 DSM IV before becoming one of the fiercest public critics of the direction the latest DSM edition is taking. “People never took seriously DSM I and II. But the [symptom] sets of DSM III became the subject of cocktail party conversation, they became the subject of research, they became the way insurance companies paid for treatment. It decided who was sick and who wasn’t. It became the vehicle for determining disability benefits and who would get school services. And it was very important in the courtroom. But each time the DSM was used beyond its capacity, the use distorted itself and the place it was being used. It was meant to help psychiatry retain its credibility, but no one realized there’d be this vast overshoot.”

By the time DSM-IV rolled around in 1994, Paul McHugh believed that his field was in trouble. The DSM had led everyone to believe they could practice psychiatry: Consider that, with the help of big pharma’s “if you have these symptoms, ask your doctor” ads, nearly 80 percent of all psychiatric meds were being prescribed by internists and family practitioners—some in the course of a seven-minute HMO visit. Hardly time to deeply evaluate a diagnosis, let alone get to the cause of the problem.

And it was that explosion of new diagnoses that most concerned McHugh. DSM IV contained nearly 300 diagnoses—three times more than DSM I. “In the early ’90s, things dawned on me. These diagnostic categories that the experts said existed were expanding way out of size. [Patients] only express [themselves] emotionally in so many ways; ultimately doctors began to put lots of people in the anxiety category and the major depressive category, and they were all getting the same kind of treatments,” says McHugh. He also believed the DSM was allowing faddish diagnoses to get in without scientific rigor.

“DSM [inclusion] gave cover to certain kinds of major assumptions, such as the ‘recovered memory’ and ‘multiple personality’ syndromes. As soon as you said in the DSM that multiple personality exists, then people could build up treatment programs based on the fact that you repressed memories of sexual abuse as an infant. And they went wild on that,” says McHugh, whose 2008 book Try To Remember recounted his and other psychiatrists’ mostly successful efforts to discredit the existence of both conditions.

The price of devotion was becoming too high for McHugh; the harm to families victimized by accusations of false memories of abuse, the infliction of stigmatizing diagnostic labels on seemingly “normal” people, the medicalization of kids to the point where 2-year-olds were being diagnosed and medicated for depression … this was a catechism McHugh could no longer embrace.

Especially because he had already found a better way.

IN the May 17 issue of the New England Journal of Medicine, McHugh and Hopkins colleague Philip Slavney laid their concerns over the coming DSM revision on the line in an essay titled “Mental Illness—Comprehensive Evaluation or Checklist?” Lead author McHugh didn’t mince words: “Identifying a disorder by its symptoms does not translate into understanding it. Clinicians need some heuristic concept of its nature, grasped in terms of cause or mechanism, to render it intelligible and to justify their actions in practice and research.”

Leading members of the APA, well aware of the criticism of the DSM levied by McHugh and others, argue the latest version will be able, thanks to electronic publishing, to respond to and potentially correct areas of diagnostic concern within the tome. “I don’t like the term ‘bible,’ says David Kupfer, who is lead editor for the current revisions. “A bible is written once, and we can write commentary on it, but we can’t change it. I think it’s important to convey the fact that this DSM is going to be a living document. We’re calling it DSM 5.0; we see a 5.1, 5.2, and a 5.3, not rewriting the whole thing, but where there is new information, and good thresholds met to change criteria, we want to be able to do that and not have it wait in the queue for 20 years.”

McHugh, who maintains a cordial relationship with Kupfer, respectfully disagrees on waiting to implement change. His solution—or at least a suggestion of where DSM 5 should head immediately—is a direction that ironically harkens back to psychiatry’s roots at Hopkins of nearly a century ago. That’s when Adolph Meyer established the first comprehensive methods for evaluating a patient’s life—the origins of the bio-psycho-social model.

That was supposed to be DSM’s 21st-century model as well. But even the APA’s then president Steve Sharfstein admitted in 2005 that his field had turned into “a bio-bio-bio model” dominated by “a pill and an appointment.”

For McHugh, such an approach is anathema to the way he’s taught the psychiatric arts to thousands of Hopkins medical students over the past 40 years. While it’s impossible for students to ignore the DSM—at the very least, it guides insurance reimbursements that sustain medical practices—McHugh says the DSM is best seen by students as a general field guide to psychiatry, much in the same way amateur bird watchers might look at an Audubon guide to separate robins from starlings.

But to really figure out what makes starlings or people tick—or at least get them flying toward their own personal True North again—McHugh and Slavney’s teachings have balanced the DSM’s black-and-white influence with their version of modern day Meyerism, which they’ve written about in The Perspectives of Psychiatry. First published in 1986 (a second edition came out in 1998), the book urges psychiatrists to invoke four perspectives with each patient to get to the heart of their condition. The book is considered the foundation of Hopkins clinical training, and its influence has reverberated across the field.

“It is a book for the ages,” says Margaret Chisolm, who directs psychiatric education at Bayview and was schooled in McHugh’s methodology. “They call it the recipe for applying the bio-psycho-social model.” Duke’s Allen Frances has an equally humanistic view of McHugh’s perspectives: “Hippocrates [says] it’s far more important to understand the person who has the disease than the disease the person has. Paul’s [perspectives] are following in those footsteps,” says Frances.

If it were up to McHugh, the perspectives would become a new organizational structure for both the DSM and the field at large. They include categorizing diagnoses by:

• Brain Diseases, such as schizophrenia

• Personality Dimensions, such as obsessive-compulsive disorder

• Motivated Behaviors, such as alcohol addiction and anorexia

• Life Encounters, including grief and post-traumatic stress disorder

To the layperson, such perspectives appear at first glance to be both subtle and contradictory. Neuro-psychiatrists might suggest that all mental illness is caused by brain disease. Similarly, in a sort of chicken-and-egg conundrum, does someone with anorexia not eat because they are obsessive-compulsive, or does the desire to not eat become obsessive over time?

To McHugh, this is where the monochromatic current viewpoint of the DSM has to yield to the investigation, reflection, and consideration of numerous causal factors that can be brought forth by applying the perspectives to each psychiatric patient. Instead of a rush to diagnosis, the emphasis becomes about understanding, insight, and appropriate treatment.

Each perspective is brought to bear, like applying rotating gel lights of different colors to the same stage. Subtle? Yes. Field changing? Perhaps. It’s worth noting that, in a journal noted for vigorous debate, there was no rebuttal from the APA or others to the McHugh/Slavney call-to-arms. If anything, some of the country’s top psychiatrists are embracing his message.

“I think Paul’s perspectives nails it,” says University of Iowa psychiatrist Arnold Andersen, an eating disorders authority who spent 15 years at Hopkins working with McHugh. “They address the issue by recognizing that different modes of reasoning are needed to appreciate the real-life, categorical differences between different types of psychological distress.

“Take alcohol abuse,” continues Andersen. “It’s a behavior with different sources. There isn’t any one treatment until you trace back the origin. The little old lady who has sherry before her Canasta game to calm a benign hand tremor is very different from the 13-year-old who just loves alcohol and has no side effects [that’s almost always genetic] and from the person who uses alcohol to cope with a high-stress situation. To categorize those three on a single checklist implies the job is done.

“By contrast, Paul’s approach is the soundest I know. The perspectives have a methodological approach; when he finishes with a global assessment [of a patient], you have a comprehensive guideline on how to begin with treatment. If DSM 5 would put their different disorders into his categories, you could begin to reason in a far more sound way.”

“I have eight pages on Paul’s system,” says Harvard psychologist Jerome Kagan, referring to his own book, Psychology’s Ghosts: The Crisis in the Profession and the Way Back (2012). To Kagan’s thinking, while McHugh’s first three categories can all lead back to biological roots, “Family four was his brilliant idea; that any of the symptoms in families two [personality dimensions] or three [motivated behaviors], can have mainly environmental causes.”

“Consider,” Kagan says by way of example, “that the best predictor, right now, in any part of the world, of whether you’re going to have anxiety, depression, impulsive aggression, gambling, or drug abuse is the social class in which you grew up.” By solely using DSM, social status might never be discussed on the way to, say, a diagnosis of depression with resulting treatment being anti-depressive drugs. However, using McHugh’s approach that considers environment, the diagnostician might uncover that the onset of the patient’s depression coincided with his being laid-off six months previously, and part of the long term therapy might include engaging social workers to help the patient find employment.

McHugh also notes the perspectival approach could be used by family practitioners to help them better evaluate which conditions can be handled comfortably in an internist’s office—especially given their longtime familiarity with most patients—and which should be referred out to psychiatrists, who in many cases could work with the internists to help diagnose and best manage care.

McHugh said he wrote the NEJM essay because, after more than a generation of teaching the perspectives he wanted to give them a public airing, especially in light of the development of DSM 5, which has been in the study group phase since 2004 and is set to be released next year. Given that, as he notes, the APA will “make millions in royalties” from the publication of DSM 5, it would be a “failure of leadership” if the book is identical in scope to the previous two that focused exclusively on descriptions of illness. “Every discipline has a right to go through a descriptive phase. We’re not blaming anybody for that,” says McHugh. “But you begin to criticize [leadership] when they say they can’t move out of the descriptive phase. We’re saying, after a generation of description, you’re going to bring out a new edition and the only thing you’re going to tell us is you’ve discovered a few other diagnoses? You don’t need a new field guide, if that’s the best you’re going to do. The time has come to move toward explanation.”

FOr as much as the DSM is being debated for its impact on patients, far less chatter surrounds the effect it has on medical students and residents at institutions where it is treated as The Book. McHugh strongly believes that such “training to the test”’ has the effect of driving would-be psychiatric residents into other fields.

“The textbook education using just the DSM does such an injustice to the field,” says second-year Hopkins psychiatric resident Rachna Hundal. Her own medical school psych rotation in Philadelphia, she says, “was just about DSM. We were taught based upon DSM definitions. Our exams were DSM definitions. That education did not draw anyone into the field.”

Even with a serendipitous mentor or attending physician who can see beyond the DSM and excite a student about psychiatry, many young doctors arrive at Hopkins after medical school—or even residencies—completely dependent upon the manual.

Kotsas Lyketsos, chairman of psychiatry at Johns Hopkins Bayview, worries that this can draw the wrong people to the field. “The DSM gives the appearance that psychiatry is easy, so people who are interested in basic research would be happy to come through psychiatry, learn the checklist, get the imprimatur of being a psychiatrist [with no intent of engaging clinical practice], and not really learn what it’s really like to think through a problem facing a patient.”

What Lyketsos and colleague Margaret Chisolm are doing is taking McHugh’s perspectives one important step further—to a place that they hope will attract more medical students to psychiatry. McHugh’s textbook on the subject is considered a masterwork, notes Chisolm, but it’s not easily digestible for students relatively new to the game. The joy has always been in listening to the entertaining McHugh speak, she says. This oration was the most accessible way to pass along his insights about the perspectives to students. It fell upon Lyketsos and Chisolm to set the sermons in stone, or as Lyketsos jokes, given his Grecian upbringing, “we had Homer; what we needed was the Iliad.

Their new book, Systematic Psychiatric Evaluation, seeks for the first time to put rules to McHugh’s perspectives and give diagnosticians more confidence in their global assessment and treatment of patients. “Rule number one is, you want to take a complete history, and there are certain elements that go into that. You want to ask general questions that are not directing the answers,” says Lyketsos. “Remember, in DSM you can’t do that; in DSM you’re directly asking questions that say ‘do you have this symptom or that symptom?’ So if you were strictly applying just DSM, you could not ask open-ended questions.”

In the end, what Lyketsos, Chisolm, and McHugh are looking for in future psychiatrists is—well, there’s no other word for it—perspective. It’s not about throwing out the DSM. “It drives treatment authorization, so you need as a practitioner to learn enough about it to use it, just as long as it doesn’t drive patient care,” says Lyketsos. Instead it’s about emphasizing the “perspectival approach” to best guarantee that every appropriate treatment option can be explored.

Will the approach ultimately find its way into DSM 5? Probably not, given the publication’s deadline of 2013. But by going public with his critique of the DSM process, McHugh is no longer a lone voice in the wilderness.

“Paul is a man of conscience and courage,” says Frances, who criticized DSM 5 because of his concerns that proposed expanded new diagnoses could, as he wrote in a New York Times op-ed in May, “define as mentally ill tens of millions of people now considered normal.”

“Paul is part of the inspiration of me [writing publicly] about this stuff,” says Frances. “It’s not really part of my personality to be a crusader, but he’s an example that you can’t just sit on the sidelines.” Not while there’s work still to be done. *