Their reanalysis suggested more modest levels of agreement than those claimed by the authors of the original studies. For example, in the study by Sandifer, Pettus and Quade, levels of agreement calculated using kappa (for example, schizophrenia = 0.68; psychotic depression = 0.19; manic depression = 0.33) appeared consistently lower than those calculated as percentages (schizophrenia = 74 per cent; psychotic depression = 22 per cent; manic depression = 36 per cent).22
Table 3.2 Kappa measures computed for six studies (adapted from R. L. Spitzer and J. L. Fliess (1974) ‘A reanalysis of the reliability of psychiatric diagnosis’, British Journal of Psychiatry, 123: 341–7).
Specific diagnoses (e.g. schizophrenia) are listed under the major diagnostic categories (e.g. psychosis). A kappa value of 1 indicates perfect agreement between raters whereas a value of 0 indicates agreement at chance level. This statistic corrects for the ‘base rate problem’ (see text) and is a better measure of agreement than raw percentages. The studies from which the data were derived were (I) Schmidt and Fonda (1956); (II) Krietman (1961); (III) Beck et al. (1962); (IV) Sandifer et al. (1964); (V) Cooper et al. (1972); (VI) Spitzer et al. (1974). The data from (V) (the US–UK Diagnostic Project) are analysed separately for the New York and London samples.
STUDY
V
Diagnosis
I
II
III
IV
US
UK
VI
Mean
Mental deficiency
.72
.72
Organic brain syndrome
.82
.90
.59
.77
Acute brain syndrome
.44
.44
Chronic brain syndrome
.64
.64
Alcoholism
.74
.68
.71
Psychosis
.73
.62
.56
.42
.43
.54
.55
Schizophrenia
.77
.42
.68
.32
.60
.65
.57
Mood disorder
.19
.44
.59
.41
Neurotic depression
.47
.20
.10
.26
Psychotic depression
.19
.24
.30
.24
Manic depression
.33
.33
Involutional depression
.38
.21
.30
Personality disorder
.33
.56
.19
.22
.29
.32
Neurosis
.52
.42
.26
.30
.48
.40
Anxiety reaction
.45
.45
Psychophysiologic reaction
.38
.38
DSM-III and the Industrialization of Psychiatry
The unsolved problem of reliability was one factor among many that led the APA to embark on the production of the third and most influential edition of its Diagnostic and Statistical Manual. Also important were political and economic concerns, together with changes in the scientific Zeitgeist.
The political concerns mainly centred on homosexuality, which was listed as a disorder in DSM-II. Following the emergence of the gay rights movement in the late 1960s, activists lobbied APA meetings – at first angrily protesting outside but later taking part in debates supported by sympathetic psychiatrists – in order to have homosexuality removed from the manual. Robert Spitzer played an important role in these discussions, shifting his support from those who saw homosexuality as a disease to those who saw it as part of normal human variation. Although these developments were peripheral to the classification of the psychoses, they drew problems of psychiatric classification to the attention of the American public for the first time, and established Spitzer as an authority on diagnostic issues in the eyes of many of his peers.23
The economic issues sprang from attempts to regulate the availability of psychological and medical treatments for psychiatric conditions. Health insurance companies in North America required a diagnosis before they would make reimbursement available to claimants, and looked to the APA for criteria to discriminate between those who really needed psychotherapy and those who did not. The US Food and Drugs Administration’s demand that drug companies specify the disorders that their new compounds were to treat created similar pressures for a comprehensive and standardized approach to psychiatric diagnosis.24
However, more important than any of these factors was a shift in the way in which many American psychiatrists thought about psychiatric disorders. During the decades following the Second World War, Freudian theory had dominated American psychiatry, and the terminology of DSM-I had reflected this. For example, psychotic disorders were grouped under the heading ‘disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain’ and, in deference to the ideas of Adolf Meyer, were individually listed as ‘reaction types’ (for example, ‘manic-depressive reaction’, ‘schizophrenic reaction’). By the end of the 1960s, many American psychiatrists had become disenchanted with psychoanalysis, partly because it had failed to deliver effective treatments but also because it threatened to sever for ever the ties between psychiatry and medicine. It was mainly in reaction to this threat that Spitzer and others placed their hopes in a thoroughly biological approach to mental illness.
American psychiatrist Gerald Klerman coined the term neoKraepelinian to describe this new attitude to mental illness. In a 1978 article, which came close to being a manifesto, Klerman identified the nine propositions that he believed united the movement (see Table 3.3).25 These recapitulated the approach to mental disorder taken by the movement’s forefather nearly a century before and emphasized psychiatry’s roots in physical medicine. According to Klerman, the neo-Kraepelinians assumed that a line could be drawn between mental illness and normal behaviour (proposition 4), and that there was a discrete and discoverable number of psychiatric disorders (proposition 5). There was an emphasis on the biological causes of mental illness and the psychiatrist’s expertise in biological matters (proposition 6). Finally, emphasis was also placed on the importance of developing a reliable and valid system of psychiatric classification (propositions 7, 8 and 9).
One of the most important early achievements of the movement was a new, unofficial diagnostic system. In a landmark paper published in 1972, a group of neoKraepelinians from Washington University noted that the unsolved reliability problem made it difficult to ensure that the patients studied by one research group were comparable to those studied by another.26 They therefore proposed what came to be known as Feighner criteria (after John Feighner, the first author of the paper) for sixteen commonly researched disorders. The paper became one of the most highly cited publications in the field of psychiatry. It was successful because the authors had finally adopted the suggestion made more than a decade earlier by the philosopher Carl Hempel. For each disorder, a precise list of symptoms was given, together with rules that specified exactly how many of the symptoms were required before the diagnosis could be made. This level of precision promised to abolish entirely the ambiguity and doubt which had previously affected the
Table 3.3 The main points of Gerald Klerman’s neoKraepelinian manifesto (from G. L. Klerman (1978) ‘The evolution of a scientific nosology’, in J. C. Shershow (ed.), Schizophrenia: Science and Practice. Cambridge, MA: Harvard University Press).
1 Psychiatry is a branch of medicine.
2 Psychiatry should use mode
rn scientific methodologies and base its practice on scientific knowledge.
3 Psychiatry treats people who are sick and who require treatment for mental illness.
4 There is a boundary between the normal and the sick.
5 There are discrete mental illnesses. Mental illnesses are not myths. There is not one, but many mental illnesses. It is the task of scientific psychiatry, as of other medical specialties, to investigate the causes, diagnosis and treatment of mental illnesses.
6 The focus of psychiatric physicians should be particularly on the biological aspects of mental illness.
7 There should be an explicit and intentional concern with diagnosis and classification.
8 Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate such criteria by various techniques. Further, departments of psychiatry in medical schools should teach these criteria and not depreciate them, as has been the case for many years.
9 In research efforts directed at improving the reliability and validity of diagnosis and classification, statistical techniques should be utilized.
selection of patients for inclusion in research. The thirst for certainty in diagnosis had at last been quenched.
The Feighner criteria became the model for DSM-III. The precise strategy for developing the new edition of the manual was decided at a day-long meeting in 1974 attended by Spitzer, Melvin Sabshin, then President of the APA, and Theodore Millon, a psychologist at the Illinois Medical Center. The production of the manual was to be a major undertaking. The task force set up to execute this project – chaired, of course, by Spitzer – decided to undertake field trials to determine whether various draft criteria were usable in practice. By the time the task had been completed, no fewer than 600 clinicians had become involved.
The DSM-III definitions of schizophrenia and manic episode, which illustrate the clarity of the manual, are given in Table 3.4. DSM-III definitions have what some have called a ‘Chinese menu’ structure. For example, in the definition of a manic episode there are three main elements. First of all, the patient must meet criterion A (one or more distinct periods of elevated, irritable or expansive mood). Second,
Table 3.4 DSM-III definitions of schizophrenia and manic episode (American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders (3rd edn). Washington, DC: APA).
SCHIZOPHRENIA
A At least one of the following during a phase of the illness:
1 bizarre delusions (content is patently absurd and has no possible basis in fact), such as delusions of being controlled, thought broadcasting, thought insertion, or thought withdrawal
2 somatic, grandiose, religious, nihilistic or other delusions without persecutory or jealous content
3 delusions with persecutory or jealous content, if accompanied by hallucinations of any type
4 auditory hallucinations in which either a voice keeps a running commentary on the individual’s behaviour or thoughts, or two or more voices converse with each other
5 auditory hallucinations on several occasions with content of more than one or two words, having no apparent relation to depression or elation
6 incoherence, marked loosening of associations, markedly illogical thinking, or marked poverty of content of speech if associated with at least one of the following:
(a) blunted, flat, or inappropriate affect
(b) delusions or hallucinations
(c) catatonic or other grossly disorganized behaviour
B Deterioration from a previous level of functioning in such areas as work, social relations and self care.
C Duration: Continuous signs of the illness for at least six months at some time during the person’s life, with some signs of the illness at present. The six-month period must include an active phase during which there were symptoms from A, with or without a prodromal or residual phase.
MANIC EPISODE
A One or more distinct periods with a predominantly elevated, expansive, or irritable mood. The elevated or irritable mood must be a prominent part of the illness and relatively persistent, although it may alternate or intermingle with depressive mood.
B Duration of at least one week (or any duration if hospitalization is necessary) during which, for most of the time, at least three of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1 increase in activity (either socially, at work, or sexually) or physical restlessness
2 more talkative than usual or pressure to keep talking
3 flight of ideas or subjective experience that thoughts are racing
4 inflated self-esteem (grandiosity, which may be delusional)
5 decreased need for sleep
6 distractability, i.e. attention is too easily drawn to unimportant or irrelevant external stimuli
7 excessive involvement in activities that have a high potential for painful consequences which is not recognized, e.g. buying sprees, sexual indiscretion, foolish business investments, reckless driving
C Neither of the following dominates the clinical picture when an affective syndrome is absent (i.e. symptoms in criteria A and B above):
1 preoccupation with a mood-incongruent delusion or hallucination
2 bizarre behaviour
D Not superimposed on either schizophrenia, schizophreniform disorder or a paranoid disorder.
E Not due to any organic mental disorder, such as substance abuse.
criterion B requires that the patient has suffered from at least three out of a list of seven symptoms over a period of at least a week. Finally, criterion C indicates some exclusion criteria, for example symptoms that, if present, would indicate an alternative diagnosis.
The final manual, at 500 pages, was more than three times longer than DSM-II.27 During a period when the American publishing industry was experiencing serious difficulties, it became an unlikely bestseller. Nearly half a million copies were bought, generating estimated revenue for the APA of over $9.8 million (a sum that does not include earnings from the numerous pocket guides to DSM-III which were later published). In the USA, the manual was widely embraced both by psychiatrists and psychologists fearful that, without a DSM-III diagnosis for each of their patients, payment from health insurance companies would not be forthcoming. Many journals would not accept papers for publication unless investigators could reassure their readers that the patients studied had been diagnosed according to the DSM-III system, thus ensuring that the criteria became a standard among researchers, not only in America but also elsewhere in the world.
Astonishingly, DSM-III has been revised twice since its publication in 1980. Within three years, a new task force, again chaired by Robert Spitzer, set to work on the changes that would be required for the revised third edition, known as DSM-III-R, which was published in 1987.28 Despite Spitzer’s assurances that only minor adjustments were necessary, twenty-five committees involving over 200 consultants worked on the project. The criteria for half of the diagnostic categories were altered, and thirty new diagnoses were added. Not surprisingly, the appointment of a DSM-IV task force within four months of the publication of DSM-III-R led some psychiatrists to protest. British psychiatrist Robert Kendell suggested that the exercise was little more than a cynical attempt to repeat the huge profits the APA had made from selling the earlier editions.29 Despite these objections, the APA decided to proceed with the new edition, partly to ensure that the official classification would be consistent with the mental disorders section of the tenth edition of the International Classification of Diseases (ICD-10), scheduled for publication in 1992. When it appeared in 1994, DSM-IV weighed in at 900 pages, and credited over 1000 consultants.30 By the end of 2000, over 960,000 copies had been sold, a remarkable volume of sales given that there were just 42,000 psychiatrists and about 300,000 other mental health care professionals in the USA.31 At about the same time, the lead character of the hit television comedy show Frasier
read out spoof DSM criteria for ‘phase of life problem’ without explaining what the letters stood for, thereby indicating the extent to which the manual had become part of American culture.
Madness Explained Page 8
