RDC and DSM-III
Hannah S. Decker
10/18/2009 8:30:59 PM
It is certainly true that Eli Robins and Sam Guze played major roles in developing diagnostic criteria for mental illness. They need to be given their due, especially Robins who learned about operational criteria from Mandel Cohen at Harvard in the 1940s. But one thing surprises me in the article by Kupfer, et al. and that is that nowhere is mention made about the contributions of Robert Spitzer, the chair of the task force that produced DSM-III. Expanding on the Feighner criteria, Spitzer was the main person to construct the Research Diagnostic Criteria (RDC)within the NIMH study of the psychobiology of depression.
One has only to look at the references to the Kupfer et al. article to see Spitzer's main role in the development of the RDC as well as the SADS. Spitzer used the RDC as a base on which he led the construction of DSM-III, a manual that bears his revolutionary stamp in so many ways. Paul McHugh appropriately praises Spitzer's "awesome" skills in his article.
Article by Dr. Paul McHugh
Joseph R. Nevotti, Ph.D.
10/13/2009 1:09:50 PM
Good article. I have always regarded the DSM as a tool in psychiatry (or psychology, my profession). To suggest that the DSM is part of the reason psychiatry is not as fascinating as it once was is a straw man. Is the DSM III/IV the reason for the decline in medical students who choose to specialize in psychiatry? Perhaps psychiatry qua psychiatry is no longer fascinating because it is no longer at the leading edge as it was during the “bad old days” of DSM-II and the psychodynamic world?
I went to graduate school in the 60’s and early 70’s so I had a front row seat when DSM-III came to the fore. In my opinion, the publication of DSM-III is arguably the most important advance in psychology during the second half of the 20th century. It was the coup de grace for the phenomenological approach, and has been instrumental in fostering a more scientific mind set in the practice of psychology. Psychologists now at least give lip service to evidence-based practice and behavioral based work. For those who love to wallow in what they think is going on inside the “minds” of others, DSM-III (to say nothing of CBT and managed care) has been a disaster. For those of us who base their work on data, the scientific method and empirical research, it has been a good partner.
I have always viewed the DSM as (a) the generally accepted professional collection of research and thinking about psychopathologies and their diagnostic characteristics, and (b) a starting point for my current experiment (n=1), aka psychological assessment. I have never thought of it as the Rosetta Stone or something written by a great oracle. It’s simply a vehicle of communication; a starting point for my hypotheses about what’s going on with the person I’m assessing. Imagine psychology or psychiatry without the DSM!
To me a much larger problem is the selection and training of those who become psychologists and psychiatrists. With some exceptions, it appears that psychology programs (I can’t comment on psychiatry) are in the business of (a) staying in business, (b) recruiting enablers (i.e. people who “just want to help”), and (c) training therapists. Imagine what would become of psychology programs (psychiatry?) if the “educators” were primarily interested in training professionals whose work could withstand the kind of scrutiny your work receives in a peer-reviewed journal or my work gets when I go to court? Imagine what would happen to both of our professions if the people doing the selection and training were primarily tasked with making sure that everything that goes on in a psychologist’s or psychiatrist’s practice could withstand intense and hostile scrutiny? Is transformation a big enough word?
Instead what we have, at least in psychology, is some very flabby thinking and practice. That is a much larger problem than the tools used by those so engaged. Put an MRI (or the perfect DSM-VI) into the hands of a Rogerian or someone psychodynamically trained and you have a very expensive machine that sits idle. The tool is not the problem. Most “clinical” psychologists, certainly those of the therapeutic stripe, largely consist of people best described as “solutions in search of a problem.” People with pet theories on psychodynamics who are hostile to things I regard as basic science, i.e. objective psychological testing, empirical evidence, professional critique and review of one’s own work, substantial evidence or conclusions based on data and solid logic. Allowing such people into graduate school in the first place, to say nothing of the flabby training they receive as “non-judgmental” therapists, is the problem, at least in psychology.
In psychiatry, my hypothesis is that your profession is simply dying a natural death. The action—or fascination, to use your word—is in psychopharmacology and neuropsychiatry. It’s not the DSM that is the problem; it’s the thought processes of those who use such tools that is the problem. Debates about making psychiatry or psychology fascinating again by focusing on the DSM is like debating about using Rosie O’Donnell or Jimmi Hendrix to sing the Star Spangled Banner at the beginning of the next Super Bowl. Fascinating, but of no consequence to the outcome of the game. Thanks for your stimulating thinking. Joseph Nevotti Forensic, Psychologist. Enjoyed your article.