A Brief History Of Psychiatric Diagnosis Allen Frances MD

1. A Brief History Of Psychiatric Diagnosis  Allen Frances MD

2. The History Of Psychiatric Diagnosis •  The Shaman (100,000 to now) • The Priest (10,000 to now)  • Hippocrates (ca 500 BC) • Galen (ca 100 AD)  • Christianity (400-1700)  • Arab Psychiatry (700-1500) • Sydenham (17 century) • Linnaeus (18 century) • Pinel (early 19 century) • Kraepelin (turn of century)   • Freud (turn of century) • Spitzer (1980)

3. The Hope in Medicine and Psychiatry Careful and systematic description will lead to an understanding of the underlying explanatory mechanisms.  

4. No Explanatory Model Because The brain is most complicated thing in the known universe All normal brains normal in same way All abnormal brains abnormal in their own very particular ways

5. The Reality of Psychiatry • Explosive gains in molecular biology, genetics, and imaging provide a neuroscience revolution • But there is little translation from basic brain to clinical behavioral science • No biological tests for diagnosis • Little progress in understanding of the • mechanisms causing psychopathology • Neurotransmitter models seems quaint

6. The Brain’s Unbelievable Complexity • 100 billion neurons each connected to 1000 other neurons • 100 trillion connections • 1000 signals per neuron • Dozens of neurotransmitters • 1500 proteins per synapse every second • Only hope- neural networks

7. No Simple Gene Findings • Hundreds of different genes/disorders • Genetic findings may be nonspecific • Any finding explains only a few percent of cases • Same is true of most medical illnesses • Remarkably heterogeneous- only hope-regulatory genes

8. Developmental challenges First 5 fetal development months- 1/2 million new neurons per minute • Have to find right place • Have to make right connections • Epigenetic interactions with environment • Have to prune appropriately

9. Receding Target • Every finding uncovers more heterogeneous complexity • Any "cause" will explain only small percentage of variance • Hundreds of schizophrenias: not one, not a small group • Parallel to breast cancer and most other illnesses

10. The definition of mental disorder is vague and provides little or no help in: • Setting a clear boundary with normality • Deciding which diagnoses should go in the manual Deciding whether a given person is best considered a patient

11. Descriptive Psychiatryis in a Rut The only way ultimately to reduce complexity and explain psychopathology will be to find higher order final common pathways, perhaps neural networks descriptive psychiatry, the study of external, readily observable behavior

12. What Is Mental Disorder- Four Epistemological Umpires First: There are balls and strikes and I call them as they are Second: There are balls and strikes and I call them as I see them Third: There are no balls and no strikes till I call them Fourth: There are balls and strikes and I call them as I need to use them

13. Our Mental Disorders Are Constructs Useful For: Clinical Research Education Forensic Administrative Statistical purposes

14. But there is not one right way to describe reality

15. Cynical view- mental disorders are what: Clinicians treat   Researchers research   Educators teach   Insurance companies pay for

16.     Recent History of Diagnosis 1860 Census- 6 inpatient diagnoses WW 1 and Freud- outpt expansion 1952 DSM I- outpt expansion 1968 DSM II- unreliable, unused 1975 RDC-few dx, criteria based 1980 DSM III- many dx,splltters system 1987 DSM IIIR- too much, too soon 1994 DSM IV- conservative

17. The Future It will likely be a slow slog with steady and gradual advances in understanding No home runs, no walks, lots of strikeouts SLOW AND STEADY WINS THE RACE

18. Current role of descriptive psychiatry is to provide a useful way station for enhancing communication in clinical practice, research, teaching, and forensics

19. We are: Astronomy before Kepler and Newton Biology before Darwin and Mendel  Physics before Einstein and Bohr

20. And medicine may never have simple, unifying models