Hippocrates the Projective Test

 

There is no doubt that the ancient physician Hippocrates was an advanced thinker in terms of medicine and its conceptualization. He is widely credited with advancing nosology and diagnostics as well as professionalism. In the field of medicine, he was studied right up until the turn of the 19^th century by physicians who attended medical schools in Europe.  Like all prominent figures from the past there is a question of whether invoking Hippocrates these days represents idealization or rhetoric more than his accurate historical position. 

I am referring specifically to a blog by Nassir Ghaemi, MD entitled Hippocratic Psychopharmacology.  After correcting the aphorism “First do no harm” to “As to diseases, try to help, or at least not harm.” he elaborates on a few ideas from Hippocrates and the implications for modern medicine. He interprets the preamble of Hippocrates statement to mean that diseases must be identified and if you cannot or will not take the disease concept seriously you cannot help anyone as a doctor. He emphasizes that there should be a focus on not doing any harm and that overall treatment should be conservative. He acknowledges a bias that too many medications are being used in modern times.

Hippocrates additional idea is that diseases are a natural process and they heal naturally and physicians should not get in the way of that process. He discusses self-limited, treatable, and incurable diseases suggesting only the treatable illnesses are a focus for physicians.

Hippocrates was apparently not enough so Holmes Rules and Osler’s rule are added. The explanation of Holmes Rules is inconsistent because initially it described prescribing based on benefits first and harms second, but in the elaboration the assumption is supposed to be that the medication is harmful. If that is your assumption harms would seem to be prioritized.  Here is an excerpt from the post from 1861:

“……I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind, – and all the worse for the fishes.”

In other words, if you wanted to prescribe something – there is nothing useful to prescribe and given the time frame - that is correct.  1861 was before the discovery of germ theory.  Of the estimated 750,000 Civil War (1861-1865) deaths at the time about 2/3 died of diseases that are treatable in modern times. The only effective medical treatments at the time were citrus fruits and vegetables to prevent scurvy, smallpox vaccines, and quinine for malaria. Four types of wound infections were described including tetanus, erysipelas, hospital gangrene, and pyemia or sepsis with mortality rates of 46-90%.  Since there were no antibiotics infected wounds were treated with repeated debridement or amputation with the hope that remaining healthy tissue would generate an inflammatory and healing response. 

In his writings, Hippocrates describes many forms of orthopedic treatment and general medical treatment for infections including gangrene and erysipelas. Those afflictions were not likely to heal without significant medical and surgical interventions. I suppose in keeping with the stated philosophy they could be reclassified as “untreatable.” The question might become were untreatable diseases less treatable in Hippocrates time than during the Civil War? Either way it is likely that Hippocrates watched at least as many of his patients die as Civil War surgeons did and those were very high mortality rates.

Ghaemi uses the example of antidepressants in bipolar disorder as breaking Holmes Rule “egregiously.” Unfortunately, the presentation of bipolar disorder may not be that clear cut.  As a tertiary care psychiatrist, it was common to see people experience manic episodes after years of treatment for unipolar depression with antidepressants or even as an antidepressant is tapered and discontinued. You must have seen a manic episode along the way in order make the diagnosis and stop the antidepressant.  It also helps if the patient is under the care of a psychiatrist and it is likely the vast number of antidepressants in these presentations were prescribed by other specialists or nonphysicians. I have never heard of a psychiatrist needing more evidence to stop antidepressants in bipolar disorder.  It was done routinely by my colleagues in acute care.

Osler is quoted in the discussion of Osler’s Rule:

“A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practicing a sort of popgun pharmacy, hitting now the malady and again the patient, he himself not knowing which.”

And what exactly was known in Osler’s time about pathophysiology and pharmacotherapy?  Probably not much more than was known at the time of the Civil War.  Paton’s reference (5) contains several additional quotes to illustrate what he describes as Osler’s nihilism including that there were no useful treatments for scarlet fever, pneumonia, and typhoid fever.  Diarrhea and dysentery were common in soldiers leading to both compromised health status and death.  A summary quote from Osler’s time suggests there were only a few useful treatments including iron for anemia, quinine for malaria, mercury and potassium iodide for syphilis and that there were no other drugs supported by experimental evidence.  It turns out that that the evidence for potassium iodide in syphilis was restricted to reducing inflammation in some late-stage lesions since it was not an anti-spirochetal agent (4).

If Osler was aware of a potentially effective drug – he may have pushed it beyond what his colleagues were using as evidenced in this quote:

'At times of crisis Sir W. Osler and others have pressed up the nitrites to huge doses, in persons upon which these drugs had been well tested. Sir William said he had never seen harm come of large doses if cautiously approached. I think he used to speak of 20-30 grains of sodium nitrite per diem. I have administered half as much in a day.' (pp 88-9).” (3)

20-30 grains of sodium nitrite is roughly equivalent to 1,329 to 1,980 mg.  In a 70 kg patient that would be 19-28.3 mg/kg.  The worrisome complication from nitrites is methemoglobinemia. In severe cases it can result in coma, cardiac arrythmias, and death. PubChem suggests that intravenous doses of 2.7 – 8 mg/kg can be problematic. A leading toxicology text suggests that when sodium nitrite is given intravenously to treat cyanide poisoning the dose is 300 mg given at a rate of 75-150 mg/minute intravenously with a repeat dose at half the amount if necessary, monitoring for symptoms of nitrite toxicity. While it is difficult extrapolating oral toxicity from IV administration there are reports of life threatening and fatal oral ingestions resulting from taking 12.5-18 g of sodium nitrite. The EPA recommends limiting exposure to 1.0 mg/kg/day. All of this toxicology information suggests the the doses that Osler was using were pushing the limit, but it also points to another deficiency in suggesting that his parsimony (or nihilism) is a touchstone for modern physicians.  That deficiency is that his outcomes were unknown. The case reports that I have found were generally limited to a case or two. I could not find any outcomes for high dose versus low dose nitrites for angina or congestive heart failure. Modern nitrate preparations such as isosorbide mono and di-nitrates are limited by tolerance to the vasodilating effect. I may be wrong but I speculate the Osler knew very little about the pharmacology of nitrites and the mechanisms of tolerance and toxicity.

A common theme for these conservative historical pharmacologists is that it is easy to be conservative when there are no known effective treatments.  When your category of treatable diseases is small – it is easy to rationalize watching the self-limited and untreatable illnesses run their course.  There was a very long period of slow progress in therapeutics between the time of Hippocrates (460-375 BCE) and Osler (1849-1914). Penicillin was not available to treat syphilis until 1943. Even though there was some basic science research in pharmacology in the mid 19^th century, Paton’s review shows that potentially effective medications, in pill form and in significant numbers did not occur until about 1920.

Apart from limited therapeutic options, the doctrine of informed consent was either nonexistent or much less clear in earlier times.  Gutheil and Applebaum (6) trace the early evolution and consolidation as occurring in the 1950s and 1960s in the US.  The earliest clear application was for surgery and invasive treatments extending to medical treatments.  In psychiatry, that also extended to medication treatment and neuromodulation but at the time of this book whether it was necessary for psychotherapy or not was not clear.  To me one of the clearest reasons for informed consent is the level of uncertainty in medicine. We know probabilities at the population level but are rarely able to predict side effects and adverse reactions at the individual level.  I have written about my approach to this problem on this blog and it is basically a shared decision-making model where the patient is informed of the uncertainty of both efficacy and adverse events as clearly as possible. That information was not available to to earlier physicians. Detailed regulatory information in package inserts is a relatively recent phenomena starting in 1968 in the US with several modifications since then.  

Ghaemi winds down his critique emphasizing diagnoses over symptoms.  He uses the bipolar disorder example again and hedges suggesting that is it acceptable to treat symptoms sometimes but there are no guidelines only the rather extreme criticism that by treating diseases and developing a Hippocratic psychopharmacology we can avoid the “eclectic mish-mash which is contemporary psychiatry.”

It is apparent to me that Hippocrates and Osler have very little to offer present day psychopharmacologists. They both a had very large body of patients who could not be treated. Both had limited evidence-based pharmacopeias and both prescribed toxic compounds with no clear guidelines or suggestion of efficacy. On diseases, syndromes, and symptoms – the issues are much clearer these days but much is still written about how these concepts are confusing. That is especially true in psychiatry where decades of debate has not resulted in any more clarity.  It is not as easy to separate out insomnia, anxiety, and mood disturbance with bipolar disorder as Ghaemi makes it seem, but treating them all at once in a single point of time is probably not the best approach. In clinical practice at least some people have insomnia, anxiety disorders, and depression prior to the onset of any diagnosis of bipolar disorder. Assuming adequate time to make those historical diagnoses, there are no clear guidelines about what should be treated first and no clinical guidelines on when medications should be started and stopped.  It all comes down to the judgement and experience of the physician and patient consent and preference. Evidence based medicine advocates always argue for that approach but it it highly unlikely that there will be clinical trials for every scenario and the trials that do occur are often limited by inclusion and exclusion criteria.   Hippocrates and Osler have no better guidance.

As therapeutics has evolved, polypharmacy has become a part of the clinical environment of all specialists.  It is common to see patients taking multiple medications in order to treat their cumulative diseases, even before a psychiatric medication is prescribed. Despite all of the rhetoric – I am convinced that experts can manage polypharmacy environments if they need to and do it with both therapeutic efficacy and minimal to no side effects.  

For the record, I agree with Ghaemi’s overall message that you need good indications for medical treatments and that the fewer medications used the better. Those decisions need to incorporate, current evidence, informed consent, and frequent detailed follow up visits to reduce the risks of inadequate treatment and adverse events. That is hard work - not helped by guidance from the ancients or modern-day philosophers.

 

George Dawson, MD, DFAPA

 

References:

1:  Ghaemi N. Hippocratic Psychopharmacology.  Jun 16, 2023. https://psychiatryletter.com/hippocratic-psychopharmacology/

2:  Burns SB.  Civil War Disease and Wound Infection https://www.pbslearningmedia.org/resource/ms17.socct.cw.disinf/civil-war-disease-and-wound-infection/  Accessed on 06.20.2023

3:  Paton W. The evolution of therapeutics: Osler's therapeutic nihilism and the changing pharmacopoeia. The Osler oration, 1978. J R Coll Physicians Lond. 1979 Apr;13(2):74-83. PMID: 374726; PMCID: PMC5373168.

4:  Keen P. Potassium iodide in the treatment of syphilis. Br J Vener Dis. 1953 Sep;29(3):168-74. doi: 10.1136/sti.29.3.168. PMID: 13094013; PMCID: PMC1053890.

5:  Howland MA.  Nitrite (amyl and sodium) and sodium thiosulfate.  In:. Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR Hoffman RS (eds). Goldfrank’s Toxicologic Emergencies. McGraw-Hill Education; 2019. P. 1698-1701.

6:  Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law, 3^rd ed. Lippincott, Williams and Wilkins; 2000; Philadelphia, PA: 154-157.

7:  Writings of Hippocrates. Translated by Francis Adams. Excercere Cerebrum Publications; 2018.

 

 

Graphics Credits:

 

William Osler aged 32: Notman photographic archives, Public domain, via Wikimedia Commons.  https://upload.wikimedia.org/wikipedia/commons/e/e9/William_Osler_1881.jpg

Hippocrates: ESM, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons. https://upload.wikimedia.org/wikipedia/commons/8/82/Facultat_de_Medicina_de_la_Universitat_de_Barcelona_-_Hip%C3%B2crates_de_Kos.jpg

Biomedical or Biopsychosocial or Psychopharmacologist?

Elements of a psychiatric evaluation

Apparently these are desperate times for some professionals.  So desperate that they have nothing better to do than argue about proven psychiatric methods that include the clinical methods that includes data gathering and diagnosis. Some would prefer to move psychiatry away from the rest of medicine based on fallacious arguments that there are no clear connections between biology and clinical phenomenon and no apparent connection between psychiatry and the rest of medicine. These arguments are so extreme that they lack clinical utility and yet there is a small by vocal group of people who try to gain political favor with what is essential reworked antipsychiatry rhetoric. As a reminder I use that term as a philosophical definition that has been used to characterize the work of Szasz and Foucault. It is agnostic in terms of the proponents. In other words, as far as I can tell you don't need to be a cult member to be a proponent of antipsychiatry. You can be a psychiatrist like Szasz.

I posted a good example of this position a few years ago.  In the post I looked at a special interest group using medical model pejoratively and applying it to psychiatry.  I illustrated how the authors account of medical model on 2 1/2 of 3 dimensions that they were using as a basis for their argument.  The eventually develop a trauma based model of psychosis and state that is all that you need to know in terms of etiology and treatment. That is their refutation of the comprehensive psychiatric model for information gathering and analysis.

Another incredible critique of the field came from the journal Health Affairs and it suggested (like most critiques of the field) that the authors really had no knowledge of psychiatry or what psychiatrists do. Specifically they seemed to have no knowledge of the biopsychosocial model of psychiatry, specific psychiatric research in that field, and how all of that information is used in day to day psychiatric practice.

The obvious point that I am making here is that psychiatrists are trained and interested in multiple factors that may be important in both the etiology and treatment of psychiatric disorders.  That includes many biological factors like toxin exposure, endocrine conditions, infectious diseases, and brain injuries as well as more subtle biologically determined factors like temperament and developmental history.  It includes the status of interpersonal relationships and psychological factors. It includes the status of other organ systems in the body and chronic medical conditions.  There are specific posts on this blog about cardiac status, sleep apnea, cirrhosis and liver disease and pancreatitis. All of these illnesses and more are encountered in routine psychiatric practice.  Psychiatrists must in some cases make the diagnosis and in other case modify therapy to account for these illnesses and not provide treatment that is contraindicated.

That leads me to the figure at the top of the page.  All of the elements are contained in the assessment of the patient. It is not unique to psychiatry, and most physicians who directly assess patients have been using one form or another of it since they were first or second year medical students learning how to examine patients.  The main difference for psychiatrists from other physicians is the formulation section. This is not the list of diagnoses, but a synthesis of all of the data gathered during the interview process and at times from collateral sources.  Consider the following hypothetical example:

========================================================================

Formulation:

The patient is a 48 year old married woman with a history of insomnia and depression dating back to middle school.  She also had nightmares and night terrors during childhood but they resolved by the time she was in her late teens. Her current sleep problem is initial and intermittent insomnia.  She has been on various antidepressant medications about 90% of the time since she was 18 years old and has not found any of them to be very effective, but she does think that she gets some partial relief from fluoxetine.  She has been married for 18 years.  Her husband is supportive and they have a solid relationship.  The couple has 3 sons who are 10, 12, and 17 years old.  she had no episodes of postpartum depression.  She took fluoxetine during the last pregnancy.  There is a family history of depression in her mother and maternal grandmother. Her maternal grandmother was institutionalized and received electroconvulsive therapy.  Father and paternal grandfather had alcohol use problems. She is an electrical engineer and works in the tech industry in chip design.  She was previously active in a group that encouraged girls and young women to focus on STEM subjects in school and as a career choice but she has fallen away from that lately.  Over the past three years her alcohol consumption has increased from 2-3 standard drinks per day to 8-10 drinks per day. When she is drinking on  daily basis her mood is significantly more depressed.  During a recent episode of intoxication she sustained an intracerebral hemorrhage that was noted on an MRI scan of the brain in the left frontal cortex. She reports no cognitive or personality changes with that lesion but has had frequent headaches. She denies any history of abuse or psychological trauma, but said that her parents spent less time with her than her older brothers and that left her with a feeling of being less valued at times and questioning her self worth. She identifies strongly with her father who was also an engineer and encouraged her interest in math and science.

Diagnoses:

1.  Persistent depressive disorder
2.  Primary insomnia
3.  Intracerebral hemorrhage - assessed and treated by Neurosurgery trauma service. Serial scans show resolution with no evident abnormality.
4.  Headaches secondary to 3.

========================================================================

A typical medical surgical evaluation using the same general outline will not put all of the data together to explain the patients psychiatric diagnoses or symptomatology.  Medical or surgical evaluations typically end with a list of diagnoses that typically focus on an organ system or the brain idendependent of any psychiatric factors.  The diagnostic formulation is a psychiatric innovation that has utility as a way to study diverse etiologies of mental illnesses and in this case to try to understand the unique biological, social, and psychological variables for each person who is being treated.  It is in contrast to the diagnoses which are supposed to be atheoretical (but are not really) in the DSM. The formulation allows us to develop unique theories about what might be contributing to the person's distress.

I have been a longstanding critic of the lack of a psychiatric focus on the conscious state.  Only recently did I have the thought that this biopsychosocial (BPS) formulation is an approach to the study of a unique conscious state. The broadest definition of consciousness is experience.  If you develop a good technique and confirm the observations and theory about how all of the dimensions impact on them - it is basically a study of a unique conscious state.  An elaboration of the elements contained in either outline - would lead to a discussion of the person's experience of any number of life events including growing up in her family of origin, going to school, working, her leisure time experience, and her experiences as a wife and mother.  That is probably a very liberal interpretation of the BPS model.  Interested readers can find original papers written by George Engel in the references below.  The BPS model generally looks at multiple systems relevant to biological organisms and the philosophy of general systems theory.  The reader can get a good overview of Engel's theory by looking at the articles and the accompanying diagrams. Ghaemi has written an excellent book on BPS (6), it shortcomings and what he considers a more appropriate model for psychiatry - method-based psychiatry.  In his book he goes so far to outline how it can be taught to residents. 

The problem with all of the terminology is that I know very few psychiatrists who practice or prefer to practice in a restricted biomedical mode. A few examples that come to mind were some of the psychoanalysts who were my teachers 35 years ago who "prescribed a little amitriptyline for sleep." I suppose there may be some psychiatrists out there prescribing fluoxetine and not attending to their patients medical disorders - but happy to report that I don't know any.

That brings me back to the central point of this post. Do you really need to distinguish yourself as a biomedical or biopsychosocial psychiatrist if every other psychiatrist is doing what you do? Do you need to call yourself a psychopharmacologist?  Do you need to call yourself a medical psychiatrist?

I would say that you do not. Psychiatric training exposes trainees to the same content and clinical contexts where they an observe and treat severe problems. In many of those situations they are responsible for the total medical care of the patient.  They accumulate medical knowledge on a consistent basis as they accumulate knowledge about diagnosis and treating medical conditions. It is an inescapable part of the practice of medicine. Where do all of these titles come from?

I see a couple of origins.  The first is political and that is people who are using the terms in a pejorative way. There are apparently psychiatrists in the UK who use the term biomedical psychiatrist in a pejorative way because they don't believe in any diagnosis or they adhere to the old Szaszian concept of disease and do not want to see psychiatry practiced as a medical specialty. Many would go as far as not using diagnoses at all. They often equate diagnosis with the pejorative term labeling. When I think about that movement and its origins and how psychiatry got to where it currently is today - I ask myself about the development of both paths of thought. Without going into too much detail - there are no geniuses on the antipsychiatry path. Many of the early proponents on that path failed because they really had nothing to offer people with serious mental illnesses. If anyone wants to refer to me as a biomedical psychiatrist - I embrace it because it certainly does not deter me from doing  thorough psychiatric assessment that includes a formulation that contains social, cultural, and biological factors unique to the person I have assessed and trying to appreciate their conscious experience in each one of those domains.

The second application of the various descriptors is to differentiate oneself from the rest of the pack. That also seems to be a dubious distinction. The best example I can think of is psychopharmacologist.  If I have studied the subject, attended the seminars and courses, but spent most of my career discontinuing medications and treating complications in polypharmacy situations - am I psychopharmacologist?  Or do I need to be the person prescribing all of the polypharmacy? As far as I can tell - all psychiatrists are (or should be) psychopharmacologists.  They should also be aware of the limitation and be able to practice specificity in the prescription of psychiatric medications. 

 Psychiatrists are psychiatrists.  They are the same, but different like any other discipline.  Apart from what they know or should know their conscious state is certainly a factor in how they practice and there are always potential differences in skill levels.

I continue to be impressed by the high level of skill of my colleagues and think that we can all be psychiatrists and be confident that we don't have to be defined by anyone else.  Anyone who suggests that they have a better approach or that they can treat patients without a diagnosis should be confident enough to proceed and compete directly.  That said we do need to refine the technical skills in the field.  A primary consideration is realizing that we have come as far as we can go with the DSM approach.  Ghaemi's suggested methods based approach presents some good ideas on a philosophical basis - but the personalized medicine and omics approaches also hold a lot of promise.



George Dawson, MD, DFAPA




References:

1:  Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129-136.

2:  George L. Engel, MD. JAMA.2000;283(21):2857. doi:10.1001/jama.283.21.2857

3: Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980 May;137(5):535-44. PubMed PMID: 7369396.

4:  Campbell WH, Rohrbaugh RM. The Biopsychosocial Formulation Manual. New York, Routledge Taylor & Francis Group, 2006, 164 pages.

5:  Chisholm MS, Lyketsos CG. Systemic Psychiatric Evaluation. Baltimore, The John Hopkins University Press, 2012, 243 pages.

6:  Ghaemi SN. The Rise and Fall of the Biopsychosocial Model.  The John Hopkins University  Press, 2010, 253 pages.  

Supplementary:

Some useful books for those interested in this topic (all referenced above):

Dr.Ghaemi on Dr. Spitzer

Nassir Ghaemi, MD has a commentary on Robert Spitzer, MD in this month's Clinical Psychiatry News.  After citing quotes by Shakespeare and John Adams to suggest that the dead are often idealized, he settles down to criticism based on whether or not the DSM-III helped or harmed the profession and Spitzer's role in that process.  Ghaemi comes down firmly on the side of harm because an unscientific approach to the diagnostic criteria for major depressive disorder has resulted in a lack of reliability and validity.  He uses the often quoted kappa score of 0.32 for diagnostic reliability of major depressive disorder in DSM-5 field trials as the main source of evidence, as well as the fact that the diagnostic criteria are unchanged since DSM-III.

Ghaemi suggests that his viewpoint is unique because unlike other eulogists, he had no personal connection with Spitzer and therefore can speak "in forthright recognition of fact from the impersonal perspective of another generation."  I am closer to Ghaemi's generation than Spitzer's and can make the same claim, but come to an entirely different set of conclusions.

I don't see Spitzer's efforts as being as corrosive as Ghaemi does, probably because I recognize the fact that there will never be a set of written diagnostic criteria that are perfect, based on science, and unambiguous.   But before I address the scientific, let me take on the rhetorical.  I would hardly blame Spitzer for the fact that the DSM criteria for depression have changed "hardly an iota" in the intervening 40 years since DSM-III.  Over that same time span there have been hundreds if not thousands of articles on the reliability of the major depressive episode diagnosis, as well as articles that analyze the symptoms according to that diagnosis.  There have been articles on standardizing various psychiatric and psychological instruments to detect major depression.  In fact, one of the rating scales basically copies the DSM criteria and asks the patient to rate on a 0 to 3 point scale - the percentage of days that they experience the symptoms. The PHQ-9 has become the standard for depression diagnosis in many primary care clinics.  There is also the fact that Spitzer's original DSM-III effort resulted in much higher reliability figures - a kappa of 0.72 to be exact (2).

There is also the issue that there have been two intervening Task Forces for DSM-IV and now DSM-5.   The Chair of the DSM-IV Task Force has since become a prominent critic of the DSM process and psychiatry in general.  I may have missed it, but at the time that Task Force was convened, I did not notice him or other members advocating for major changes to the major depression diagnostic criteria.  These are supposedly the top minds in the field.  Highly motivated academics with one axe or another to grind.  The idea that everyone would defer to Dr. Spitzer based on his original approximate efforts seems unrealistic to me.  More than a few people would have noticed his bungled and unscientific approach.

My major problem is using a single reliability figure as the grounds for this criticism.  Every year outpatient based psychiatrists can see up to a thousand new people a year.  They may find that up to 50% of those patients have had a life-long sleep disturbance.  Many can recall nightmares and sleep terrors as children.  Another 20-30% will have generalized anxiety or social anxiety since childhood.  In some there will be a performance based anxiety that is comorbid with the social anxiety.  Another 10-20% will have post-traumatic stress disorder to some degree.  About one-third will have a significant substance use problem.  These percentages will vary by clinic location and referral base.  The majority will be referred for a diagnosis and treatment recommendations for depression.  A substantial number of people with depression have comorbid anxiety and anxious temperaments.  I don't think it is a stretch to say that on any given day, many of the identified depressives will identify themselves as primarily anxious.  It is not unexpected to find that many patients don't really understand the difference between anxiety and depression or they will overtly say that they are the same problem - indistinguishable from one another.  Unless there is a clear differentiating factor like a manic episode, the postpartum state, or psychotic symptoms I would not expect that anxiety and depression are distinct disorders for most people.  At the minimum anxiety might morph into depression, but in most cases they are coexisting chronic conditions.  A low kappa in this situation should be expected and not a shock.

Does that mean that psychiatrists should be wringing their hands and blaming Spitzer for it?  Neither response is appropriate.  Psychiatrists are highly successful in diagnosing and treating mental illness, not because of a DSM manual, but because of clinical training.  When it comes to anxiety and depression there are no known ways to parse all of the symptomatic possibilities.  The human brain is designed to realize all of the possible combinations of human experience.  Why would we expect it to be different when it comes to experiencing anxiety and depression?  The only chance that a psychiatrist has to make sense of the world is a number of patterns of diagnoses based on their training and practice experience that they can match against the patient they are currently seeing.  These patterns guide the diagnosis and treatment plan.  A clinically astute psychiatrist is not plowing through the interview to see if the patient "meets criteria".  A clinically astute psychiatrist carefully attending to the patient's conscious state and trying to figure out how they can be helpful.  That includes figuring out the real problems and prioritizing them in a complex matrix psychiatric and medical problems.  None of that flows from the DSM and none of that resembles research based on lay people interviews using DSM criteria.

In closing, any commentary on Dr. Spitzer should include his role in eliminating homosexuality from the diagnostic manual.  This detail and how it occurred is never taught to residents.  I had to learn it from public radio many years after residency.  This detail is significant any way you cut it.  It invites criticism that monolithic psychiatry is currently moving too slow in other areas or that monolithic psychiatry was just responding to public pressure.  There is also criticism directed at Dr. Spitzer for a paper based on self report that was withdrawn years later on this same issue.  There are always advocacy groups seeking publicity by their own spin on the issue.   In my opinion, none of that diminishes that significant achievement that put psychiatry four decades ahead of most people in the United States.  Say what you will about the DSM, that accomplishment alone is enough.  I am thankful that Dr. Spitzer was open minded enough to listen to the advocates and eventually side with them.              


George Dawson, MD, DLFAPA


1:  Nassir Ghaemi.  Commentary:  Dr. Robert L. Spitzer - An impersonal appraisal.  Clinical Psychiatry News.  March 2016. p 12-13.

2:  Riskind JH, Beck AT, Berchick RJ, Brown G, Steer RA. Reliability of DSM-III diagnoses for major depression and generalized anxiety disorder using the structured clinical interview for DSM-III. Arch Gen Psychiatry. 1987 Sep;44(9):817-20. PubMed PMID: 3632255.