TY - JOUR
AU - Nussbaum, Abraham, M
AB - Abstract Immediately before the release of DSM-5, a group of psychiatric thought leaders published the results of field tests of DSM-5 diagnostic criteria. They characterized the interrater reliability for diagnosing major depressive disorder by two trained mental health practitioners as of “questionable agreement.” These field tests confirmed an open secret among psychiatrists that our current diagnostic criteria for diagnosing major depressive disorder are unreliable and neglect essential experiences of persons in depressive episodes. Alternative diagnostic criteria exist, but psychiatrists rarely encounter them, forestalling the discipline’s epistemological crisis. In Alsadair MacIntyre’s classic essay, such crises occur in science when a person encounters a rival schemata that is incompatible with their current schemata and subsequently constructs a narrative that allows them to reconstruct their own tradition. In search of rival schemata that are in conversation with their own tradition, psychiatric practitioners can utilize alternative diagnostic criteria like the Cultural Formulation Interview, embrace an epistemologically humble psychiatry, and attend to the narrative experience of a person experiencing a depressive episode. Cultural Formulation Interview, DSM-5, interrater reliability, major depressive disorder, psychiatric diagnosis I. INTRODUCTION In the care of persons with mental illness, disagreements occur daily between the map and the territory. The territory is a person experiencing a depressive episode, a person whose mood has saddened or soured and who has often lost interest in the activities and habits constituting their identity. The map is an abstraction of the territory, of the person experiencing depression, which renders the dark territory knowable and navigable (Nussbaum, 2013a). In psychiatry, the current consensus map is the fifth edition of the DSM, the Diagnostic and Statistical Manual of Mental Disorders, which concisely describes the territory of a person’s depressive episode in nine symptoms. If a person is experiencing depressed mood or anhedonia, along with at least five of the nine symptoms for at least two weeks, a practitioner diagnoses a major depressive episode (American Psychiatric Association, 2013). However, psychiatric practitioners frequently experience a divergence between the DSM-5’s map and the territory itself. The map is unreliable when used by two trained practitioners to describe the same territory (Freedman et al., 2013). The map also neglects essential aspects of the territory, like the anxious mood and somatic complaints common to persons in depressive episodes (Kendler, 2016). Despite frequently experiencing this divergence between the experience of depression and the DSM-5 diagnostic criteria for a major depressive episode, psychiatric practitioners rarely experience what Alasdair MacIntyre (1977) called an epistemological crisis in science, an encounter with an alternative schema representing a different theory incompatible with a person’s current schemata. Both the divergence and the need for an epistemological crisis can be seen in the care of a person, Jessica, whom I recently met as a patient. Jessica was a middle-aged woman who reported several major depressive episodes. When admitted to our hospital overnight, a trainee documented in the electronic health record that Jessica presently exhibited five of the nine DSM-5 major depressive episode diagnostic criteria during the same two-week period—depressed mood, anhedonia, insomnia, diminished concentration, and recurrent thoughts of death and suicide—which impaired her ability to work and care for her two toddlers. The trainee scrupulously recorded that the patient was not disqualified from the diagnosis because her condition was not caused by another medical condition, mania, psychosis, or substance use, but the trainee never said why Jessica became depressed or what this depressive episode meant for the story of Jessica’s life. When we met Jessica the following morning, we asked why she was depressed. She said “I worry all the time. What is becoming of this world? I cannot stop thinking about the president and what he’s doing. Sometimes I worry so much I don’t feel real. I’m not a part of this world. My kids aren’t a part of this world either, so I decided we should leave.” Jessica reported anxiety and depersonalization, experiences the trainee had not solicited because those features are not part of the DSM-5 diagnostic criteria. Worse, Jessica’s thoughts of suicide had developed into thoughts of killing her own children. The territory was more complicated and far darker than the DSM-5 map evinced; Jessica’s mood had soured into a violent despair that extended beyond the DSM-5 criteria. These divergences between the map and the territory are commonplace in clinical psychiatry, well-known by psychiatric researchers, and neglected by the healthcare executives and policy experts who have built the map ever more deeply into today’s health systems, where practitioners with limited training in mental health are encouraged to screen and treat for mental illness by locating a person’s experience on a DSM-5 map (Fancher and Kravitz, 2007).1 By neglecting the divergence between the lived experience of depression and the DSM-5 diagnostic criteria for a major depressive episode, psychiatry forestalls the epistemological crisis necessary to transform the future care of persons with mental illness. If psychiatric practitioners consider the DSM-5 field trial data in context of the care of persons experiencing depressive episodes, they may recognize the disagreement between the map and the territory as an epistemological crisis and pursue a clinically pragmatic and epistemologically humble psychiatry. Psychiatrist practitioners could then attend to the narrative experience of a person with mental illness, what MacIntyre elsewhere characterized as the story of the “central characteristics of human life and agency” in which the events of a depressive episode are connected to, and given meaning by, an intelligible story of a person’s life (2007, 144).2 II. MAJOR DEPRESSIVE DISORDER: A SINGLE MAP By most measures, major depressive disorder is increasingly common and oft-disabling. The World Health Organization (WHO) estimates that 300 million people are affected by depressive disorders and the prevalence increased by 18.4% between 2005 and 2015. The prevalence is greater among women than men, among older adults than younger adults, and among residents of Africa than other global regions. Depressive disorders are both the leading nonfatal cause of disability and a risk factor for suicide (World Health Organization, 2017). Depressive disorders are also treatable conditions, so leading policy-makers like the WHO encourage practitioners to treat depression, which “involves symptoms such as depressed mood, loss of interest and enjoyment, and decreased energy” (2017, 7). In this definition, the WHO employs a phenomenological approach to mental illness that describes symptoms without offering a narrative understanding of the meaning of those symptoms. The phenomenological approach to diagnosing mental illness utilized by agencies like the WHO was popularized in DSM-III, a manual that displaced narrative understandings of mental illness rooted in psychoanalytic accounts of why persons develop and experience mental illness, whether as the result of maladaptive “reactions” to life’s events in 1952’s initial DSM (American Psychiatric Association, 1952) or as unresolved unconscious conflicts that produced major and minor “neuroses” in 1968’s DSM-II (American Psychiatric Association, 1968). In 1974, the APA’s Committee on Nomenclature and Statistics began a series of Task Force meetings led by a young psychiatrist named Robert Spitzer. Spitzer, and other members of the Task Force, criticized then-regnant psychoanalytic theory for being subjective and unreliable.3 Spitzer wanted to move psychiatry from a psychoanalytic to a biological diagnostic model, but concluded that psychiatry did not know the etiology of most mental illnesses and that, in the absence of etiology, the present task of psychiatry was careful to observe patients to create diagnostic criteria that were specific, reliable, and concise. Spitzer hoped that careful study and reliable diagnosis would eventually lead psychiatrists and researchers to discern the etiologies left unnamed in DSM-III (Decker, 2013). In the meantime, psychiatrists would describe the symptoms characteristic of a specific mental illness to reliably distinguish one disturbance from another. While Spitzer’s phenomenological approach to psychiatric diagnosis deferred discussions of etiology, every description has a theory of what should (and can) be described and known (Sadler, Hulgus, and Agich, 1994). Theories are inscribed in the very names of diagnoses. The initial DSM conceptualized a depressive episode as a depressive “reaction” to psychological, biological, and social factors, reflecting the influence of Adolf Meyer. DSM-II eliminated the Meyerian “reaction” and conceptualized a depressive episode as a depressive “neurosis” in response to internal conflict, a more general psychoanalytic approach (Decker, 2013). The first and second editions of DSM spent little time describing diagnoses; these manuals ran to 130 and 134 pages, respectively. DSM-III ran to 494 pages and devoted most of its pages to descriptions of “disorders,” significant disturbances that impair social or occupational functioning irrespective of the cause or meaning of the disturbance. The DSM-III diagnosis for depressive episodes was called major depressive disorder, emphasizing the degree—major as opposed to minor—and its associated impairment—sufficient to cause a disorder—of a depression, rather than a cause. In the years after DSM-III was released, refined, and reified as the dominant psychiatric diagnostic schemata, Spitzer published multiple defenses of DSM-III in which he articulated the theory underlying DSM-III: psychiatric treatment requires an accurate diagnosis, psychiatric knowledge is generated by empirical research studies, and psychiatric researchers should present this knowledge in a way useful for practitioners (Spitzer, 2001). So, the DSM-III criteria set for major depressive disorder was designed by researchers and defined a time-period—at least two weeks—in which a person must experience a discrete set of specific symptoms—either depressed mood or anhedonia and a total of five of nine symptoms—in a list that made them readily accessible for clinical use (American Psychiatric Association, 1980). In their efforts to create a useful diagnostic system, Spitzer and his colleagues prioritized utility that is, itself, a theory: many forms of human sadness can, without naming an etiology or participating in the narrative experience of being ill, be diagnosed as major depressive disorder so clinical treatment can be initiated (Olbert, Gala, and Tupler, 2014). In pursuit of clinical utility, Spitzer and the other authors of DSM-III created a single map of human sadness. The DSM-III diagnosis of major depressive disorder is a categorical condition, in which a person either is or is not experiencing a depressive episode; it is also expansive, uniting multiple forms of sadness—melancholic, neurotic, and psychotic—under a single diagnosis. These forms of sadness, once separated, were now classed in the same measurable condition from the inception of DSM-III’s planning.4 The data available for major depressive disorder were not generated by Spitzer or the Committee on Nomenclature and Statistics. Instead, they relied on the eponymously named Feighner criteria for fourteen psychiatric illnesses (Feighner et al., 1972). These criteria were created during a research project John Feighner conducted during his psychiatry residency. During the project, Feighner and his co-authors reviewed a thousand articles (Decker, 2013), but their criteria for a depressive episode was built on data from a single published trial of one hundred hospitalized patients with “manic-depressive disease,” most receiving electro-convulsive treatment (Horwitz, Wakefield, and Lorenzo-Luaces, 2017).5 The DSM model of MDD began with profound psychopathology—people ill enough to require hospitalization and electro-convulsive treatment—but was expanded out by Spitzer and colleagues to include ordinary unhappiness, quotidian problems of living, by broadly applying the depression criteria Feighner and colleagues published in 1972. Like the eventual DSM-III criteria, the Feighner criteria required five of the same nine criteria and conceptualized depression as an illness that subsumes multiple subtypes (Feighner et al., 1972, 58). Before DSM-III elevated the Feighner criteria to consensus, psychiatry was fragmented, with multiple competing claims about what depression is, why it occurs, and how to treat a person with depression. At its best, DSM-III unified mental health practitioners, providing practitioners with rival accounts of the etiology of depression, a way to move forward while awaiting diagnostic clarity (Kinghorn, 2011). At its worst, DSM-III was a hegemonic system that forestalled conversation while departing from centuries of experience of caring for persons with depression (Shorter, 2013; Horwitz, Wakefield, and Lorenzo-Luaces, 2017). Previous diagnostic schemata, beginning at least with Hippocrates but extending through the initial and second editions of DSM, emphasized the relationship between a depressive episode and an event in a person’s life. Depressed mood after losing a child, anhedonia after losing work, and hopelessness after losing faith could be a person’s normal response to loss. If a person’s response was disproportionate in duration or magnitude, then it signaled what Hippocrates called melancholia, characterized by excessive anxiety and sadness (Telles-Correia and Marques, 2015). A depressive episode could also occur without a precipitating event in a person’s life, but either way, a practitioner diagnosed a depressive episode in relationship to the associated events of a person’s life (Horwitz, Wakefield, and Lorenzo-Luaces, 2017). When a practitioner narrated depression as an experience within a person’s life, they created a story that could have both clinical utility for psychiatric care and personal meaning for the person experiencing depression. The Feighner criteria distinguished between primary depression, which occurred irrespective of life events, and secondary depression, which occurred in association with a life event (Feighner et al., 1972). The DSM-III criteria for major depressive disorder did not require a practitioner to assess the presence of symptoms in consideration for the meaning of depressive symptoms in the context of a person’s life. As Horwitz and colleagues recently wrote, “In the urgent quest for reliability, the adoption of the current depression criteria for the most part inadvertently rejected the previous 2,500 years of clinical diagnostic tradition that explored the context and meaning of symptoms in deciding whether someone is suffering from intense normal sadness or a depressive disorder” (2017, 20). Pursuing reliability, the authors of DSM-III excluded the context of symptoms in a person’s life; it also excluded many of the clinical features experienced by persons experiencing a depressive episode. III. MAJOR DEPRESSIVE DISORDER: WHAT WENT MISSING FROM THE MAP In the decade before the publication of DSM-5, the leaders of the American Psychiatric Association organized public meetings, convened expert workgroups, and wrote impassioned op-eds arguing that DSM needed revision. In a prominent editorial, the architects of DSM-5 opined that they were addressing the high rates of co-occurring mental illness, the common use of not-otherwise specified diagnoses, and the heterogeneous conditions living under a single diagnostic category. They stated that their goal was to validate the hypotheses proposed by the Feighner criteria and popularized by DSM-III and wrote that the “single most important precondition for moving forward to improve the clinical and scientific utility” is to include “simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries” (Regier et al., 2009, 649). The draft versions of DSM-5, accordingly, began with an account of what it meant to move away from a categorical approach to diagnosing mental illness and toward a dimensional system that encouraged practitioners to diagnose and measure symptoms that cut across existing diagnostic categories, like sleep disorders in persons with schizophrenia or cognitive problems in persons with anxiety disorder. However, when the final text of DSM-5 was published, this section was eliminated, the dimensional approach was declared “premature” for clinical use, and its use was curtailed in the final text (American Psychiatric Association, 2013, 13).6 Depression was resituated—within DSM-IV-TR, major depressive disorder was in a “Mood Disorders” chapter that included bipolar and depressive disorders—and the accompanying text was changed, but the diagnostic criteria for major depressive disorder are essentially unchanged in DSM-5. Despite decades of research into one of the world’s most common and disabling conditions, the Feighner-DSM-III map for major depressive disorder, formulated with limited evidence from an ill population in the early 1970s and designed to maximize clinical utility at the expense of narrative understanding in the 1980s, remains the primary way psychiatrists diagnose a depressive episode. Yet, as in my experience with Jessica, this map neglects important features of the experience of depression. To quantify what is missing, a prominent member of the DSM-5 Work Group on Mood Disorders, Kenneth Kendler, recently reviewed psychiatric textbooks published between 1900 and 1960 to understand how psychiatrists described depressive disorders in the diagnostic era between Emil Kraepelin, the pioneering German psychiatrist whose work inspired the Feighner criteria, and the dawn of the DSM era. Kendler identified 19 essential textbooks that describe 18 signs and symptoms of a depressive episode. Kendler observed that these signs and symptoms are either partially covered by DSM-5 criteria or not covered at all: anxiety, cognitive content, depersonalization/derealization, mood, volition, speech, and other physical symptoms. In his conclusion, Kendler wrote that, in search of specificity, psychiatrists avoid criteria more specific to other disorders, like anxiety. In search of concise criteria sets, psychiatrists avoid signs that require longer descriptions, like cognitive problems. In search of reliability, psychiatrists avoid criteria that require inference and interpretation, like derealization (Kendler, 2016). Psychiatry’s search for reliability, specificity, and concision has led us to endorse a criteria set for major depressive disorder that diverges from the lived experiences of people with depression like Jessica, who experienced anxiety and depersonalization that psychiatrists before the DSM era would have been trained to both identify and narrate. IV. MAJOR DEPRESSIVE DISORDER: AN UNRELIABLE MAP Kendler concluded that if psychiatric practitioners, educators, and researchers understand DSM-5 as a way to orient them to a person, it is a reasonable place to begin, but it hardly suffices for a full understanding of a person and her illness. Indeed, he worried that “we have been misusing the DSM diagnostic criteria because we have confused them with the diagnostic entities they are designed to assess” (Kendler, 2016, 780), that we are effectively confusing the map for the territory itself.7 The DSM-5 criteria for major depressive disorder are surely more concise than the diagnostic systems studied by Kendler, but the APA-supervised field trials of DSM-5 diagnostic criteria exposed concerns about their reliability. Reliability is the stated benefit of DSM-5 over earlier and alternative diagnostic systems; the first line of its preface characterizes the text as “a classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders” (American Psychiatric Association, 2013, xli). The preface does not discuss the field trials designed to establish the reliability of these diagnoses. Those field trials were conducted at prominent academic medical centers “to determine the degree to which two practitioners would agree on the same diagnosis for patients representative of the DSM clinical population” (Clarke et al., 2013, 44). Mental health practitioners with at least two years of post-graduate training received training on the draft documents of DSM-5 and how to use them for a diagnostic interview. Patients experiencing a target symptom—like anxious worry, depressed mood, or thoughts of self-injury—were enrolled as research subjects in a test-retest diagnostic evaluation study. Each research subject completed a self-administered dimensional assessment tool to screen for key symptoms of DSM-5 disorders. Afterward, the research subject was evaluated by a practitioner whom they had never previously encountered. The practitioner reviewed the subject’s self-completed diagnostic assessment tool, interviewed the patient using the proposed DSM-5 criteria, and completed any DSM-5 diagnostic specific severity measures. After the subject left, the practitioner recorded a DSM-5 diagnosis. The subject returned—between four hours to two weeks later—for an evaluation by a second practitioner. Without knowledge of the first practitioner’s evaluation, the second practitioner repeated the diagnostic process. Afterward, researchers compared the reliability of the diagnostic criteria using a test-retest design, which assessed how well the first practitioner’s diagnosis predicted the second practitioner’s diagnosis, using a statistical measure called intraclass kappa. The field trials were first conducted for DSM-III by Spitzer and colleagues (1979), who regarded a kappa score greater than or equal to 0.7 as “satisfactory” (Bentall, 2017, 227). While designing their trials, the authors of DSM-5 characterized an intraclass kappa greater than or equal to 0.8 as signifying excellent agreement, between 0.60–0.79 as very good agreement, between 0.40–0.59 as good agreement, 0.20–0.39 as questionable agreement, and below 0.20 as unacceptable agreement. The stated goal was for each studied DSM-5 diagnosis to achieve at least good agreement (Clarke et al., 2013).8 However, the DSM-5 field trials found that many proposed diagnoses had intraclass kappa signifying questionable or unacceptable agreement. Only one diagnosis, major neurocognitive disorder scored higher than the 0.7 previously regarded as satisfactory (Bentall, 2017). In some cases, these results meant diagnoses that were in draft versions of DSM-5, like mixed anxiety-depressive disorder and nonsuicidal self-injury, were removed from the final version of DSM-5 half a year before publication. Not every diagnosis that performed poorly in the field trials was removed from the published text. In both the adult and pediatric DSM-5 field trials, major depressive disorder had an interrater reliability of 0.28, signifying questionable agreement, but remained in the published version of DSM-5 without substantive change from the draft version (Freedman et al., 2013, 2). In a journal article summarizing the field trials, prominent thought leaders of American psychiatry wrote that: The questionable reliability of major depressive disorder, unchanged from DSM-IV, is obviously a problem. Major depressive disorder has always been problematic because its criteria encompass a wide range of illness, from gravely disabled melancholic patients to many individuals in the general population who do not seek treatment. (Freedman et al., 2013, 1) When reviewing the results of the field trials, these psychiatric leaders concluded that when two mental health practitioners who had been trained in the use of DSM-5 diagnostic criteria used the criteria to evaluate a person who self-reported mood problems, practitioners reached a level of agreement best characterized as “questionable.” Even by its own stated standard, reliability, the DSM-5 map for major depressive disorder is an unreliable guide to the experience of depression. It did not, however, stop the leading architects of DSM-5 from heralding, in a separate journal article that, with the publication of DSM-5, “the future arrived” (Kupfer, Kuhl, and Regier, 2013, 1691). V. MAJOR DEPRESSIVE DISORDER: ALTERNATIVE MAPS In MacIntyre’s (1977) account of how change occurs in science, an epistemological crisis occurs only after a person encounters a rival schemata incompatible with their existing schemata. A process like this occurred for Spitzer. He had once admired psychoanalysis—he secretly self-enrolled in psychoanalytic treatment at the age of fifteen over his parents’ objections—and had trained in psychoanalysis as a resident before encountering the symptom-based approach of the Feighner criteria and eventually transforming psychiatry through DSM-III’s categorical, symptom-based approach (Spiegel, 2005). Despite eventual evidence that this diagnostic approach leads to questionable agreement in the diagnosis of major depressive disorder, excludes known aspects of the experience of depression, and conveys only moderate information about the experience of a person with mental illness, psychiatrists have not yet experienced an epistemological crisis for the care of persons with depressive disorders. Perhaps, this is because individual practitioners do not experience the disagreements between the map and the territory as a patient themselves, as Spitzer did when he personally underwent analysis. Perhaps this is because institutional medicine prioritizes utility and treatments whose administration is independent of a particular practitioner, rather than the time-intensive and practitioner-dependent analysis in which Spitzer was trained. Perhaps, this is because individual practitioners rarely read journal articles about clinical trials about psychiatric diagnoses, as Spitzer did when he became a practicing psychiatrist. Perhaps, this is because the contemporary psychiatric societies and systems that Spitzer helped build often operate from rhetorically defensive positions, and emphasizing the disagreement might impede their interests in mainstreaming psychiatric care within medicine. Instead of allowing the disagreement to precipitate an epistemological crisis, psychiatrists have embedded DSM-based diagnostic criteria for major depressive disorder within analog and digital screening tools widely used throughout clinical medicine. We psychiatrists operationalized DSM-based diagnostic criteria instead of encouraging practitioners to encounter alternative schemata for depression. Alternative schemata are now being developed by organizations that once partnered with the American Psychiatric Association in DSM projects. When the DSM-5 process began, the National Institutes of Mental Health (NIMH) was an engaged partner. After the final publication of DSM-5, the leader of the NIMH criticized DSM-5 as inadequate and proposed to reconfigure major depressive disorder, and other psychiatric illnesses, as neural circuit problems organized into Research Domain Criteria (RDoC), but at present, RDoC remains conceptual rather than clinical (Cuthbert and Insel, 2013; Kozak and Cuthbert, 2016). Even in its conceptual form, RDoC addresses one of DSM-5’s root problems by naming etiology, but deepens another root problem. Using the DSM schemata, a practitioner abstracts symptoms from a person’s experience of depression, neglecting the narrative of a person’s life in which these symptoms have meaning. Anhedonia becomes a recorded symptom rather than the interruption in habits and relationships constitutive of personhood. RDoC, which focuses on treatment outcomes, similarly neglects narrative reflection on how a person’s self-understanding changes during mental illness and its treatment (Hoffman and Zachar, 2017). Outside of the research community, several rival mental health professional societies have endorsed the Psychodynamic Diagnostic Manual (PDM) as an alternative to DSM-5. The PDM, now in its second edition, trains practitioners to understand a person’s personality patterns and mental functioning before considering the symptoms described in DSM criteria sets. Throughout, these experiences are interpreted in a narrative that is psychoanalytically oriented (Lingiardi and McWilliams, 2017). Neither alternative presently threatens the clinical dominance of DSM-5, but the development of these diagnostic systems may foreshadow the demise of Spitzer’s compromise, which held together mental health practitioners and researchers with disparate accounts of the etiology of mental illness in a consensus that diagnoses should be categorical, neutral with respect to etiology, and evident in the clinical interview rather than in the context of a person’s narrative experience. Perhaps a practitioner or researcher will encounter these rival schemata and experience the kind of epistemological crisis MacIntyre described; they can even find signs of alternative schemata within DSM-5 itself. The “Sleep-Wake Disorders” chapter organizes DSM-5 criteria in conversation with the second edition of the International Classification of Sleep Disorders, which often relies on polysomnography for diagnosis (American Academy of Sleep Medicine, 2005), the first time in which biological validators have been added to DSM criteria. Section III of DSM-5, Emerging Measures and Models, includes several alternatives. While the dimensional perspective was de-emphasized between the draft and the published versions of DSM-5, a curious reader can either find aspects of the dimensional schemata in Section III’s “Cross-Cutting Symptom Measures” and “Clinician-Rated Dimensions of Psychosis Symptom Severity,” or try the shelved “Alternative DSM-5 Model for Personality Disorders” (American Psychiatric Association, 2013).9 Within Section III of DSM-5, a practitioner or researcher can also find the Cultural Formulation Interview (CFI), a novel tool that holds particular promise for developing narrative diagnoses of mental illnesses like major depressive disorder. In the main section of DSM-5, diagnostic criteria are descriptive symptom lists written in the passive voice. These criteria require interpretation before a practitioner should ask them of a patient. In practice, practitioners often either read the criteria or offer partial interpretations. A well-defined symptom that is supposed to be engaged in context with the other diagnostic criteria for major depressive disorder diagnostic criteria, like “Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day” (American Psychiatric Association, 2013, 161), is frequently translated into something like “Has your weight changed?” Even more, the implicit goal of those criteria, even when operationalized in APA-approved versions like the Structured Clinical Interview for DSM-5 Disorders (First et al., 2016), is to fit the territory of a person onto the diagnostic map. Yet, when practitioners experience disagreements between the map and the territory when we care for patients like Jessica, the solution may not be better maps but ways to explore the proverbial territory. This concern is shared by prominent psychiatric diagnosticians like Michael First, the lead author of the research Structured Clinical Interview for DSM-5 Disorders, who recently wrote that the categorical DSM model “is at least partly to blame” for psychiatry’s inability to develop the fully scientific diagnostic system Spitzer anticipated would result from DSM-III (Phillips et al., 2012, 17). First continued, Scientists attempting to discover the neurobiological or genetic underpinnings of psychiatric illnesses have all too often treated the man-made psychiatric constructs in the DSM as if they were “natural kinds,” looking for the gene for schizophrenia or the neurocircuitry underlying a major depression as if they were real disease entities. (Phillips et al., 2012, 17) Psychiatrists like First are aware that DSM criteria are pragmatic constructs rather than distinct, valid diseases, but fear this awareness is not shared by his fellow practitioners who use these criteria daily.10 Unlike the main diagnostic criteria about which First is concerned, the CFI is a structured interview presented as a table rather than a list, with a guide to the practitioner on the left and questions for the practitioner to ask on the right side of the table. Instead of criteria, there are patient-centered questions to seek understanding from a person. In its main version, the CFI consists of sixteen questions spanning four domains: Cultural Definition of the Problem; Cultural Perceptions of Cause, Context, and Support; Cultural Factors Affecting Self-Coping and Past Help Seeking; and Cultural Factors Affecting Current Help Seeking. The questions are open-ended, as in the ninth question, “For you, what are the most important aspects of your background or identity?” (American Psychiatric Association, 2013, 753). The CFI is a structured invitation to understand a person’s cultural identity, how they conceptualize distress, the ways they are variously vulnerable and resilient, how they interact with the larger cultural identities they describe as formative, and how these cultural factors will affect their relationship with a practitioner. Its questions, while scripted, are neutral, implicitly inviting further exploration. If used with a person like Jessica, the CFI would have helped both Jessica and the trainee who initially evaluated her to understand Jessica’s dark thoughts. The CFI encourages an interviewer to explore what a person understands as a problem, and situates that problem within the context of the person’s family and friends and culture. The CFI, in short, structures the practitioner-patient relationship as a narrative encounter that seeks understanding of the person. If interested, a practitioner can use some of the available supplements to the CFI to better understand particular facets of a patient’s identity (Lewis-Fernández et al., 2016). Using the CFI, an interview may understand Jessica’s cultural identity and her values. In pursuing this understanding, a practitioner would gather data from Jessica, while simultaneously building a therapeutic alliance with her. Together, they would produce a narrative reflection of how depression alters a person’s self-understanding in relationship to her community, instead of a numerical rating of her depressive episode. VI. MAJOR DEPRESSIVE DISORDER: OPPORTUNITIES FOR HUMILITY When one gathers data while building a shared commitment to the health of a patient like Jessica, one seeks the meaning of a person’s experience of depression. Psychiatric diagnosis is, at its best, an interpersonal activity between a practitioner and a patient. To diagnose well, it helps to move beyond the DSM-5 criteria and, figuratively, put down the map in order to explore the territory together in pursuit of a narrative understanding and mental health. Psychiatric practitioners and researchers have repeatedly demonstrated the salutary benefits of forming these kinds of therapeutic alliances. Those benefits were characterized by Jerome Frank, a pioneering researcher of the therapeutic alliance, in Persuasion and Healing (Frank and Frank, 1991). Recently, several of Frank’s protégés revisited his work in a collected volume (Alarcón and Frank, 2012). In a chapter on depression, David M. Clarke offered a taxonomy for different kinds of depressive episodes—anhedonic, demoralized, posttraumatic, and grief—with differences in mood, affect, hedonic tone, volition, sense of self, and cognition. He observed that there are differences between depressed people who are, say, grieving and those who are demoralized. Taking demoralization as one example, Clarke (2012) identified the thought process characteristic of a demoralized depression, its emotional expression, and suggested therapeutic interventions for a practitioner to undertake. Clarke was not offering a map, but encouragement to understand another person’s experience. Both the CFI and the approach articulated by Clarke—two examples of many known alternatives—explicitly invite narrative responses. They invite a patient like Jessica to tell the story of her darkening mood. In a narrative encounter like these, a practitioner asks a person like Jessica for what foreshadowed her depression, when her depression began, what it means, and what it will take to brighten her dysphoric story. In contrast, categorical approaches like DSM quantify instead of narrating a depressive episode (e.g., Kroenke, Spitzer, and Williams, 2001; Chekroud et al., 2017). A categorical approach like DSM encourages a practitioner to ask Jessica if depressed mood or anhedonia is present, what symptoms she has from a predetermined list, and to assess the severity of the depression. While a practitioner could seek a story, they are not explicitly encouraged to do so in the criteria sets and are implicitly discouraged to do so by contemporary electronic health records and healthcare practice models that prioritize efficiency over narrative. Instead of a story, a trainee generates a measurement. Implicitly, both the CFI and Clarke’s approach rebuke the DSM-III model, that a person’s experience can be measured for clinical utility without understanding the cause of their experience. Perhaps it will take an explicit rebuke to precipitate a change in psychiatric diagnosis. In his essay, MacIntyre connected narrative and epistemological crises, writing that “dramatic narrative is the crucial form for the understanding of human action” (1977, 464). MacIntyre wrote that to understand a human action, presumably including the actions a person undertakes during a depressive episode, one needs a narrative. The narrative records of an encounter—the subjective report of a patient, the history of present illness crafted by a patient—which once headlined the patient’s records are now, in electronic health records, buried at the end of the report.11 While alternative narratives for depression are legion, contemporary psychiatrists rarely encounter them. In part, it is because, as in the two examples above, the alternatives are literally at the margins, either published apart from the main criteria at the back of DSM-5 or as chapters in an edited volume published by an academic press. Perhaps it is also because these alternative narratives are structured as diagnostic tools for a personal encounter between an individual practitioner and an individual patient. Like the practitioner listening carefully through a stethoscope to a patient’s breath sounds or peering intently through an otoscope at the vasculature of a patient’s optic disc, tools require the personal skill of a practitioner, the tolerant endurance of a patient, and a physical encounter between them. Diagnosis is a process of discernment, of sifting through possibilities, in pursuit of the illness affecting a person and, when possible, the cause of the illness. The iconic tools of modern medicine—the stethoscope, the otoscope, the electrocardiogram—were invented over a century ago. Modern medicine clothed physicians in diagnostic tools that symbolized their allegiance to science, but designed them for personal encounters that allowed continuity with the pre-modern, Hippocratic medicine that depended on understanding of an ill person. The development of bedside diagnostic tools is no longer a central aspiration of medicine; physicians are instead working to develop diagnostic tools that continuously gather health data from patients before they develop a disease (e.g., Gambhir et al., 2018). As the philosopher of medicine, Ivan Illich recently observed, the era of diagnostic tools in medicine is over. Today we live in an age of systems, distinct from both the pre-modern and modern eras of medicine. As Illich said: All traditional doctors—in the Hippocratic tradition as much as the Galenic—believed in people, their patients, telling them about their nature. Nature was experienced, was felt, was smelled, was tasted by people; and the physician was trained to feel the circumstances of the individual in front of him who, in his human condition, had been caught in some mess, in something contrary, which nature was trying to heal. It was as if the physician were participating in a Greek tragedy, and, like the spectator in the Greek theatre, reached out through mimesis, sympathy, which became feeling the other. (Illich and Cayley, 2005, 203) Instead of participating in the Greek tragedy that is becoming ill and needing medical assistance, of seeking narrative understanding of a person, or even wielding a diagnostic tool, we live, Illich says, in an era where a physician engages an ill person in a system of health care. The practitioners work in teams in which no member is irreplaceable, and follow standard work that can be measured in outcomes. In these standardized systems, the evaluation of a person like Jessica requires mapping her onto the system’s criteria. She is experiencing a major depressive episode if the psychiatric trainee checks either depressed mood or anhedonia and enough symptoms for five of the nine boxes on the admission order-set in the system’s electronic health record to be filled in. A conscientious physician recognizes that, as psychiatric researchers like Kendler caution, the DSM-5 criteria set for major depressive disorder is only a starting point to a true diagnosis. In fact, the DSM advises something similar in its “Use of the Manual” statement, which reminds readers that a diagnosis requires a case formulation, the contextualization of a patient’s symptoms amidst her medical history, social history, psychological structure, and cultural identity. Those reminders preface the main text of DSM-5, and the accompanying companion volumes the American Psychiatric Association publishes, but they are absent from the diagnostic criteria themselves and the electronic health records in which they are operationalized into screening tools and checklists. Electronic health records are even more committed to clinical utility than Spitzer’s DSM-III. In today’s system-based medicine, a trainee rarely encounters DSM-5’s reminders, let alone a rival schemata for the diagnosis of a depressive episode, outside of journal articles or teaching rounds, educational activities separate from the clinical encounters where they make diagnostic decisions. Without encountering a rival schemata in clinical practice itself, it becomes difficult to precipitate an epistemological crisis in an individual practitioner. It may be difficult to encounter rival schemata in contemporary psychiatry, but it remains possible so long as the territory remains available. After all, you still meet people like Jessica. She wears the hospital-issued gowns of a patient and her shoes are held on her feet by woven surgical tape because the staff has removed her shoelaces to forestall suicide. You wear the hospital-issued identification badge that announces your professional qualifications on the front and is embedded with a magnetized strip that allows you to exit the locked unit to which she has been admitted. She sits in a durable chair that is weighted, to prevent its use as a weapon, and constructed of rotationally molded polyethylene, to render it chemically resistant to bleach, blood, urine, feces, and the tears that often fall when a person tells of her shadowy mood. You sit close enough to look directly at each other, but not close enough to touch unintentionally, and you can ask after Jessica. And the remarkable nature of medicine remains that if you ask Jessica in the right way she will, even in her captive state, even in her dark dysphoria, answer. She will tell you about her dashed hopes, her growing fears, and the ways that her own story has unraveled. If you listen to patients like Jessica, they implicitly teach you about what it is to experience depression. Perhaps that is why, as psychiatry retreats from narrative, first-person narratives of depressive illness are winning wide audiences and critical acclaim. Consider Andrew Solomon’s The Noonday Demon, a bestseller crowned with the National Book Award. Solomon built the book on closely-observed narratives of persons, including himself, who experienced depression. In the final chapter, he told the stories of these people. He used their names, told their progress forward and their stumbles back, and implicitly showed that there are no average or generic persons whose features perfectly match the map of a depressive episode, only particular persons. In the conclusion, he explained the surprises of writing a book about depression by beginning with the stories of particular people. Solomon wrote that it was: not until I had written about three-quarters of the book did my purpose fully reveal itself to me. I did not anticipate the intense, shattering vulnerability of depressed people . . . Depression exaggerates character. In the long run, I think, it makes good people better; it makes bad people worse. It can destroy one’s sense of proportion and give one paranoid fantasies and a false sense of helplessness; but it is also a window onto truth. (2001, 428–9) If you listen carefully to a person with depression, if you attend to their story, their vulnerabilities crack open a window to their character. If psychiatrists attend to their vulnerabilities, it similarly cracks open a window. Humbled by the limited reliability of our diagnostic system, we might admit its vulnerability for major depressive disorder, the questionable agreement between the map and the territory. We can begin with DSM-5 criteria, but seek alternative schemata, narrative accounts of the people we meet as patients. In pursuit of narrative understanding, we may experience the epistemological crisis psychiatrists, and persons with mental illness, need.12 Footnotes 1. At present, the map is used within patient-practitioner relationships structured by health systems. In the near future, the map will be embedded within daily life outside of health systems. For example, Google recently began directing the general population to self-assess their mood using a version of the DSM-5 map for major depressive disorder (Duckworth and Gilbody, 2017), without mentioning its questionable reliability. 2. This essay responds to MacIntyre’s “Epistemological crises, dramatic narrative and the philosophy of science” (1977), and so follows his account of narrative. MacIntyre eventually expanded his 1977 argument in After Virtue. In After Virtue, MacIntyre wrote that there are different kinds of narratives of human life and agency, with attendant differences in the virtues. MacIntyre wrote that “Every particular view of the virtues is linked to some particular notion of the narrative structure or structures of human life,” contrasting the virtues attendant to a drama by, say, Sophocles and Shakespeare (2007, 174). Since MacIntyre’s essay and After Virtue, philosophers like David Velleman (2003) have provided competing accounts of narrative explanation. Psychiatric researchers could profitably engage these competing accounts of narrative explanation to understand what would count as an adequate narrative of a depressive episode. MacIntyre recently revisited narrative explanation in Ethics in the Conflicts of Modernity (2016). 3. The Stanford psychologist David Rosenhan demonstrated this subjectivity and unreliability in a famous experiment from the era. Rosenhan recruited eight persons to present at twelve separate psychiatric facilities in five American states. Rosenhan’s recruits reported a single symptom, hearing unclear voices saying “empty,” “hollow,” and “thud.” Most were diagnosed with schizophrenia; all were hospitalized. While they denied symptoms after hospitalization and reported a return to health, the average length of stay for their hospitalizations was nineteen days. In the ensuing report, published in a prominent journal, Rosenhan observed that “The facts of the matter are that we have known for a long time that diagnoses are often not useful or reliable, but we have nevertheless continued to use them” (1973, 257). Spitzer (1976) engaged Rosenhan while preparing DSM-III, characterizing Rosenhan’s work as “pseudoscience.” 4. According to Shorter’s history of depression, Spitzer conceptualized depression as a distinct disorder with multiple subtypes with limited scientific evidence. Shorter wrote that Spitzer’s “first fateful decision” as director of the APA’s Committee on Nomenclature and Statistics was “to separate the committee that dealt with depression from that which dealt with anxiety” on a bureaucratic rather than scientific basis (2013, 132). 5. The phrase “manic-depressive” is not DSM-5 terminology, but an anachronism authentic to the 1957 trial on which the Feighner criteria for depression are based (Cassidy et al., 1957). 6. While largely excised from the symptom criteria themselves, the dimensional approach still informs the deep structure undergirding DSM-5. The authors of DSM-5, unlike the authors of earlier versions, organized its 265 diagnoses by putative pathogenesis, grouping diagnoses into nineteen chapters on the basis of their shared pathology. They arranged chapters based on the age at which disorders typically first occur. So within DSM-5, depressive disorders are discussed in the fourth of nineteen chapters, a position that indicates that depressive disorders can begin early in a person’s life and that psychiatric researchers believe depressive disorders share pathophysiological similarities to its nearest neighbors in the diagnostic manual, bipolar and anxiety disorders. Dimensional measures survive in the various measures of severity within DSM-5, as in when a depressive episode is assessed as mild, moderate, or severe. Dimensional measures also survive in some of the rating scales in Section III of DSM-5 (Nussbaum, 2013b, 33–40). 7. Kendler’s concerns echo qualifications included within DSM-5 itself. The “Use of the Manual” section informs readers that “The case formulation for any given patient must involve careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis” (American Psychiatric Association, 2013, 19). This call to embed diagnostic criteria in a case formulation echoes the psychoanalytic approach derived from Adolf Meyer—Meyer named those three specific factors—which informed the initial edition of DSM. However, this call to narrative understanding does not resonate throughout the text of DSM and is absent from the brief, operationalized versions of DSM criteria commonly employed in clinical practice. 8. In a separate and subsequent analysis comparing DSM-5 criteria to epidemiologic and self-report datasets of mental illness, Charles Olbert and colleagues recently observed that the DSM-III phenomenological model is polytheistic. By listing multiple symptoms, not all of which are required to meet a diagnosis, the DSM-III model allowed the possibility for individuals with little symptom overlap to share the same diagnosis. They calculate that since the DSM-5 diagnosis of major depressive disorder requires one of two symptoms—depressed mood or anhedonia—and a total of at least five of nine symptoms, a total of 227 symptom combinations can result in a major depressive disorder. The authors concluded that “knowledge of a person’s diagnosis conveys only moderate information about the particular symptoms specific to that disorder he or she happens to be experiencing” (Olbert, Gala, and Tupler, 2014, 459). 9. After the field trials, the most dimensional of the diagnoses in draft versions of DSM-5, the dimensional model for personality disorders was moved from the main text to the appendix. 10. The psychiatrist Warren Kinghorn wrote the most thorough-going analysis of the DSM criteria as pragmatic constructs. Kinghorn wrote that “The DSM is, rather, from cover to cover a pragmatic manual of clinical practice, bound to a particular time and cultural context” (2011, 200). Kinghorn observed that the DSM allows a community of practitioners to work together despite competing views about what causes a mental illness and how to treat a mental illness. 11. When health records were maintained on paper, clinicians recorded the patient encounter in a narrative format that followed the sequence of the examination. These so-called SOAP notes followed the clinician and patient sequentially through the Subjective, Objective, Assessment, and Plan portions of the encounter. When SOAP notes were translated into electronic health records, they were found to be inefficient, so leading electronic health record designers embraced new APSO notes, beginning with the Assessment and Plan, and including the Subjective and Objective only as supporting material (Lin, McKenzie, and Pell, 2013). In these formats, the Subjective and Objective portions of the record, which contain the narrative account of the encounter, are often “collapsed” so that they are visible to a reader of the record only with additional effort (Belden et al., 2017). 12. Psychiatric practitioners, researchers, and policy-makers interested in experiencing an epistemological crisis may benefit from the growing literature on the role humility plays in scientific inquiry and practice. This literature has been renewed over the past two decades; a good introduction can be found in Intellectual Humility (Church and Samuelson, 2017). Such approaches remain nascent within mental health, but there are treatments of humility by psychologists (i.e., Worthington and Allison, 2018) and a few appreciations of humility as a virtue have appeared in the psychiatric literature (e.g., Christensen, 1995; Steller et al., 2018; Young, 2018). At present, much of the literature on humility is found within contemporary Christian theology, including forthcoming texts like Humility and Human Flourishing (Austin, 2018) and Humility, Pride, and Christian Virtue Theory (Dunnington, 2018), but it can be read by anyone interested in ethics and philosophy. For readers less familiar with the philosophical literature, one way to turn toward humility is to consider the recent shift in cultural approaches to medicine, from cultural competence to cultural humility, an analogous shift from confident knowing to humble learning (e.g., Hook et al., 2017). REFERENCES Alarcón , R D and J Frank, eds. 2012 . 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TI - Questionable Agreement: The Experience of Depression and DSM-5 Major Depressive Disorder Criteria
JO - The Journal of Medicine and Philosophy
DO - 10.1093/jmp/jhaa025
DA - 2020-11-30
UR - https://www.deepdyve.com/lp/oxford-university-press/questionable-agreement-the-experience-of-depression-and-dsm-5-major-v8OrwkHHsW
SP - 623
EP - 643
VL - 45
IS - 6
DP - DeepDyve
ER -