Volume 3, Issue 7, March 2, 2005

Scientific Progress on the Inside and the Outside

Author: Dr. Siegfried Othmer

We are living through the messy business of a new scientific revolution becoming established, and in the process we stand in awe of the scientific pillars and edifices of the status quo with which we have to contend. It seems like a David and Goliath kind of mismatch. Thus it was exceedingly satisfying to read an article by Alex Spiegel in the New Yorker recently, dealing with the messy history by which the Diagnostic Statistical Manual became established within American psychiatry. Read about it and you will feel better.

Imagine that the person most responsible for cementing the legitimacy of the DSM, Robert Spitzer, got his start in the mental health field by undergoing therapy that involved Wilhelm Reich’s orgone box. Somehow either the box or the accompanying therapy helped him to tame his anxiety, and to come to terms with his turbulent inner life, which was compelled to cohabit with his repressed affect. Resolution lay in a rational exploration of the “wilderness of the emotions.” Ultimately Spitzer helped to discredit Reich, and the FDA relied upon his paper among others in their persecution of Reich and his prosecution for fraud.

Spitzer had an auspicious start to his medical career, but was not much of a success as a psychoanalytically grounded therapist. “I was always unsure that I was being helpful…I just didn’t know what the hell to do.” He had become a psychiatrist just in that time of transition in American psychiatry where the issue of diagnosis first became acute. Prior to the discovery of lithium for manic-depressive illness, diagnosis was not a priority at all. There were rather large categories of neurosis and schizophrenia in which nearly everyone was accommodated. The Freudians were in charge. The primary psychiatric issue was internal conflict, and a preoccupation with symptoms was not thought to be productive. No one was losing sleep.

First published in 1952, the DSM has become a scientific point of reference of tremendous influence. The reimbursement system depends upon it; the courts rely upon it; and it infuses the debate on many a Law and Order segment. In its early years, however, the DSM was rightly questioned for its lack of reliability, of any kind of scientific validity. Just before the launch of the first DSM, interrater diagnostic reliability had been found to be at the 20% level. More than a decade later studies fell in the range of 30-40%. One had hoped for more.

Spitzer was assigned to the DSM-II committee as a scribe, but then was put in charge of the DSM-III project. At the time, the job was of no consequence. Even the A.P.A. leadership had low expectations for the project. The advantage to Spitzer was that this status of relative neglect allowed him to fashion the project to his own design. He gathered about him a number of data-oriented people to launch what we now call evidence-based medicine. Unfortunately at the time there was not much of that evidence available. There was a circularity problem. How does one obtain reliability when it does not already exist, when the absence thereof plagues all of the literature.

The process essentially remained one of science by committee. And the process was not pretty.

“The sessions were usually chaotic.”

“The loudest voices usually won out.”

“The haphazardness of the meetings could be ‘disquieting’.”

“Spitzer seems to have made many of the final decisions without consultation.”

At one point Spitzer banged out on a borrowed typewrite the outlines for yet two more diagnostic categories (“brief reactive psychosis” and “factitious disorder”) after a mere hour’s discussion with proponents whom he had just met.

A crisis was now also looming with the DSM-III in that the word “neurosis” was about to be outsourced as essentially irrelevant to the era of symptom-based diagnosis, one that was to rely on directly observable behaviors. The analytic community was aghast, as the most common diagnosis employed in private practice at the time was something called “depressive neurosis.” Peace with the psychoanalytic community needed to be restored. The word neurosis was discreetly retained. That hurdle having been surmounted, the DSM-III was welcomed to applause at the APA meeting. For the first time, claims were made that the manual was “scientifically sound.” “The reliability problem has been solved,” it was optimistically announced.

The wish, apparently, was father to the thought. “The DSM revolution in reliability is a revolution in rhetoric, not in reality,” said the critics. “No one scrutinized the science very carefully.” Sheer bulk may have conveyed more substance than was behind the enterprise. Nevertheless, the team confidently took on the project of the next iteration, the DSM-IIIR. By this time, the DSM project became more identified with Spitzer, certainly in his own mind, and he asserted his opinions even more adamantly. For the DSM-IV, he was replaced in the lead role.

The reliability issue still hung out there in the midst of all the self-congratulatory propaganda. A study had in fact been sponsored by the MacArthur Foundation and completed, but never published---ostensibly for lack of funds. Other studies, conducted by Spitzer’s wife, herself a psychiatrist, found reliability values that were not much better than those obtained in the fifties and sixties, and sometimes worse. Clinicians have their favorite diagnoses, which they inflict on most of their patients, and that pattern of diagnosing has not changed significantly even with the formal reign of the DSM model.

The chair of the DSM-IV enterprise, Allen Frances, takes a more sober view. “In a vacuum, to create criteria based on accepted wisdom as a first stab was fine, as long as you didn’t take it too seriously.” The DSM-III would not have been thrust into prominence the way it was if he had been in charge, given his own role as a skeptic. The outcome would have been more nuanced. As it was, however, it was “good for everyone at that point in time to have someone whose view may have been more simple-minded than the world really is.” It was a starting point for the enterprise of establishing reliability; it was something around which the conversations could coalesce into coherency, and this purpose would be served almost independently of the inherent truth value of the DSM.

Concluded Spiegel, “The revolution came not just from the material itself, from the substance of it, but from the passion with which it was introduced.” And whereas we may have suffered the downsides of the DSM revolution, this truth holds for us as well. It is never the skeptics who lead you into the future, but rather always the ones who hold a vision confidently. The skeptics help to clean up the mess and to restore order to things. But as Allen Frances says himself, if he had been in charge the revolution would not have happened. One does not put the skeptics in the front of the boat. Unfortunately, in the biofeedback organizations, that’s where they have been.

I have reviewed the piece in the New Yorker as an exemplar of a revolution taking place within the palace walls, within the mainstream. This is relevant to psychology because it is facing the very same issue of a revolution emanating from the domain of physiology. Significantly, the revolution in psychiatry had to establish itself first outside of the limelight, and absent the hazing of critics, for a considerable period of time. (If we mark the acceptance of the DSM-III as the turning point in 1987, we’re talking about 35 years since the publication of the first DSM in 1952.) EEG Biofeedback did not have the luxury of such silence until after it was rejected in the mid-seventies. When Joe Kamiya first asked the question about the relationship of the EEG to feelings and to states of awareness, things moved too swiftly into the realm of brainwave alteration and to clinical claims. It was too much too soon. The quiet of the laboratory that the field needed had thus become impossible. We have collectively now had thirty years out of the limelight to find our footing, our confidence, our professional community, and our voice. As it happens, Sue and I are at this very moment celebrating our own twentieth anniversary of association with neurofeedback. (Brian went for his first neurofeedback session with Margaret Ayers on March 5, 1985.) Now it’s full speed ahead; the skeptics be damned.

A second example of the development of a new discipline---aging medicine---from the outside is given by the Life Extension Foundation. In a recent edition of their journal, founder William Faloon writes of their twenty-five-year history, and of the ordeal of the early days. “Few people in 1980 thought that intervention into biological aging was possible, and many questioned why we would want to interfere with nature.”

“Being controversial carries a heavy price. The news media viciously attacked our position and had no problem finding academic scientists to denigrate us in every way possible. The Federal government raided our facilities twice, initiated an 11-year criminal investigation, and threw us into jail in 1991.” That’s a fate worse than we suffered in biofeedback. Lexicor was slapped with a fine by the FDA; Nancy White had her instrumentation confiscated and trashed, as a further signal to Lexicor; there were warning letters. But no fine was ever paid; and no one was ever apprehended. And those dark days are certainly over both for the Life Extension Foundation and for the biofeedback enterprise.

Where is the Life Extension Foundation now? “When the FDA conducted its first raid in 1987, we had only 4,000 members….We now have over 100,000 members and each month mail 250,000 copies of Life Extension Magazine.” By comparison, where is the biofeedback enterprise now? I estimate that some 100,000 clients are trained in neurofeedback every year in the United States, at the hands of some 6,000 professionals seeing some 17 clients per year. These estimates are more likely to be conservative than not.

by Dr. Siegfried Othmer