A Long Way From 'Insanity and Idiocy'

Jeffrey A. Lieberman, MD


January 30, 2013

Hello. This is Dr. Jeffrey Lieberman from Columbia University in New York City, speaking to you today for Medscape.

In December at its Board of Trustees meeting, the American Psychiatric Association (APA) approved the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is an aid to clinicians for establishing psychiatric diagnosis. This is the result of almost 10 years of work, for which the APA convened a large number of experts to pore over the literature; to review the latest scientific findings; and to annotate, amend, or change the DSM diagnostic categories and criteria, based on the latest scientific findings and the best evidence.

Thus, the approval by the board of the proposed revisions in DSM-5 represents the culmination of a long, scholarly, and rigorous effort. It also represents the state of the art in psychiatric medicine as reflected by the latest scientific evidence.

Now, to understand the DSM-5 and its strengths and limitations, it is important to see it in historical context. Mental illness has not been well understood and scientifically defined. In the 1840 census, which was the first time it was actually evaluated on a widespread population basis, there were only 2 psychiatric diagnoses: insanity and idiocy. Over the ensuing century and a half, these 2 diagnoses were disentangled, through scientific research, into multiple, distinct diagnostic entities.

Insanity became dementia praecox, then schizophrenia, melancholia, depression, manic-depressive illness, bipolar disorder, and so on for all of the other major psychiatric diagnoses, through painstaking efforts of research and careful observation and description.

Idiocy, an unfortunate term that was used to describe intellectual disability, has since become disentangled into multiple different disorders, including genetic, neurodevelopmental disorders and acquired and environmental conditions such as fragile X syndrome, Prader-Willi syndrome, William syndrome, Rett syndrome, autism, and so on.

The APA instituted the development of a formal DSM in 1952. This was revised in the 1960s; however, these first 2 editions were rather slim volumes with less than a page describing the features of each diagnostic category. It was not until 1980, with the release of the third revision of DSM, that we achieved a rigorous, precise, and consistently defined description of each of the diagnostic categories. This elaborate, almost 400-page, scholarly manual became the benchmark for evaluating patients who had mental disturbances and establishing reliable psychiatric diagnoses. In part, this was motivated by the fact that up until then, many doctors seeing the same patient would not necessarily agree on the diagnosis. DSM-III took a giant step forward in terms of standardizing the way diagnoses were determined and ensuring consistency across different clinicians and particularly psychiatrists.

The DSM-IV was published in 1994, with a "text revision" in 2000, but there has not been a [thorough] revision prior to DSM-5 in almost 20 years. Many people think, however, that given the period of time since DSM was first created, we should be further along in our sophistication and technological ability in making psychiatric diagnoses. We should, by now, have been able to establish diagnoses based on etiology and the results of laboratory or radiographic diagnostic tests, such as those that exist for most of our sibling disciplines in medicine and other disorders.

The brain is a very complicated and difficult organ to completely understand mechanistically. Psychiatric disorders have proved to be elusive in terms of defining their etiologies, and the DSM-5 represents the state of our science today. It is not something to be ashamed of or make apologies about, and it does not limit our ability to practice psychiatric medicine effectively and in a way that is helpful to people in need. It simply reflects the reality that the process of reaching our goals of defining the causes and developing the cures [for psychiatric disorders] is very challenging and requires more effort.

And efforts are under way to improve upon this. The National Institute of Mental Health has initiated an ambitious project to establish the neurobiological and neural circuit foundations of specific mental, emotional, cognitive, and behavioral functions. This is called the RDoC, or Research Domain Criteria project, an important venture that will ultimately serve the field well. RDoC is, however, a decade or more away from coming to fruition and being useful clinically in any practical way.

Until we have scientific progress that enables us to revise the DSM in a way that leads to greater specificity and greater validity in relation to causation of mental disorders, including the use of various laboratory-assisted assessments, the DSM-5 represents the state of our art and the best that we have. It is important to realize that although many people may be frustrated with the pace of scientific progress, this does not diminish the utility of this important and historic instrument, which remains a valuable and essential component in the clinical care of patients with mental illness.

I look forward to the release of the volume and the full description of DSM-5 in May. We will closely watch for further developments in terms of progress with scientific research that may lead to more enhancements in the DSM.

This is Dr. Jeffrey Lieberman of Columbia University, speaking to you today for Medscape. Thank you for listening.