1. A Brief History Of Of Psychiatric Diagnosis Allen Frances MD Allen Frances MD A Brief History Of Of Psychiatric Diagnosis Allen Frances MD Allen Frances MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

17. 1860 Census- 6 inpatient diagnoses WW 1 and Freud- outpt expansion 1952 DSM I- outpt expansion 1968 DSM II- unreliable, unused 1975 RDC-few dx, criteria based 1980 DSM III- many dx,splltters system 1987 DSM IIIR- too much, too soon 1994 DSM IV- conservative Recent History of Diagnosis

18. The Future It will likely be a slow slog with steady and gradual advances in understanding No home runs, no walks, lots of strikeouts

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

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

21. And medicine may never have simple, unifying models