Book Review

“Make-Believes” in Psychiatry, or the Perils of Progress

N Engl J Med 1993; 329:1134-1135October 7, 1993

Article

“Make-Believes” in Psychiatry, or the Perils of Progress
(Clinical and Experimental Psychiatry. Monograph No. 7.) by Herman M. van Praag. 304 pp. New York, Brunner/ Mazel, 1993. $39.95. ISBN: 0-87630-680-6

In his whimsically titled book, Dr. van Praag has assigned himself the monumental task of reformulating contemporary psychiatric diagnostic methodology, as reflected in the third and third revised editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-III-R). Drawing on his impressive body of clinical and basic research, starting during his residency in the late 1950s and continuing throughout his distinguished career, most recently as chairman of the department of psychiatry at Albert Einstein College of Medicine, van Praag proposes a “root and branch” restructuring of our contemporary concepts of psychiatric diagnosis.

This complex and sometimes repetitive book starts with a lengthy critique of the “consensus” method that was used to derive the diagnostic classifications in the DSM-III. Dr. van Praag accurately points out the scientific weakness of the current classification, which is phenomenologically based and etiologically “blind.” His principal argument is that without systematic validation studies, our diagnoses lack firm scientific footing. In his review of his own research and that of others, particularly on the clinical phenomenology of mood disorder, he makes the telling point that our current diagnostic criteria are too broad, incorporating heterogeneous subgroups, and that it is therefore difficult to conduct replicable clinical research. He proposes, in the first instance, that additional criteria, incorporating severity, course, duration, family history, and etiologic variables, be incorporated into the diagnostic formulation. This greater specificity would then allow for more consistent classification of patients for research purposes.

The other major thrust of van Praag's argument is that research on the neurobiology of psychiatric disorders, including his own pioneer work on the role of serotonin in depression, suggests that various psychiatric disorders share common biochemical “fingerprints” that may be clues to their causation and that may serve as a basis for the reclassification of psychiatric diseases according to their chemistry, as well as their clinical features. In support of this hypothesis, he cites the multiple disorders of “impulse control,” ranging from suicidal behavior in patients with major affective disorder to homicide and assault in the nonpsychiatric population, all of which appear to share the trait of lower-than-average cerebrospinal fluid levels of serotonin metabolites such as 5-hydroxyindoleacetic acid. He cites clinical data indicating that all these disorders have been shown to respond some of the time to serotonergic agents. This observation leads van Praag to suggest yet another method of grouping disorders: according to their response to treatment.

Many in the field share van Praag's concern about proceeding with yet another revision (DSM-IV) of psychiatric diagnostic nomenclature and about the dangers of adding more discrete new diagnostic entities before we have validated those we already have in DSM-III-R. However, he makes only minimal allusion to the empirical value of the DSM-III and DSM-III-R and to the fact that their diagnostic criteria are more objective and phenomenologically based than those in the DSM-II. The latter, in its description of psychiatric disorders as “reactions,” perpetuated Mayerian and Freudian views about the presumed causes of major psychiatric disease. Anyone who has lived through the shift from DSM-II to DSM-III and the tremendous increase in the power the newer editions provide the clinician to categorize psychiatric illness systematically and reliably and to prescribe treatment would find van Praag's criticism of the DSM-III excessive.

The proposal that we adopt an etiologic-diagnostic approach, based on the putative neurochemistry of the major psychiatric disorders, belies the controversy that still exists in the field about the reproducibility and meaning of studies by van Praag and others. Furthermore, van Praag does not address the question of how we measure serotonin metabolites without analyzing spinal fluid. In clinical psychiatric practice, it is unlikely that lumbar puncture will become a standard part of the diagnostic assessment of the millions of patients who present with major affective disorders each year.

More unsettling are comments interspersed throughout the book that the ultimate goal of more precise diagnosis and biologic treatment is “understanding the treatment and cure of the underlying psychological disorder.” Here, it seems, van Praag has returned full circle to DSM-II, with its strong assumptions that the schizophrenic and depressive “reactions” are secondary to an occult psychological process. In a book that is filled with references to the descriptive and psychobiologic literature, it is noteworthy, and rather alarming, that van Praag does not in any way substantiate his bald statement but, rather, essentially asks the reader to accept it on faith.

In summary, though this is not a book for the general reader's shelf, it adds a thoughtful perspective to what are often strictly polemical arguments about the current and future status of psychiatric diagnostic methods.

Morton G. Miller, M.D.
Lahey Clinic Medical Center, Burlington, MA 01805