Carson Aristotle, Galileo, And the DSM Taxonomy_1996

8/13/2019 Carson Aristotle, Galileo, And the DSM Taxonomy_1996

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J o u r n a l of C o n s u l t i n ga n d C l i n i c a l Psychology1996. Vo l . 6 4 .No. 6. 1 1 3 3 - 1 1 3 9 Copy right 1996 by the Americ an Psychological Association. Inc.0022-006X/96/S3.00

Aristotle,Galileo,and theDSM Taxonomy: TheCaseof SchizophreniaRobertC arsonDukeUniversity

W i t ht he diagnosis schizophreniausedas anexam p l e t h r oug hou t, th efou r th edi t ion of theDiagnos-tic and Statistical Manna/ ofMental Disorders's(American Psychiat r ic Associat ion, 19 94)approachto psychopathologict axonom y issubjected to crit ical analysis asrepresenting afund am en t a l l y A r is -totelian conception of thephenomenao fm en t a ldisorders. This approach iscontrasted,in the m an-ner suggested by Kur t Lewin 's ear ly wr i t ing on the subject , wi th th e G al i l e i anmode o f t houg h t ,em p has i z i ng t he dyn am i c causalmatr ix in whic h behavioroccurs.SomeO fthe posi t ive im pl icat ionsof an altered viewof theproblem o ft axonom y w i t h i nth e latter perspective aredr aw n ou t , an d briefsuggest ions a rem adeas todi rect ions for thef u t u r e .

It ha s been almost a century since Emil Kraepel in (1899/1937),in thesixth editiono f hiscelebrated textboo kofpsychi-atry, explicitly identified dementia praecox (or whatw e nowcallschizophrenia)as a specific category of m ental disorder, dis-cr iminable from th e undifferentiated mass of mental disorderin general, as well as from certain other discernible types ofpsychopathologynotably manic-depressive insanity.Itwouldseem timelyif notbelated, therefore,to ask forsome acco untingamong those professionals assuming stewardship through th eensuingdecades over this purportedly most challengingof thementalhealth problemso fhumank ind .Theseriousnesso fthischallenge in theUnited Statesandelsewhere appears in fact tobe w idely underestimated.Ibegin this essay withabrief,objec-tiveexaminationofthis question.H owlargeis theproblem,andhowwellhave researchers coped withth esevere typeso fdisor-der nowmerit ingth eDiagnostican dStatistical Man ualo f Men-tal Disorders(DSM) designation schizophrenia?

Extentof theProblemIncidence and prevalence estimates fo r schizophrenia ar ewidely variant (American Psychiatric Association, 1994),largelybecauseofinstability over timeandplacein the criteriaused foridentifyingcasesb utalso probably because ofsubstan-tial real variations in occurrence of these conditions amongdifferinggroups(Stevens &Hallick, 1992).Th e most accurate

datafor theU nitedStatesar eundoubtedly thosederiving fro mth evenerable Nation al InstituteofMental H ealth( N I M H )Ep-idemiologic Catchment Area survey.A searching analysis ofthese data by Tien and Eaton (1 9 9 2 ) suggests an occurrencerateo f ASAf-defined full schizophrenia ashighas two casesper 1,000personsp er year,anestimatethat dwarfs previous,less reliably based ones. Th e medianage for first admission isin the 20s, somewhat earlierfo rmale than fo r female patients.Behaviorthat meets criteriafor thediagnosiso fschizophreniais ,thus,o frather common occurrence. What happens, then,t o

Correspondence concerning this ar t i cle shouldbeaddressedtoRob-er t C.Carson, B o x90085, Duke Univers i ty, Durham, Nor thCarolina27708-0085.

thissignificantlylarge subgrou pof the populationw hodevelopbehavioraldeviancesof the schizophren iformvariety?It isimportant in addressing th e question ofoutcomes withthisclass of disorder to be clear about the criteria to be used.Th e mere'absence or pharmac ologic suppression of the mo redram atic signs associated withthediagnosis,often termedpos-itivesymptoms,havefrequently, itwould seem, been given un-due weightinsuch assessments. This poin tisillustratedi nsomeobservationsoffered byHarv ard U niversity psychologist RogerBrown (Brown & Herrns te in , 1975). Brown ha d attended ameetingof alocal chaptero fSchizophrenics Anon ymou sto ac-q ua in thimselfwithth ec linical phenomenon ofschizophrenia.Hedescribeshi sexperienceasfollows.

T he members each seemed tocome alone, trailingin and out o f then i g h t , wi th a l m os t no g r oup acknow l edg em en t of the successivear r ivals . [A remembered former s tudent of m i n e ] was thegroup's leader that n ight , and h ebegan wi th an optimistic testi-m ony abou t ho w things were going wi th h im , designed inpart tob u c kup theothers.Someofthem alsospokehopeful ly;othersweres i lentand s tared at the floor throug hou t . I g rad ual lyfelthopedrain-in gout of theg r o u p asthey began totalk of thei r inabi l i tyto holdjobs,of l ivingon welfare,of findingthemselves overwhelmedbys i m p l e dem ands . N o t h i ng b i za r r ew assaid ordone;therew asrathera pervasive sense of inadequacy, of livesi n w h i c heach day was ad re a d fu l t r i a l . D oug hnu t s and coffee were served, and then eachone, stillalone, t ra i ledo ffi n t o t he C am br i dg e n i g h t .

W h a t I s aw a l i t t le of at the meet ing of Schizophrenics Anony-m ous i ss im pl y tha t there i s somethingabout schizophrenia tha tth e an t i p sycho t ic d r ug s d o n o t cu r e o r even remi t on a long-termbasi s. (Br ow n & H er r ns t e i n , 1975,p .6 4 1 )

Clin ic ianshavingexperiencewiththese typesofpatientswill,Isuspect,findlittlequarrel withtheaccuracyo fBrown 's obser-vations. In short, what is so devastating about what iscalledschizophrenia is not flagrant b iz arre n es sn o t hearing th ingsother people don't hear or expressing beliefs others finda b s u r d b u t rather th e kindso f social deficits that Brownsoeloquently ye t concisely identified. Fenton an d McGlashan(1 9 9 4 ) ,infact, referredto a deficit syndrome asrepresentingth e u l t ima tein prediction ofpoor men tal health outcome.B ycontrast, Romme and Escher ( 1 9 8 9 ) have reported on a well-attended congress of chronichallucinatorsamong the Dutch,1133


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S P E C I A L SECTION: ARISTOTLE,G A L I LE O , A N D T H E D SM 1135a poorly conceived idea, on e that o n logical grounds alone isunl ikely toyield penetrating insights. Iattempt to showw hythisis so inwhatfollows.

DSM andth eAristotelian Modeo fThoughtIn anearlier critiqueof theD SMtaxonomy(Carson, 1991a),

Iconjectured that th e pa infu l lyslow rate ofprogress inunder-standing schizophrenia(as wellas other presumed entitiesofdisorder)may to asignificant extentbe theproduct of atypeofin tel lectual inertia, in which originally inaccurate judgmentsaboutthecoreelementsand theboundariesoftaxa have simplybeen permittedtopersist unchallenged. AlthoughIcontinuetof ind th is a likelysource of difficulty, further ref lection ha scon-v inced me that it ismerely th e inevitable manifestation o f afar more basic problemnamely,thethoroughly Aristoteliancharactero f theD SM effort.A sM i l l o n ( 1 9 9 1 ) hasaptly noted, the current state o fpsy-chopathologic nosologyanddiagnosis resembles thatofmedi-c ineacentury ago (p. 2 4 5 ) . Itresembles, in other words,afieldthathas yet tocometogrips withthenaturalanddynamicprocesses producing the (disordered) phenomena observed.Theexplanationof thedisorder residesin theclassorcategorytowhic htheattendant observationsareallocated,as in thelistsof symptoms by which 19th-century medical students weret a u g h tt o identify th evarious diseases then recognized. Consid-eredin the world hypothesis or rootmetaphor, terms orig-inal lyproposed by Pepper ( 1 9 4 2 ) , th e approach is a type o fformism, whereintheultimate natureof a phenomenon is as-sumed to reside in the careful ly discerned properties it shareswith other phenomena (i.e., in i ts accurate categorization).Thus,fo rAristotleandother early Greek philosophers, lightob -jects tendedtoriseandheavy objectsto fallbecause these prop-ertieso flocomotion were inherent, respectively,inlightnessandheaviness. In l ikemanner, persons withschizophrenia hal luc i -nate, so theimplicit proposition affirms, because it is in the na -tureofschizophreniafor itsvictimsto do so.T heimpedimentsofAristotelian thinking osound scientif icprogressi npsychology were explicated many yearsag o in aclas-si cworkby one o f the field 'smost seminal thinkers, Kurt Lewin(1935). Inthat article,in fact,Lewin made direct reference toacontinuing problemin theverydef in i t ion ofpsychopathology.N o t i n gthat Aristotle'sconceptswereoftenheavilyinfusedwithv a lu econsiderations, hewent on tosuggest that, like th edis-t inc t ionbetween earthlyan dheavenly,the noless valuative dis-t i n c t io nbetween'normal' and 'pathological' has for along timesharply differentiatedtwo fields ofpsychologicalfactandthusseparated th ephenomena whichar ef u n d a m e n ta l lymost nearlyrelated (p .3). A srecently pointed out inimportant analysesbyGorenstein ( 1 9 9 2 )and Wakeneld (1992a , 1 992b) , the f ieldof psychopathology verymuch remainsd ef in i t ional ly encum-bered byseemingly inextricable issueso fvalue. Even more im -portant,perhaps,isLewin's somewhat offhand suggestion thatit is amistaketoassume that different psychological principlesapplyto thenormaland thepathological.O fmore immediate relevanceto thepresent argument, how-ever,areLewin's observations pertainingto thesubstitutionofd imens iona l fo rcategorical modelsa sessential to the scientificachievements of theGalileian andpost-Galileianeras, and h is

insistence that behavioral phenomena mustbeunderstood notin terms ofstatistically average propensities of persons catego-rizedin one o ranother fashion bu trather intermsof an appre-cia t ion o f theimmediatea n ddynamic causal matrix inwhichth ebehavioral eventsofinterest areembedded. Theformero fthese issues,as i trelatest odistinguishing among various formsofpsychopathology,hasbeen th esubjecto fmuch discussion inrecent years, someof itencouraginglyby researchers centrallyinvo lved in the development of the latest version of the D SM(e.g.,Widiger, 1993; Widiger&Frances, 1985).In theend,therecent ly installed DSM-IV (American Psychiatric Associa-t ion, 1994) , like it spredecessors, w asorganized according to aca tegor ica lformat. Several formidable problemswillhaveto beovercome(see,e.g., Clark, Watson, &Reynolds, 1995;Franceset al., 1991; Mil lon , 1990)beforewe mayreasonably look for-ward to athoroughgoing dimensionalization of the field, butth e strictlyscient if ic benefits o fdoing soremain acompellingincent ive .Lewin' slatter point, pertainingtocausal analysis,isreallyth eheart of hiscritiqueof theAristotelian model and of h isargu-m e n tthat scientific progress isultimately dependent on adop-tionof theGalileian investigationalmode.In his ownwords,

in the psychologicalfieldsmostf u n d a m e n t a l to thewhole behavioro f l i v i n gt h i n g st he t r ans i t i onseemsinevi table to a Gal i leian viewo f d y n a m i c s , wh ichderivesall i tsvectorsno t from singleisolatedobjects , but from th em u t u a lrelationsof thefactorsin theconcretewh ol e s i tua t ion ,thati s,essentially, from th emomentary conditionof the i nd i v i dua land thestructureof thepsychological situation.Th edynamics of t heprocessesisalwaysto bederivedf r om th erela-tion of theconcrete individualto theconcrete situation and,so fara si n t e r n a l forces areconcerned, from t he m u t ua lrelationsof thev a r i o u s f u n c t i o n a l systems that m ake up t he ind iv id ua l . ( 1 9 3 5 ,p. 4 1 )

Quite clearly,Lewin ishere advocating anabandonment oftheformist orAr is to te l ianroot metaphor in favor ofwhatPep-per ( 1 9 4 2 ) described as a contextualist one, inwhich everyevent is a his tor ica l ly uniqueproduct of i ts owncausal matrix,an dwhere such contextual matrices may b eexpected constantlytochange.Thesame rootmetaphor wouldin contemporarylanguage probably qualify as one oranother version ofgeneralsys temstheory (see, e.g., Bronfenbrenner,1979) .T he scientificrevolut ion ( K u h n , 1970)spawnedbyGalileoa n dother natu-ra l philosophers of the late Renaissance an d beyond isthusone inwhic hevents cameto beseennot as due to theintrinsicpropertiesof theobjects involvedinthose eventsb u t rather asthedynamicoutcomeof a mix ofinternalandexternal influ-ences( f o r c e s ) immediately determiningth eobserved behaviorof those objects. ForGalileo, such objects of interest rangedfrom ballsrol l ingdownaninclined planeto themovementso fth e heavenly bodies of thesolar system. Moreover,hedemon-strated that th elaws governing such motiona repotentially dis-coverable through precise, quantified observation andthroughex per imenta t ion .For thepsychologist Lewin( 1 9 3 5 ) ,t heobjects an deventso finteres t were, respectively, living organisms (chief ly humanb e ing s ) and the differ ingbehaviors emittedbythem invariousor g an i s micstates andsituational settings. I t wasLewin's hopeto convince psychologists that, byavoiding Aristotelian think-


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1136 C A R S O Nin g an d adopting th e perspective and the methodological ap-proach epi tomized inGalileo's work, they might product ivelyt r ansform their science in a manner s imi l a r to Galileo's trans-formation of Ar is totelian m echanics . As iswellk n own b y h i s -to r ians ofpsychology, Lew in's m essage has had apr of ound im -pact on the development o f American personal i ty an d socialpsychology, wh ich by the late 1960shad become so thorou ghlys i tuat ional in f ocusas to provoke th e ques t ion, Where is theperson in personalityresearch? (Car l son, 1 9 7 1 ) . The conceptof personality does not , of course, au tomatical ly dictateanAris totel ian mode o fth oug h t , but the risk here is a seductiveone in that m uch personal i ty research in volves one or ano therformofcategorization ofpersonality types.Theconceptual d is tance between personal ity typingan dpsy-ch ia t r i c d iag nos is is hazardous ly smal l , an d hence, th e latterfield isequallyatriskforadopting,inadv ertently as itwere, theAris totel ian thoughtmode.A s Ihave already suggested, thereism u c h reason tobelieve that it has often d one so. Forex ampl e ,even the mos t cursory famil ia r i ty w ith the research l i tera tu reon schizophrenia underscores the huge gu lf existing betweenpresent realitiesandLewin' sepistemologicidealas representedin the foregoing remarks . To a remarkable extent , in fact,w h a thas been em pir ica l ly es tabl ished as rel iab ly t ru e of the psycho-biology of schizophrenia derivesfrom statis tical ly s ign i f ican tb ut q uan t i t a t iv e l y minor mean differences between markedlyover lapping cr i ter ion ( i .e ., persons meeting c ur ren t d iagnos t icg u ide l in e s )a n d control group d is tr ibut ions .

Concrete s i tuat ions are almos t never serious ly s tud iedasthey m ay bear on the behavior o f persons designated to beschizophrenic, the most notable recent exception being thework on Expressed Em otion; low levels of expressed emotio na m o n gfami lymem bers areassociatedwith d elayed relapse afterremiss ion from sc hizo phre nifo rm episodes (see, e.g. , Hooley,1985) .Thereis a l so some n ow quite dated ev idence that poor lyunders tood personal i ty factors in a therapis t may impor tant lyd e te r minethe( u n m e d i c a t e d ) schizophrenicperson's responseto psychotherapeutic approaches (Betz, 1962; see Car s on ,1967, for a rev iew) . Hypotheses rela t ing to behav ioral depen-d ency on in te rac t ions o f s i tua t ions w i th in te r na l f unc t iona lsystems that ma y beassociated w ith th e diagnos is are, in thepresent c l imate of les ion seeking, pract ical ly unheard of . Thed ea r th o fresearch ofth issortseems p ar t ic ular ly regrettab le inviewof itshighpotent ia l fo rcas t ing analy t ical l igh ton the psy-chology of the schizophrenic exper ience.

Galileian Developm ental PsychopathologyGal i leo, being concerned chiefly wi th th e und er s tand ing o fmot ion ( pa r t i cu l a r l y th a t o ffall ingbodies) and the demons tra-t ion o f planetary hel iocentr ic i ty ,appears to have had little in -terest inhis tor icodevelopmental processesin th e epigenesis,ifany, of phys ical phenom ena. Lewin w as s imilar ly ah is tor ical ,perhaps even ant ih is tor ical , in h is approach to psychologicalproblems; by and large, for example, he avoided questions re-l a t ing to the or ig ins of internal s t ructural and funct ional var ia-t ions among behav ing persons , a l though he was by no meansloathtomak e s uch v a r ia t ionsacentral aspect of histheor izing.Researchers, therefore, havenodirect m odelonw h i c htobaseano t ion o fdevelopm ental processes according to the Gal i leian

mod e of th oug h t .Ifthere were one, how ever, it seems reason ablycer ta in th a t i t woul d b e one h av ing st rong l y d y namic , in te r ac -t ive,epigenet ic features .B y con t r a s t , th e d eep l y en t r ench ed Ar i s to te l i an / Kr aepe-

l in ian mode of thoug ht that has dominated the f ield of psychia-tr y over mos t of i ts h is tory has encouraged a decidedly s ta t ica n d u n d y n a m i c viewof the origin s of psychopathology, perhapspar t icu la r ly in regard to sch izophrenia . A notable examplefrom that his tory is the etiologic p romin ence afforded the no-t ion ofta inted genes . I think i t no exaggeration tosugges t thatth i s id ea r emain sad o m i n a n t t h em e incon temporary b iologi-cal psychia try, despiteitsev ident problems, w hich include(a)the largely unexamined myster ies of the impl icated pathwayfromta inted genes to the complex phenom ena o f sch izop hreni-form behavior , (b) the progress ive reduct ion of the estab-lished pairwiseconcordance ratefor thedisorderin monozy-g o t ic tw ins from 86% in the 1940s (Ka l lma n, 1946) to 28% inthe 1990s (Torrey,B ower, Taylor,&Gottesman, 1994 ), (c) thefact that in any event the biological identity of mono zy g o t ictw in s i s e l imina ted s h or t l y after conception (Torrey et al.,1994) , and (d ) the co nv inc ing ev idence of widespread genet ic-e n v i r o n m e n t a ln onind ependen ce (see, e.g ., Plomin, C hipuer , &Loehl in , 1990) .These observat ions do not , of course, i m p ly that genet ic orother pe rsistently operative biological facto rs have no role in theetiology of sch izophrenia . The maintenance of any such pos i-t ion wo uld seem to m e torequire denialof theper t inen t empi r -icalev id enceon a t ru lymassive scale. Theyd o i l lus tra te,Isug-gest, th e cons iderable a t t ract ion o fstatic an d u n i d i m e n s i o n a let iologic models to modes o f thoug ht s t ronglyin f luenced by anAris totel ian perspect ive. By contras t , an ad equate unders tan d-in go f the et iology of the sc hizoph reniform disorders willalmos tcer ta in ly r eq u i r e th e ad op t ion o f an e l ab ora te and mu l t ipa thmod e l o f epigenesis, quite likely (i n view o f th e i r r ampan theterogenei ty)o neal lowingforcons iderable id iosyncrasy , suchas M eehl 's ( 1978 , 1989) bad luck factor, in th e manner inwhic h v a r i o u s r i sk / p ro t e c t i ve elements developmentally in -teract to produce the outcome (C arson & Sanislow, 1 9 9 3 ) .T hesolut ion of th is epigenetic puzzle (Gottesma n & Shields ,1982)will ,thus , depend on wha t is here terme d a Gal i leian ap-proach to the inves t igat ive chal lenge.O ne s hou ld also not lose sight of the possibil ity, indeed l ikel i -hood, that th e course ofschizo phreniform processes aftero n-set ofd isorder is notd e te r mined , once and forall ,bystatic andpriorpropertiesof theaffected organ ism.A farmore reasonableassum ption is that the schizo phrenic person and h is or her d is -o r d er con t inue to respond to im p in g in gen v i r onm enta l ev en t s.Cons idered from this perspective, th e notion of a def ici t syn-drome in w h i c hadeteriorated stateis thenecessary an du n a l -terable outcome m ust be regarded as an extremely pernic iousideaone that conta ins the seeds of i ts own fulf i l lment . Forexample, there is ev idence in the lon gi tud inal data gathered byW a r n e r(199 4) , c i ted ear lier , that suc h imp rove men t as had oc-cur r ed in ou tcomes in schizophrenia after World War I I wasm a in l y due to a l tera t ions in the psychosocia l env iro nm ents ofmenta lhospi ta ls , ra ther tha n to the ad vent of new drugs .Researchersareac tua l l y b eg inn ingto seesome reemergencehere and the re of the sor t of dy na mi c perspect ive, largely aban-doned in ps y ch ia t r yby the 1970sthat Isuggesti ssorely needed .


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SPECIAL S E C T I O N : A R I ST O T L E ,G A L IL E O , AND THE ASM 1137Fo r example, there is now a wealth of evidence that manyofthe persons a cquiring the diagn osis of schizophrenia a s youn gadults began life with subtly compromised nervous systems,producing var ious neurological softsigns an d min imal ly im-pairing neurom otor abno rmalities. The causal factors involvedin these anomaliesappearto be quite varied, and the anomaliesthemselves are not un com mo n in the histories of ma ny personswho do not become psychiatric casualties (Carson etal., 1996).Depending, one maysurmise, on thereactions of the affectedchi ld 's social environment, these anomalies, which may befairly obtrusive (see, e.g., Grimes & Walker, 1994; Walker,Grimes, Davis,&Smith, 1993;W alker,Savoie,&Davis, 1994) ,might(o rmightn o t )have detrimentaleffectso n theyoun gster 'spersonality an d social development. Such detrimental effects,wherethey occur, might(o rmight n o t )inturn enhancetheriskfor aschizophreniform outcome, probably again dependingo na hos t of o ther largely unknow n impinging influences (seeB e-renbaum & Fujita, 1994;Zborowski &Garske, 1993, forotherva r i an t s o fthis generalapproach).The foregoingscenario obviously contains a large componentof speculation. It isoffered herenot as a formal hypothesisre-lat ing to the etiology of schizophrenia but rather as ane xa mp le i n fac t, aprobably oversimplified o n e o f t h ekindof extended and com plicated pathw ay thatappears to be in-volved inm a n yif notmost developmental patterns even tuatingin aschizophreniform outcome. Thetu nn el v is ion encouragedby an Aristotelian world view and soendemic to this field ofi n qu i ry(Carson, 1991b)is, in m yju dgme n t ,averyseriousob-stacle to the scientif ic progress of which , as earlier shown, re-searcherso fschizophreniaare inrather desperate need.

Fixing theDSMIt iseasy to underestimate th e impac t of the DSM and i t s

fundamenta l ly Aristotelian character on both the direction ofpsychopathologic research and the methodologies used. Twosomewhatrelated issues seem pa ram oun t here:(a) In thepres-en t era, it isvi r tua l ly axiomatic that research participants beselected according to the prevailing D SM diagnostic criteria,t h u s ensur ingt he cont inuing prominence in the li te ratureo fthe field and in the co gnitive schemas of its investigators of thecategory thu s delineated, whether or not the category created o rth e taxon om ic system of which it is a compon ent representsmaximal ly productive ways oforganiz ingthe phenomena ad -dressed;and (b) investigativeeffort ispowerfully bu tsubtly pro-pelled toward m akin g the category, and the n onc riterial charac-teristicso fpersonsw ho fit it, thefocusof i nves t ig a t ionin em -ula t ion,as it w ere, ofAr i s to t leincontradistinction to afocuson careful funct ional analys is relat ingto theoriginsa ndm a i n -t enance of the problematic behaviors enacted by indiv idua ls.Forexample, Paula nd Lentz( 1 9 7 7 )have demon strated in im-pressive fashiont he powerful effects that an alteration ofre in -forcement contingencies can have on the behavior of peoplewithschizophrenia, inthis caseevenafterm any yearso fcontin-u o u shospitalization.In m y own jud gm ent, it cannot be seriously doubted that astrategy ofdirectly addressingspecific dysfunct iona l behaviorsas difficulties to beeradicated an dreplaced with more effectivetechniques of social survival would be maximal lyeffective in

te rms ofclinicaloutcomes in schizophrenia. Instead, the mentalhealth professions have uncritically adopted the Aristoteliannotion that these problematic behaviors are the manifestationof a generalized and still who lly mysterious intrinsic propertyexisting wi thin persons whose behavior meets certain classifi-catory c r i te r iac ri ter ia, moreover ,that lack obvious internalcoherence oreveng reat stability over time(Carson& Sanislow,1993). From this perspective, it isless than surprising thatwecan dem onstrate little overall success in coping with the chal-lenge schizophrenia presents.Iti s areasonable prediction tha t institutionalized psychiatrywould strongly resist abandon ment of a categorical taxonom icmodel of the present D SMvariety. The disorders as so arrayedbear as trong analogytoclassical medicaldiseases,and the re-medicalization o fpsychiatryinrecent yearsha sbeen quite suc-cessful infur ther ingcertain peripheral aimso fthat profession,not all of them (as in all professions, in clud ing other m entalhealthp rofession s) necessarily favorableto scientific advance.Therem ay be,however,acur ious i ronyinthis position.The dis ting uished nuclear physicist J. Robert O ppenheimer,ofW orldWar IIM anha ttan Projec t fame,m any yearsagogavean address to the American Psychological Association (Op-penheimer, 1956) ,in w hich he warned psychologists not to pat-tern the developmento ftheir disc iplineafter aphysics thatw asnot there a nym ore. He was speaking, ofcourse,of the paradig-matic revolut ion involv ingth eov erthrow (absorption?) of clas-sical physicsb y quantum mechanics. Whether psychologistshaveheededth i sadviceisdebatable,but avar iantofOppenhei-mer'swarn in gm aywellapplyto thepresent situation ofpsychi-a t ry: Do no tpattern th edevelopmento fyou r disciplineafter amedic inetha tis notthere anymore.Mynonpsychiatric medicalfriends, someofwho m are at thec ut t ing edge of their special-ties,tellm ethat theynolonger treat diseases; they treat patients,or mo re specifically, pathophysiologic andpa thoanatomic sys-tems that in terferewithessential or desired functioning. On theassumption tha t m y friends a re correct and that medic ine isincreasingly Gali le ian in its conception of individual illness,psychia t ry 'srelianceon thedisease m etaphormay yetprovetohavebeen illadvised.Politico-econom ic considerations aside, thereappears to beam ple reason from bothscientificandc linic al perspectivesfor aprofound and serious reconsideration of what characteristics agood taxo nom ic model for menta l disorders should have, as thecaseof schizophreniaillustrates.In my ownview,thereisnoth-in gmo re impo r tan tto thefuture promotion ofrapidandgenu-in eadvancein theunders tandingofpsychopathology thanfind-in ga m ore product ive so lu tion to the taxonomic conun drum .Th e challenge, I acknowledge,is a formidable one, bu t likema n yothers (e.g. , Cla rketal., 1995), I ampersuaded to begin.As m y friend Allen Frances, Chair of the DSM-IV TaskGroup, has remind ed me direc t ly (personal comm unicat ion,May 10 , 1994), it ism uc h easierto be acritic inthis area th anitis to suggest comp elling and pragma tically realistic solutions.Without question, he iscorrect inthat surmise, an d I readilya d m i t tha t th e m a n y h u n d r ed so f hours I have spent mullingover this agoniz ing problem have produced chiefly personalfrustrat ion an d enhancedhumil i ty .I dohavetw osomewhat re -lated sug gestions, or perhaps they wou ld be better consideredpredictions, aboutth e likelyform of asatisfactory solution, nei-


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1138 C A R S O Nther of them either new or originating with me. They are asfollows.

1. Ithinkitextremely unlikely that the apparently seamlesscharacter of hum an behavior, including abnormal human be-havior, wi l l ever satisfactorily yield to a categorical system ofclassification(Carson,1996). Fortunately, there alsoappearstobe no substantive need for such a system in the area of psycho-pathology, inasmuch as researchers would probably do aswellorbetter byfocusingon particular behavioral problems deemedto be in need of therapeutic intervention . Of course, there wouldsometimes be value-based controversy in rendering such judg-ments, but such issues already confront researchers and clini-cians and, as earlier noted, may be inescapable for any currentlyconceivabledefinitionof psychopathology.

2. Advances in scientific understanding have historicallybeen, to a strikingdegree, dependent on increasingly precisequantification with respect to the phenomena of interest. 1 seeno reason why it should prove to be otherwise for the science ofpsychopathology. On the contrary, although I do not underesti-mate the d i f f i cu l t i e s to be overcome, I see no acceptable long-term alternatives to (a) establishing what are the critical un-derlyingdimensions in behavioral pathology and (b) proceed-ingto develop reliable and valid means of measuring personswithrespecttothem.Thecommon complaint that suchacum-bersome procedure appliedtoindividual patients would undulycomplicate the lives of busy clinic ians is, it seems to me, withoutnotable merit when considered in relation to the high stakesinvolved. Misdirectionand triviality at the level of assessing,diagnosing,andconceptualizingtheproblems patients presentw i l l inevitably produce both compromised treatment optionsa n d , over the longer term, compromisedscientificadvance.

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Received August30, 1995Revision received November 27, 1995AcceptedDecember22,1995

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