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The Washington University school developed a scientific approach to psychiatric diagnosis.

Robins and Guze proposed five phases for establishing the validity of psychiatric diagnoses in 1970.

DSM-III improved diagnostic reliability but departed from the WashU group's emphasis on validity.

As the American Psychiatric Association moves toward the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), questions concerning psychiatric diagnosis and classification will once again come to the forefront. Surprisingly, relatively little has been written for general audiences about one of the most important developments in the history of psychiatric diagnosis: the Washington University approach to psychopathology.

Developed at Washington University in St. Louis during the 1950s, 1960s, and 1970s, this approach sought to establish psychiatry firmly as a branch of medicine by grounding psychiatric diagnosis in empirical research rather than theoretical speculation or professional consensus. Its influence was enormous, although many of its central principles were eventually neglected.

I wish here to briefly describe this approach, which informs my recent proposal with psychiatrist Ronald W. Pies for a validity-based diagnostic hierarchy in DSM-6, forthcoming in Psychiatric Services.

The Historical Background

In the mid-20th century, American psychiatry was dominated by psychoanalysis, which generally placed little emphasis on formal diagnosis. With some notable exceptions, such as Roy R. Grinker Sr. and Otto Kernberg, psychoanalysts tended to classify patients broadly as either neurotic or psychotic, while the question of whether particular syndromes represented distinct diseases or conditions received less attention.

Psychiatry also faced criticism over diagnostic unreliability. David Rosenhan's influential 1973 study, although later discredited (Cahalan, 2019), fueled public skepticism. More compellingly, the U.S.–U.K. Diagnostic Project found that American psychiatrists diagnosed schizophrenia at roughly twice the rate of their British counterparts (Kendell et al., 1971), largely because of differences in diagnostic practice. Psychiatry needed more reliable diagnoses, but reliability alone would not establish whether those diagnoses represented actual conditions.

It was against this backdrop that a group of psychiatrists at Washington University in St. Louis, most notably Eli Robins, Samuel Guze, and George Winokur, developed a fundamentally different approach to psychiatric diagnosis.

The Problem of Psychiatric Classification

Unlike other branches of medicine, psychiatry generally lacks laboratory tests capable of establishing specific diagnoses. The 19th-century anatomical-clinical method linked symptoms to identifiable pathological changes, transforming much of medicine. In psychiatry, however, this method produced relatively few successes, apart from conditions such as neurosyphilis.

The German psychiatrist Emil Kraepelin recognized that........

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