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More Or Less Biology In Psychiatry–That Is The Question

Much newsprint has been wasted recently on the split between the APA (American Psychiatric Association) and the NIMH over the revision of the DSM (Diagnostic and Statistical Manual of Mental Disorders)  that is going to be called the DSM-5. In my view, letting the 100,000 manuals bloom is not going to be any better of a solution than letting the 100,000 diagnoses bloom in the long run. If we are going to treat every patient as an individual, for the sake of the individuality of his or her condition (and genetic makeup), that’s going to make for a whole lot of variation in disorder (and/or order) expression.

The New York Times covers the story, regarding the NIMH APA divide, in a story with the heading, Psychiatry’s Guide Is Out Of Touch With Science, Experts Say. Of course, it always depends on which experts you ask. The experts the mass media is still slow to consult, and the New York Times is no exception in this regard, are those experts with lived experience on the receiving end of mental health treatment.

While typically critics of the DSM have tackled the subject from one side of the political psychiatric spectrum, here comes mob boss Thomas Insel, godfather of the NIMH, attacking from the other. In the first instance, you have people who object to the biology in biological psychiatric theory, (Theory, now there’s as important a word as any.) in the second, you have a group that doesn’t think the APA is biologically grounded enough.

The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said in an interview Monday that his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

The DSM focuses on symptoms precisely because we don’t know the causes. Dr. Thomas R. Insel, apparently, thinks otherwise.

Precision seems to be a big part of the problem. In psychiatric diagnosis, theoretical speculations aside, there are no precision tools.

The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr. Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a former director at the National Institute of Mental Health. “They chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this is totally wrong in a way they couldn’t have imagined. So in fact what they produced was an absolute scientific nightmare. Many people who get one diagnosis get five diagnoses, but they don’t have five diseases — they have one underlying condition.”

Or, a possibility not considered here, we’ve got five misdiagnoses floating around for which there was no underlying condition in the first place.

Solution. The NIMH is developing it’s own manual, Research Domain Criteria, or RDoC.

About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. Dr. Insel said in the blog that the National Institute of Mental Health would be “reorienting its research away from D.S.M. categories” because “patients with mental disorders deserve better.” His commentary has created ripples throughout the mental health community.

Consider, ripples sent throughout the mental health community, ripple throughout the “mental illness” community (i.e. the mental health ghetto). Now whether “patients with mental disorders” are going to get “better” treatment thereby is a big leap. Too big a leap in fact to make. So sorry, my poor victims of standard psychiatric malpractice!

Whatever you call it, my guess is that this switch still represents a way of billing insurance companies, the most important role for patient consumers a psychiatrist assumes. Of course, given that this paradigm change is all about biological explanations, I expect the treatment the insurance companies will be paying for is a chemical fix. Given this situation, the extent to which pharmaceuticals damage patients is still the great unasked question biological psychiatrists do their best to avoid asking.

Allen Frances And The DSM-5

Allen Frances, Duke University psychiatry professor emeritus, isn’t so much a critic of the Diagnostic and Statistical Manual of Mental Disorders as he is a critic of the DSM revision process. Apparently he has a love/hate relationship with the manual itself. He doesn’t object to the DSM, psychiatry’s label bible, so much as he objects to what he sees as a rushed and flawed job that could result in a shoddy product. He objects to a process that he thinks will produce a lower quality product than a more thorough going process would produce.

He himself was one of the architects of the DSM-IV. The DSM-IV was notorious for raising the “mental illness” rate throughout the world. The DSM-5 is expected to smooth out a few more of the wrinkles in the DSM-IV. Although current criticism of the DSM revision process may make the DSM-5 less of an open Pandora’s Box, or contagion zone, than no criticism whatsoever would, the publication of the DSM-5 is expected to raise the rate of mental illness around the world substantially again. Make no mistake about it; what is going on here, with the hoopla surrounding the revision and publication of this manual, is the selling of “mental illness”!

His latest jabs at this process on his Huffington Post blog have been aimed at the price tag. A recent blog post of his bore the title, DSM-5 Costs $25 Million, Putting APA in a Financial Hole. The DSM-5 has cost 5x the amount already that the DSM-IV cost. The APA is in the hole right now because of this price tag.

The American Psychiatric Association just reported a surprisingly large yearly deficit of $350,000. This was caused by reduced publishing profits, poor attendance at its annual meeting, rapidly declining membership, and wasteful spending on DSM-5. APA reserves are now below “the recommended amount for a non-profit (reserves equal to a year’s operating expenses).”

$350,000 in the hole to be exact because of a multi-million dollar revision process owing in part to the objections of critics such as Allen Frances.

APA has already spent an astounding $25 million on DSM-5. I can’t imagine where all that money went. As I recall it, DSM-IV cost about $5 million, and more than half of this came from outside research grants. Even if the DSM-5 product were made of gold instead of lead, $25 million would be wildly out of proportion. The rampant disorganization of DSM-5 must have caused colossal waste. One obvious example is the $3 million spent on the useless DSM-5 field trial, with its irrelevant questions, poorly conceived design, and embarrassing results.

The DSM-5 was due to be published in 2012. Because of the objections of many psychologists and the likes of Allen Frances publication was suspended for a year. The revisers of the DSM-5 are also going out of their way to get input from interested parties. Actually, and to be more precise, the revisers are busy at damage controll by giving the appearance of giving an ear to critics for public relations purposes. The upper echelon of the APA don’t want democracy. Dialogue is not what coming up with “mental disorder” labels is all about. There is, for example, no No Mental Disorder Not Otherwise Specified category in the manual.

If stage one were field testing, stage two is quality control. Stage one a disaster, in his view; he sees quality control as the issue in a more recent post, Follow The Money, on these monetary difficulties lost to the DSM-5 revision process.

APA was faced with 2 choices: 1) go ahead with Stage 2 to clean up the mess; or 2) declare Stage 2 unnecessary and publish a poorly edited, unreliable, and untested DSM-5. APA chose the second option and is rushing toward a forced, premature birth of DSM-5.

Actually, as pointed out above, publication had been suspended earlier, and so this would entail suspending publication yet again. This suspension proposed by Allen Frances also begs the issue of the rising tab and the debt. If the DSM-5 revision has cost $25,000,000 already, continuing to haggle over the minutae and specifics of “mental disorder” labels is not going to bring this tab down.

Since there is no pressing need to publish the DSM-5 quickly, let’s follow the money. The APA budget depends heavily on the huge publishing profits generated by its DSM monopoly. APA needs the money badly. It is losing paying members; other sources of funding are also on a downward trend; and its budget projections require a big May 2013 injection of DSM-5 cash.

Is there a pressing need to publish the DSM-5 at all? Oh, yeah! The money! The patients? Well, they’re going to rot anyway, and so we might as well take advantage of them and their plight. What can they do?

As someone with a history of activism in the psychiatric survivor movement, I have objections to the DSM-I through 5. Our problem stems precisely from the fact that these psychiatrists, with their medical degrees, and their drug company ties, are putting professional interests ahead of their patients’ health. These medical doctors are putting their own standing above the health of their patients to the detriment of their patients’ health. Allen Frances, the retired psychiatry professor, is as guilty as any of them.

Allen Frances is playing a double game. If he has to settle for a shoddy product, to him it’s better than no product at all. This product could be “medicalizing normal”, as he puts it, right and left. This represents a glitch the next edition can potentially clear up. He can immediately start projecting his wishes onto a revision of the DSM-6. He may not be alive then, but his followers can continue to opt for a little more rigor in the revision efforts. I just don’t see how any amount of rigor is going to resolve the basic lack of real science you’ve got in the DSM. There is no real science involved in the selection of “disease” labels by committee.

We don’t really have a potentially bad edition of a good book going on here. We just have another bad edition of a bad book that was a bad idea to start with. The DSM should be scrapped altogether for other approaches that don’t owe so much to biological bias and drug industry profiteering. Lives are on the line, and as long as the current toxic paradigm, supported by the DSM, is in operation, more of those lives are going to be lost. The APA can find other ways to fund its nefarious activities. The DSM is basically fraud, but unfortunately it’s a fraud that it appears is going to continue for some time to come. Again, and emphatically, it should be scrapped entirely!