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.