Psychology/Psychiatry

Experts Say 'Psychiatry's Guide Is Out of Touch With Science.' What Science?

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APA

With the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) scheduled to be published later this month, a story in today's New York Times quotes experts who think "Psychiatry's Guide Is Out of Touch With Science" (as the headline puts it). No less an authority than Thomas Insel, director of the National Institute of Mental Health (NIMH), complains that the DSM continues to suffer from a "lack of validity." In other words, we cannot be confident that psychiatry's bible, on which mental health professionals rely every day to diagnose patients and (not incidentally) get paid by medical insurers, identifies things that actually exist. That's a pretty big problem.

Broad Institute neuroscientist Steven Hyman, a former NIMH director, says the DSM's symptom-based taxonomy is "an absolute scientific nightmare." The NIMH is "reorienting its research away from DSM categories" because "patients with mental disorders deserve better," Insel recently explained on the institute's blog. "As long as the research community takes the DSM to be a bible," he tells the Times, "we'll never make progress."

What does Insel mean by "progress"? Or to put it another way, what is the "science" with which experts think the DSM should be in touch? The Times explains that critics like Insel and Hyman hope "the science of psychiatry [will] follow the direction of cancer research, which is moving from classifying tumors by where they occur in the body to characterizing them by their genetic and molecular signatures." I think they've skipped a step. While oncologists deal with objectively verifiable tumors, psychiatrists deal with hypothetical disorders identified by patterns of behavior. If those symptoms correspond to a biological abnormality, it is not one that can be verified by physical testing or examination. Shouldn't psychiatrists locate their "tumors" before investigating what causes them?

So far the search for the biological basis of mental illnesses has met with little success. University of Pittsburgh psychiatrist David Kupfer, who chaired the panel that produced the DSM-5, explains that the new edition does not incorporate the diagnostic insights gained from such research because there are none. "The problem that we've had in dealing with the data that we've had over the five to 10 years since we began the revision process," he tells the Times, "is a failure of our neuroscience and biology to give us the level of diagnostic criteria, a level of sensitivity and specificity that we would be able to introduce into the diagnostic manual." Or as the Times puts it:

Basic research into the biology of mental disorders and treatment has stalled, [DSM critics] say, confounded by the labyrinth of the brain.

Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions. Genetic glitches that appear to increase the risk of schizophrenia in one person may predispose others to autism-like symptoms, or bipolar disorder. The mechanisms of the field's most commonly used drugs—antidepressants like Prozac, and antipsychosis medications like Zyprexa—have revealed nothing about the causes of those disorders. And major drugmakers have scaled back psychiatric drug development, having virtually no new biological "targets" to shoot for.

So the choice is between muddling along with the same symptom-based approach that has prevailed since the first edition of the DSM in 1952, with no way to know whether patients given the same label have the same underlying problem, and trusting in a supposedly more rigorous biological approach that so far has done nothing to improve diagnosis. Such is "the science of psychiatry." 

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  1. That’s just plain nuts.

    1. Most of the voices in my head disagree.

    2. my best friend’s step-mother makes $84/hr on the laptop. She has been without work for 9 months but last month her income was $20795 just working on the laptop for a few hours. Read more on this site…. http://WWW.DAZ7.COM

      1. Your friends stepmother is a regular fucking neuroscientist.

    3. Don’t forget, psychiatry was a GREAT tool for the Soviet Union? You are UNHAPPY in the Worker’s Paradise, you say?!?!? Off to the shrink bin with YOU, you sicko you!!! We dare NOT call it political prison, because we are FAR more SCIENTIFIC about it these days! Are we so far removed from that today here in the USA? I’m not sure? Maybe the shrinks can wring some more money out of STUDYING that whole question, totally scientifically of course, no politics involved here at all? When studying such issues, please keep in mind, only credentialed shrinks need apply, no peons allowed?

  2. It’s a convoluted pile of electro-chemical jelly. I’m surprised it does anything at all.

    1. Brain? Brain? What is brain?

        1. Dr. Michael Hfuhruhurr, is that you?

          1. Go away, I’m doing science.

            1. “Ladies and gentlemen, I can envision a day when the brains of brilliant men can be kept alive in the bodies of dumb people.”

              1. “I don’t know. I’ve always just loved to kill. I really enjoyed it. But then I got famous, and – it’s just too hard for me. And so many witnesses. I mean, *everybody* recognized me. I couldn’t even lurk anymore. I’d hear, “Who’s that lurking over there? Isn’t that Merv Griffin?” So I came to Europe to kill. And it’s really worked out very well for me.”

  3. What chapter tells doctors which patients should be stripped of their 2nd Amendment rights?

    1. It’s in the Foreward.

  4. I’ve heard that NIMH has a secret.

    1. Nicodemus knows.

      1. “Move your house to the lee of the authoritarian dictatorship”

      2. You know, if I recall, the movie wasn’t half bad. It could never live up to the book but at least it wasn’t the abortion that The Black Cauldron was.

        1. All I remember is that some parts were scary as fuck for a nine year old.

        2. I’ve watched it probably a dozen or two times this year after getting it for my kids. It is pretty good. The bad guy is a reactionary who opposes change, so that’s something. It does have a bit of an anti-animal testing vibe too though.

    2. I’ve heard that NIMH has a secret.

      Eric Idle voicing an Evil Mouse who wants to take over the world?

  5. more medicine chemicals for everyone!
    http://www.nybooks.com/article…..tion=false

    I believe this link was from another Reason article – but it is worth reading.

  6. It’s hard to believe that a group of people with mental health problems would get into the mental health field and then not be able to agree on what mental health looks like.

    1. 80% of the women I’ve dated are crazy, and 80% have been psychology majors. It’s not a perfect correlation, but it’s there.

      1. You should have married the hottest of the .

  7. The problem is that outside the really extreme destructive behaviors, most “illness” is just whatever is out of fashion at that time. Cross dressing was once an illness. Then cross dressers managed to get society to accept them more and now it is not an illness. What “science” drove the removal of cross dressing and homosexuality from the manual? None I can see. The only thing that changed was societal views on the behaviors.

    I am coming to the conclusion that beyond strict neuroscience which explains the physical functioning of the brain, all other study of human behavior needs to be sent back to the philosophy and ethics department and stop being called science. If we want to have a debate on whether cross dressers are good people, that is fine with me. But we shouldn’t be calling that debate “science”.

    1. the science is settled, dammit!

      1. According to Tony you can just let all the scientists vote on it, and the majority is correct. Past evidence notwithstanding.

        1. Well, yeah, of course!

          After all, the scientific method is like this:

          – Hypothesis
          – Consensus

          – Confiscate PROFIT!!!!

          /prog

    2. You’re right.

      They HAVE to make case by case judgments concerning when the patient is right and when society is right.

      That ethics, baby dolls.

    3. Then cross dressers managed to get society to accept them more and now it is not an illness. What “science” drove the removal of cross dressing and homosexuality from the manual?

      I’ll tell you what, wearing that top with those shoes IS a mental illness.

      *snap snap*

    4. John is right. There was, IIRC, a weak sauce argument about how they’d “studied” homosexuality and found it wasn’t destructive as previously believed, but it all comes down to them acting as a rubber stamp for society’s views.

      These people wield a truly dangerous amount of power with no accountability and no objective justification of their views.

      You know who else wielded…

      1. They bowed to political pressure, which in that case was fine. Homosexuality should have never been considered a mental illness in the first place. But the scary thing is that it just showed these “illnesses” are driven by societal mores instead of science. If whether homosexuality is an “illness” depends on popular opinion, then what else can be an “illness” if society decides it doesn’t like it?

        1. That’s easy:Tobacco use.

    5. You’re neglecting conditions that don’t cause extremely disruptive behaviors, but do wreck the life of the person with them. I don’t know how things are right now, though I don’t think it’s changed much, but when I studied it in the late 1970s it was mostly about conditions that have such patterns of complaints that even a cursory examination would drive most observers to conclude that something physiologic is wrong with the person, because no degree of simply being “wrong” would cause such patterns. It defies just about anyone’s intuition that those complaints could be produced merely by subjecting persons to experiences.

      The complaints I’m referring to are not things like cross dressing or homosexuality. Those are just matters of people liking certain things that most people don’t like. I’m referring to conditions like major depression, wherein someone has no reason based on life conditions to be so unmotivated and anhedonic; mania, wherein people likewise have no reason to be so enthusiastic; hallucinations that are frequent and at least distracting, if not disturbing; being stuck like a wax figure; or stuck in cycles of thinking about and doing trivial things so repeatedly they can’t do or think about anything else. These are not matters of merely being unconventional, nor of being threats to others.

  8. Welcome to the world of credentialed idiots.

    1. Engaged in cargo cults.

      1. That is insulting to actual cargo cultists.

    2. Not cargo cults, John. Shameless and transparent gate-keeping. And very well-paid, too.

      Also, ask ’em about their success rates and watch ’em squirm.

  9. What are you treating and what is the goal of your treatment?

    They can’t even answer THOSE questions.

    1. Oh, they know the goal.

    2. To answer those they would have to decide what behavior is bad and needs to be eliminated. Now, that is not to say there isn’t such a thing as mental illness. There are people in hospital right now who if given the opportunity would stick a pencil up their penis and break it off. There are people who are literally driven mad by voices inside their head.

      Of course psychiatry has no clue what to do with those people. And no one has since the beginning of time. We have made some progress in developing drugs that brings those people somewhat back to reality. But those drugs have huge side effects and the person has to be aware enough to want to take them.

      Those few extreme cases don’t justify the existence of such a big field. So what they have done is expanded into distasteful or dumb or moderately destructive behaviors and called them “illnesses”. The damned manual is huge. And with regard to those things, they really have no idea what these behaviors are much less how to change them.

      1. Oh, OK, then never mind what I wrote in response to what you’d written above that. You know the same that I do.

    3. Speaking about mental illness in a broad sense, probably impossible to answer.

      Speaking about a few specific conditions, (and a much more narrow set than the expanded DSM-V details) is going to be easier.

      1. Easier but still not easy. When I studied it, we didn’t use DSM either for most things. We were taught the Research Diagnostic Criteria (which relative to DSM3, put more patients into the categories of affective disorders and fewer into schizophrenia), and most psychiatrists were just winging it. It’s a lot easier to figure out that someone who sits glumly in a chair all day and doesn’t get up even to go to the bathroom but keeps swatting at insects that aren’t there and won’t talk enough for you to figure out his thought patterns has some psychiatric condition than it is to decide which condition it is.

  10. If those symptoms correspond to a biological abnormality, it is not one that can be verified by physical testing or examination.

    Citation needed, unless you’re going to insert “currently” in there somewhere.

    1. But what is a biological abnormality? At most you can have a statistical normality,

      1. Statistical abnormality on what measure?

      2. I think it would be something like a tumor in your brain that was affecting your behavior. Or maybe you had a stroke and your brain functions changed and that caused a change in your personality. That is the only thing I can think of.

        1. A pure genetic marker would be a start, and in (for instance) the case of Schizoaffective disorder, or even something like tourette’s, a clear genetic marker has not been found, but twin studies indicate a genetic component.

          Puzzling, to be sure.

      3. But what is a biological abnormality?

        IN regards to mental illness only?

    2. In addition, people need to be careful to not make the same mistake the creators of the DSM volumes have made: Lumping a bunch of behaviors in an attempt to diminish earnest scientific study in the realm of mental health.

      The field of mental health is, alas a collossal mess, and precisely because it’s difficult to ascertain physiology to a large number of mental disorders, politics creeps its way in and screws things up further.

      There are reams of good science in the realm of twin-studies with regards to some of the most severe conditions which indicate a physiological basis– even though a precise marker hasn’t yet been found.

  11. While oncologists deal with objectively verifiable tumors, psychiatrists deal with hypothetical disorders identified by patterns of behavior. If those symptoms correspond to a biological abnormality, it is not one that can be verified by physical testing or examination. Shouldn’t psychiatrists locate their “tumors” before investigating what causes them?

    I think a better analogy would be heart arrhythmia. It’s obvious that something is objectively going wrong with the organ, but it’s often very hard to pin down exactly what the biological cause of it is.

    1. That is a good way to put it.

      1. Except for mental illness not showing up on objective diagnostic tests so the analogy totally fails.

  12. I work at a place that requires me to review people’s medical records. What always shocks me is that, when a person goes to multiple psychologists, they all have a different diagnosis. One says they have bipolar disorder. Another says they are depressed. Another thinks they have adjustment disorder. After I started seeing how the supposed experts couldn’t decide upon what “disorder” the people had, I became suspicious of the whole thing.

    Contrast this with normal physical doctors who can run a test and say “this person had cancer” or “this person has a heart blockage”

    1. But they all agreed something was wrong with the person. So it’s not as if the problem were imagined, just that people can’t figure out what’s wrong.

    2. But they all agreed something was wrong with the person. So it’s not as if the problem were imagined, just that people can’t figure out what’s wrong.

      1. So they’d be on firmer ground if they just collapsed the DSM into three categories: “Weirdo”, “Nutjob”, and “Fuckin’ psycho”

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