Psychiatry’s Reformation?

By Neuroskeptic | May 9, 2013 3:41 pm

In a short blog post last week, Thomas Insel, director of the National Institute of Mental Health (NIMH), announced that the organization would be “re-orienting its research away from DSM categories.

After criticizing the fact that

Unlike our definitions of lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure… Patients with mental disorders deserve better.

Insel went on:

NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system…

This comes just weeks before the final publication of the latest edition of the American Psychiatric Association’s (APA) DSM – the notorious DSM-5.

In response to this, the APA released a statement saying, in essence, “Come back when you’ve actually done it; until then, we’ll carry on.”

What does this mean?

Well, you don’t need me to tell you. There’s been a lot written about this, some that’s good, much that’s not. A rule of thumb – if it mentions “paradigms” it’s probably the latter. For informed commentary, start out here, here and here.

In this post, rather than get into the details, I’d like to propose an analogy for NIMH’s move.

Some people have likened this to a ‘revolution’. In a previous draft of this post I toyed with the idea of a ‘civil war’ or a ‘coup’. But none of those really fit.

Rather I think that this ought to be seen as a Reformation, as in Protestant. Hey, we’re almost at the 500 year anniversary of the ‘post’ that started the last one.

We have an old, hegemonic institution, once revered but increasingly regarded as sclerotic – the DSM system / Catholic Church. This institution is, in theory, the one true embodiment of an idea – biological psychiatry / Christianity. But along comes a critic who believe in the idea, perhaps more fervently than ever, but want to reform the institution that they believe has failed its mission – Thomas Insel / Martin Luther.

Note that in this model, the DSM is the Church, not the Bible. Although a lot of people call it ‘The Bible of Psychiatry’, this ascribes to the DSM too creative a role. All the DSM does is codify and elaborate on a much older set of ideas. You can find the roots of most DSM diagnoses in psychiatry textbooks from decades before it was written. The DSM is more like the Catechism of psychiatry. The RDoC is a rival one.

This is why it’s wrong to see this as a paradigm shift. The NIMH proposals don’t mean a revolution in either research or treatment. Although researchers applying for NIMH grants will have to adapt the language of their pitches, framing it in terms of domains rather than disorders, I suspect that what they do with the money will be much the same.

Catholics and Protestants make much of their differences but to the rest of the world, they’re all Christians.

  • lissanna

    Problem with developmental disorder research is that you aren’t often going to have deficits that are specific to any one domain (so, you end up with 20 different “specific” deficits in the same child that people wouldn’t examine if they are related or not if you can only ever look in one domain bin at a time). So, individuals with autism may have both social and language deficits. Looking at any one of those domains in isolation (and discounting any other domain) also leaves you with a picture that is almost useless to work with. In fact, psychology studying typical development has been carving up the mind into those same RDOC bins for many, many years and haven’t found any better answers than the disorder research using DSM or other disorder criteria systems. So, it’s equally possible for the RDOC to turn out to not be any better of an approach if 100 different causes could lead to the same “disorder” deficits under RDOC criteria. Telling parents that their child has problems with (totally hypothetical) RDOC domains 1,3,6,9,43,21 isn’t any more helpful than giving that symptom cluster a name and calling it “Neuroskeptic disorder” for example. The RDOC doesn’t necessarily end up being any better than the system we have now if our tools aren’t actually good enough to measure the 100 different causes that could lead to the same domain problems, and for knowledge of that cause to have a treatment impact. In fact, in many cases, the neural, genetic, and “biological” data only provides information about risk for depression, and not about whether you are likely to commit suicide tomorrow and should be hospitalized. There’s still some useful information about having diagnostic labels and clinical judgement to know if some risk factor is actually causing problems in your everyday life.

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  • Frank Blankenship

    Reformation is a strong word, but you’ve got the right idea when you connect biological psychiatry with religion. The real conflict is between biological psychiatry and other approaches to mental health care that don’t lay it all on biology. Psychologists, for instance, have taken over the job of psychoanalysis, or talk therapy, from psychiatrists. Neither the APA nor the NIMH think psychoanalysis is scientific. Both think biological psychiatry is scientific, not because it is scientific, but because it increases the clout of psychiatrists. Assuming that a great rift exists between the APA and the NIMH would be presumptuous. The two are in cahoots. The NIMH just took advantage of an opportunity to change the game plan. The real rift is between proponents of biological psychiatry and proponents of other approaches emphasizing the role of society and the environment. Skepticism of biological psychiatry, well, you won’t get it from its proponents, and those proponents are found in abundance in both the APA and the NIMH..

    • Neuroskeptic

      Yes, that’s what I mean. This is an internal debate/power struggle over (to outsiders) the fine details.

  • psycritic

    How about this for a crazy analogy: Instead of invoking religion, let’s talk science. Biological psychiatry is the Milky Way galaxy, while psychiatry that includes consideration of social, cultural, and family factors is the entire universe. DSM is like the Aristotelian view of the universe, while RDoC is like Galileo’s view of the universe, which is better and more accurate, but still missing quite a bit (namely, other galaxies outside our own).

  • petrossa

    What’s lacking is any kind of way to measure outcome of treatment in any kind of objective way. Most of all in psychology, because that’s impossible to separate out from placebo it being a placebo in itself. As a profession it’s therefor the same as homeopath. Both offer no credible proof of effectiveness.

    Taking that as starting point working a backwards it follows that the basic tents supporting it are wrong/inaccurate/false. Where we arrive at diagnostic manuals. As stated, they are a bunch of circular logic criteria based on age old observational studies and as such completely beyond any from of scientific examination.

    Psychiatry is the same, also based on the same manuals, with as difference that it has a vast array of symptom suppressing medications at hand making it seem like treatment works since the symptoms are less evident.

    Both are incapable to cure any serious mental disorder. The broken bone equivalent that’s curable, but anything more complex is a toss of the dice and mostly depends on sheer luck to actually diagnose a disorder with some kind of accuracy. Which doesn’t mean the patient actually has the disorder, it only means they arrive at properly matching symptoms with one of the various random disorders in the manuals.

    In other words, psychiatry/psychology is a mess. A quack profession based on insubstantial successes for over a century now.

    • NuBN247

      I disagree as the bedrock of science is observation, i.e., if I do A and B consistently does C happen. The Egyptians observing the stars gave us an astrological chart and was it not Newton’s observation of a falling apple that led to his body of work on gravity and motion? What is broken bone triage if not observation and making an educated guess? While not perfectly precise the DSM is indeed an educated guess and most certainly has value. While psychiatry does have a way to go in locating biological markers and indicators in the brain there have been gains that hopefully will continue. Meanwhile, the observation of symptoms offers a way to provide assistance to someone who would otherwise go untreated.

      • petrossa

        By sheer coincidence i read this today from the British Division of Clinical Psychology:

        The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently,there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model

        Seems they agree with me

        • NuBN247

          By sheer coincidenfce I read this article today referencing a joint statement by NIMH and the APA publicly affirming the necessity and viability of the DSM.

          Seems they agree with me.

          • petrossa

            Seems they are just as ill advised as you are. That APA and NIMH support fully DSM is not very surprising since their members livelihood depend on it. i think i’ll go for the less biased viewpoint.

          • NuBN247

            Changing the goalposts does not change the fact that the DSM remains a viable document.

          • petrossa

            For later study by amazed historians that a book existed which only purpose was to label people for pill-distribution and health care insurers. That it was impossible to determine if the labeling had any positive effect for the patients involved since the only way to determine if there was an improvement was using the same book making an objective assessment impossible. It is meaningless if one has a book with labels and tests based upon the unscientific unproven assumptions those labels represented were in any way, shape or form a valid collection of descriptions. Astrology also has those kind of books, and is even more ‘scientific’ since at least there is a calculation system at it’s base which guarantees it is repeatable. What it has in common with DSM et al is that the basic premises are just as moronic.

          • NuBN247

            Medical doctors are amazed today that bleeding a patient was considered to be an effective treatment. In fact, one of the things that killed Lincoln besides being shot was the physicians who kept sticking the filthy fingers into the wound, a fact that amazes us today. There were maps once labeled “there be dragons” and many of the dinosaurs were mislabeled. My point being people worked with what they had at the time and, in most cases, it served them well. To say the DSM would be laughed at 200 years from now is to say they will still be driving the same Ford truck of today and only psychiatry will have changed. I’m sure that doesn’t make sense even to you.

          • petrossa

            I rest my case:

            Just two weeks before DSM-5 is due to appear, the National Institute of Mental Health, the world’s largest funding agency for research into mental health, has indicated that it is withdrawing support for the manual.

            In a humiliating blow to the American Psychiatric Association, Thomas R. Insel, M.D., Director of the NIMH, made clear the agency would no longer fund research projects that rely exclusively on DSM criteria.

  • Phillip Alday

    The comparison to AIDS is especially interesting: the ‘S’ stands for ‘syndrome’ and comes from a time when AIDS was defined as a cluster of symptoms with unknown aetiology. Only later did we begin to define AIDS as ‘symptomatic HIV infection’.

  • Pedro Oliveira

    “Catholics and Protestants make much of their differences but to the rest of the world, they’re all Christians.” What rest of the world?

  • toostoned tocare

    Ha! Have you ever read ‘The Manufacture of Madness’ by the late great Thomas Szasz?

    • Neuroskeptic

      You mean the Quran, in this analogy?

      • toostoned tocare

        I have read both. Have you?

        • toostoned tocare

          btw… Thomas Szasz supports your view in this piece.

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  • toostoned tocare

    Szasz vindicated! Psychiatrists are becoming anti-psychiatrists!

  • Indigo Rhythms

    I think this is a good thing since many disorders in the DSM seem questionable. On the other hand there are disorders in Neurology, such as migraine, which aren’t diagnosed from labs and are still accepted as valid disorders. I think psychiatric diagnosis are questioned more due to the fact that many people are threatened by the field.

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  • George

    Freud was a quack and any movement away from his ideas is in a positive direction.

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About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.


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