Psychiatrists split on whether to ditch DSM
How much do we really know about the causes of mental illness and how it should be treated? As Antony Funnell
reports, there’s a growing rift within the field of psychiatry over the
effectiveness of traditional mental health treatment, with some
practitioners declaring it’s time to throw out the diagnostic handbook
and start again from scratch.
There has long been a contradiction at the heart of psychiatry.
While
the profession is staffed with doctors (a medical degree being the very
basic prerequisite), psychiatrists have, over the past century or so,
shown very little interest in the discipline of biology. Although they
dispense medications, their system of diagnosis is unlike any other in
the field of medicine.
To understand the difference is to understand why psychiatry is currently experiencing a global schism.
As some people have said, the brain has not read the text. So
we really need to try to find alternative ways of conducting research to
take advantage of the explosion of knowledge that we're getting about
how the brain works.
Dr Gary Greenberg, psychotherapist and author
Led by the powerful US National Institute of Mental Health,
practitioners across the world are in open revolt, demanding that the
practice be brought into the modern world and be anchored not in
conjecture but in contemporary science.
‘There are many
practitioners, including psychiatrists, who wonder about the sanity and
the soundness of the enterprise in general,’ says Dr Gary Greenberg, a
practicing psychotherapist and trenchant critic.
The essential
problem with traditional psychiatric practice, according to its
detractors, is its over reliance on ‘symptom-based’ diagnosis. That is,
the diagnosis of psychiatric conditions based almost exclusively on
clinical observations.
Under the current system, a standard
consultation goes something like this: the psychiatrist talks with a
patient about his or her problems and then uses the substance of that
verbal exchange to identify the underlying cause of the patient’s mental
illness.
Then, in order to prescribe treatment, the symptoms
exhibited by the patient are matched to a set of pre-determined
psychiatric labels, for example depression or ADHD—attention deficit
hyperactivity disorder—and medication is dispensed accordingly.
Those labels—or ‘disorders’, as they’re known—are listed in a book called the
DSM, The Diagnostic and Statistical Manual of Mental Illness,
which is published by the American Psychiatric Association, and is
often referred to as the ‘psychiatrist’s Bible’. Though it’s an American
publication, it heavily influences the practice of psychiatry and
affiliated mental health professions around the world.
However,
critics charge that treating people according to their mental health
symptoms makes as much sense as a physician prescribing the same
medication to everyone with chest pain, regardless of whether that pain
is the result of heartburn, a simple muscle spasm or the beginnings of a
massive myocardial infarction.
In other words, it makes no sense
at all. The symptom doesn't necessarily tell you anything about the
specifics of the underlying cause.
‘The problem here is the
problem of the map and the terrain,’ says Dr Greenberg, author of
several books on psychiatric practice including
Manufacturing Depression and
The Book of Woe: The Making of the DSM and the Unmaking of Psychiatry.
‘The
DSM
is a map. The question is, is it mapping anything real? Or are the
people who are using it engaging in a kind of self-contained exercise,
not unlike, to be a little bit provocative about it, going down the
rabbit hole with Alice into an alternate reality.’
Dr Greenberg
and other critics are demanding a re-emphasis in psychiatry in favour of
a more biologically-based assessment procedure, having long accused the
authors of the
DSM of failing to appreciate developments in neuroscience and medical technology.
While
he says an increasing number of psychiatrists personally view the
manual with disdain—or even outright contempt—he says it continues to
have an ongoing influence over the profession and, crucially, over
mental health research.
‘In the US and around the world, who gets
treatment and who gets special services in schools and who gets special
treatment in the courts, and all sorts of really important policy
decisions and distributions of funds are made based on the
DSM,’ says Dr Greenberg.
‘So there's a disconnect between the extent to which the
DSM truly represents the reality of mental suffering on the one hand and the power that it has on the other.’
Read more: What happens when Asperger's no longer exists?
In
April 2013, Dr Greenberg and other detractors were given a decisive
boost to their reform campaign when the head of the National Institute
of Mental Health in the United States came out publicly against the
DSM and its symptom-based diagnostic approach.
‘Patients
with mental disorders deserve better,’ declared Thomas Insel, whose
organisation is the world’s largest funder of psychiatric research. He
then announced that the NIMH would begin redirecting its money toward
projects that involved a greater understanding of genetics and the use
of modern medical technologies.
‘All of the [current] diagnoses
are done according to presenting symptoms, but we increasingly know a
lot about genetics and neural circuits and we know that the symptoms
don't map very well onto those genetics and neural circuits,’ says
Professor Bruce Cuthbert, the director of the NIMH’s Division of Adult
Translational Research and Treatment Development. ‘So we are finding
that for research purposes, the
DSM is not serving us very well,’
‘As
some people have said, the brain has not read the text. So we really
need to try to find alternative ways of conducting research to take
advantage of the explosion of knowledge that we're getting about how the
brain works.’
The reason the current debate about the primacy of the
DSM is important is that for all the good psychiatry has done over the years, it's also been responsible for incredible harm.
Oxford psychiatric professor Tom Burns acknowledges as much in his newly released book
Our Necessary Shadow: The Nature and Meaning of Psychiatry,
taking readers back to some of the questionable, and arguably
unscientific, psychiatric practices of the recent past. Practices like
‘recovered memory’ and lobotomy.
It’s a desire to be more specific
about the cause of mental problems and thereby avoid mistreatments that
appears to be driving the current push against the
DSM.
Dr
Greenberg argues that a failure to anchor psychiatric disorders in
evidence-based research has led to the manipulation of diagnoses over
time in order to suit funding priorities, the demands of the big
pharmaceutical companies and social fashion. The most prominent example
of the latter being the psychiatric profession’s attitude toward
homosexuality.
‘Homosexuality is a special case in the sense that
the disorder pathologised what we now think of as a political problem,’
he says. ‘It turned it into a medical problem. I don't know that there
are too many of those. There are a few of them still in the
DSM
that may in subsequent years look like they were just an attempt to
diagnose dissent. But the larger question, whether or not we are going
to look back in 50 or 100 years and say, “Oh my God, what were those
people thinking”, I think they are going to think that about every
disorder in the
DSM, frankly.’
Another less political, but still controversial disorder, Asperger syndrome, has also come and gone from the
DSM
in recent decades as the fluid and open nature of psychiatric diagnosis
has changed. According to Professor Cuthbert, even prescribed disorders
that once looked more solid and promising are now beginning to fail
their purpose.
‘If you have depression, for instance, you can have
Anhedonia, which means you fail to find pleasure in your usual things,
you may have sleeping problems, eating problems, social withdrawal. You
may feel tense and jittery. All of these different things may have
different ways of expressing themselves in the brain. So trying to come
up with a treatment for depression is very difficult,’ he says. ‘It's
like saying, “well, we are going to fix your car without specifying
exactly which part of the car you're going to fix.”’
At Stanford
University in California, Assistant Professor Amit Etkin has been at the
forefront of efforts to begin building a more scientific basis for
psychiatric diagnoses.
Using what's called fMRI, or functional
magnetic resonance imagining, Dr Etkin has been working to measure the
activity of the brain and link it to particular behaviour.
‘Any
time when you think about somebody who has a mental illness, you have to
think about what is it that we are trying to do, what organ are we
trying to effect when we talk with them, when we give them medications.
Fundamentally, that organ is the brain,’ says Dr Etkin. ‘The MRI machine
takes pictures of the brain every two seconds or so, and from that you
can see what brain activity did at different points.’
While Etkin
is convinced that modern medical technology is the key to better
psychiatric practice, he says he understands why the profession has
taken so long to adapt. Because the brain, he points out, is an
extremely complicated organ and unlike any other in the human body. He
also acknowledges that even his own neuroscientific work is really only
at the beginning of a very long process of discovery.
Related: We need to talk about my big brother
However,
according to Dr Etkin, the future of psychiatry has no option but to
pursue a more
evidence-based diagnostic approach, because the
traditional approach, he says, has clearly run its course.
‘We are
no further along now than we were several decades ago. We don't have
any new treatments that dramatically decrease the morbidity and
mortality associated with psychiatric disorders. Medications have not
been created for any new targets in the past several decades. In fact,
those that we have created have really only been discovered by chance.
That is, serendipity revealed itself and somebody said, “well, maybe
this is useful for depression or schizophrenia.”’
‘So it has been a
gradual process of realising that there has to be another way. Any
ability we're going to have for new treatments is going to have to come
out of neuroscience.’
It seems some of that message is getting through.
In
2007, in an attempt to deal with already growing unrest within the
psychiatric community, the American Psychiatric Association announced an
extensive review of the
Diagnostic and Statistical Manual of Mental Disorders. It set up a review taskforce under the chairmanship of Professor David Kupfer from the University of Pittsburgh.
That taskforce led to the publication last May of the
DSM-5, the first major revision of the manual in 20 years.
‘Many
of us were in a sense picked, and I certainly was involved in picking
many people who were both clinicians and also, if you will,
neuroscientists,’ says Professor Kupfer, who uses the word ‘iterative’
to describe his new version. He says the manual will be modified in
future on a much more frequent and regular basis.
‘We've talked
about this as a living document, but it's living in the sense that we
believe that we would change parts of it where there is new science and
new clinical evidence to change it,’ he says. ‘What we want to do is to
set up a process by which perhaps every five years we might make
appropriate changes to improve the criteria so that diagnoses might be
more easily made. This is also an opportunity for us to include any of
the neuroscience findings that reach a level of reliability and
replication that they can help clinicians to make a more appropriate
diagnosis.’
However, he cautions against presuming that the
DSM will change dramatically any time soon.
‘What we've done is prepared
DSM-5 in a much more flexible framework than was available previously. Even in the one year since the
DSM-5
has been published, there have been a number of scientific advances in
autism and some of the other major disorders which I think are signals
to us that in a few years, as these advances get really tested
clinically, we will be able to make that first iteration of
DSM-5.1—something that incorporates more neuroscience than what we have now.’
So are the critics convinced?
‘In my mind
DSM-5 is really not much different than
DSM-4, in practice very few things have changed in the
DSM,’
replies Dr Etkin, while acknowledging that the manual is moving in what
he believes is the right direction. ‘It's probably not of no use, but
it's probably not the ultimate answer.’
Dr Greenberg, however, still has significant doubts. Claims that this new version of the
DSM is helping to move psychiatry toward a more rigorous scientific approach are dubious, he says.
‘Without
wanting to impugn the integrity of the people who make that claim, it
is a circumscribed claim about science, especially medical science. It
may be wrong for us laypeople to expect that scientists really know what
they're talking about, that they can point to the data. But I think we
do expect that, and there are many fields in which they can.’
‘In
psychiatry, the problem is that there is no external reference. No
psychiatrist will tell you that he or she thinks that the disorders
listed in the
DSM are valid. They will not claim that because
they know it's not true. Now, if you accept that you can create a
document full of disorders that are just convenient labels and you
define them well enough, then you can do science with that. There's no
question about that. You can do rigorous inquiry using statistics. But
that doesn't necessarily mean that at the end of the day you've proved
anything. You may have simply made an argument about something that
doesn't exist.’
‘So the problem isn't that they are sloppy or that
it's unscientific in that sense. The problem is that it isn't what we
expect science to do, which is to expose, reveal and understand the
bedrock reality of the world in which we live.’