RIP Diagnostic Psychiatry: My Take on an Edge Question
Several months ago, I began doing pieces based on Edge questions. Edge, which bills itself as an online salon, annually asks a provocative question of leading scientists and writers and the like. The answers are published as a series of books.
You can find my three previous bipolar takes to the following questions by clicking the links below:
New question: What Scientific Idea Is Ready for Retirement?
It took all of 1.3 nanoseconds for “diagnostic psychiatry” to pop out. Once you read my explanation, you will wonder why it took me so long.
You have diagnostic psychiatry to thank for your current “bipolar” label. But one day in the future, based on a lab assay, your doctor may tell you instead that your brain suffers a failure to process the compound glycine, and write a prescription to address that shortcoming.
Or, based on a gene scan, your doctor may inform you that you have a genetic vulnerability to stress, and focus on therapies based on how to better respond to the challenges of your environment.
I am painting an extremely simplistic version of the future, but my point is this: Once we acquire the ability to open up the hood and look inside and fix some of what is going on, the game will change entirely. “Bipolar disorder” will only survive as a descriptive term, not an illness. Likewise for “depression” and “anxiety” and “schizophrenia” and most of the rest.
The experts describe bipolar disorder and depression and other psychiatric conditions as “multifactorial and heterogenous.” In other words, what we call bipolar is a combination of many possible causes, each cause of small effect.
Thus, even though my outward symptoms may somewhat resemble your outward symptoms, something very biologically different may be going on inside. This is the best explanation for why there is no one-size-fits-all treatment for bipolar or depression.
What is good for you may not work for me. Worse, what is good for you may be a disaster for me. Compare this sorry state of affairs to “physical” medicine:
Back in 1971, during the Apollo 15 moon landing, ground controllers in Houston picked up anomalous EKG readings from astronaut Jim Irwin. After communicating with Irwin, the flight surgeon at Mission Control diagnosed a specific type of heart arrhythmia known as bigeminy.
As it turned out, the oxygen-rich, zero-gravity command module amounted to better treatment than any ICU on earth. Irwin’s heart soon settled back to normal.
So: Way back, four decades ago, a doctor on the ground was able to accurately diagnose a heart condition and recommend treatment in an astronaut floating around the moon 240,000 miles away.
Compare that to the manifold uncertainties of a face-to-face psychiatric visit today. We are a long way from catching up to 1971.
It would be tempting to end this piece right here, but then I would be telling only half the story. Those who oppose psychiatry are quick to point out the field’s inability to link biological cause to effect. But in the process, they miss a few key nuances.
We know, for instance, how absurd it would be for doctors to treat both viral and bacterial infections as “runny nose disease.” Yet runny noses do exist. Ergo Kleenex.
The triumph of diagnostic psychiatry over the twentieth century has been to distinguish various types of runny nose conditions from each each other (such as bipolar from schizophrenia) and to give doctors and patients more to go on than “insanity” and “psychosis” and “neurosis.”
In this context, the DSM-III of 1980 was a breakthrough. For the first time, in one definitive manual, we had something approaching a rough diagnostic guide.
Fast-forward to the DSM-5 of 2013, which is sitting on my desk, along with its (not so) immediate predecessor, the DSM-IV-TR of 1994 (the TR stands for some strictly textual revisions from 2000). Aside from the different color covers, the two could almost pass as identical manuals.
Likewise, there is little to distinguish the DSM-IV from its two predecessors, the DSM-III-R of 1987 and the landmark DSM-III of 1980.
In the interim, we have had more than three decades of cellular and molecular biology, brain scans, genomic mapping, cognitive psychology, and more, not to mention new insights into old approaches.
The authors of the DSM-5 clearly understood this. But they also knew that we’re at least a decade away from any definitive explanations. And they were extremely mindful of the dangers in trying to serve up answers based on evidence that is not there yet.
In the meantime, they had a publishing deadline. The result was a DSM dead on arrival.
In his NIMH Director’s Blog of April 29, 2013, Thomas Insel took the words out of everyone’s mouth - psychiatrist and antipsychiatrist, alike - by characterizing the DSM as a “dictionary” rather than a “bible,” with “not any objective laboratory measure,” and that “patients deserve better.”
In the same blog post, Dr Insel announced an NIMH initiative to “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.”
If I were the betting type, I would be placing my money on the virtual certainty that there will be no DSM-6. To sum up:
Let’s credit diagnostic psychiatry for how much it has improved our understanding of mental illness, but also let’s acknowledge that, in its present form, it has far outlived its sell-by date. Diagnostic psychiatry as we know it is a scientific idea long overdue for retirement.