Psychiatry in the shadow of DSM-5
When the pressures of modern society become too great for a person, when one’s chemical dynamic becomes such that they are unbalanced, that they cease painting within the lines, they come to us. These are the people that society would prefer just go away — the shadow people. The shadow people that project upon us their shadow and remind us just how tenuous mental health is. Our worst fears. They remind us how easy it can be to slip.
—Dr Robert Banger, M.D., fictional state hospital psychiatrist on the TV show Wonderland (2000)
As an update to the previous Left Flank post on psychiatry, here are two things I have written about the Annual Meeting of the American Psychiatric Association last month.
The first is a blog post for local industry magazine Psychiatry Update on the conference itself, and the second is a more general op-ed about DSM-5 that the Sydney Morning Herald commissioned and got me to update but then didn’t run. There’s a little warning in there from Al Frances about the Gillard government’s decision to go further down the path of Headspace “early intervention” services (which are being farmed out to the NGO sector rather than being directly government run).
Politics vs psychiatry at APA 2013
APA annual meetings can be hard to pin down, attracting over 10,000 participants to hundreds of sessions over five days. This year’s event should have been more unified for the debut of the DSM-5, but it was soon clear that controversies surrounding the revision had taken their toll.
Rather than scientific triumphalism there was self-congratulation for simply having survived the process, and a mixture of anger and hurt that NIMH had effectively ditched the DSM.
Oft-repeated claims that DSM-5 is a “work in progress” and a “living document” may be honest but such uncertainty will not help the profession’s authority problem. DSM-5’s critic-in-chief Al Frances also impacted on the meeting in absentia, with a number of speakers taking time to snipe at him from the podium.
Perhaps surprisingly, the bipolar workgroup actually delivered tighter definitions; it is now harder to meet criteria for mania or hypomania.
But the new “Section III” of DSM-5, a netherworld of “to be further studied” diagnoses promises to be the source of future controversies. It reflects how the DSM’s creators have been unable to validate many new entities – such as “attenuated psychosis syndrome” – yet are unwilling to make tough decisiona to reject unproven pet projects.
In a revealing speech, psychosis workgroup head Will Carpenter outlined how DSM-III Schizophrenia had utterly failed to deliver therapeutic advances, yet then made a series of tendentious assertions about early intervention that even enthusiasts like Pat McGorry would have trouble backing. It seemed more than a little desperate – a triumph of hope over evidence at a time when lack of evidence has cruelled ambitions for diagnostic advance.
The meeting also offered sessions on dissident views. The APA Radical Caucus ran two well-attended sessions with the UK Critical Psychiatry Network. An entire session was devoted to deconstructing the child bipolar epidemic, although child bipolar guru Joe Biederman still got a couple of plenaries to peddle his mantra despite his tainted record. And the debate over drug treatment in borderline personality was given a full airing.
David Healy delivered a bravura critique of evidence-based medicine as part of a closing session on antidepressant efficacy organized by Nassir Ghaemi. Ghaemi has become critical of the political nature of “Major Depression” and wants to see it broken up (with recognition of melancholia, etc.). DSM-5 co-head Darryl Regier responded from the floor by admitting he’d hoped to make it more “scientific” but politics made that impossible.
Maybe, then, that was the unifying theme: how politics frustrates psychiatric ambition. It was therefore fitting that a politician, Bill Clinton, was keynote speaker. And that he pulled out of physically attending for health reasons, another small disappointment for the APA.
DSM-5 failure shows need for psychiatric humility
Even before it was launched at the annual meeting of the American Psychiatric Association (APA) at the weekend, the latest edition of United States psychiatry’s diagnostic “bible” — the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) — was under fire from all sides.
In late April the leading US psychiatric research body, the National Institute of Mental Health (NIMH), announced it was “re-orienting its research away from DSM categories”. Since 1980 DSM diagnoses have revolved around symptom checklists and been largely silent as to underlying causes. NIMH director Thomas Insel is disappointed that DSM-5 has not gone far enough in redefining mental disorders as “biological disorders involving brain circuits”.
Ironically this is what DSM-5 was supposed to do, yet was impeded by a sheer lack of neuroscientific evidence to support such claims. In pushing for even more biological reductionism the NIMH, like Samuel Beckett, may simply be calling on psychiatrists to “Try again. Fail again. Fail better.”
At the opposite end of the spectrum, the British Psychological Society’s Division of Clinical Psychology (DCP) is calling for a “paradigm shift” in diagnosis — away from a biomedical “disease” model towards a psychosocial one, although clear evidence for such a move is also still in short supply.
Controversy has dogged the DSM revision process almost from the start. Professor Allen Frances — the psychiatrist who coordinated DSM-IV — has campaigned against DSM-5, arguing that many of its changes will cause harm, including by reclassifying normal human emotions and behaviours as disorders. For example, in DSM-5 sadness following bereavement can be labeled “Major Depression”. On the other hand, the incorporation of Asperger’s Disorder into the more tightly defined “Autism Spectrum Disorder” has raised fears that some sufferers will lose access to services.
Such criticisms occur in the context of a lack of transparency in the rewriting process, scandals involving leading psychiatrists and drug company dollars, public concern about overmedication (especially of children), and growing evidence of the limited effectiveness of top-selling medications such as modern antidepressants.
At the APA meeting inflated claims about DSM-5 have been replaced by a more modest tone and occasional defensiveness. Many of the problematic changes have been downsized by political reality. For example, the contentious plan to label the risk of psychosis as a disorder in its own right has been relegated to a subsidiary section. Frances told me this week he sees this as an instance where the “cause of DSM-5 failure was its grand, but terribly premature, ambition to further the cause of preventive psychiatry” — an unproven early intervention model he notes is still being rolled out by the Australian government.
In my view those, like Frances, who call for DSM-5 changes to be ignored or used with extreme caution are correct. But I would frame the problem more broadly to consider the impasse of the dominant neurobiological paradigm in psychiatry. That paradigm’s deficiency lies not in its recognition of biological factors in mental illness — such factors are clearly important — but in its claim that psychiatry can be a value-free brain science when dealing problems that are clearly value-laden and thoroughly embedded in social realities.
Rather than rush to find a new paradigm to rescue its authority, it would be more profitable for my profession to reflect more critically on its important social role. It is no coincidence that psychiatry’s institutional power and business model are viewed with suspicion in an era where other institutions and corporate interests are increasingly being scrutinized.
If we’re to avoid repeating mistakes, new paradigms will have to be built not from above by expert committees, but from below through the struggles of patients and clinicians for a mental health system driven by quite different social priorities. And it will require patience and humility that has not always characterised psychiatric debates.
Hi Dr_Tad,
Most of my learning has been in the field of philosophy, vastly ignorant of psychiatry (sadly, though how I would love to remedy that), and reading this sentence:
“in its claim that psychiatry can be a value-free brain science when dealing problems that are clearly value-laden and thoroughly embedded in social realities.”
I’m wondering in what sense “value-free” is meant? What follows seems to suggest the kind of valuations a human being necessarily engages in by virtue of occupying a first-person perspective on their own life? So to take an example, you talk about sadness following bereavement. “Valuations we necessarily make from a first-person perspective on our own life”: my life partner is very important to me losing them is a devastating blow. Does the reductionist (who I guess we’re talking about) claim that kind of valuation has nothing to do with the “Major Depression” – i.e. it’s just a faulty brain, sort of thing?
Hi Tim
When I talk about “value-free” I’m referring to scientific positivism, which in psychiatry expresses itself in attempts to model the discipline on what is presumed to be the approach found in the natural sciences. That usually means some kind of biological reductionism that strips mental disorders of human/social meanings. So the NIMH states that diagnostic criteria it wants to develop will be based on premises (which it considers essentially proven) such as “mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior”.
For me this misses two things: (1) That the best scientific explanations of causation of mental disorders is not necessarily done with a reductionist framework of this sort, and (2) that the very decision that some entity is “healthy” or “disordered” is itself a socially-constructed meaning, and hence the product of social struggles over meaning.
Thanks, Dr_Tad.
Positivism sounds like the dominant philosophical perspective in psychiatry – I wonder to what extent that flows from a preference for “value-free” explanations because of positivist fears of “values” as merely subjective and therefore “unscientific” – as opposed to a preference for reduction on other grounds more properly considered to be “scientific merit”?
This post particularly took my interest because, in my view, one of the most important areas of philosophy considers the role (or rather curious absence of) values in inquiry, especially given the (apparent) dominant influence of positivism – at best a philosophical program with many crucial problems which is far from universally accepted. I dunno if you’re familiar with it, but Hilary Putnam’s work in this area, and in particular his book “The Collapse of the Fact/Value Dichotomy” is highly recommendable. I’ve found his arguments useful in making the case for values – one time I had a professor of logic, fairly internationally renowned, couldn’t quite respond to what I was saying – “there MUST be something wrong with that, but I just can’t see what it is.” I’m still grappling with it all, but it’s fertile stuff.
If it sounds interesting, here’s an extremely brief attempt to summarise Putnam’s perspective. Values are judicious evaluations of what’s “good” by way of whatever it is you’re doing, be that discovering knowledge (epistemic values), living in a community with others (moral or political values), or making art (aesthetic values). Done objectively, the evaluation refers to the objective features of what’s being studied, and in this way reality can refine standards of judgment and science can progress; when done subjectively, the evaluation might refer to simple matters of taste – e.g., “I just like the blue one”, and inquiry’s likely to get stuck in the mud (“fail again, fail better”?). Seen in this way, “objective” science, and even physics (positivism’s great pet), involve epistemic evaluative judgments top to bottom. (Putnam himself claims to have made these observations to a room full of hundreds of Nobel winners, with no complaint). If these judgments are of a similar kind, then arguing against “values” as such threatens to prove too much against science and, e.g., render theory selection in physics an exercise wherein scientists merely express their subjective preference for one theory and not another, e.g., “I just like the one which doesn’t overthrow the paradigm in which I’ve been professionally invested for the past 40 years :)”
Then I guess there’s the political aspect of admitting values – we don’t like to think of experts as making value decisions for people, just value-free objective technical judgments. Otherwise we might have to take that dangerous “democracy” thing seriously, eh 😉
All the best, Dr_Tad.
Tim.
I guess the way I see it is that any truly scientific understanding of (say) nature is the product of society, and so you cannot simply take part of that socially-produced knowledge or its application and claim it escapes the social relations in which it was produced. In the end science is science as it has meaning for humans.
So therefore I see attempts to create value-free knowledge as unscientific because they leave out their own production.
To understand positivism as a dominant theme in science in the bourgeois era, I think it is useful to consider Marx’s argument that the workings of the capitalist mode of production inverts subject and object so that impersonal economic relations (“relations between things”) appear to dominate relations between humans. In fact, he argues, this is a “fetishised form of appearance” and these relations between things are in fact the form of appearance of relations between humans. Nevertheless, this means that there appears to be a primacy of objective phenomena which then leads to the hegemonic modes of thought seeing objective things as being able to be understood as if outside of social relations.
The second aspect to this is that the workings of the system therefore appear naturalised and dehistoricised, and hence you get silliness like people thinking that complex social behaviours can be understood as the ahistorical, automatic workings of biology.