Poet Robert Browning and the DSM-5 Controversy.
When David Kupfer, chair of the American Psychiatric Association (APA) DSM-5 Task Force was asked early this year what the biggest surprise was in developing the manual, he responded that it was finding himself on the front page of the New York Times. One of the more intriguing moments in the DSM-5 debate was National Institute of Mental Health Director (NIMH), Tom Insel’s criticism of DSM-5 diagnoses for their lack of linkage to valid biomarkers of disease—an effort the NIMH is undertaking through development of the Research Domain Criteria [RdoC]. The APA and NIMH have since issued a clarifying joint statement, but what is behind this part of the reaction to DSM-5?
The simplest answer is found in Robert Browning’s line, “Ah, but a man’s reach should exceed his grasp, Or what’s a heaven for?” Psychiatry’s current ability to grasp [i.e., DSM-5] is far less than its reach [e.g., the RdoC], and we have to live with our limitations in order to treat patients—which is why as a member of the APA Assembly I voted in favor of adopting DSM-5.
Psychiatry and clinical psychology are imperfect sciences. We clinicians diagnose based on symptoms that link to syndromes, like major depression or anorexia nervosa, and that is the best we can do right now. There are no lab tests or imaging studies that can make these or the vast majority of other psychiatric diagnoses. There is a fervent wish to make psychiatric diagnosis as precise as in the rest of medicine. That is, rather than using clinically observable syndromes like congestive heart failure, the hope is to define the multiple underlying causes of congestive heart failure and know which is operative in this patient. Is there a myocardial infarction that calls for dissolving a clot and placing a stent in an artery? A mitral valve that needs replacing? Atrial fibrillation that needs a pacemaker? Fluid overload that needs a diuretic? Cardiomyopathy that needs antiviral drugs or even a transplant? You get the picture. A set of symptoms defining a syndrome like congestive heart failure or schizophrenia isn’t as good as knowing the underlying cause, and treating it precisely. This is the “reach,” if you will, of psychiatry—but the bad news is we aren’t even close, and, worse yet, there is reason to think we are reaching in the wrong direction.
In my next blog posting I will elaborate on this a bit more, explaining the four false assumptions contemporary psychiatry is making despite its own emerging research findings. So an apt quotation for next time would be the proverbial English saying, “There is none so blind as those that will not see.” Meanwhile I encourage you to take a look at Allen Frances’ blog posting on this issue. Allen has been quite critical of DSM-5 in ways worth taking seriously—though I oppose throwing the baby out with the bathwater.