The war of the manual of mental illness

Wired covers the battle raging over the next version of the ‘manual of mental illness’ – the American Psychiatric Association’s DSM-5.

The piece discusses how the chief editors of two previous version of the manual, Robert Spitzer and Allen Frances – who edited the DSM-III and DSM-IV, have heavily criticised the proposed new manual for lack of transparency in development (non-disclosure agreements are required) and for ever-widening categories.

We’ve covered the (surprisingly personal ) battle on a couple of occasions but the Wired piece does a great job of getting into the nitty gritty of the arguments.

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this.

As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

My only gripe with the article is it seems a little star-struck by the idea that mental illness could be validated or even wholly defined by reference to neuroscience, which is a huge category error.

How would we know which aspects of neuroscience to investigate? Clearly, the ones associated with distress and impairment – mental and behavioural concepts that can’t be completely substituted by facts about the function of neurons and neurotransmitters.

That’s not to say that neuroscience isn’t important, essential even, but we can’t define disability purely on a biological basis.

It would be like trying to define poverty purely on how much money you had, without reference to quality of life. We need to know what different amounts of money can do for the people in their real-life situations. Earning $5 a day is not the same in New York and Papua New Guinea.

Not even physical medicine pretends to have completely objective diagnoses, as, by definition, a disorder is defined by the impact it has.

An infectious disease is not solely defined by whether we have certain bacteria or not. First, it must be established that those bacteria cause us problems.

The urge to try and define all mental illnesses in terms of neuroscience is, ironically, more an emotional reaction to criticisms about psychiatry’s vagueness than an achievable scientific aim.

Link to article ‘Inside the Battle to Define Mental Illness’.

9 thoughts on “The war of the manual of mental illness”

  1. it seems to get laymans turms on anything in mental health is quite diffficult take wiki for example the wording is to jargon or big words syndrome ive decided with BPD im going to do BPD in a nutshell and then take all the big words out
    so it is crystal clear and in easy languge for ever one to understand including myself

  2. If they are going solve all of their problems in psychiatry it’s the same solution as with psychology, evolutionary understanding. The only way to understand what is happening in reality is by understanding the functions and origins of the systems and particles that are interacting. It’s just taking forever because as we know, science advances one funeral at a time.

  3. I’d say that there’s an additional category error (and this isn’t that off from what @Harold is saying — I think): Trying to define a mental disorder only with reference to neuroscience is like trying to debug a piece of software only by looking at the silicon and the wires (the ‘computer analogy’ is as useful as it ever was!). In a particular mental disorder, all the neurotransmitters, neurons, hormones, etc., might be working exactly how they’re supposed to. It’s just the WAY they’re wired up — how they give rise to a particular pattern of perception, emotion, belief, or action — that’s causing the challenge.

  4. A manual that over time changes, is a manual that is composed of incompleteness. Incompleteness still occurs if one is still located at a distance from the actual truth. At a distance from the truth, one practices mere beliefs.

    Certainty can not be based upon incompleteness, and thus can not be based upon beliefs.

    Thus if people are certain that there are “other” people out in the world that clearly suffer from a mental illness, say Schizophrenia for instance, then an error has taken place.

    At a distance from the truth, we are still always dealing with probabilities, NOT cases of certainty.

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