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’.

Change of pace

Mind Hacks posts may be a little irregular in the future as I’ve just moved location and job. I’ve left the wonderful city of Medellín and am now living in Colombia’s impressive capital, Bogotá.

I’ve also started working as a psychologist for Médecins sans Frontières (Doctors Without Borders if you’re American) and, as you might expect, the pace of work is a little more intense and unpredictable than usual – not least because I will be spending quite a bit of time ‘on the road’ to work with some of the many MSF projects in the rather more troubled areas of the country.

In fact, I hear that some of areas we work in are so badly affected that they don’t even have Twitter, so blogging is likely to be a bit restricted at times.

However, Tom and I are mulling over some interesting new plans and we’ll still both be posting when in internet enabled zones, but you might see a change of pace.

This also seems a great opportunity to thank the psychologists and psychiatrists I had the pleasure of working with in Medellín, especially from the Department of Psychiatry at the University of Antioquia, from whom I learnt a great deal and with whom I had some incredibly enjoyable times.

Muchas gracias a todos!