Psychiatry divided as mental health ‘bible’ denounced

(NEW SCIENTIST)   The world’s biggest mental health research institute is abandoning the new version of psychiatry’s “bible” – the Diagnostic and Statistical Manual of Mental Disordersquestioning its validity and stating that “patients with mental disorders deserve better”. This bombshell comes just weeks before the publication of the fifth revision of the manual, called DSM-5.

On 29 April, Thomas Insel, director of the US National Institute of Mental Health (NIMH), advocated a major shift away from categorizing diseases such as bipolar disorder and schizophrenia according to a person’s symptoms. Instead, Insel wants mental disorders to be diagnosed more objectively using genetics, brain scans that show abnormal patterns of activity and cognitive testing.

This would mean abandoning the manual published by the American Psychiatric Association that has been the mainstay of psychiatric research for 60 years.

The DSM has been embroiled in controversy for a number of years. Critics have said that it has outlasted its usefulness, has turned complaints that are not truly illnesses into medical conditions, and has been unduly influenced by pharmaceutical companies looking for new markets for their drugs.

There have also been complaints that widened definitions of several disorder have led to over-diagnosis of conditions such as bipolar disorder and attention deficit hyperactivity disorder.

Now, Insel has said in a blog post published by the NIMH that he wants a complete shift to diagnoses based on science not symptoms.

“Unlike our definitions of ischemic heart disease, lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,” Insel says. “In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain, or the quality of fever.”

Insel says that elsewhere in medicine this type of symptom-based diagnosis been abandoned over the past half-century as scientists have learned that symptoms alone seldom indicate the best choice of treatment.

To accelerate the shift to biologically based diagnosis, Insel favors an approach embodied by a program launched 18 months ago at the NIMH called the Research Domain Criteria project.

The approach is based on the idea that mental disorders are biological problems involving brain circuits that dictate specific patterns of cognition, emotion and behavior. Concentrating on treating these problems, rather than symptoms is hoped to provide a better outlook for patients.

“We cannot succeed if we use DSM categories as the gold standard,” says Insel. “That is why NIMH will be reorienting its research away from DSM categories,” says Insel.

Prominent psychiatrists contacted by New Scientist broadly support Insel’s bold initiative. However, they say that given the time it will take to realize Insel’s vision, diagnosis and treatment will continue to be based on symptoms.

Insel is aware that what he is suggesting will take time – probably at least a decade, but sees it as the first step towards delivering the “precision medicine” that he says has transformed cancer diagnosis and treatment.

“It’s potentially game-changing, but needs to be based on underlying science that is reliable,” says Simon Wessely of the Institute of Psychiatry at King’s College London. “It’s for the future, rather than for now, but anything that improves understanding of the etiology and genetics of disease is going to be better [than symptom-based diagnosis].”

Michael Owen of the University of Cardiff, who was on the psychosis working group for DSM-5, agrees. “Research needs to break out of the straitjacket of current diagnosis categories,” he says. But like Wessely, he says it is too early to throw away the existing categories.

“These are incredibly complicated disorders,” says Owen. “To understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time, but in the meantime, clinicians still have to do their work.”

David Clark of the University of Oxford says he’s delighted that NIMH is funding science-based diagnosis across current disease categories. “However, patient benefit is probably some way off, and will need to be proved,” he says.

The controversy is likely to erupt more publicly in the coming month when the American Psychiatric Association holds its annual meeting in San Francisco, where DSM-5 will be officially launched, and in June in London when the Institute of Psychiatry holds a two-day meeting on the DSM.


4 Responses to Psychiatry divided as mental health ‘bible’ denounced

  • It seemed like such a good idea for the managers and team leaders, to streamline diagnosis into a checkbox system and we here outside the US fought the DSM (nicknamed dangerous, sad and mad index here in the UK) being forced on our hospitals but may as well have pushed water uphill for the good it done.

    When I trained as a psychiatric nurse, we used the tried and trusted methodology of observation, incidence, family and other agency feedback, close partnering between patient and nurse or doctor and diagnosis was 99 per cent on the nose and care was tailored to the right diagnosis but DSM doesn’t allow for this, it doesn’t allow for elevated mental conditions or emotional trauma, its black and white and unable to pursue threads that a human can follow that could lead to an important discovery of that patients illness.

    And so we tick them off one by one and then we invariably prescribe SSRI’s and hope it all works out, it fitted well for the British government who seized on this way as a means to sell off the old asylums and hospitals for top price to build houses on and a lot of people made a lot of dirty money out of this, care in the community can only ever work for people after their rehabilitation, not before or during where a quiet out of the way hospital ward takes that person away from the negative influences in their lives and allows them to be observed clinically, but its all about profit and nothing about caring or helping anymore.

  • Due to the "awakening" of the sheep, along with their speaking out, we see that those who are trying to manipulate us are beginning to back down from their non-sense science. Just like Global Warming, psychiatry is a false-manipulated-science.
    We CANNOT stop now folks, we have them on-the-run. This story is definite proof of that.

  • I left the mental health field in 1990 after six years working with teens after two of the teens I was working with overdosed on meth; having done so while on a weekend pass from a locked hospital facility. These teens died because the insurance and pharmaceutical companies WOULD NOT let us bill for chemical dependency education and groups; they would only let the payee bill the carrier for behavioral health – which inadequately addressed the teens’ need for help with a drug problem. This I call negligence and profiteeering. I have since resolved my disgust and starting working with adult SMI starting in 2008. The DSM whatever volume DOES NOT speak to the need of the common recipient; the need for resources to recover. I know a person healed of schizophrenia after over 15 years of suffering, and it all came about from resources that were made available to him; and despite the DSM, he has been decertified – and is now as NORMAL as you and I can be. Go figure huh!

  • @Strayhorse – I know of several people who have been seemingly cured of schizophrenia, it would seem the paranoid category seems to have a moderate success but needs dedicated intervention programmes and professionals to work with the patient intensely to bring them out of their self-normalised behaviour into acceptable behaviours. This of course costs a lot of money to the state so we see instead a prescription cycle of depot and "an eye" on the patient with no therapies whatsoever invariably forcing the patient to lie undetected as their thought processes unmonitored go into the darker sides of schizophrenia.

    It was during my time as a nurse that the fifth classification of schizophrenia was dropped and I still do not agree with that, that being the schizphrenic panic attack, which through stress or intense emotional disturbance, a patient could develop a short term version of schizophrenia but an intense version of it, some of this was absorbed by PTSD diagnosis but I still think the original classification had merit as PTSD is long lasting but SPA’s were not.

    I am on the side of the anti-psychiatrists like Szaz and consider that sometimes when our perceived reality filters are removed, slowly or in one fell swoop, the paradigm shift can sometimes manifest itself as a mental type illness and perhaps some of them out there just cannot cope with life after finding out what really is going on and remain in a shock realising that society, culture, the whole bloody lot is just one big con and human beings are really quite disgusting animals.

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