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DSM critique in the New England Journal of Medicine is not what it seems 05/21/2012

Posted by ALT in DSM-5, Mental Health Research.
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I heard the rumors of a fight, and I came a-running. 

Fisticuffs, you say? I’m in!

This morning, I read [here] that the following inflammatory remarks were published in this week’s New England Journal of Medicine:

 … [Only when psychiatrists address] psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations … by the causal processes and generative mechanisms known to provoke them … will psychiatry come of age as a medical discipline and a field guide [the DSM – Diagnostic and Statistical Manual] cease to be its master work.

- Paul McHugh, MD and Phillp Slavney, MD in the NEJM [emphasis added]

Damn, that’s cold.  And did I mention it was published in the New England Journal of Medicine (!), which is “one of the world’s most prestigious medical journals… cited in scientific literature more frequently than any other biomedical journal”?  All kinds of doctors, clinicians, and practitioners read this thing!

A big deal.

Sounds like the authors are saying mental illness is fundamentally NOT like diabetes, that psychiatry as a discipline will continue to suffer from its immaturity and crippling inferiority complex (“we wanna be scientists, too!”) as long as diagnosis doesn’t rest on a firmly established foundation of physical pathology, and that the DSM is a poor substitute for that kind of a foundation.

Them’s fighting words.  Words that might make the NEJM readership think twice before handing out diagnoses and their accompanying pharmacological interventions like the proverbial candy.

Don’t believe every rumor you hear

Having matured a bit from my high school days of running directly to join the ring of kids chanting “fight, fight, fight!”, I decided to get a little context.  Who are these guys -– researchers? psychiatrists? some other kind of doctors? — and what does the rest of their NEJM editorial say?

“These guys” are two psychiatrists, professors at the Johns Hopkins School of Medicine.  Paul McHugh, the lead author, is a rather famous one.  He’s attended Harvard, designed a famous cognitive test often used as a dementia/Alzheimer’s diagnostic tool (a mere 11 questions!), served on the Presidential Council of Bioethics under GW and on a lay panel put together by the Catholic Church to look into the abuse of young boys by priests – none of these things being very high recommendations in my book.  The two, together, have written a popular paperback for the general public entitled The Perspectives of Psychiatry which takes the biopsychiatric/disease-based approach to mental health.

And their editorial?  It starts off very nicely with a critique of the DSM-delineated “field guide” method of diagnosis – the main problem being that clinicians no longer think too long or hard about causation.  This promotes a “rote-driven” method of treating folks, and as the authors so rightly state “identifying a disorder by its symptoms does not translate into understanding it.”  Or treating it effectively, if long-term studies of schizophrenia outcomes are any indication.

But things go sour real fast as we get to the “what’s to be done about it” part.  We simply must establish causation for psychiatric disorders, and – guess what?—the authors have already done that! 

The causes of psychiatric disorders derive from four interrelated but separable families: brain diseases, personality dimensions, motivated behaviors, and life encounters.

-McHugh et al.

Good, good.

They have also helpfully sorted out some common psychiatric disorders into the four families, or “causal perspectives”:

It’s written in a table so it MUST be true!

Right there, in the NEJM (remember – prestigious medical journal read by everybody), we’ve got schizophrenia neatly categorized as “brain disease.” 

Oh, dear.

I diagnose thee… Flipfloppers!

Contrast the NEJM editorial with the polite phrasing the authors used in the aforementioned co-authored The Perspectives of Psychiatry, chapter 6:

The continuing failure to identify a particular cerebral pathology or pathophysiology in these disorders [manic depression and schizophrenia] undermines attempts to proclaim them as diseases with complete confidence.  They remain mysteries in the sense that a confirmation of their essential nature is lacking…

- authors Paul McHugh, MD and Phillp Slavney, MD in The Perspectives of Psychiatry [emphasis added]

And yet they feel comfortable, only a few years after these words were published, with proclaiming schizophrenia as a “brain disease,” without providing any citations for new, groundbreaking research whatsoever.  Clearly this “DSM critique” is not what it seems.

Middle way protestors all the way

As it turns out, these guys are total middle way DSM protestors – the only thing they’d like to fight is the bad public image of the DSM, not the institution of psychiatric diagnoses masquerading as science, and all of the poor treatment that goes along with such posturing (symptom suppression via pharmaceuticals, coercive treatment, et al.).

According to McHugh and Slavney, “no replacement of the criterion-driven diagnoses of the DSM would be acceptable; clinicians are too accustomed to them.”  Rather, the only solution is for everyone [clinicians, researchers, families, patients] to embrace their causation groupings – and for that to be coded and billable, too, one can only presume.

In no other field would you continue to reach for an admittedly blunt, ineffective tool simply because it’s “what people are used to.”  Surely there are some other possiblities?

I believe that there is another way – instead of fitting people and their “symptoms” into predetermined boxes, we could communicate with each unique individual, offering our support and encouragement (help) when it’s wanted, and offering our respectful non-interventionism and acknowledgement of the humanity of the suffering individual when our “help” is neither helpful nor desired.

I believe there is life after the DSM – and I’d like, as a society and a community, to live it!

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Comments»

1. Rossa Forbes - 05/22/2012

Good analysis.


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