The American Psychiatric Association (APA) is rolling out the fifth edition of its DSM, the Diagnostic and Statistical Manual of Mental Disorders, this month. Like Game of Thrones‘ Stannis Baratheon, it’s the rightful heir, but no one wants it. As I’ve mentioned in previous posts, I’m a mental health social worker by trade. DSM 5 was a work in progress when I was in grad school eight years ago and it hasn’t earned a lot of positive early reviews so far. Furthermore, as it falls under HIPAA, my agency will switch to ICD-10 anyhow.
Arguably most damning, the National Institute of Mental Health recently released a statement that it will be “re-orienting its research away from DSM categories.” Its rational is long, technical, and for the most part, makes a lot of sense. Here’s the gist of it (and the emphasis is mine):
The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. 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. 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. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.
To summarize, unlike other fields of medicine, psychiatric disorders are classified by symptom (like persistent cough and sore throat) rather than etiology (like streptococcal infection). I should note the DSM’s creators’ goal was to create a purely descriptive diagnostic system that looked at “symptom clusters” without inferring underlying cause.
Of course, a lot has changed about our understanding of the mind since 1952. Schizophrenia was once though to result from poor parenting. Not only is that patently false, we can now detect apparent differences in brain activity in unsymptomatic children with a genetic predisposition for schizophrenia.
Daniel Amen is an American psychiatrist known for his reliance on brain scans, not just as a research tool, but for diagnosis. Last year, the Washington Post published a compelling article about him:
“Psychiatry is broken,” he is given to say, and psychiatrists “remain the only medical specialists that rarely look at the organ they treat.” He scoffs that diagnostic methods have scarcely progressed since “the days of Abe Lincoln.”
So you may think at this point think I’m a critic of DSM and advocate for advances in brain imaging technology. You’d be wrong. Let me tell you for what I’m advocating…
That’s right. Bring back the witch doctor. Because I believe in my heart that’s all a great psychiatrist really is. A witch doctor learned in the scientific method and perhaps heavily indebted to higher education, but a witch doctor nonetheless.
Here’s where I take issue with Dr. Amen: he claims psychiatrists “remain the only medical specialists that rarely look at the organ they treat.” He’s right in they rarely look at what they treat and wrong in that it’ an organ. A psychiatrist is not strictly a doctor of the brain. That’s a neurologist. The word, psychiatry is derived from the Ancient Greek “psykhe,” meaning “the soul.”
A psychiatrist is a doctor of the soul.
And what’s the difference? Can we even say such a thing as a soul exists? No. It’s by its very nature radically unknowable.
As much faith as Dr. Amen has in brain scans, the fact of the matter is, there are no widely-accepted diagnostic criteria based on brain scan markers. Though scans can show a difference in brain activity with someone impaired by a severe thought disorder, they can’t for many other debilitating mental illnesses. Furthermore, how could you ever tell the difference between, say people with obsessive compulsive traits that cause severe dysfunction in everyday life and people with obsessive compulsive traits that make them really organized and good at their jobs? Mental illness is a continuum we all fall within somewhere. You see a lot of lists of famous people who have struggled with mental illness. In some cases, they’ve not only overcome symptoms, but channeled traits such as compulsion or mania or depression into insight and organization and creation.
The fact of the matter is, modern psychiatry isn’t that different from folk-medicine. “Take one of these for a week. Tell me if you feel better. Experience says you will, but we don’t know for sure. We don’t know why it might make you feel better either.” I’m oversimplifying obviously. We have clinical trials and quantifiable rather than anecdotal evidence of efficacy. We also have mounting research about the brain/cognition link. The mechanism by which most psychotropic medication works is still theoretical, however. Drugs are created and tested to mimic existing drugs or speculated properties. Trial and error. Like the witchdoctor and the salve.
As witch doctors go, this one was card-carrying.
In my job at a community mental health center, I don’t think in terms of “what would be this person’s diagnosis per a SPECT?” I think, “how does this person need help?” And that’s the strength of the psychiatrist. She or he befriends the unknowable; the “how do you feel?”; the “who are you?”
Don’t get me wrong. I’m cynical about DSM5–especially the ways in which its writers have generally loosened diagnostic criteria, which could lead to over-diagnosis and over-medication. I can also believe assertions that its diagnoses lack validity and internal consistency. But the latter I chalk up to the DSM pretending to be something which its not–which is a dictionary of disorders that actually have validity and internal consistency. If you ask me, the DSM should imitate the holy book of Vonnegut’s Cats Cradle and preface itself with the following:
“All of the true things I’m about to tell you are shameless lies.”
I like the idea of a psychiatry that’s a fellowship of witch doctors and like the witch doctors of old, one that answers to its communities (plural). These include the general public, mental health peer/consumer/survivors, advocacy groups and yes even the least among them, NIMH. There’s something audacious about saying a psychiatrist treats the intangible. That yes, psychiatry cannot be removed from its cultural context; can manifest as social control, but that’s the baby’s bath wash. We can be okay with that because to accept psychiatry as such is a victory for the individual who doesn’t meet a machine’s dubious diagnostic criteria. It’s a victory for the power of the subjective.