1 Boring Old Man

Paradigms lost: NIMH, McGorry & DSM-5’s failure
Left Flank
by Dr_Tad
May 4, 2013

… Last week the National Institute of Mental Health — the peak US mental health research body — delivered a body blow to the authority of the DSM by announcing that it was abandoning the manual in favour of its own Research Domain Criteria [RDoC].

This is a new phase of the controversy that has dogged the DSM-5 at every turn. Petitions opposing the project have garnered the signatures of thousands of clinicians. The revision process has been attacked for being kept behind closed doors, and for favouring the pet research areas of expert committee members. The corporate media — usually uncritical of mainstream psychiatry — has reported substantial criticisms of proposed changes. The taint of academic psychiatry’s incestuous relationship with Big Pharma has fed accusations of financial influence. And the psychiatrists who headed DSM-III and DSM-IV — Robert Spitzer and Allen Frances — have attacked the DSM-5.

Even on the aims its creators set, the DSM-5 is a failure; an incoherent compromise and a mess. Significantly, its contents will reflect the impasse of the diagnostic paradigm that became hegemonic with the DSM-III in 1980, following a “revolution” in diagnosis designed to save US psychiatry from its profound crisis in the 1970s. It will be a further sign of the failure to create a “scientific” basis for psychiatry through symptom-based diagnoses, as NIMH director Thomas Insel has argued on his blog.

But the authors of DSM-5 also wanted the kind of quantum leap Insel advocates. When they started work over a decade ago they saw their task as going beyond simply describing disorders in terms of the symptoms and behaviours [the DSM is currently silent as to the “aetiology”, or cause, of almost all the disorders it defines]. Instead they would align diagnoses to the “underlying” genetics and neurobiology. Yet as they proceeded it became increasingly obvious that there was insufficient evidence for this shift. More importantly, the biomedical model was increasingly being challenged from a number of directions: A series of major scandals involving kickbacks from drug companies to psychiatric “thought leaders”, mounting public concern about the over-diagnosis and gross overmedication of adults and children, and the growing evidence that many top-selling psychiatric medications [especially anti-depressants] worked little or perhaps no better than placebo.

It is no wonder that DSM-5 “innovations” like removing bereavement as an exclusion criterion for Major Depression are widely opposed. It feeds into a suspicion that psychiatrists and drug companies are cynically expanding potential markets for the expensive services and products they are selling. The finished DSM-5 will have most of its original raison d’etre missing, some of the rewriting [e.g. personality disorders] relegated to an appendix, and a pall of controversy, mistrust and confusion surrounding it. The APA has suffered financially in recent years from a stagnant membership base and growing regulation of its financial ties with industry. Sales of the manual [not cheap at US$199] and its various guides to use form a major part of the APA’s annual revenue and seems to have been a driver for getting a new edition out for sale. In the end politics hobbled the DSM-5 because the “objective” scientific advances its developers saw as being just around the corner proved to be a mirage…

While this is a setback for the DSM, it is far from being a defeat for the dominant neurobiological model of mental health and illness. As blogger 1 Boring Old Man points out, Insel is simply taking the established NIMH position to its logical conclusion by formally breaking with DSM-5. And the last half-century is proof of how profoundly that model shapes psychiatric research and practice. No matter how lean the pickings they deliver, biologically based approaches remain powerful and those who question them tend to be sidelined. You can see this in Insel’s alternative program for devising new diagnostic boundaries:

• A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
• Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
• Each level of analysis needs to be understood across a dimension of function,
• Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

Such assumptions are little more than speculative, yet they are presented as conclusive. They serve to close off avenues of research that fall outside their boundaries rather than open them up. They point to the imperviousness of the dominant biological paradigm to evidence that contradicts it. In the words of Samuel Beckett, “Try again. Fail again. Fail better.”

I know I thought those things when I read about the RDoC, but why didn’t I say them? I think I’ve been a Straw Man in too many conversations where people want to unload their contempt for psychological or psychoanalytic thinking. So I’ve limited myself to only questioning scientific misbehavior, not basic assumptions. Having been on the other side of contempt, I don’t want to be it’s agent. But in this case, I should have started my blog pointing out that Dr. Insel’s RDoC assumptions have skipped way too many steps, or said, as Dr_Tad did, "Such assumptions are little more than speculative, yet they are presented as conclusive," which is perfect – perfectly said and perfectly true.

The real problem afflicting all these attempts to find a way out of the current impasse is that they have failed to accurately diagnose the sources of the crisis. Because psychiatry, like the rest of medicine, is deeply imbued with scientific positivism [that real science is free of social values] and methodological individualism [that social processes are merely the aggregate outcome of individual behaviours], it cannot fully grasp that all health and illness — mental and physical — is both socially embedded and socially constructed. Therefore it cannot critically reflect on its own social nature, its own ideologies and practices that are inextricably bound up with wider social conflicts in their historical contexts.

The reaction to the 1970s crisis of American psychiatry was to use claims about the “reliability” of diagnosis to strengthen the profession’s “scientificity” in appearance but not reality. That model served powerful interests in the psychiatric profession, academia, government bureaucracies, and the pharmaceutical industry, but has unraveled when so many of its claims to help those with mental health problems have been exposed as hollow. A new paradigm that doesn’t simply repeat those flaws cannot be built from above, not by DSM committees nor NIMH directors. It can only be built through the struggles of patients and clinicians for a mental health system driven by quite different social priorities.