1 Boring Old Man

Kuhnian paradigm shifts:
^{An epistemological paradigm shift was called a scientific revolution by epistemologist and historian of science Thomas Kuhn in his book The Structure of Scientific Revolutions. A scientific revolution occurs, according to Kuhn, when scientists encounter anomalies which cannot be explained by the universally accepted paradigm within which scientific progress has thereto been made. The paradigm, in Kuhn’s view, is not simply the current theory, but the entire worldview in which it exists, and all of the implications which come with it. It is based on features of landscape of knowledge that scientists can identify around them. There are anomalies for all paradigms, Kuhn maintained, that are brushed away as acceptable levels of error, or simply ignored and not dealt with… Rather, according to Kuhn, anomalies have various levels of significance to the practitioners of science at the time…}

^{When enough significant anomalies have accrued against a current paradigm, the scientific discipline is thrown into a state of crisis, according to Kuhn. During this crisis, new ideas, perhaps ones previously discarded, are tried. Eventually a new paradigm is formed, which gains its own new followers, and an intellectual "battle" takes place between the followers of the new paradigm and the hold-outs of the old paradigm… Sometimes the convincing force is just time itself and the human toll it takes, Kuhn said, using a quote from Max Planck: "a new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it." After a given discipline has changed from one paradigm to another, this is called, in Kuhn’s terminology, a scientific revolution or a paradigm shift. It is often this final conclusion, the result of the long process, that is meant when the term paradigm shift is used colloquially: simply the change of worldview, without reference to the specificities of Kuhn’s historical argument…}

^{A common misinterpretation of paradigms is the belief that the discovery of paradigm shifts and the dynamic nature of science [with its many opportunities for subjective judgments by scientists] is a case for relativism: the view that all kinds of belief systems are equal. Kuhn vehemently denies this interpretation and states that when a scientific paradigm is replaced by a new one, albeit through a complex social process, the new one is always better, not just different. These claims of relativism are, however, tied to another claim that Kuhn does at least somewhat endorse: that the language and theories of different paradigms cannot be translated into one another or rationally evaluated against one another — that they are incommensurable.}

^{[Melancholia] A term from the past, in this manual used to indicate a typically severe form of depression that is particularly responsive to somatic therapy. The clinical features that characterize this syndrome have been referred to as "endogenous." Since the term "endogenous" implies, to many, the absence of precipitating stress, a characteristic not always associated with this syndrome, the term "endogenous" in not used in DSM-III.}

^{For example, there has been a continuing  controversy as to whether or not severe depressive disorder and mild depressive disorder differ from each other qualitatively [discontinuity between diagnostic entities] or quantitatively [a difference on a severity continuum]. The inclusion of Major Depression With and Without Melancholia as separate categories in DSM-III is justified by the clinical usefulness of the distinction. This does not imply a resolution of the controversy as to whether or not these conditions are in fact quantitatively or qualitatively different."}

It matters for two reasons. First, they shot a number of biological researchers in the foot by essentially relegating the object of their research to a fifth digit add-on diagnosis. And second, they opened the door for drug companies to radically expand their markets for any drug they could get approved as an anti-depressant – leading to a lot of really questionable clinical trials and unethical, misleading marketing. This was an active decision over objections from people one might have thought were in the framer’s camp.

And, as I [and many before me] have mentioned, they expanded, complexified, and revised Mania diagnoses into the multiple flavors of Bipolar Disorder without reasons that have any scientific rhyme – a change that continues to confound to the present. After the DSM-III came, we went through "chemical imbalance" and "Bipolar" epidemics making it hard not to be suspicious that this was another drug promo decision. If it was on solid evidence-based grounds, that evidence hasn’t been widely disseminated.

As I mentioned in my last post, the "shifted to" paradigm relies on biology, not in the abstract but in reality – biological underpinnings to mental illnesses and biological treatments. The former are elusive and the latter… well, they haven’t worked out so well as was hoped, in spite of topping the charts in sales [being widely prescribed by non-psychiatrists].  And the new paradigm requires that the leading edge be always moving forward, because anything that can be turned into a simple "algorithm" can [and will] be done by primary care physicians.

So maybe the framers of the DSM-III had no intention of ushering in an era of increasingly corrupt and/or trivial science, but they facilitated that development by restricting the psychiatric paradigm to biology and counting on a steady stream of scientific discoveries to carry the day. And maybe they enabled the development of the whole Clinical Research Industry that specializes in finding its "evidence" in large studies with small differences [resulting in small efficacy in the pill bottle]. And maybe they pushed psychiatrists into an alliance with the pharmaceutical industry because that’s where the necessary biological treatments usually originate. And perhaps the proliferation of flim-flam men in high places [KOLs] in psychiatry has something to do with needing people with the charisma to "keep the dream alive." And worst of all, maybe the emphasis on keeping the new treatments flowing and the high premium on "translational science" [speeding up the movement from bench to the drugstore] has been at the expense of encouraging and developing careful and creative researchers who would best be left alone to move in their own directions at their own pace.