1 Boring Old Man

A Perfect Storm for Psychiatry
Psychology Today
^{Blog: How Everyone Became Depressed}
by Edward Shorter, Ph.D.
May 8, 2013

What a week! Last week began with the announcement that suicides are up sharply. This means that all the “antidepressants” that people have been gobbling by the handful — one in ten Americans — have been ineffective against the grimmest consequence of depression of all: killing yourself.

Last week ended with NIMH Director Tom Insel’s announcement that the National Institute of Mental Health was cutting loose from the Diagnostic and Statistical Manual of the American Psychiatric Association, the famous “DSM.” Insel charged, “The weakness is its lack of validity.” That means that we here at NIMH in Bethesda, speaking as neuroscientists and fast-lane clinicians, don’t believe that your main diagnoses are valid. Insel didn’t specify which ones he thought invalid, but for years a small group of Nosological Rebels – clinical scientists rebelling against the official disease classification – have been casting doubt on such entities as “major depression.,” “bipolar disorder,” and “schizophrenia.” Depression and psychosis [the core of schizophrenia] exist alright, but not in the forms that the disease-designers of DSM have cast them, and from which the pharmaceutical industry has made so much money.

Now, the DSM crowd has its defenders. Many have stood up in the last 48 hours and said, “Well, how about you, Mr Smarty Pants Insel: If the DSM diagnoses are invalid, tell us which ones you think are valid.” And of course Insel has nothing to respond – at this point. The Research Domain Criteria crowd [RDoC] at NIMH have not yet gotten far enough in their attempts to link basic neural mechanisms to clinical phenomena. They are not yet able to say which are the “valid” phenotypes, which correspond to underlying genetic and biochemical realities. Maybe some day they will, after spending the hundreds of millions of dollars that the Obama Administration is allocating to the brain. Or maybe not. That’s irrelevant at this point. 

The point is that, floating around in nosological cyberspace, there are diagnoses that correspond to what people really have. Some, such as melancholia, possess genuine biological validation: the dexamethasone suppression test [DST], high serum cortisol, and a host of findings from sleep studies that show melancholia is a depressive illness sui generis, a disease of its own in other words. This has been known for centuries! And the DST has been available to psychiatry since Bernard Carroll introduced it for the study of depression in 1968.

Catatonia is another basic disease entity that only now is being detached from “schizophrenia,” a non-disease, and made a disease of its own. DSM-5 goes part way in acknowledging catatonia as a separate illness. And there exist pharmacological verifications and validations of catatonia: the response to benzodiazepines and electroconvulsive therapy. So it’s a real disease too [no other serious disorder in psychiatry responds to benzodiazepines, though many garden-variety illnesses do]. 

And what do we do about chronic psychosis, all forms of which up to now have been called “schizophrenia”? The term embraces many different patterns of illness. One in particular is onset of social isolation and withdrawal in adolescence, first psychotic break, then stabilization with some kind of mental “loss” – or “defect,” just to use the ugly technical term – at a relatively high level of functioning. You can work as a porter; you can get married and be a good husband and family father; but a neuroscientist … ahem … you’ll never be. Let’s call this hebephrenia, core schizophrenia. 

So there we’ve got three diagnoses right off the bat that correspond to what people actually have. We don’t need a lot of cogitation about “negative valence systems” – à la RDoC – to make progress, though fundamental progress in neuroscience is devoutly to be desired.

It’s going to be so exciting: DSM-5 will be launched at the American Psychiatric Association’s annual meeting in San Francisco in a matter of days. And the bleachers will be filled with skeptical fans yelling, “Why are your patients all killing themselves!” and “Give us some diagnoses that really work!” Don’t you wish you were going to be there?

^{"Major Depression doesn’t exist in Nature. A political process in psychiatry created it…"}