{"id":4658,"date":"2011-02-04T16:46:26","date_gmt":"2011-02-04T21:46:26","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=4658"},"modified":"2011-02-04T19:08:59","modified_gmt":"2011-02-05T00:08:59","slug":"been-there-done-that","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/02\/04\/been-there-done-that\/","title":{"rendered":"been there, done that&#8230;"},"content":{"rendered":"\n<p align=\"justify\">In writing about evidence-based medicine, I&#8217;ve run across or been sent a lot of interesting information. One such article was in <strong>Wired<\/strong> [<u><a target=\"_blank\" href=\"http:\/\/www.wired.com\/magazine\/2010\/12\/ff_dsmv\/all\/1\"><strong><font color=\"#200020\">Inside the Battle to Define Mental Illness<\/font><\/strong><\/a><\/u>]. It&#8217;s really good, and has a lot of information I hadn&#8217;t run across. Of particular interest &#8211; the part about Al Francis, Editor of the DSM IV, who now thinks they blew it and has been vocal about the coming DSM V. The article speaks for itself and I&#8217;ll leave you to it with hearty recommendations from me. The thing I want to mention is a couple of paragraphs from the article:<\/p>\n<ul>\n<div align=\"justify\">The DSM-5 battle comes at a time when psychiatry&rsquo;s  authority seems more tenuous than ever. In terms of both research  dollars and public attention, molecular biology &mdash; neuroscience and  genetics &mdash; has come to dominate inquiries into what makes us tick. And  indeed, a few tantalizing results from these disciplines have cast  serious doubt on long-held psychiatric ideas. Take schizophrenia and  bipolar disorder: For more than a century, those two illnesses have  occupied separate branches of the psychiatric taxonomy. But research  suggests that the same genetic factors predispose people to both  illnesses, a discovery that casts doubt on whether this fundamental  division exists in nature or only in the minds of psychiatrists. Other  results suggest new diagnostic criteria for diseases: Depressed  patients, for example, tend to have cell loss in the hippocampal  regions, areas normally rich in serotonin. Certain mental illnesses are  alleviated by brain therapies, such as transcranial magnetic  stimulation, even as the reasons why are not entirely understood.<\/div>\n<p>             <\/p>\n<div align=\"justify\">Some mental health researchers are convinced that the DSM  might soon be completely revolutionized or even rendered obsolete. In  recent years, the National Institute of Mental Health has launched an  effort to transform psychiatry into what its director, Thomas Insel,  calls clinical neuroscience. This project will focus on observable ways  that brain circuitry affects the functional aspects of mental  illness&mdash;symptoms, such as anger or anxiety or disordered thinking, that  figure in our current diagnoses. The institute says it&rsquo;s &ldquo;agnostic&rdquo; on  the subject of whether, or how, this process would create new  definitions of illnesses, but it seems poised to abandon the reigning DSM  approach. &ldquo;Our resources are more likely to be invested in a program to  transform diagnosis by 2020,&rdquo; Insel says, &ldquo;rather than modifying the  current paradigm.&rdquo;<\/div>\n<\/ul>\n<div align=\"justify\">While I am all for a thorough reevaluation of the DSM Classification, this couple of paragraphs raised the hairs on the back of my neck involuntarily. In the mid-twentieth century, Psychoanalysis was a major player in American Psychiatry, focusing our attention on the <em><strong><font color=\"#200020\">mind<\/font><\/strong><\/em> rather than the <em><strong><font color=\"#200020\">brain<\/font><\/strong><\/em>. I am a psychoanalyst, a&nbsp; doctor, yet I agree that our influence on Psychiatry had become a hindrance rather than a help over time. The helpfulness of analytic treatment is limited to a particular set of problems, and is as time consuming and costly as its critics complain. It&#8217;s just not a general theory\/treatment to inform a psychiatric nosology. But that limitation doesn&#8217;t mean that human beings don&#8217;t have <em><strong><font color=\"#200020\">minds<\/font><\/strong><\/em>, nor does it mean that a lot of human suffering doesn&#8217;t have something to do with the <em><strong><font color=\"#200020\">mind<\/font><\/strong><\/em> rather than the <em><strong><font color=\"#200020\">brain<\/font><\/strong><\/em>. The mistake was to create a <em><strong><font color=\"#200020\">brainless<\/font><\/strong><\/em> nosology, based on one view of the <em><strong><font color=\"#200020\">mind<\/font><\/strong><\/em>. It happened because it was something new, something exciting, a shiny new object that offered great promise. They way overdid it.<\/div>\n<p align=\"justify\">So now we read, &quot;<em>Depressed  patients, for example, tend to have cell loss in the  hippocampal  regions, areas normally rich in serotonin. Certain mental  illnesses are  alleviated by brain therapies, such as transcranial  magnetic  stimulation, even as the reasons why are not entirely  understood.<\/em>&quot; Exciting! Emerging! Novel! Advances in &#8230;! It sounds like the titles to the review articles that have filled our literature for years [Corlux [RU-486], VNS, Transcranial Magnetic Stimulation, Deep Brain Stimulation]. We&#8217;re well aware of this kind of neuroscience cheer-leading, often from the ranks of some of our least-reliable colleagues. Unfortunately, NIMH Director Tom Insel isn&#8217;t exactly free from their taint himself. Consider his recent <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2010\/06\/29\/plausible-deniability-is-neither-a-medical-nor-scientific-standard\/\"><strong>walk down the road<\/strong><\/a> with Charlie Nemeroff, head cheer-leader extraordinaire.          <\/p>\n<div align=\"justify\">Insel, himself, is also on the cheer-leadering squad [<u><a href=\"http:\/\/www.nimh.nih.gov\/about\/director\/publications\/psychiatry-as-a-clinical-neuroscience-discipline.shtml\" target=\"_blank\"><strong><font color=\"#200020\">Psychiatry as a Clinical Neuroscience Discipline<\/font><\/strong><\/a><\/u>]:<\/div>\n<ul>\n<div align=\"justify\"><sup><em>In this commentary, we argue that psychiatry&#8217;s impact on public health  will require that mental disorders be understood and treated as brain  disorders.<\/em><\/sup><\/div>\n<div align=\"center\">&#8230;<\/div>\n<div align=\"justify\"><strong><font color=\"#200020\">Where to Go From Here?<\/font><\/strong><\/div>\n<div align=\"justify\">The 1990s were identified as the  &quot;decade of the brain&quot; with major new insights into brain circuitry and  function. The current decade may be recognized in retrospect as the  &quot;decade of discovery,&quot; during which many of the major candidate  molecules, cells, and circuits for normal and abnormal brain function  will be identified for the first time. A goal of the Decade of Discovery  must be the description of the basic pathophysiology of each of the  major mental disorders [<strong><a href=\"http:\/\/www.nimh.nih.gov\/about\/director\/publications\/psychiatry-as-a-clinical-neuroscience-discipline.shtml#Figure%201\" target=\"_blank\">Figure 1<\/a><\/strong>].<\/div>\n<div align=\"center\"><img decoding=\"async\" width=\"480\" vspace=\"5\" border=\"1\" src=\"http:\/\/www.nimh.nih.gov\/images\/about\/estimate%20of%20time%20chart.gif\" \/><\/div>\n<div align=\"justify\">  Currently, patients with mental disorders are treated episodically with  medications that are focused on symptoms and not on the core pathology.  The available treatments are slow, incomplete, and can be limited by  adverse effects. In mental disorders, just as in the rest of medicine,  better understanding of pathophysiology should yield diagnosis based on  biomarkers and treatments based on rational designs targeting the  pathophysiology. It is critical to realize that clinical  neuroscience does not entail designing exotic technologies for a few  privileged patients. The ultimate goal is personalized or individualized  care for a broad spectrum of patients with mental disorders. Recently a  better understanding of pathophysiology has led to a strategy for  individualizing treatment of cancer. Currently in  psychiatry, specific treatments for any given patient are largely  developed empirically. With more knowledge about the pathophysiology of  mental disorders, treatments should become more specific, more  effective, and ultimately more accessible.<\/div>\n<p align=\"justify\">Clinical neuroscience  can now look forward to an &quot;era of translation&quot; with more accurate  diagnoses and better treatments as well as very early detection and  prevention. Early detection will require a thorough understanding of  risk, based on a comprehensive understanding of genetics and experience.  For example, preventive interventions might be available to prevent a  first psychotic episode in an adolescent at high risk for schizophrenia.<\/p>\n<div><strong><font color=\"#200020\">Conclusion<\/font><\/strong><\/div>\n<div align=\"justify\">At  the intersection of an age of discovery in the neurosciences, behavior,  and the complexities of human mental life, psychiatry should emerge  once again as among the most compelling and intellectually challenging  medical specialties. This promise of the future will depend on  psychiatry&#8217;s incorporation of the insights and tools of modern  neuroscience, integration into the mainstream of medicine by focusing on  the public health needs of those with mental disorders, and retention  among the medical specialties of a unique focus on the contribution of  human experience and behavior to health and disease.<\/div>\n<\/ul>\n<div align=\"justify\">Psychiatry as a Clinical Neuroscience Discipline has been the wish of many in high places for decades. Like the Freudians after World War II, Insel suggests that we should focus on the shiny objects of the future, perhaps even wrap our nosology around what might be in the wished-for future &#8211; a <strong><em><font color=\"#200020\">mindless<\/font><\/em><\/strong> nosology. He addresses treating &quot;causes&quot; rather than symptoms, assuming that he knows where those causes will be found. He speaks of personalized treatments [genetic markers predicting which drug will work is one version], yet that genetic research is at best speculative, if not pie-in-the-sky or&nbsp; downright wrong [see <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2010\/07\/05\/hows-your-life\/\"><strong><font color=\"#200020\">how&rsquo;s your life&hellip;<\/font><\/strong><\/a>]. Transcranial Magnetic Stimulation? Hippocampal shrinkage? We&#8217;ll see&#8230; His conclusion sounds very much like a talk I actually heard in the 1980s &#8211; over twenty-five years ago. My point, we don&#8217;t need another &quot;maybe&quot; nosology to replace the last &quot;maybe&quot; classification&#8230;<\/div>\n<p align=\"justify\">I&#8217;ve encountered lots of exciting things in my days in Psychiatry. When I understand a connection between a person&#8217;s biography and some current dilemma, and that understanding helps them undo a knot or two, I feel excited. When I see a young psychotic person with Schizophrenia and instead of sending them off to an institutionalized life, I give them a medication that controls the psychosis, I feel excited. When I meet someone whose life is consumed by obsessive compulsive rumination relieved with medication, I feel excited. When I help a person connect a previous trauma with the symptoms that have doomed them to misery and begin the &quot;untangling&quot; process, I get excited. Psychiatry has been full of excitements for me.<\/p>\n<p align=\"justify\">But we&#8217;ve had enough of the &quot;exciting&quot; fantasies of the enthusiastic neuroscientists. They have a strong place in the Psychiatric cosmology. But&nbsp; Psychiatry as Clinical Neuroscience? Not on your life. What we&#8217;ve gotten from that talk is an infusion of Pharmaceutical Industry influence that has actually done a hell of a lot of harm. We&#8217;ve also gotten some fairly shaky science, some outright corruption, and some un-necessarily toxic medications. If anything, the complaints are actually directed <strong><font color=\"#200020\">at<\/font><\/strong> neuroscientists and their irrational exuberance. To Insel, I would suggest that neuroscience is too important to Psychiatry to have misbehaved at this level, and that it&#8217;s not a very good time for him to say Psychiatry<strong><font color=\"#200020\"> is <\/font><\/strong>Neuroscience, sounding like a clone of his friend in Miami. Psychiatry will become Clinical Neuroscience if and when it actually is a Clinical Neuroscience, not because of his wishes or excitement.<\/p>\n<div align=\"justify\">It&#8217;s a bit like suggesting that Donald Rumsfeld take over the Pentagon again. Been there. Done that. Has Tom Insel been asleep?&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>In writing about evidence-based medicine, I&#8217;ve run across or been sent a lot of interesting information. One such article was in Wired [Inside the Battle to Define Mental Illness]. It&#8217;s really good, and has a lot of information I hadn&#8217;t run across. Of particular interest &#8211; the part about Al Francis, Editor of the DSM [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-4658","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4658","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=4658"}],"version-history":[{"count":1,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4658\/revisions"}],"predecessor-version":[{"id":7584,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4658\/revisions\/7584"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=4658"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=4658"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=4658"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}