I couldn’t resist that title, but the only rat I’ll write about here is me. Actually, Nasir Ghaemi didn’t call me a rat in his psychology today blog. He called me an “extremist psychologist.” I think I’d rather be a rat.’

Not that I mind the extremist part. But I am not a psychologist. I never claimed to be a psychologist. The psychologists own that word, and insist that only people licensed as psychologists can call themselves psychologists. Which is fine by me. I wouldn’t join a club that would have me as a member unless I needed to in order to make a living or get laid or something like that. This whole guild thing makes me a little nuts.

I’ll explain. Back in the 1990s, when I was getting my Ph.D. in psychology, the American Psychological Association, as if to prove that the American Psychiatric Association was not the only APA that could be power hungry, took over the licensure apparatus in as many states as possible. They created a model statute and regulatory scheme that required people who did not get their degree from an APA-approved program, which mine was not, to plead their case to the state, submitting course syllabi and other arcana for their review. I could have gone through that whole painful (and expensive; everyone I knew who succeeded did so only after lawyering up)  process, but I already had a license-=-as a Professional Counselor–and a full practice, so I figured, why bother. And I didn’t.

As to the extremist part. To my great surprise, neither Laura Miller nor Ben Nugent nor Dwight Garner seems to think so. One way or another they all make reference to my middle course. Miller goes out of her way to tell Scientologists that I am not on their side, and Nugent finds enough nuance in my argument to tease out the antipsychiatry from the propsychiatry strand. Actually, I don’t totally agree with this; my book is less dialectical than I would have wanted, but mostly because the APA (the psychiatrist one) didn’t do a very good job of creating narrative tension for me. Which is the biggest reason I was glad when Tom Insel called them out.

So I think Ghaemi is wrong to tag me as an antipsychiatrist; on the other hand, he;s a psychiatrist, so he is bound to diagnose what unsettles him. And I know he’s wrong to say that I believe “that no psychiatric condition can ever be a biological disease.” Of course I know that the brain can malfunction as surely as the liver can, without any prompting, for no particular reason other than that the body is a time bomb that will explode at some point or other, eventually lethally. Some of the mental disorder out there is undoubtedly as “medical” as the kidney disorder or the bacteriological disorder out there. But despite decades of effort, psychiatry has yet to tell us which mental disorder that is, and therefore which properly falls under its aegis. In the absence of limits the profession, largely through the DSM, has expanded to encompass all of it–an expansion that serves its interests in unsavory ways. When psychiatry can tell me what mental disorder is really a brain disease, and when it finally figures out the distinction between necessary and sufficient conditions, then maybe I will stop ratting it out.

David Kupfer, chair of the DSM-5 task force, shot back at Tom Insel, head of NIMH today with a statement that even by the standards Kupfer has set over the last five years is immensely obfuscating.

The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting. In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.

Where to start? How about with that “we’re still waiting”? You’re still waiting? How about all the people whom you have diagnosed with what you insist are real illneesses (even if you acknowledge that they aren’t) caused by biochemical imblances (which you know don’t exist) and treated by drugs (whose mechanisms you don’t understand). They’re still waiting for your knowledge to catch up with your claims, and the idea that your clinical experience and empirical research somehow add up to more than a stopgap measure that is increasingly problematic, that has spawned a drugging of the population that is going to look to future historians like the lead contamination of the Roman water supply does to us–this idea is really beginning to wear thin.

But that;’s not the best part. The best part comes here–after the obligatory defense of DSM-5 as “the strongest system available,” leaving out the part about how it’s pretty much the only system available.

RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.

RDoC is the NIMH initiative, harebrained in its own way, to find the neurocircuitry of psychopathology and develop a diagnostic system based on it. NIMH has a long time frame for RDoC, ten yeaqrs or so. But they’re not issuing any promissory notes, except maybe to congress to whom they are promising research results in return for appropriations. The people being asked to take psychiatry on faith are the patients, and the people soliciting the credit are psychiatrists, especially the psychiatrists of the APA. We still,they are saying,  after 150 years, don’t know what a mental illness is, we gave up a long time ago on trying to figure it out, we can’t agree on how to identify the mental illnesses that we think might exist, we just spent $25 million to make a diagnostic manual that, by our own measure, is worse than the last one, and we can’t even articulate a decent defense of it that doesn’t sound like saying we know it’s a mutt but it’s our mutt and it protects our house and if it Biedermans on the floor or Nemeroffs on the carpet or once in a while Abilifies the neighbor’s cats, well, that’s just the cost of having us around, and so you should just trust us, and by the way if you don’t, then you either don’t care about the mentally ill or you are just an antipsychiatrist following Tom Cruise because he’s so cute.

I mean, if the DSM-5 ain’t a promissory note, then I don’t know what is. and like many promises issued by confidence men, it’s not worth the paper it’s printed on.

A truly remarkable event today. Tom Insel,  director of the National Institutes of Mental Health, decided to say out loud what he’s been saying quietly for a few years now: that the US Government has lost faith in the DSM. And the problem, he says, is not really the DSM-5, which he says will be little different from DSM-IV, and that this is the problem.  Here’s his analysis

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.

So the problem is the DSM itself, the way its descriptive approach can’t be anchored in something beyond itself, which is why none of the mental disorders it lists are valid. And, Insel concludes “people with mental disorders deserve better.”

This isn’t the first time Insel has gone public with his contention (which is virtually unassailable) that the DSM does not offer validity.  He talked to me about this for The Book of Woe. “There’s no reality to depression or schizophrenia,.” he said. Indeed, the idea that there is a reality to them has dominated–and in Insel’s view hamstrung–research for more than three decades. “We might have to stop using terms like depression and schizophrenia because they are getting in our way.” And he didn’t stop there. “Whatever we’ve been doing for five decades,” he told me, “it ain’t working. And when I look at the numbers–the number of suicides, the number of disabilities, mortality data–it’s abysmal, and it’s not getting any better.. All the ways in which we’ve approached these illnesses, and with a lot of people working very hard, the outcomes we’ve got to point to are pretty bleak…Maybe we just need to rethink this whole approach.”

It’s a stinging rebuke, and the timing of his blog post makes it even more so. Two weeks before the DSM-5 comes out, Insel indicts the manual. It’s as pointed as it gets at his level: he’s taking the APA to task for not having found a way out of its “epistemic prison”– a term coined by Insel’s predecessr at NIMH, Steve Hyman, who first expressed these concerns in 1999. Hyman likened the job ahead to repairing an airplane while it is flying. Now Insel has suggested that we all might be better off if they just landed the thing and let the passengers look for another flight.

With a special guest

Actually, not a reading at all, but a conversation with Mitch McCabe, who is making a film about the DSM.

Come one and all!