My personal favorite absurd thing that got said at the APA convention: a statistician on the DSM task force said, “The DSM guides diagnoses. It doesn’t define disorders.”

Say what?

First of all, why can’t it do both? Come to think of it, doesn’t it have to do both? Unless they’re thinking of it like the Field Guide to the Birds, in which someone else’s taxonomy is taken for granted and then the book helps guide you in identifying whether that bird is a blue-footed booby or a grey-crested tit. Which, I think, is exactly what they wish were the case. But it’s not, and that is why they;ve spent, as they’re so fond of reminding all of us, ten years and 25 million dollars, wrangling over which disorders exist and how to define them. And really, if the DSM doesn’t define disorders, then who exactly does? God? Webster’s Collegiate? Google?

Second, and more important, why waste time trying to cover over the fact that you’re producing an authoritative document? I don’t think the APA has thought this one through all the way. This same statistician also repeated the party line about how the DSM is a living, breathing document. (Which sounds a little scary to me; I have visions of a book storming down city streets, eating cars and stomping on buildings.) Can’t you just see this in court, the defense having just proved that its client suffers PTSD, as defined int he DSM. and the prosecutor quoting the authors of the DSM saying that the book doesn’t define disorder and that it’s not a Bible, but a living breathing document? Or school systems holding off on providing services because the APA says the  DSM is still being beta-tested?

I don’t blame them for trying to have it both ways: the authority of medicine and the flexibility demanded by the complex human mind. But really, you can’t square that circle, and the closer they try to move toward this brain-based account of subjectiv e suffering, the more they’re going to have to try,.

“You could ask whether something happens to change brain development,” tom Insel said, “but you could also ask if it’s something about the brain that leads to pathology.” He was talking about attention-deficit hyperactivity disorder, showing an animated slide depicting, side-by-side, the the brain development of a normal and an ADHD kid. “We call this ADHD,” he went on, “but it really looks like a disorder of cortical maturation.” ADHD, he acknowledged, encompasses some behaviors, but if you continue to focus on them, “if you don’t start to think abouit it as a cortical maturation problem, you lose.” We have to “stop looking at the behavioral,” he went on, because “the behavioral and the cognitive are the last thing to change. So long as we only stick with what’s observable, he conclluded, “we’re talking about getting into this game in the ninth inning.”

Insel then showed another slide–a moth called the Tropical Skipper. Turns out that the Tropical Skipper can come from ten different caterpillars. In other words, many different genotypes can lead to the one phenotype. There are many neural paths to depression, many genetic paths to schizophrenia, and many different ways in which the same biochemistry, neural and/or genetic can show up in behavior and cognition. Thsi problem–what scientists call heterogeneity–is what haunts phenomenological accounts of suffering. We are blinded by the light of lived experience and fail to see  the true reality underneath it.

If Insel grasps the religious nature of this argument, of this idea that appearances are the work of the devil who doesn’t want us to see the4 divine truth, he doesn’t indicate it.

What he makes of it, however, is something that your average knuckle-rapping nun would fully appreciate: that the earlier you catch onto a person’t pathology (the nun would of course call it sin) the more effectively you can intervene. That kid bouncing off the walls in school? The fight between Insel and the nun isn’t over whether or not the problem is in the kid or the school; it’s over what exactly is wrong inside the kid. Is it sinfulness or a lack of cortical thickening?

Either way, it is incumbent to do something now, to prevent perdition later. “Behavioral or pharmacological treatments” is what the modern psychiatrist always says (“behavioral treatments” being some kind of therapy, whcih is acceptable because we know that therapy can have brain effects too), but really they mean drugs. I mean, if you really can’t afford to wait for the ninth inning, there is no behavior to treat.

So don’t think for a second that the drug companies aren’t listening very closely to Insel.

This is why the DSM-5 is going to include Attenuated Psychotic Symptoms Syndrome (or whatever they call it) and Disruptive Mood Dysregulation Disorder (formerly Temper Dysregulation Disorder) and other “subthreshold” diagnoses–because the wave of the future is early detection of pathology, and early intervention. You just can’t start rapping their knuckles too early.

So why, you might ask, this sudden pessimism on the part of psychiatrists? (Or is it just honesty? Remember depressives are better at reality testing than non-depressives, which implies that pessmism is more trustworthy than its opposite.)

The answer is simple. It’s safe for psychiatrist to come clean about how bankrupt the scientific and intellectual underpinnings of their discipline are because they think they have something with which to replace it. Actually, they have two things: a new DSM and a new project initiated by the National Institute of Mental Health. DSM-5 and RDoC  actually have very little in common, although no one quite wants to admit it, preferring instead to pretend that the APA and the NIMH are singing kumbaya together. But they do share this sudden antipathy toward psychiatry up to this point, and they’ve both pointed the finger at the same culprit: the DSM-IV.

So this convention is very much a DSM-IV hatefest. The book not only reflects the lack of what Insel calls Science; it is one of the big reasons why psychiatry is so benighted, and its continued use can only further benight the profession.

So far, it’s hard to disagree with them. But in their view, the DSM-IV fails because it is a phenomenological account of human suffering, i.e., because it looks to the actual lived experience of distress in order to understand it. It’s important to see that their beef isn’t with the quality of that account. It’s not like they’re saying that the DSM-5 needs to provide a better phenomenology than the DSM-IV. It’s that it should pay as little attention to people’s experience as possible, and  only until neuroscience makes it unnecessary. Evidently, the mistake Bob Spitzer made in formulating DSM-III (and DSM-IV is really only a modification of Spitzer’s approach) was in not sufficiently eliminating the human. Spitzer, they think, didn’t throw the Freudian baby–the idea that our suffering has some kind of meaning, that its specifics are important–out with the bathwater of Freud’s metapsychology.

Of course, neuroscience was just a twinkle in psychiatry’s eye when Spitzer was in charge, and not much more than that when Al Frances came along. But now, what with those fMRI and PET scans, with genetics and genomics and all the other biochemical techniques at their disposal, psychiatrists are ready to try to cut out the middleman–that’s you and me and our lived experience–entirely. They want to drill down to the deepest level of all, the molecular world where, in their view, we are assembled into selves. Why bother listening to patients, what with the vagaries of their language and all the deceptions and evasions in whcih they engage (not only because they are sick, mind you, but because they are human and therefore incapable of reporting accurately what’s going on in their amygdalas and their DNA), why bother trying to make sense out of what they tell you when you can just look at the readout or the brain image and find the pathology there? Why bother wondering if a person is schizophrenic or bipolar, if he has depression or anxiety, if what we think today is Asperger’s disorder really is mild autism when the answer is really none of the above, when the answer is that this person’s ventral medial prefrontal cortex and the circuits it feeds have gone haywire. What difference does it make how that pathology manifests. I mean, do we really care what kind of pain a cancerous tumor causes, or whether it causes pain at all?

Among the most interesting things Insel said was in his discussion of the disappointing results of the various genomic studies. Psychiatry is not alone in having found very few illnesses that correspond to particular genetic variants, but in the context of all the other problems, this failure is more problematic.

Psychiatry may be different from other specialties, however, it the extent to which it has promised much more than it has produced when it comes to the discovery of biochemical causes of disease. And here something Insel said bears particular notice. He went out of his way to point out that there are no variants that map onto disruptions in the metabolism of serotonin or dopamine, the neurotransmitters most familiar to us from the repeated assertions, in doc tors’ offices and advertising and news stories. “It may be that neurotransmitters have nothing to do with pathophysiology or etiology of mental illness,” he added. Which he didn’t have to do, and every word Insel utters is significant, since he decides what studies get funded and therefore the overall direcction of psychiatric research. So what he was saying is, “Don’t come to me with more studies about neurotransmitters. That’s not where it’s at.” Someone will have to break the news to the drug companies that their best advertising strategy is kaput.

What I wonder is, in the 90 minutes that  Insel spoke, how many doctors told how many patients that they were suffering from a chemical imbalance or a serotonin deficiency or dopamine surge, which means they have a lifelong illness like diabetes and need to take drugs for it? The disconnect here between waht docs know and what they tell the rest of us is stunning and just plain wrong.

Here at the annual meeting of the American Psychiatric Association, I’m learning all about what terrible shape psychiatry is in. It used to be that this kind of bad news was delivered by fringe groups–gay psychiatrists, for instance, who informed the APA at annual meetings in the early 70s that neither they nor their patients were mentally ill just because they liked to have sex with people of the same sex, or the psychoanalysts who argued that the world would end if the industry turned to a non-Freudian conceptualization of mental illness, or just your usual doomsayers carping about reduced insurance payouts and so on.

But this year, it’s coming from the top, from America’s #1 psychiatrist, Tom Insel, the head of the National Institutes of Mental Health. In a speech kicking off the conference yesterday morning, Insel didn’t mince words. “We don’;t talk much about this,” he said, but when it comes to mental illnesses, psychiatrists lag far behind their colleagues in other specialties. “Diagnosis is by observation, detection is late, prediction is poor. Etiology is unknown, prevention is undeveloped. Therapy is by trial-and-error. We have no cures, no vaccines. We’re not even working on vaccines. Prevalence has not decreased. Mortality has not decreased.”

And it’s not like we’re talking about treating wrinkles or baldness here. Accordinb to the World Health Organization, mental illnesses are the most disabling afflictions worldwide, measured in something called Disability Adjusted Life Years. There were 34 thousand suicides in 2007, 90 percent of them related to mental illness. That;s more people than die in traffic accidents, and double the rate of homicide–and both of these have decreased in the past decade. People with serious mental illness have a 25 percent reduced life expectancy. And so on.

In short, mental illness is out of hand and psychiatrists don’t really understand what it is, how to diagnose it, or what to do about it.

At least that’s what they say to each other.