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!

A busy 24 hrs.

A NY Times review, in which Dwight Garner says I pace the psychiatric stage like a cross between George Carlin and Gregory House. I have to share space with Allen Frances’s Saving Normal but on the other hand the review ran on the front arts page, so I’ll settle.

A Nature review (probably need a subscription, but I’ll post in the reviews page soon. By David Dobbs, who calls BOW a “splendid and horrifying read.” It’s a nice, chunky review.

A Q&A at atlantic.com. Which is really funny, or something like funny, because I had no idea it was a Q&A. I kept wondering why the writer, Hope Reese, was asking me questions that seemed intended to get me to recite my book, when she could get all that by reading the book (which she clearly had done) and spare herself the transcribing. Answer: she wasn’t writing an article. She was going to write what I said, verbatim. Whoops. I am definitely more House than Carlin, that is, more growly than  funny, and I say some pretty intemperate things, like “They should just take the damn thing [the DSM) away from them [the APA]. But only a couple are embarrassing.

A blog post at newyorker.com  that I thought would convince people that I really don’t think disease is a biochemical category, but I was wrong.

A nice interview on CBC, public radio in Canada, to be broadcast later in the month.

And best of all, lots of happy-for-me emails from friends and family. My self-loathing is at an all-time low today.

From the mailbag: Barney Carroll, a former Blue Devil psychiatrist who blogs here, took the time to make a lengthy comment, which is meaty enough to give its own post, and to respond to in some depth.

It seems we have a major case of cognitive dissonance here, Gary. When I read your post I was bothered first by the dismissive references to Ike. It does not advance the dialogue to say that Ike was sucking the MIC tit all his life. His farewell speech in 1961 contained an enduring insight: that national security is paradoxically threatened by an unchecked military-industrial complex because both partners commit to flawed paradigms out of misguided self-interest and perverse incentives. This insight finds other applications today, such as in the academic-industrial-government complex. Ike’s warning went to other stakeholders besides the military and the executive branch of government.

I agree that Eisenhower’s farewell address contained a great deal of wisdom, but whether or not it advances the dialogue to point out that it was a case of biting the tit that feeds you depends on the dialogue you are trying to advance. I think what’s interesting about the address is not the insights it provided, which, true as they were, were nothing terribly original. For example, Dr Strangelove came out in 1964, three years after Ike’s swan song, and Kubrick always said it was based on Red Alert, published in 1958, so I think it’s safe to say that people outside government were onto the MIC problem before the farewell address.

This doesn’t mean it’s not to Eisenhower’s credit that he could see it at all, or that he said anything about it. It is surely impressive that he could get outside himself enough to do what he did. One only wishes he had had the insights before he was leaving office, i.e., when he still could do something about it. Maybe if he had, we wouldn’t be where we are today. (On the other hand, as the most recent presidency has shown, a president has limited powers to turn the ship of state off its course.) So the dialogue I wish to advance, or at least the point I was trying to make, is that the question of what Ike said is not as interesting as the question of when he said it, and why.

But more to the point, I mentioned Eisenhower only because the example is so obvious, the parallels with Frances unmistakable. And I say that at first it looks like what Frances is doing is what Eisenhower did. But I dont’ think he is. Unlike Eisenhower, who stopped short of drawing out the connections between the MIC and the way capitalism and empire work, and to his great credit, Frances did more than chide his institution on the way out the door. As much as he wanted (and continues to want) to pin the whole DSM-5 fiasco on bad management at the APA, he also (at least to me, which he may well regret) spoke openly and often about the problem that the APA was, at least in its own account, trying to fix, first with its abortive attempts at brain-based diagnosis, then with its unsuccessful stab at dimensional measures: that the DSM is, by necessity, a book of useful constructs. And he said that this was why the APA’s behavior was so maddening: that the DSM was fragile, that it might not be able to withstand incompetence and overreaching. So Al went Ike one better, getting at the root causes in a way that cannot help but call into question the authority of psychiatry over our inner lives.

Now of course Al would say, “but they’re not only constructs” but publicly discussing this fact at all was a risky move, because psychiatry (like all medicine) is based on a myth: that disease is a biochemical entity whose pathogens can be specified and targeted. It’s an infectious disease model that works pretty well for tuberculosis but not so well for many other conditions, including psychiatric disorders. (I’ll have a blog on this at newyorker.com later this week.) It’s risky to bring attention to the way that psychiatric diagnosis fails to conform to this myth, because, unlike the rest of medicine, psychiatry doesn’t have slam-dunks like pneumococcus, which conform quite nicely. Once you point out that its diagnoses are constructs, you open the door to a kind of public scrutiny that is reminiscent of the scrutiny of the late 60s and early 70s. You give the Scientologists ammunition. You invite wise guys like me who are naturally suspicious of people with power over our inner lives to say, “Now just a second here!” So the question I’m raising (and accusing myself of having failed to answer) is why he would do that.

Next I was bothered by the attitude that calls psychiatric diagnosis “closer to fiction than to fact.” Here cognitive dissonance enters again. We should recall that patients afflicted by serious disorders existed before the healing professions arose. The history of the healing professions is in large part a history of trying to make sense of those disorders – efforts at nosology, that is. Nosology is a prelude to differential treatments. But I think you invert the issue by the way you frame it. We are not bent on seizing sovereignty over the inner lives of patients, as you put it. The patients have always been there, afflicted by psychosis, mania, melancholia, crippling anxiety, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. The members of the healing professions did not manufacture these disorders – rather, people suffering from them came to us for help.

As you know if you are reading my book, I don’t entirely disagree with this. Where we disagree is over whether or not these disorders are best understood as medical disorders. Historically,it’s not clear to me that people have always gone to doctors about all the troubles that psychiatry currently claims to treat, but even if they have, that doesn’t occur in a vacuum. The last 20 or 30 years have been a case study in how to grow a market by convincing people that their everyday troubles are a deficiency that a particular product–psychiatric treatment–is best suited to correct. Pharma has done the heavy lifting on this, but psychiatry has helped–for instance by turning the ECA and NCS numbers into the myth of undertreatment. And what psychiatry has not done a very good job of is delimiting its domain. None of this would be happening if we had stuck with the original 14 diagnoses of the Washington group, or the 21 (?) of the RDC.

I also don’t think it’s fair to say that I believe psychiatrists are “bent on seizing sovereignty” over our inner lives. It’s clearly a dance between people who want magic bullet cures and doctors who would like to provide them. To me, however, there is no question who is leading the dance, and who therefore has the obligation to pay attention to whether or not the couple is about to bang into someone else, or to slip out the door of the dance hall and over a cliff.

Finally, I would say that fiction and fact are probably not categorical but dimensional. Even the bacteriological model of disease is still a model.You can watch bacteria multiply in a petri dish and then watch penicillin kill them and extrapolate from there to the person who recovers from pneumonia after a dose of antibiotic, but you still have some storytelling to do about why and how that actually happened, and what its relationship is to what happened in the petri dish. So the mere fact that the DSM is a collection of stories doesn’t bother me. What bothers me is that it is not presented that way, disclaimers at the beginning notwithstanding. ONe purpose of the modern DSM, according to Spitzer, was to restore the credibility of psychiatry, whose woes at the time were largely nosological. “Open it up,” he says. “It looks scientific.” And indeed it does. So what is troublesome about psychiatric nosology that at least some of the people who promulgate it have an interest in it appearing to be toward one end of the spectrum when it really is closer to the other.

When you say Allen Frances believes that power in the right hands does not necessarily corrupt but can be used for good, I would disagree. Enter cognitive dissonance again. It is not a matter of power but of duty and obligation, essential features of a disinterested profession. I would make the same argument in the case of Ike: he was less interested in power for its own sake than in discharging what he saw as his duty over a lifetime in the military.

Here we do disagree. I don’t believe there is any such thing as a disinterested profession. Power is always at work. That’s why Freud’s notion of countertransference was so important. (Although I don’t think he meant it as a check onanalyst power. There’s not much indication that Freud was very interested in that issue.)

I have made my share of criticisms of DSM-5 but I take second place to nobody in affirming the reality of major psychiatric diagnoses. I caution against your inclination to over-generalize about the weaknesses of psychiatric diagnoses. Yes, there have been serious missteps – pediatric bipolar disorder and the elimination of the bereavement exclusion for major depression, for instance. Yes, some of the players seem driven by therapeutic zeal rather than by good clinical science. Yes, the black and white perspective turns to gray as we move further from ‘show stopper’ disorders to the extremes of normal variation. But I take exception when you say psychiatry has been granted a license to medicalize our suffering. The suffering was already there, as were the calls for help. Allen Frances does not hold such a license… he is discharging a duty.

I’m not sure why you take exception. We have collectively placed our mental health in the hands of psychiatrists, no less than we have placed our digestive health in the hands of gastroenterologists. That gives doctors a license. They don’t have to go out on the street with nets to snag patients, but that doesn’t mean they haven’t been granted authority. Here again, we disagree about the inescapability of power.

AS for the reality of major psychiatric diagnoses, I am sure there are mental disorders that properly come under the purview of medicine in general and psychiatry in particular, and that do so because they are fundamentally organic in nature, no less than kidney disease or TB. But I don’t think we know yet what they are, or how to find them, or how to distinguish them from those extremes of normal variation. No doubt this is true all over medicine, but only in psychiatry, I would argue, is it the norm.

Thanks for your comments, Barney, and for your respect in the way you frame them.