Science and Psychiatry

By A. G. Moore 5/7/2013

Impression of a Brain Affected by Borderline Personality Disorder
Author: Mmm Daffodils
On Wikimedia Commons Public DomainThere was an upheaval of sorts in the medical community last week. Dr. Thomas Insel, Director of the National Institute of Mental Health, challenged the validity of the DSM, the diagnostic “bible” of psychiatry. Dr. Insel made his announcement shortly before the release of the DSM’s 5th edition.Members of the American Psychiatric Association’s DSM Committe should have seen this challenge coming, but arrogance got in the way. Controversy about the contributors, research methodology and content of DSMV-5 has been swirling around for years. Leaked copies of the manual led to protests by providers and consumers; both are bound by the DSM’s pronouncements. Despite the vociferous objections, however, the APA insisted its decision about the DSM was final and publication of the 5th edition would go forward.The details of the objection Dr. Insel outlined in his challenge to the DSM was even more startling than the fact that he questioned the manual’s legitimacy. Dr. Insel asserted that psychiatry needed to depend more on research and scientific tools than on subjective impression.What? Let me say that another way. Dr. Insel would like psychiatric practice to conform more closely to the research-based practices of other branches of medicine; he believes advances in gene studies and neuroscience should underpin psychiatric diagnosis and treatment. In order to illuminate his point, Dr. Insel described recent advances in cancer research.Dr. Douglas A. Levine, for example, co-leader of a Sloan Kettering study, discovered that common genetic markers exist between sub-types of uterine, colorectal, breast and ovarian cancers. The common markers suggest a link that might lead to understanding the causes of these cancers and that also might lead to targeted cancer treatments.Dr. Insel, as head of the NIMH, has challenged psychiatry to use science the way the Sloan Kettering team has: to discover common causes of seemingly different mental illnesses. Since funding from the NIH drives so much of medical research, Dr. Insel’s suggestions will certainly have a profound effect on the direction psychiatry takes in the future.Though his perch at the head of the NIMH gives Dr. Insel power to influence the future of psychiatric practice, his is not the only voice challenging DSM’s diagnostic criteria. In 2009, Dr. Paul McHugh of Johns Hopkins Medical School wrote about the APA’s flawed methodology in arriving at the DSM’s diagnostic criteria (see: Psychiatry at a Stalemate). Dr. McHugh also called for greater reliance on genetics and neuroscience in the profession.What both Dr. Insel and Dr. McHugh hope to retire is the “checklist” approach to psychiatric diagnosis. This approach entails looking for common symptoms instead of common causes. This “soft” approach to diagnosis and treatment is not used in other branches of medicine. While doctors in other branches look at symptoms, they also rely on objective evidence to support a “hunch” they may have.The bottom line of Dr. Insel’s bold move is this: psychiatry has been prompted to move in the direction of hard science, of proof not conjecture. This is good news. The bad news is, we are still stuck with DSM-5; this flawed manual will govern standards of care, because there is nothing else for psychiatrists to go by. Insurance reimbursement, school and government programs will still look to the DSM. So lives will continue to be affected by this flawed instrument.However, with the public criticism of DSM-5 by the National Institutes of Health, doctors and patients may feel more bold in their skepticism of this diagnostic “bible”. Private moments between doctor and patient may see more instances of discussion about options and alternatives. The DSM straightjacket has been loosened, and maybe in the slight freedom offered a more enlightened approach toward psychiatry can prevail.Thank you Dr. Insel.

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