.
Dr. Allen Frances, co-author of the previous version of the "Diagnostic
and Strategic Manual of Mental Disorders" (DSM-4) -- known as "the psychiatrist's bible" -- discusses new, controversial changes to the text. Frances is the
author of a new book called
"Saving Normal."
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Psychiatry divided as mental health 'bible' (DSM-5) denounced
from NewScientist.com - Health - May 2013
Guest editorial:
"One manual shouldn't dictate US mental health research"
by Dr Allen Frances
The world's biggest mental health research institute is abandoning the new version of psychiatry's "bible" – the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), questioning its validity and stating that "patients with mental disorders deserve better." This bombshell comes just weeks before the publication of the fifth revision of the manual, called DSM-5.
On 29 April, Thomas Insel, director of the US National Institute of Mental Health (NIMH), advocated a major shift away from categorising diseases such as bipolar disorder and schizophrenia according to a person's symptoms.
Instead, Insel wants mental disorders to be diagnosed more objectively using genetics, brain scans that show abnormal patterns of activity and cognitive testing.
This would mean abandoning the manual published by the American Psychiatric Association that has been the mainstay of psychiatric research for 60 years.
The DSM has been embroiled in controversy for a number of years. Critics have said that it has outlasted its usefulness, has turned complaints that are not truly illnesses into medical conditions, and has been unduly influenced by pharmaceutical companies looking for new markets for their drugs.
There have also been complaints that widened definitions of several disorder have led to over-diagnosis of conditions such as bipolar disorder and attention deficit hyperactivity disorder.
Now, Insel has said in a blog post published by the NIMH that he wants a complete shift to diagnoses based on science not symptoms. |
"Unlike our definitions of ischaemic heart disease, lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," Insel says. "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." Insel says that elsewhere in medicine this type of symptom-based diagnosis been abandoned over the past half-century as scientists have learned that symptoms alone seldom indicate the best choice of treatment.
To accelerate the shift to biologically based diagnosis, Insel favours an approach embodied by a programme launched 18 months ago at the NIMH called the Research Domain Criteria project.
The approach is based on the idea that mental disorders are biological problems involving brain circuits that dictate specific patterns of cognition, emotion and behaviour. Concentrating on treating these problems, rather than symptoms is hoped to provide a better outlook for patients.
"We cannot succeed if we use DSM categories as the gold standard," says Insel. "That is why NIMH will be reorienting its research away from DSM categories," says Insel.
Prominent psychiatrists contacted by New Scientist broadly support Insel's bold initiative. However, they say that given the time it will take to realise Insel's vision, diagnosis and treatment will continue to be based on symptoms.
Insel is aware that what he is suggesting will take time – probably at least a decade, but sees it as the first step towards delivering the "precision medicine" that he says has transformed cancer diagnosis and treatment.
"It's potentially game-changing, but needs to be based on underlying science that is reliable," says Simon Wessely of the Institute of Psychiatry at King's College London. "It's for the future, rather than for now, but anything that improves understanding of the etiology and genetics of disease is going to be better [than symptom-based diagnosis]."
Michael Owen of the University of Cardiff, who was on the psychosis working group for DSM-5 , agrees. "Research needs to break out of the straitjacket of current diagnosis categories," he says. But like Wessely, he says it is too early to throw away the existing categories.
"These are incredibly complicated disorders," says Owen. "To understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time, but in the meantime, clinicians still have to do their work."
David Clark of the University of Oxford says he's delighted that NIMH is funding science-based diagnosis across current disease categories. "However, patient benefit is probably some way off, and will need to be proved," he says.
The controversy is likely to erupt more publically in the coming month when the American Psychiatric Association holds its annual meeting in San Francisco, where DSM-5 will be officially launched, and in June in London when the Institute of Psychiatry holds a two-day meeting on the DSM.
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http://www.newscientist.com/article/dn23487-psychiatry-divided-as-mental-health-bible-denounced.html
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History of the Argument
OPINION (thoughts on an
article by Dr. Allen Frances)
(NOTE: What Dr. Allen Frances said was different than the opinion expressed below, as well as much longer and more scientific. To see the entire work, now 4 years old, you can type in a search for "A Warning Sign on the Road to DSM-V" and the article will come up. You'll have to sign in to Psychiatric Times to read the whole article (but it's free), and.worth a careful read.)
"A Warning Sign on the Road to DSM-V: Beware of Its Unintended Consequences."
Originally published in Psychiatric Times June 26, 2009--4 years ago.
An article by Dr, Allen Francis lays out the history of the arguolemt about how ro classify certain types of medical / mental conditions. It also gives access to the APA higher-ups' response to Frances, and a counter response from Dr. Robert Spitzer, who was the head of the Task Force of the DSM-III-- both articles from the first days of July, 2009.
The professional parrying to "win" an argument can make a complex issue even harder to follow. And even get ugly--but don't let that distract you.
Part of the problem is that psychiatry has tried to make itself a more exact science--to be more like medicine--with clear-cut diseases.
So for well over 50 years they have been seeking "chemical imbalances in the brain" as a form of disease.
(At the same time, the medications professionals give people don't correct those "chemical imbalances" in the brain.)
(The issue of negative side-effects of medication; how they affect people's ability to cope; and the disastrous effects of stigma that the term "mental illness" evokes are also go ignored).
We also need to take into account that psychiatry has a long history of practicing denial.
After Freud was pressured into abandoning his paper on "The Aetiology of Hysteria," (1896) in which he identified childhood trauma and molestation as a cause of adult distress, he concocted the Oedipus Complex---that childhood memories of sex were "fantasies" of what the child had desired. This provided a perfect cover-up to incest and child molestation.
It was the accepted psychiatric theory until the 1970s. Then, in rap groups of the women's movement, women began to share their stories and realized how common child abuse and molestation were--and started speaking out.
(There was also D.L Rosenhan's very thoughtful article in Science "On Being Sane in Insane Places" (1973)--angrily denounced as a hoax and made a taboo subject to research for many years).
(And Gregory Bateson's critique of the Behavioral Sciences in the Introduction of his book Steps to an Ecology of Mind (1973) was roundly ignored by too many)
After PTSD was included in the DSM-III (1980)--first for war trauma--people started coming into counseling with additional symptoms and at least some professionals realized that childhood trauma was more than just PTSD.
By 1990 these professionals (some were psychiatrists themselves) were trying to get childhood trauma into the DSM. For a while it was called DESNOS--Disorders of Extreme Stress, Not Otherwise Specified.
It was rejected for the DSM-IV (1994).
They kept working on it, doing the research, even though without official recognitiion it was much harder to get funding, and finally decided that Developmental Trauma was the better term--interpersonal trauma--trauma in relationships during the developmental years of childhood--or even intergenerational trauma--trauma passed down as learned behavior from generation to generation.
Despite the fact that many laypeople can easily understand that a child with trauma or dysfunctional relationships in their childhood is going to have behavioral problems, some influential higher-ups in the APA have continued to block recognition of the effects of trauma in childhood on a child's ability to develop normally.
That's the context in which this dispute is going on.
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