The new Diagnostics and Statistical Manual, DSM-V, is out. Not surprisingly, it has sparked some controversy. Psychiatry deniers are proclaiming that this is the collapse of the mental-illness fraud (I believe reports of the death of psy...
The new Diagnostics and Statistical Manual, DSM-V, is out. Not surprisingly, it has sparked some controversy. Psychiatry deniers are proclaiming that this is the collapse of the mental-illness fraud (I believe reports of the death of psychiatry are exaggerated).
What the DSM-V does represent, to some degree, is an attempt to advance psychiatry to the next stage of our understanding of illness. It seems that we are not quite ready for this step in psychiatry, but the effort is sincere and interesting.
For background, the DSM (now in the fifth edition) is essentially a list of official psychiatric diagnoses, based upon clinical criteria. For mental illness and disorders we mostly lack clear biological markers or pathology, and so we have had to make due with clinical descriptions – lists of signs and symptoms. This is very much a descriptive phase of scientific understanding.
What almost every popular article I read on the subject gets terribly wrong, however, is in characterizing this as a unique feature of psychiatry, unlike the rest of medicine. A recent Wired article, for example, writes:
In most areas of medicine, diagnoses are based on the cause of illness. Heartburn and heart attacks both cause chest pain, but they’re different diagnoses because they have different underlying causes.
At least they added the qualifier “most”, but even that is misleading.
In fact most disorders and medical illnesses begin their life as a description of signs and symptoms – a purely clinically defined entity. Scientists then investigate possible causes, with the full spectrum of success. Some illnesses we have very little idea, nothing but guesses, about the cause and pathology. In others we have a completely fleshed out model of what is happening, down to the most reductionist level.
The Wired article also notes:
What doctors now diagnose as schizophrenia may in fact be several disorders with different causes that happen to produce an overlapping set of symptoms.
True, but his is also true of many medical illnesses. ALS (Lou Gehrig’s disease, which causes progressive weakness), for example, is a clinical syndrome. We don’t know the ultimate cause, so it is entirely defined clinically. It is very likely to be multiple pathophysiological diseases with a common manifestation.
Migraine headaches are another favorite example. They are diagnosed by a list of symptoms, just like DSM diagnoses. Migraine is likely many different underlying biological entities that all manifest in a similar fashion. It is also possible that underlying biological traits manifest in some people as classic migraines, in others as a different type of headache, and in still others with no symptoms.
Medical diagnoses span the entire spectrum from a pure description of clinical features, to some knowledge of mechanism, to fairly complete pathophysiologal description. Mental illness is not unique for being at the clinical description end of the spectrum.
What neuroscientists focusing on mental illness are seriously trying to do is advance pyshicatric diagnoses to the next step, from pure clinical description to at least classification by underlying mechanism. No one thinks this is going to be easy. The brain is very complex, and the higher cognitive manifestations of the brain are subject to a host of influences. Teasing apart those influences to determine their relative contribution to a mental disorder is a herculean task, but not impossible.
Possible influence include genes, epigenetic factors, developmental factors, biological factors such as nutrition, and all possible environmental factors.
Scientists understand this complexity, but you would not know that from reading many popular treatments of the current DSM and efforts to advance our understanding of mental illness. For example, a recent Slate article, Double Inanity, claims right in the subtitle that “twin studies are pretty much useless.” It opens with this howler