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The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is here, and it’s dead on arrival. A few weeks ago, the National Institute of Mental Health (NIMH) announced it will no longer fund research based on DSM symptom clusters — for the simple reason that the DSM is irrelevant to determining the cause and treatment of psychological problems. Here’s why:
A huge disconnect exists between DSM categories and treatment.
Some diagnoses have no viable treatments, some have the same treatment (for example, David Barlow’s unified treatment for emotional disorders), and some have multiple evidence-based treatments. If DSM diagnosis doesn’t inform treatment, what good is it? The answer is one, to facilitate the exchange of money between payers and providers, and two, to create silos for focused research. With the NIMH announcement, scratch number two.
The DSM is a topographical symptom map that doesn’t point to the actual causes — underlying mechanisms — that drive and maintain disorders.
These mechanisms, sometimes called trans-diagnostic factors and/or vulnerabilities, are how we now formulate and explain psychological pain. Trans-diagnostic factors like experiential avoidance, rumination or “stewing on it” and cognitive misappraisal, along with vulnerabilities like intolerance of uncertainty, hyper-arousal, and negative schemas create psychological disorders. Our treatments must be aimed at these causative mechanisms rather than outdated symptom clusters.
Dr. Insel, you’ve been quoted, and Dr. Lieberman did describe the DSM as sort of a dictionary. And you said that patients with mental disorders deserve better. What did you mean by that?
INSEL: That’s a way of saying that we now have a dictionary to describe the disorders, just as Jeff said, but what we’re really lacking is a deeper understanding and a way to do for people with mental disorders what we do typically for people with other medical problems, that is to have biomarkers, have predictors of who will respond best to which treatment, and have guides based on the biology of the illness that helps to tell us where the best treatments might come from in the future.
We’re missing all that. So when I say they deserve better, what I mean is we’ve got to do more than just produce a dictionary. We’ve got to actually produce an encyclopedia, something that has much deeper information so that we can provide much better interventions, and ultimately get much better outcomes.
FLATOW: Gary Greenberg, you’re most critical. The subtitle of your new book is “The DSM and the Unmaking of Psychiatry.” What is wrong with the DSM?
GREENBERG: Well, you know, the DSM is – reflects both the best and the worst about American psychiatry. It certainly represents a sincere effort to understand mental illness. And if all it were was an attempt to create good clinician communication, then we wouldn’t be sitting here and talking about it.
The problem with the DSM is that while psychiatrists would be quick to say it’s not really a bible in the sense that it shouldn’t be taken literally, it is a bible in the sense that it underlies psychiatry’s authority. And with the kind of problem that Dr. Insel just described, which is that it doesn’t go to the question of what actually mental illness is, and, in fact, its descriptions may not correspond or line up with whatever biochemical or genetic findings we come up.
What has happened is that psychiatry’s gone – been led down the path by the DSM into a situation in which its disorders are constructs. They aren’t real in the way that we generally expect diseases to be real. And this has – this is not just a philosophical problem. This is a real problem, because what happens is that research follows the DSM. And so doctors end up researching and scientists end up researching disorders that are, in some way, mythical.
So whatever uses the DSM…
FLATOW: Well, when you say mythical, and let me get into a couple of those. So you have schizophrenia or bipolar, or – you’re saying these are mythical?
GREENBERG: Well, in my book – I interviewed Dr. Insel for my book, and he’s a very forthright man, and he said look, this is a problem. Psychiatrists come to think that schizophrenia is real. But schizophrenia is not real in the sense, again, that we normally expect diseases to be real, as he just said, with biomarkers and so on.
What schizophrenia is is a label applied to a group of symptoms. But there may be many ways to get to those symptoms. And, in fact, to some extent, what we see is that the genetics especially, and with family history, show that a common genetic underpinning may lie underneath both schizophrenia and bipolar disorder. The most venerable distinction in the DSM is between bipolar disorder and schizophrenia, and yet it may be that they have a common pathway.
So the – it’s like, look, using the DSM to understand the terrain of mental illness is like using a map of the moon to get around Manhattan.
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