This post follows part one, on the Human Genome Project and the inheritance of psychological traits and psychiatric conditions, and part two, on the past failures of neuroscience to comprehend the nature of human experience and to address psychopathology. In part three, I discuss how the fundamental dispute over the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which has already been rejected by the director of the National Institute of Mental Health, is about what it means to be a human being.
American psychiatry is in crisis. The New York Times declared: "Before the long-awaited publication of a new edition of the so-called bible of mental disorders, the federal government's most prominent psychiatric expert has said the book suffers from a scientific 'lack of validity.'" And the remedy, according to this expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, is "to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience."
Insel represents a crucial American school of thought -- by far the dominant one in the United States today -- that equates the future of mental health with the brain, pure and simple. This school of thought is fundamentally wrong, has always been wrong, will always be wrong. And it is misleading our nation in trying to fathom and deal with our apparently untrammeled descent as a nation into madness. While Insel feels that we need to define mental illness purely biologically, according to the Times, "Decades of spending on neuroscience have taught scientists mostly what they do not know, undermining some of their most elemental assumptions." In parts one and two of this series, I reviewed how similarly confident genetic and neuroscientific claims to Insel's have been decisively proven wrong over the decades, while we undergo an epidemic of mental illness.
Other practicing psychiatrists take the exact opposite position to Insel in relation to DSM-5. Paul McHugh (formerly psychiatrist in chief at Johns Hopkins Hospital), in his piece in WSJ entitled "DSM-5: A Manual Run Amok," complained,
Psychiatric practices became centered on using the manual to identify disorders, much as a naturalist uses a field guide to identify birds or trees. The treatments derived from these diagnoses had no particular theory behind them. They were efforts, mostly pharmacological and rule-of-thumb, to provide relief from symptoms. Psychiatric thinking about patients and their disorders withered.
So far, McHugh's objections are similar to those raised by Insel. But from this point on, McHugh diverges. He's not in favor of expanding the pharmacological remedies now commonly prescribed and whose use will only increase: "A recent nationwide diagnostic census based on DSM claimed that the majority of Americans have or have had a mental disorder. As a result, an appalling number of young adults in schools and colleges are on one form or another of psychiatric medication."
Moreover, rather than demanding a greater "focus on biology, genetics and neuroscience," this is how McHugh sees the underlying nature and diversity of mental disorders, in this case depression and anxiety, basic signposts in any list of disorders:
Psychiatrists know, for instance, that depression and anxiety can derive from a number of different sources: cerebral diseases such as schizophrenia and bipolar disorder; alcoholism or drug addiction; experiences of loss, deprivation or trauma; and, more generally, a vulnerable temperament, characterized by introversion, shyness and emotional intensity.
Deciding which of these sources, alone or in combination, applies to a particular patient requires hours of evaluation. Prescribing an appropriate treatment involves not checking symptoms but determining who the patient is and what he or she has experienced and done.
In McHugh's vision, psychiatry requires exploring the whole human being and his or her lived experience. And when evaluating McHugh's versus Insel's perspectives, keep in mind that, in reference to diagnosing depression, the World Federation of Societies of Biological Psychiatry's consensus paper asserted: "No biological markers for major depression are currently available for inclusion in the diagnostic criteria." So how would Insel have preferred to define and measure depression, anxiety (which is even less likely to show one distinctive marker), schizophrenia, etc. instead of DSM-5? He doesn't answer this question in his media appearances.
Here is another psychiatrist, Nigel Bark, who as a member of the Assembly of the American Psychiatric Association voted to approve DSM-5. Bark uses exactly McHugh's argument (this time in reference to schizophrenia) to defend the manual versus Insel:
The search for genes and biological markers in psychiatric illnesses is essential, but to expect "the biological underpinnings of disorders" to solve the inevitable problems of any diagnostic system is both unrealistic and unscientific.
For example, schizophrenia, like most chronic physical illnesses, has multiple causes: genes, infection during pregnancy, lack of oxygen at birth, abuse or neglect in early life, marijuana in adolescence, discrimination and acculturation difficulties, among many others. The biological findings may be consequences of the causes and not "underpinnings" and may not be specific for schizophrenia and are not yet useful for diagnosis.
McHugh's and Bark's basic vision -- which they share, even though they take opposite positions toward DSM-5 -- is not one explicitly discussed by DSM-5. They are speaking of the nature of human beings and their experience, and of the multifarious causes of human psychological dysfunction. The debates around the psychiatric manual are bumping up against the fundamental reality of what being human means. And these discussions cannot proceed sensibly without comprehending the concept of the reductive fallacy -- the belief (oft-disproved) that biological psychiatry can resolve all of human functioning into biochemical terms.
Insel does not acknowledge this philosophical issue nor, seemingly, any of the evidence that supports McHugh's and Bark's views. Nor is Insel deterred by the failure of the approach he favors to appreciably improve the condition of the human psyche -- when, in fact, the reverse has occurred in America over the last several decades. As we shall see in part four, not even the critics of the BRAIN Initiative seem aware of any reason to doubt that dissecting the wiring of the brain will solve our psychiatric and social problems.
Disclosure: I consulted on substance use disorders for DSM-IV, but wasn't asked to contribute to DSM-5.
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