Tuesday, June 11, 2013

So What’s All the Fuss About DSM 5? Part 1

I’m assuming you’ve heard of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, that doctors use as a handbook to help them diagnose our psychiatric conditions. Since the 1980s DSM has been the clinical ‘Bible’ and given professionals a common language. Periodically it is revised by the American Psychiatric Association. Well, DSM mach 5 is due to roll out any day now, and it is surrounded by controversy.

Controversy about DSM revisions is nothing new. But this time, the National Institute of Mental Health (NIMH) has rather spectacularly proclaimed that DSM 5 categories will no longer be used for funding research. NIMH wants to start a new system for researching and classifying studies on a scientific basis, which it is calling Research Domain Criteria (RDoC). You can read the 4/29 blog post by NIMH Director Thomas Insel here: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.

Basically, the idea is that rather than doing research into a chosen cluster of symptoms with a group name (e.g. ‘Schizophrenia’), they want to start diagnosing using scientific and biological markers: genetics, imaging, and other laboratory measures. A symptom could be studied no matter which DSM category it formerly fit into, to eventually be reclassified once the facts are in. The example given is anhedonia (loss of interest in formerly pleasurable things), which could now be funded and studied whether it was part of depression or an eating disorder. The goal would then be to discover how anhedonia actually worked, and possibly reclassify types of anhedonia later based on collected evidence. In other words, how about we find out what’s CAUSING these disorders, instead of just describing them?

There are two problems with this scheme. One is that it is 50 years too early; the other that it is 50 or 100 years too late.

Early because the data aren’t there. Nobody has really studied symptoms this way, and it will be a very long time before there is enough information to start collating and classifying, much less constructing an entire new diagnostic framework.

Late, because psychiatry should have been put on a strictly evidential basis a very long time ago. The mentally ill have always been prey to uninformed guesswork by doctors and society alike, since very ancient times. Long ago they were sure we were possessed by demons. At the turn of the last century, horrific water treatments and chains and other tortures were going to ‘cure’ us. Then it was psychobabble about what kind of family environment produced schizophrenia. We are certainly better off now, with drugs that actually work sometimes, but finding the right medicines - many of which were discovered quite accidentally, by the by - is still a crapshoot, a matter of blind experimentation.

I was giving a presentation in a psychiatric ward last Friday. We were over and over disrupted by a patient yelling that psych meds were bunk, that there were no biomarkers for our diseases, and that cymbalta had ruined his liver and his life. We eventually had to ask him to leave so that we could go on with the presentation. But I had a sneaking sympathy for him. Where ARE the proofs? Where is the real, objective evidence? We deserve better, and we have deserved it forever.

But meanwhile, back on the ground, who’s going to run things? How are clinicians to decide what to do with people who walk into their offices? Until we have all that good new data, we will have to use the DSM. Of course. There’s nothing else available, unless you want to go by the ancient Chinese system which blames ghosts for our disorders, or the Ayurvedic system which blames astrology. Sorry, but no.

So, what does the DSM 5 say that’s different? I’ll look into that and try to sum it up for you in my next blog.