National Institutes of Mental Health Director Rejects DSM V | Hacker News Reader

National Institutes of Mental Health Director Rejects DSM V

blogs.scientificamerican.com

61 pointssehugg25 comments

The blog statement by the director of National Institute of Mental Health

http://www.nimh.nih.gov/about/director/2013/transforming-dia...

is much more informative and balanced on this issue.

I am part of a local "journal club" of psychology researchers and graduate students in psychology at my alma mater university, and what several of those researchers are seeking are more reliable diagnostic criteria based on biological information.

From what I get from reading around, it seems like pretty much all parties involved agree that most sound way to diagnose mental disorders is by being able to actually measure the physiological causes of the disorders, whatever they might be.

It's just that the group pushing DSM5 believes that we really need an updated set of definitions to guide diagnosis, that we have no reliable tests to look for physiological signs of mental disorders, and are unlikely to find and flesh out any in the near future (as in few years to a decade time frame), so we may as get DSM5 out for now, which does appear to update the various definitions and groupings to more accurately reflect our current understanding of the disorders - for example the groupings for various previously distinct diagnosis into spectrums.

There are certainly other issues with DSM5, such as exactly what thresholds are used and what not... but I certainly think that many of the issues (like omg! big pharma is trying to define everything so they get more sales) won't go away even with 'reliable' physiological tests.

How do you distinguish between the physiological causes and symptons? Given that it's possible for different thought patterns to produce different physiological effects how can you ever be sure whether physiological state is the cause or effect?

Thought is physiological state.

Thought is a dynamic and emergent property of the system, the combination of physiological state and stimulus. Perhaps a better way to phrase my original question would be: if the brain is a chaotic system, how do you distinguish between the emergent physiology and the factors which combined to cause it?

If talk therapy fixes a measured neurochemical imbalance, great. If temporary use of pharmaceuticals can help patients overcome negative thought patterns, also great. So in that regard, I don't think the distinction matters so much as long as the problem is solved.

If I were to design a diagnostic and treatment system for psychological conditions, I would take an engineering approach. I would start by identifying all the inputs and outputs of the system and correct undesired inputs one by one until the outputs reach their intended values.

I'm not particularly well versed in control theory, but I'd be willing to wager that one could use feedback loops to model the tricky bits of the human mind where one element (e.g. a particular neurotransmitter) could be considered either an input or an output. Maybe it doesn't matter whether you treat the thoughts or the chemicals, because rather than one being cause and one being symptom, they're both elements in a feedback loop, and all you have to do is interrupt the loop.

I certainly agree with what you're saying about the feedback loops, as long as you're able to manipulate the loop into healthier behaviour then it doesn't really matter where in the loop you intervene. My issue with pharmaceuticals is that they are used completely inappropriately. There are people who have neurochemical imbalances which do require pharmaceutical intervention. Taking the USA as an example though there is a huge proportion of the adult population taking pharmaceuticals for psychological issues. Many of these issues are related to what you might call experiential issues i.e. they're not happy with the circumstances of their life. In these cases there is no physiological issue that requires correction, the brain is functioning correctly. The issue is with the configuration of the neurons and while drugs can encourage reconfiguration in a particular direction (happier say), it would be far more useful if those individuals could learn to deal with the hardships of life without external intervention.

Definitely. Hopefully the move away from the DSM will also facilitate a much more responsible use of pharmaceuticals. Instead of chemically making people apathetic about crappy lives, we should be making better lives.

Given that the majority of these disorders do not have any clear etiology, and may not have any biological reality, requiring measurement of causes would destroy most of DSM.

Not just pharma but the whole psychiatric establishment has a vested interest in handing out diagnoses, whether they are understood or not. Prescriptions are not just convenient for big pharma, they can be given out in a short time so that a doctor can turn over many more patients per day.

The current state of psychiatry is like a world in which antibiotics were discovered before the germ theory of disease. Imagine you go to a doctor and he diagnoses you as having pneumonia. That's the best he can do, a symptom-based diagnosis. He tells you to take penicillin for seven days, and to go see him again after 14 days, to see if the medication is working, or if you'll have to switch to amoxicillin.

If this hypothetical doctor knew what caused infections, he could test for specific strains and choose the best medication without this trial and error phase. He would also know that pneumonia and skin infection, two apparently completely unrelated diseases, may in some cases be caused by the same bacteria and treated with the same medicine. Does it mean he should stop prescribing antibiotics until he knows exactly how they work? Of course not. Those are saving lives, and there are clinical trials to prove it. What it does mean is that researchers should work on discovering the underlying mechanisms, because the payoff would be absolutely tremendous. Assuming, as you said, that they exist.

Have I understood that correctly as follows? The key is "RDoC, for now, is a research framework, not a clinical tool." The director of NIMH is saying that although DSM is the clinical tool at present, it must remain open to revisions as new evidence is found, particularly etiology. So if we continue to use DSM also as a research framework and a criterion for awarding grants, thereby we restrain ourselves from achieving the needed evidence.

Should the pharmaceutical industries reimburse the patients and insurance companies for having essentially asked for money for treatments not based on science but on opinion for the last 50 years? It most likely won't happen, but that's really the question that should be on the table here...

Sorry, but that's garbage: the time frame you've set includes the wide adaptation of antipsychotics and biopolar disorder treatments. We know those work, e.g. in late '50s a while after my mother did the psychiatric ward portion of her nursing residency she was amazed to see one of those "hopeless" cases working in a janitorial or orderly role in the same hospital.

I am just glad that theses kind of issues with DSM are being talked about. I just feel that most people are unaware of these issues

The DSM has been my main gripe with psychiatry. I always thought it was a vague way of labeling things that society deems unacceptable, rather than a way of identifying mental disorders.

A quote right outta the old manual: "clinically significant distress or impairment in social, occupational, or other important areas of functioning" It boils down to if its not causing distress, leave them alone, which sounds like a reasonably libertarian outlook on life.

Its also a classification system, not a theory (why it happens) or a treatment plan system.

The best computer science analogy I can come up with is its something like "a list of sorting algorithms and how to identify them" rather than a history of each, or implementation guidelines. So if you see an algorithm that sweeps thru an array sequentially and swaps adjacent items if they're outta order, and keeps doin it until it can't find anything outta order anymore, then you're probably looking at a bubble sort.

Nothing to do with how someone who read Knuth or wikipedia would laugh at you, or how to avoid 0/1 referenced array bugs (and at the other end, running off the end of the array) or how to use (or not use) pointer arithmetic, etc.

>Its also a classification system, not a theory (why it happens) or a treatment plan system.

This is the exact problem. It provides a means for categorizing what could be considered normal mental phenomena, and then calls it a disorder.

As far as your quote: '"clinically significant distress or impairment in social, occupational, or other important areas of functioning" It boils down to if its not causing distress, leave them alone, which sounds like a reasonably libertarian outlook on life.'

There are plenty of kids who were diagnosed with ADHD and other disorders via the coercive force of their parents and teachers who would disagree with the above statement.

Who calls it the "psychiatric bible" other than well-biased Scientologists who want to replace it with their own "religious technology"?

> Who calls it the "psychiatric bible" other than well-biased Scientologists who want to replace it with their own "religious technology"?

A number of people, actually:

http://minnesota.publicradio.org/display/web/2012/12/18/dail...

http://healthworkscollective.com/michaeldouglas1/98946/gover...

http://www.cbsnews.com/2100-204_162-6193716.html

http://www.scientificamerican.com/article.cfm?id=dsm-5-updat...

http://www.theglobeandmail.com/commentary/editorials/new-psy...

http://www.psychologytoday.com/articles/200906/the-psychiatr...

Thanks! Is that a pop usage, or do any professionals jokingly refer to it as such?

The critique of modern psychiatry has a long and intellectually serious tradition. Ironically, as your comment shows, the Scientologists have discredited it by association, at least with the ignorant.

I'm not saying it's "beyond critique".

The dictionary that comes with Mac OS has this one definition for bible: (bible) informal, any authoritative book.

So yes, it can be 'the bible', like the ICD can be called 'the bible of diseases'

About the critique the article does, I have nothing to add.

"bible" is often used to mean "authoritative work". It has often been used for programming languages. "The C++ Bible", etc.

Calling the DSM a "bible" just means it's the authoritative, definitive, work for many professionals.

Makes more sense.

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