NIMH: A Requiem for DSM - and its Critics

It is the beginning of the end. Just weeks before the publication of the fifth revision, the NIMH leadership has spoken out against the APA leadership, and the reign of DSM-III to 5 will end sooner rather than later. At the same time, the NIMH approach rejects, as it should, those critics of DSM who are anti-biology critics.

Finally, some sense between two extremes of nonsense.

For the past three years, I’ve been writing about how DSM-IV has been a major obstacle to the advance of science in psychiatry, often in direct debate with the leader of DSM-IV, who also has a blog on Psychology Today. I’ve also been debating other bloggers who oppose biology in psychiatry under any circumstance.

My view is consistent, though maddening to those who prefer the extremes. The defenders of DSM are wrong who claim that all “disorders” are medical diseases; the critics of DSM are wrong who claim that all “disorders” are not medical diseases. Some are; some aren’t. The problem with DSM is that it doesn’t care. It’s been based on a cynicism which thinks that it doesn’t matter; all it wants is to force clinicians to practice the way DSM leaders wish.

This paternalistic approach needs to end, and the NIMH is the political power that has weighed in to end it.

This is not a personal debate; it is a generational one.

I’ve noticed something:

Despite the fact that the specific leaders for each DSM revision are different people, those leaders are all of the same generation (in their 70s or more now). Their second-in-command has been the same person for each revision. And the majority of leaders of DSM task force subgroups have not changed since DSM-III in 1980 to IV to 5. The only thing that’s changed is their ages: they were 30 or 40 somethings then; they are 60 or 70 somethings now. (I could name names, but I won’t since some readers would assume personal motivation).

These American men (by and large) have controlled psychiatry for two generations, not allowing younger generations like mine to have hardly any say in how our profession is led. Though they cannot physically be present to control a future DSM-6 (although they would if they could), the damage they have done and are doing is not going to be easily fixed by current and future generations.

The problem has been with the basic philosophy of DSM, which the generation of the 1970s and 1980s swallowed completely. They have not appreciated how ideologically committed they have been to that philosophy. Let me given it a simple name: cynical pragmatism.

The leader of DSM-IV was not happy with DSM-5 because it changed a few matters of detail, sometimes based on minor matters, such as huge scientific studies. These changes were minor, and even then, the result was outrage that changes were made, especially if they at all increased the likelihood of certain unpopular diagnoses, like bipolar disorder.

When confronted, the leader of DSM-IV made some admissions that shook me personally out of a deep slumber. I had assumed that the DSM leadership used science as a top priority in their decisions. I was told by the head of DSM-IV, in this blogspace, that science was a low priority, and the results of science could be and would be ignored if they conflicted with whatever the DSM leadership wanted to do, on “pragmatic” grounds, in their judgment of what is best for patients and for the profession.

“Pragmatism” trumps science. This approached has doomed psychiatry to failure for two generations.

If DSM leader X doesn’t like disease Y, he makes it hard to diagnose it. If he doesn’t want people to use certain drugs, he’ll make it harder to make certain diagnoses by raising the symptom and duration thresholds. This DSM pragmatic deception has been dangerous. This is why everyone has been yelling at each other for the past two years, as DSM-5 has inched to publication. A recent anti-DSM-5 book, written by an extremist psychologist who apparently believes that no psychiatric condition can ever be a biological disease, consists of a long rant about how psychiatrists don’t understand human psychology.

And yet the defenders of DSM-5 have been simplistically extreme as well. How can anyone defend each of 400 “disorders” as being biological diseases? Even those non-biological psychiatrists, the psychoanalytic camp, who love borderline personality “disorder”, defend the DSM approach because it allows their “disorders” to try to be equal to other “disorders” in diagnostic and therapeutic attention. Hence the never-ending borderline versus bipolar debate. No one says: Well, let’s see – manic-depressive illness has an immense neurobiological and genetic basis, and borderline personality has much much less. They seem to be quite different in neurobiology and genetics and course, even though they may have some superficial symptom overlap. DSM has been all about symptoms: genetics and biology and course have been largely excluded.

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So we have a book based on symptoms, pragmatically chosen, not scientifically so, to fit the cultural beliefs of late 20th century American Psychiatric Association leaders. As I’ve been saying for three years, why would nature and biology follow the dictates of that “pragmatic” text?

And yet, there has been an unquestioned assumption that all of DSM is scientifically valid, and researchers like me have been forced to try to follow its definitions when doing studies, and pharmaceutical companies and the FDA have been following it blindly when testing drugs. No wonder we have had such little progress in developing new drugs that are truly effective and in finding out the causes and biology of mental illnesses.

Now, the postmodern critics of science, like the psychologist above and the leader of DSM-IV and many PT bloggers, see science as being about scientists trying to push their agendas, not finding out the truth. But the NIMH leadership has weighed in, finally. Science matters; it is science that will improve patients’ treatments, nothing else.

“Patients deserve better…. A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories….”

That’s it; the battle is won. The past DSM leaders’ "pragmatism" is shown to be the cynicism that it is. The current DSM’s tinkering with a false model is shown to be more of the same.

We cannot predict how this will play out, whether the specific “domains” proposed by the NIMH will be verified, and for which conditions. But that’s the nature of science; it doesn’t prejudge, it tests. Certainly not all, not even most, psychiatric problems are biological diseases. But some are. And the NIMH is taking the matter seriously so that we will find out what's what, if we honestly pursue that task, instead of presuming nothing is there.