Burning the Bible

Thomas R. Insel, M.D., Director of the National Institute of Mental Health, has issued a sharply worded condemnation of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM has long been considered the "Bible" of Psychiatry and has recently been under attack from many angles, but this announcement might be a game changer. It will be interesting to watch how it all plays out.

According to Dr. Insel, "it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment."

One obvious problem is that the reliance on "objective laboratory measure" is also full of problems. In an attempt to turn real Psychiatric issues into "medical diseases," there has been a widespread effort to claim depression and bipolar disorder a "chemical imbalance." In "Psychiatry’s New Brain-Mind and the Legend of the 'Chemical Imbalance,'" Dr. Ronald Pies said, "In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the “chemical imbalance” trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves. And, yes—the “chemical imbalance” image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding. In truth, the “chemical imbalance” notion was always a kind of urban legend- - never a theory seriously propounded by well-informed psychiatrists."

I have long argued that the definitions in the DSM regarding depression and bipolar disorder are not accurate. Basing assessments on a short list of symptoms is a huge part of the problem without also considering intensity, awareness, understanding, functionality, comfort, value, and length time it can be kept under control. But, abandoning any criteria because they have yet to find "biomarkers" for depression or bipolar disorder can leave real problems unaddressed. Depression and bipolar are dangerous conditions that destroy the lives of far too many people.

The bigger issue for me is the assumption that the "disease" includes the "symptoms" that are not in disorder. Any biomarker found in the future needs to recognize this fact before they throw the baby out with the bath water. Let's assume that some day they are able to link bipolar to specific chemical reactions in the brain at specific regions. They will be able to tie the "symptom" of racing thoughts, for example, to a real difference in the brain compared to "normal" people. If they somehow eradicate the "disease" of racing thoughts by altering the brain, they destroy something that has moved mankind forward for millennia. They need to be extremely careful to separate the "disorder" of not understanding the racing thoughts from the in-ordered ability to function highly with them.

My proposal all along is to separate disordered bipolar from in-ordered bipolar. Bipolar Disorder means the condition is causing suffering and incapacitation, whereas Bipolar IN Order does not. Unless Bipolar IN Order is taken into account, using biomarkers to "prove" the condition an illness to be removed is a step backward. As I described in my article challenging the paradigm of remission; "With so many people thinking that remission is the same as 'cured,' the problem is all too real. They assume when I say Bipolar IN Order that they have achieved the same thing because they are not currently ill, but during the next cycle they are back in disorder while I am exploring yet another fascinating state with its own unique rewards. What they do not understand is that I, and the many others I have taught, are not 'symptom' free in the way commonly thought; we experience 'traits' every bit as intense as anyone in disorder, but we neither suffer nor are incapacitated by them. We are no longer in danger of relapse because we are already functioning highly at intensities that those without our understanding mistake for the illness."

It is great news that the NIMH has decided to challenge the DSM. I hope that in rethinking "mental illness" they do not make the same mistakes in confusing what the "disorder" is.