Last week the National Institute of Mental Health made a significant announcement: they will no longer be prioritizing research proposals that are framed around categories of mental disorders promoted by the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM.
The announcement, which I first read about on the excellent Mind Hacks blog, comes two weeks before the American Psychiatric Association is set to release the newest iteration of the DSM, the DSM-5. I'm sure there are loads of politics behind this shift in policy and the timing of the release. Certainly there's a lot of money at stake, and it must be causing a lot of anxiety over at the APA (I wonder what their health care is like?)
For those of us who see the DSM primarily as a tool of insurance companies, the pharmaceutical industry, and corporate medicine, one that represents such an extreme compromise as to not be very helpful to the people it purports to both categorize and help, this seems like good news.
In a nutshell, the NIMH is saying that the DSM categories are fundamentally flawed, and so research that is based on those categories will never get us to where we want to be.
The DSM approaches our thoughts and feelings as if they are the same as our blood and bones. It pretends to offer objective diagnoses, but they are based on symptoms that are highly contrived in their description and orientation. It confuses symptoms with disease. The director of the NIMH Thomas Insel pointed out in a prepared statement,
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.He goes on to say that the DSM lacks validity and "patients with mental disorders deserve better."
This is something that doctors, academics, activists, and many of those aforementioned "patients" have been pointing out for years. It's not news that the DSM lacks validity. It is news to have someone in a position of such power and influence admit it. Mind you there is a lot of history and a lot of politics to be read between the lines of this decision, and it's worth noting that the head of the NIMH doesn't have to rely on industries that profit from the DSM for his salary, making him freer to speak this way in public.
Still, it seems like good news for some, and at least interesting news for most. But for those of us who are less interested in the idea of some grand classification system that allows us to describe all the ways it's hard to live in the world, for those of us who are most interested in how we can support people to live in the world in ways that allow them to participate as much as they want to, there are other questions to ask. We should be asking ourselves, what is the alternative being proposed by the NIMH? Where is the place they want us to be, that they believe the DSM is leading us away from?
I'm encouraged by the fact that the NIMH is pointing out the ways the DSM essentially produces mental disorders by clustering symptoms around diagnoses. I don't think that what gets called mental illness is the same as physical illness and disease. And I agree that we need a better conceptualization of mental health. But there are a few lines in Insel's statement that make it sound as like their answer is to double down on science that hasn't served this area very well, by applying what they call "precision medicine" which relies more on " genetics, imaging, cognitive science."
Imaging technology (like fMRI) are only gaining in popularity, and researchers are now looking for (and claiming to find) everything from gender to PTSD to Internet addiction in the brain, thanks to imaging technologies which remain controversial and questionable. The critiques of imagining technologies are never as easily reduced to sound bytes as the research often can be, but if you're wondering what I mean see here, here, here, or here, to name but a few.
I'm happy that the DSM is being called out for it's problems, I'm less excited if we are only going to turn to a new kind of guessing game, one that uses euphemisms like "precision medicine" (could that be anything like a "precision airstrike"?) and continues to deploy the power of Science in order to impose one dominant bio-medical, socio-cultural understanding of illness and health on all of us.
Read More - NIMH: Transforming Diagnosis