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DSM-5 and the Fight for the Heart of Psychiatry

The fifth edition of the Diagnostics and Statistical Manual (DSM-5) was recently released. This is the standard reference of mental disorders and psychiatric illnesses released by the American Psychiatric Association (APA).

As with previous editions there is a great deal of discussion and wringing of hands over the details – which disorders were created or eliminated. For example hoarding is now considered its own disorder, rather than part of obsessive compulsive disorder (it has its own reality TV show, why not its own DSM diagnosis?).

This time around, however, the debate over the DSM goes much deeper than the particulars of specific diagnoses. The real debate is about the very existence of the DSM – its validity and utility. While this discussion is nothing new, it has taken on an unprecedented dimension with the rejection of the DSM by the National Institutes of Mental Health (NIMH). Director Thomas Insel wrote:

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, 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.


Categorization in Science and Medicine
The debate is largely about how we categorize mental disorders (I will use the term mental disorders as a non-specific catchall in this article for mental illness, disease, psychiatric conditions, etc.).  This will likely turn out to be bigger than the demotion of Pluto to a dwarf planet.

As with the categorization of planets, this is more than just an issue of definition. In planetary astronomy the issue was with how we understand planetary formation and solar system dynamics. With mental disorders the real debate is about our understanding of underlying cause.

Insel may be overstating the case, but historically he is correct- the DSM is mainly a dictionary of terms, so that psychiatrists can talk to each other and publish using a consistent lexicon. The DSM gives specific diagnoses an operational definition based upon a list of signs and symptoms.

While this approach has been criticized, it is almost universal in medicine as a starting point for our exploration of any new disease. I disagree with Insel in his implication that symptom-based diagnosis is inherently flawed and largely abandoned in the rest of medicine.

When we first identify a new disease or disorder it is almost always first recognized by its symptoms, signs, and course. This is the purely descriptive phase of our understanding. Epidemiology comes next – who gets it, how, and when. Scientists then hunt for an underlying cause – the pathophysiology. It takes years to decades to fully understand a disease, and for many we still lack a full understanding even after decades of active research.

In ALS, for example (motor neuron disease) we know that motor neurons are dying, but we don’t know why. So the diagnosis is defined largely clinically, although based upon exam findings and test results. The diagnosis is not based upon any understanding of cause, however. Further, this means that ALS is likely not one disease but many, that have the same manifestation because the same cell population is dying.

Migraine is another example. Headaches are entirely classified by a list of symptoms (frequency and location of headache and association with other symptoms).

Multiple sclerosis is a mixture, like many diseases. We understand a great deal about pathophysiology, and diagnosis is based upon hard findings. But we don’t know the ultimate cause, and there are subtypes of MS that are entirely clinically based (mostly on the course of the disease – relapsing remitting, chronic progressive, etc.). We don’t know why the different subtypes are different.

In reality, the degree to which medical diagnoses are clinical – based upon signs, symptoms, and course – vs based upon pathophysiology is entirely dependent upon our current understanding of pathophysiology.

Criticizing a diagnostic scheme on this criterion, therefore, seems odd. What is the alternative? If we lack a sufficient understanding of pathophysiology, we need to categorize based upon what we do now (how patients present). These diagnostic labels are placeholders. We expect and hope to replace them one day with a categorization based upon a deeper understanding of the disease.

The reality is that medical diagnoses today are a mishmash of clinical features (signs, symptoms, disease course, age of onset), biological markers, pathology, response to treatment, and pattern of inheritance if any. Psychiatric diagnoses are no different – except that we largely lack biological markers and pathology. This reflects the complexity of mental disorders and the current state of our understanding.

The NIMH, however, is now saying that it also, and predominantly, reflects a flawed approach.

The Biological Model of Mental Illness
The NIMH is taking what critics call the extreme biological approach to mental disorders – that all mental disorders are brain disorders, and properly studied we should be able to figure out those biological causes.

What Insel is saying is that the DSM is not just a convenient list of placeholder diagnoses, but it is a straitjacket. Researchers have been forced to base their studies into biological causes on DSM labels that may not (and probably don’t) reflect underlying reality.

This situation would then be similar to doing biological research based upon classic Linnaen taxonomy rather than evolution-based cladistic categorization. Linnaeus based his categorization of life upon often superficial features. Now that we understand the origin of the diversity of life, evolution, we can re-categorize all of life in a way that reflects true evolutionary relationships.

Insel is in essence saying that the NIMH has failed to find biological markers for mental illness because they have been forced to labor under a false categorization system, the DSM. A cynic might say that he is blaming the DSM for the failures of the NIMH. A charitable interpretation is that Insel is responding to disappointing progress appropriately by rethinking basic strategy.

Some critics have essentially said, a pox on both houses (the DSM and NIMH).

The DSM is criticized as being “cynically pragmatic” – for putting a practical clinical approach above scientific evidence in drawing DSM diagnoses.  At the very least, the DSM needs an evidence-base overhaul, and it probably won’t get it until the old-guard releases its iron grip.

Meanwhile, the NIMH claim that all mental disorders are biological is overly simplistic. Mental disorders are a complex combination of brain function and environmental factors. We will therefore never get completely away from clinical criteria, even if they are better informed by biological information.

As with many disputes, reality is likely in the middle of these two extremes (the pragmatic clinical approach and the biological approach).  One area that should have complete agreement, however, is that scientific evidence should be the ultimate determining factor.

The New Approach
Meanwhile, neuroscientists seem to be taking their research into mental disorders away from the DSM and more in the direction indicated by the NIMH. The new emphasis is on genetics and functional brain imaging. This is partly driven by technological development – they are researching in these areas because they have the tools to do so.

Researchers are therefore stepping back from classic clinical diagnoses and trying to think about mental disorders in a more fundamental way.  They are trying to identify networks or modules in the brain that correlate to specific fundamental behaviors or experiences. Rather than thinking about full clinical syndromes, neuroscientists are trying to reduce them to specific and well-defined neurological phenomena.

In a recent interview on the SGU with one such researcher, Heather Berlin, she described how in her research on obsessive compulsive disorder she is looking at the brain responses to disgust. OCD patients, it turns out, have an increased disgust response. Perhaps, then, we may eventually understand a subset of what are now called OCD patients as individuals with hyperactive disgust response disorder.

Researchers are also building on the genome project to identify genes that correlate with mental disorders. No one expects to find a single gene that equates to a specific mental disorder, but we are finding gene variants that correlate to increased risk. Autism researchers, for example, have been very successful in identifying genes that correlate with risk of ASD.

Here is where Insel’s complaint about the DSM comes in. He is arguing that genetic research might be doomed to failure if researchers are forced to correlate genetic variants to disease labels that don’t reflect biological reality. Such research is set up to fail from the beginning. It remains to be seen if stepping back from the DSM will yield greater success.

Conclusion
Psychiatry’s critics have been having a field day spinning all of this controversy as the death knell for psychiatry. Rather, I see it all as a very healthy sign of growth. Psychiatry has had a prolonged infancy as a scientific discipline, stuck for decades in the descriptive clinical phase of understanding illness.

This phase is necessary and does have some practical utility. But it can also be a mental straitjacket, if the placeholder labels are mistaken for necessarily real biological entities (they may or may not be). This straitjacket effect is not unique to psychiatry (nothing here is) – I teach students frequently that they need to understand the nature of various diagnoses. Some are specific pathophysiological entities, others are vague clinical syndromes that exist for purely practical purposes.  Don’t confuse the two.

All medical specialties are trying to advance their field by deepening their understanding of pathophysiology. All need to practice medicine in the meantime, with imperfect knowledge.

Psychiatry might be suffering from a bit of a complex since it is lagging behind most other medical fields.  I don’t think this can be entirely blamed on the DSM, however. Perhaps it is partly due to the fact that the DSM has had a disproportionate effect on categorization in psychiatry. The profession made a bargain with the DSM, trading flexibility for consistency.

Medical practice can have it both ways – we can (and do) use labels as placeholders, but not as iron-clad entities that constrain our thinking or research. The problem, however, is that regulatory agencies take the placeholder labels as iron-clad. The FDA, insurance companies, and research funding agencies use them as constraints.

In this regard perhaps the NIMH had to back away from the DSM.

Part of the lag of psychiatry, however, is that the subject matter is genuinely complex, and there are strong non-biological influences. I don’t think we will ever get to a pure biological categorization of mental disorders. I do think that neuroscience and genetics research will transform the field and our thinking of mental disorders, as all successful scientific research should do.

If I am being hopeful I see this current controversy as a sign that psychiatry is ready to push through to the next level – more evidence-based, and more biologically informed categories and diagnoses.

The DSM is a necessary placeholder, but that means its reign must end one day, and that will not represent failure, but progress.

Posted in: Neuroscience/Mental Health

Leave a Comment (47) ↓

47 thoughts on “DSM-5 and the Fight for the Heart of Psychiatry

  1. kathy says:

    “The problem, however, is that regulatory agencies take the placeholder labels as iron-clad.”

    Same thing in botany/biology … those who practice taxonomy realise that species (and other ranks) are moveable conveniences, but non-taxonomists don’t. Actually many of species are as fuzzy as clouds and appear and disappear depending on the opinion of the taxonomist doing the study of that group. Some high-profile plants are notorious for this, e.g. orchids and cycads. But those responsible for conservation of species base their lists of rare or endangered plants on the described species as if they were hard, clear-edged entities, trusting in the judgement of a taxonomist who may be inexperienced, biased or just plain incapable.

    Certainly efforts like cladistics and DNA work are changing this to an extent, but there’s still a lot of alpha-taxonomy to be done. These methods work above the species level. At species level many groups are still poorly known.

  2. goodnightirene says:

    I’ve been looking for some good commentary on the new DSM and very much appreciate this post. As the mother of a child with a serious “mental” disorder, I have tried very hard over the years to understand the complex origin of the diagnosis. The quote marks for “mental” are because I have never found the “mental” on a diagram of the brain, no more so than I find a “soul” on any anatomy chart. Mental disease (I’ll dispense with the quotes) has to originate in the brain. Surely, environment plays a role, and no doubt it’s the mother’s fault. :-/

  3. mousethatroared says:

    Interesting look at the issue. Most of the complaints about the new DSM I’ve read have to do with concerns over how a particular disorder is defined. It’s interesting to read an article questioning the basic principles of the categorizations.

  4. mousethatroared says:

    goodnightirene “Mental disease (I’ll dispense with the quotes) has to originate in the brain. Surely, environment plays a role, and no doubt it’s the mother’s fault. :-/”

    (yes, I recognize the ironic tone, but if I could add to that?)

    Yes, clearly the mother must have done something wrong. Either by being to strict or too permissive – too protective or not protective enough – too smothering or too distant. Let’s never look at the healthy children and wonder how they turned out healthy in basically the same environments.

    I look at environmental factors for mental illness similarly to how I think of environmental factors for auto-immune diseases like Lupus. We may be able to see that some environmental factors have an effect on the disease, can bring on the disease or a flare, but we don’t have a good handle on what most of the environmental factors are, so one can’t do much to avoid risks. Many of the known environmental factors, we can’t control well, e.g. stress.

    Studies done on CBT for stress reduction in Lupus patients showed that the patient’s quality of life improved, due to better coping skills, but their disease activity markers and medication requirements remained the same. There are similar studies with similar results with RA patients. Basically it seems the only environmental factor that is known and somewhat controllable for those diseases is avoiding infections (with vaccinations, etc). Even that is no where near a cure.

    As far as I know, we don’t have any information nearly that solid with any of the “mental” illnesses. But people will jump at the explanation of “poor parenting” because (I think) it saves them from the thought that really the only causative factor in many mental illnesses is based on chance.

    Sorry for the rant, I’ve just heard too many blaming stories lately (not in the news – from family members).

  5. DugganSC says:

    I sometimes wonder if part of the problem with mental illness is that, well, it’s all in our head. And no, I’m not talking about the mentally ill people’s heads, but rather the heads of those diagnosing. Diseases usually have something concrete to test for, and it’s rare for someone diagnosed with pneumonia one year to have their diagnosis changed to lupus the next year. Amputations don’t change sides from year to year. It’s rare for the medical community to say “Oh hey, I know we said this is Disease A, but about half of those people actually have Disease B instead and by the way, we’ve decided that heart murmurs are no longer a disorder, but rather a societal choice.” And yet, for mental illnesses, we’re constantly changing things around, and sometimes it seems like the people being diagnosed take their cues from what they’re told they’re supposed to have. I’m not saying that psychology can’t eventually be a scientific discipline, but currently, diagnosing a particular disorder seems like classifying a work of art. 90% of the people will agree that a piece of art is dadaist impressionism in a modern style, but not all of them, and a decade later, the same piece might be decided to be neo-impressionist post-modern performance art.

    Or, to use the metaphor above of the DSM being more a dictionary than a guidebook, currently it seems like we’re rewriting the dictionary every few years with words entirely changing their meaning and some words being removed because certain people believe they shouldn’t exist as words. And all the while, people are reading multiple editions of these dictionaries and using it to write their scripts according to how they understand the words to be used.

  6. Tim Kreider says:

    Thanks, Steve, for a post that’s thoughtful as usual on this hot topic. I emerge from (psychiatry) residency to comment because I just got back from the American Psychiatric Association’s meeting in San Francisco, where the DSM-5 was unveiled. I was able to talk with some of the psychiatrists involved in the process of creating the document, and I also was subjected to the incoherent street protests that inevitably dog the APA annual meetings. I would make two points to SBM readers.

    First, the majority of people involved in organized psychiatry and the formulation of DSM are, IMHO, very thoughtful and of good intentions. No question: the field has a troubled history, and the delivery of psychiatric care is far from perfect. However, the leaders of APA seem to take very seriously their responsibility to help patients get care in a way that is clinically pragmatic and scientifically based. The anti-psychiatry rhetoric in the streets, on the other hand, was simplistic and demonizing (“how many children have you drugged today?”). I trust that SBM readers can easily distinguish between thoughtful critics who should be engaged rationally (Frances, Insel, Greenberg) and evidence-free ideologues akin to anti-vaccinationists.

    Second, as Steve beautifully illustrates with analogies, the challenges for psychiatry are different from the rest of medicine primarily in degree, not type. Sometimes over the course of my training I have been shocked by how small that degree actually is! Medicine is full of diagnoses that are made by meeting X of Y clinical criteria, as determined by expert consensus based on incomplete evidence. The “number needed to treat” for psychiatric medications compares favorably to much of medicine. You think gold-standard RCT evidence is limited in psychiatry? Look at surgery. You think industry influence and professional protectionism are problems in psychiatry? I completely agree, and I point you also to every other profession inside and out of medicine as further examples. I don’t mean to get “tu quoque” here, but it is increasingly clear to me that psychiatry comes under extra scrutiny not because it is grossly problematic, but rather because its focus is more personally meaningful to the average human being than that of cardiology or rheumatology.

    Psychiatry, like all disciplines, is a work in progress. Here’s something neat I learned from the chair of the DSM-5 task force: the numbering was changed from Roman to Arabic numeral (i.e., DSM-IV, DSM-5) to better enable incremental updates (e.g., DSM-5.1) so that the document can evolve closer to real time. No longer will we need to wait decades for the next major revision to incorporate new data. Critics and journalists love to call DSM a “bible;” not a single psychiatrist I’ve met treats it that way. DSM-5 is intended to be a “living document.”

    In addition to buying DSM-5 this week, I bought “Book of Woe” to get a critical viewpoint. For non-physicians, I recommend the book “We’ve Got Issues: Children and Parents in the Age of Medications” by Judith Warner.

  7. compulsive_empath says:

    Dr. N makes the excellent point, unfortunately rarely heard, that many diagnoses in medicine (very much including outside of psychiatry) are descriptive, rather than etiologic. In my own practice (primary care), most of our assessments are NOT based on etiology, but rather on what you need to do about them. Examples: URI’s (we never test for specific viruses in outpatients, we just treat with antibiotics! (kidding)), vertigo (we give it names like Meniere’s or labyrinthitis, but are fooling ourselves (and our patients) if we think those are accurate), low back pain (specific etiology undiagnosable >95% of the time), hypertension (high renin? mild hyperaldo? increased sympathetic tone?). And that’s OK. So criticizing psychiatry for the same thing is a bit specious.

    DSM III and subsequent iterations pulled psychiatry out of the dark ages of Freudian ids and Jungian collective consciousness, and at least pointed it toward a scientifically testable structure. Unfortunately as it has become the bedrock of not only research, but also for billing codes and benefit eligibility testing, it has skewed the thinking of its users in maladaptive ways. I always tell my students, when it comes to psychiatric problems in your patients, don’t treat diagnoses… treat symptoms. Address the individual symptoms the patient is having as best you know how, whether at the neurobiological level with medications, or at higher integrated levels with cognitive-behavioral or even psychodynamic techniques, or whatever combination seems most appropriate and seems to work best. And remember that all these symptoms exist on a continuum, whether sadness, or anxiety, or inability to concentrate, or personality problems. Another analogy: Think of it as multiple gauges on your dashboard for various emotional, cognitive and behavioral states, rather than warning lights that light up with a diagnosis. Treat when they’re problematic enough to warrant the risks and costs of treatment.

    As to the NIMH Director’s objections, I am not at all convinced that at this point in our understanding, pretty fMRI pictures and genetic data mining will give us a better research structure than what we have now. Maybe someday.

  8. Duggan,

    You are being unfair.

    First, there are plenty of diagnostic categories in medicine that work by consensus of experts. Headache diagnosis, for example. Here is another – immune mediated neuropathy. This diagnostic scheme has been evolving for years, taking into account clinical syndrome, antibody markers, and neurophysiology.

    What immune mediated neuropathy shares in common with mental disorders is that the diagnoses are fuzzy around the edges. We do not have one antibody with one clinical syndrome and one pattern on nerve testing. We have antibodies that occur some of the time in multiple diseases, with overlapping clinical syndromes, and overlapping features on nerve conduction studies. You have to put it all together in a complex way. And, guess what, the specific nomenclature of diagnosis was agreed upon by consensus of expert opinion. It literally was – last year we called this patient X, but now we are calling them Y.

    It is absolutely not the fact the mental disorders are mental that result in shifting clinical diagnoses – it’s the fact that the diagnoses are actually fuzzy and overlapping, so no one scheme can be perfect.

  9. DugganSC says:

    You’re absolutely right. That was unfair of me. For whatever reason, I was in a snit yesterday, and posted without really reading what I was writing. There is still a nature of ambiguity in psychology, but as was noted above, it’s a young discipline.

    1. gewisn says:

      “You’re absolutely right. That was unfair of me.”
      I can count on one hand (acutally, one finger) the number of times I have seen that in a blog reply. I was already blown away by the intelligence and thoughtfulness of the blog entry and the replies when I read this.
      Kudos to both of you for making me want to be better.

  10. BobbyG says:

    Is psychiatry “junk science”? Y’know, that whole Szasz thing (before he himself went nutty)?

  11. goodnightIrene says:

    @mouse

    Loved the rant. Many thanks.

  12. Lost Marble says:

    I have many arguments about words, one therapist gave me 7 diagnoses, another doesn’t believe in labels, yet others use my diagnosis to dismiss me as a troublemaker. I would very much like for someone to say such and such is wrong with your brain, therefore we will push this magic button and you will be fixed. The problem is with my thought patterns, and those are rather complex. Also I don’t know if I would even trust the treatment if it came to be.
    The DSM has its uses, though more for communication of treatment, I would think less so in research.

  13. Dick Steal says:

    @BobbyGon

    ‘Is psychiatry “junk science”? Y’know, that whole Szasz thing (before he himself went nutty)?’

    Did Szasz go nutty? Maybe crazy, mad, bonkers, insane? Any other terms of stigmatisation or abuse you can think of? What Szasz said, and I and many many others are in agreement with is that treating ‘mental’ disorders as the result of a brain disease is faulty logic. A child suffering abuse may act ‘strange’ or ‘abnormal’ and yes may even have a change to brain circuits that can be measured by neuroscience. The treatment though, currently adopted by biopsychiatry, is to provide drugs that attempts to change and cure the brain. Is this logical and based in science? Trouble is with the ‘skeptics’ is that any criticism of psychiatry is now called ‘mental illness denial’ and ridiculed. Shame.

  14. evilrobotxoxo says:

    Even though I don’t have a bunch of profound insights, as a psychiatrist I feel the need to comment. I think Dr. Novella does a great job here of explaining something that the average person doesn’t understand, which is that all of medicine has areas where it’s fuzzy diagnostically and based on clinical exam.

    Regarding the same person receiving multiple or different diagnoses, there are a few reasons for that. One of the most common is with diagnoses that artificially split a spectrum up into pieces. For example, I think most psychiatrists agree that schizophrenia and bipolar I are on a spectrum, with schizoaffective disorder bipolar type between. So the clinical picture is on a continuous spectrum, but we have to group people into three artificial categories. There are a lot of other similar examples. Another reason is that for certain syndromes, it’s more common to see several DSM diagnoses together than it is to see each separately. For example, I see more people who have both depression and anxiety than I do people with depression alone.

    One point raised by several posts is that psychiatrists treat symptoms, not DSM diagnoses. That’s partially true, but not entirely. It is true that my treatment recommendations could not be predicted based on which DSM diagnosis the person has. However, I do actually believe that a lot of the stuff in the DSM actually reflects genuine pathophysiological entities. For example, I could see a person who comes in with anxiety, insomnia, sexual dysfunction, and inability to concentrate. If I were just treating symptoms, I could give that person Xanax, Ambien, Viagra, and Ritalin. However, in reality I would dig a little deeper and eventually probably figure out that the person has depression, and all of those symptoms are just epiphenomena. So I’d recommend an antidepressant + CBT and go from there, so in that case you could argue that I’m treating the DSM diagnosis and not the symptoms. The point is that we treat BASED ON the symptoms and on a diagnosis, but we’re not just treating the symptoms or the diagnosis.

  15. windriven says:

    “You are being unfair. ”

    Perhaps. But is it just me or are the fields of psychiatry and clinical psychology burdened with an inordinate share of kooks, freaks and quacks? Some years ago one of my daughters was the victim of an attempted assault. We went to half a dozen or more psychiatrists and psychologists in an effort to find one with whom my daughter could connect and who could help her work through the emotional trauma. A couple of them just weren’t good fits. But fully half were, in my daughter’s (and my) personal and entirely non-clinical assessment, bat-crap crazy*.

    She never found a therapist to work with. When she threw in the towel it was sort of a Jerry Springer moment for her: those people are way worse off than me so maybe my life ain’t all that bad.

    In the end it worked out kind of OK. But somehow I’m pretty sure that isn’t how therapy is supposed to work.

    *The straw that broke the camel’s back as it were, was a psychologist who was enamored (in the Tom Whats-his-name jumping on the sofa kind of way) with EMDR. My daughter, a hard-nosed skeptic, listened and, as she relates it, when she’d had enough asked the woman if she was on drugs. Thus abruptly ended the session and with it my daughter’s final effort to find a therapist.

  16. compulsive_empath says:

    evilrobot:

    Exactly so. I didn’t mean to imply that I would, for instance, prescribe Ambien to someone if they complain of insomnia, without further elucidating the type, and searching for causes. (And very commonly it’s depression, especially for sleep maintenance, rather than sleep initiation issues.) But when you make the diagnosis of depression, couldn’t you consider that a symptom for which antidepressants may provide benefit? You don’t use different meds for patients that qualify for DSM diagnoses of dysthymia or depression NOS or major depression, because you understand that these different diagnostic labels are for billing and possibly research, not for therapeutic choices (though severity of course does play a role in your decisions.)

    So i’ll bet you prescribe Adderall when a patient has enough attention difficulties to warrant the cost and risk of the med, and mood stabilizers when there is enough periodicity in mood symptoms to suggest they may be of benefit, etc., rather than whether they meet DSM diagnostic criteria. No?

    The problem occurs when practitioners DON’T understand this, and focus on questionnaires and lists, rather than the human being in front of them.

  17. evilrobotxoxo says:

    @windriven: as someone in the field, I can verify your assertion that half of the providers in the mental health field are idiots. It’s one of the things that you have to deal with when you become a psychiatrist. Half of neurosurgeons are not idiots. Half of cardiologists are not idiots. But half of psychiatrists are. It really saddens me that this is the case, particularly when mental illness represents such a massive disease burden in society, but there’s no other possible conclusion when the dominant idea in society is that mental illness is somehow less real than other types of disease. If society believes that psychiatric conditions are “all in your head” or moral failings or whatever, then that means that the doctors who treat those conditions are fake doctors who treat fake conditions. What medical student is going to sign up for that? Either one who really believes in what they’re doing, or one who can’t do anything else. There’s also a significant geographical component. If you live in NYC or Boston, for example, you will have no problem finding a competent mental health practitioner, but good luck finding one that takes insurance. For large parts of the country, you’re out of luck, insurance or not.

    One other point about EMDR: it works, and there’s plenty of data supporting that. The underlying theory is 100% BS, but it incorporates actual science-based aspects of extinction learning and etc and packages it in a way that patients sometimes find easier to deal with than classical CBT.

    @compulsive_empath: I pretty much agree with everything you’re saying. I’m just saying that it isn’t quite as simple as saying that we target symptoms only. Diagnostic concepts do play a role, even though they don’t conform to the DSM.

  18. windriven says:

    @evilrobotxoxo

    “One other point about EMDR: it works, and there’s plenty of data supporting that.”

    Yes, I was aware that there is some good support for EMDR – though nothing that marks it as a superior therapy. It wasn’t the EMDR per se that troubled my daughter, it was the off-the-wall pushing of it as the best thing since sliced bread. My daughter was just looking for someone to talk to. She didn’t have nightmares or freak outs but she had, I think, concerns about whether she caused the attempt because she was drinking (17 at the time). She didn’t need drugs, she didn’t need EMDR, she just needed an interlocutor who wasn’t emotionally invested.

    “If you live in NYC or Boston, for example, you will have no problem finding a competent mental health practitioner,”

    Agreed. A lot of other places too. New Orleans, not so much…

  19. evilrobotxoxo says:

    @windriven: one thing you see among mental health practitioners is that they often specialize in a given treatment modality, and then they try to use that on everyone who walks through the door. In the NYC area where I practice, this is particularly the case with old school psychodynamic Freudian types. The psychologist you saw probably just got certified in EMDR and was eager to use it on everyone with the slightest hint of trauma history.

    In fairness to the practitioners you saw, it’s also likely that the patients they typically see have much, much more severe problems than your daughter, and that’s probably part of what made them seem a little crazy to her. It’s easy to bash mental health professionals, and it’s sometimes justified, but it’s hard job that we have treating people sicker than the average person can imagine with inadequate scientific data to go on. We just do the best we can. The DSM-5 sucks, and everyone in the field thinks so, but it’s the best we’ve got.

  20. Coot says:

    I emerge from (psychiatry) residency to comment because I just got back from the American Psychiatric Association’s meeting in San Francisco, where the DSM-5 was unveiled.

    What’s this, we’ve got Tim Kreider on our team? I am chuffed. That makes two brave and cool and awesome people on our side, so there is hope.

    https://whyweprotest.net/community/threads/san-francisco-megathread-2013-all-you-can-eat-entheta-buffet.107751/page-10#post-2310916

  21. DugganSC says:

    I’ve seen the occasional comment, before, that there’s a higher rate of mental disorders in psychologists, although the reasoning varies from going about mad people to people who were disturbed to start with getting interested in psychology in an effort to understand and help others to psychologists simply being more self-aware of how crazy we all are under the surface.

    I also don’t know if the figure is true, or if it’s the equivalent of how “everyone knows” that you swallow six spiders a year, or that you use only 10% of your brain.

  22. Coot says:

    “But is it just me or are the fields of psychiatry and clinical psychology burdened with an inordinate share of kooks, freaks and quacks?”

    I blame the business schools for churning out a bunch of scientifically illiterate psychologists.

    When I was an undergrad in the early 1980s, it was the psychologists who taught critical thinking. Getting into a graduate program in psychology was as difficult as getting into medical school. Only the brightest and the best need apply.

    Then to meet public need for more practicing psychotherapists, the Psy.D. degree was invented –easier than a PhD as it doesn’t require a candidate to defend an original research project.

    At the same time, the psychology of marketing and human resources matured and shacked up with the large group awareness people, spawning business consultants offering “leadership” seminars and “motivational” speakers. These people believe they are psychologists –and they actually are in a sense. But they come from a culture lacking a tradition of broad-based, cross disciplinary peer review. That requires a university and some effort to get people who don’t like you to come listen to your talks.

    The organizational, trans-personal, and self psychologists have since invaded academic departments and have changed the prior tradition of independence and criticism. Ekhart Tolle seems to be a big deal in a lot of places, according to young people I meet in master’s programs. One academic at a state program told me her department head had asked the faculty to sign a document stating that they “loved” their students.

    Add to the above distance learning programs like Dr. Weil’s thing in Arizona. Lord knows how many young people are seeking these degrees in theology thinly disguised as science.

    All that’s needed to stop cultish psychology spamming us into submission is a functioning peer review filter. Nothing should be published or taught that hasn’t survived a period of rough-and-tumble criticism.

    On second thought, peer review alone is probably not enough. We also need to be open and vocal –but not paranoid– about conflicts of interest.

    It’s not so much the money coming in but what happens if you want to walk away from the money that counts. What happens, for example, if you buy an expensive transcranial magnetic field machine for your office to treat patients with depression and three years later the scientific consensus is meh? Can you walk away?

  23. Coot says:

    “The treatment though, currently adopted by biopsychiatry, is to provide drugs that attempts to change and cure the brain.”

    The rule actually is: Collect a set of treatment options that might help the patient’s problem. Pick the one with the best risk-v-benefit profile.

    In some cases medication has the best risk-v-benefit profile as compared to lifestyle alterations or psychotherapy.

    The people who market “alternative” therapies want the public to view psychiatry as “drugs to change the brain.” But psychiatry is simply the study and treatment of mental illness. The field is not married to any particular treatment intervention.

  24. mousethatroared says:

    windriven – it sounds like I had a similar experience to your daughter at the same age. A number of years later I was approached by a naked masked guy in a park (unfortunately at dusk when there weren’t many other people around). Luckily he was an exhibitionist not an attacker, but the two occurrences together, threw me for loop.

    I found martial arts classes to be quite helpful for the anxious/helpless feeling that followed. Not the gungho type, just a family ymca program, although something that has sparing I think is good. Although, maybe it’s all in the past for your daughter.

    Sorry, I know off-topic and for (unsolicted) advise, if it’s not wanted.

  25. zplat says:

    I suffer from behavioral problems and I’m glad that psychiatry exists. I’m glad that my parents had me hospitalised when I was psychotic. I’m glad that my shrink doesn’t think that I’m lazy or that if I really wanted I could have a normal life, like a lot of people in my family seem to think. I’m glad to know that there are people trying to understand why my life is now a nightmare.

    But I can’t stand how psychiatrists act like they know what they’re doing.

    We don’t even understand how the brain of a fly works, yet they have no problems flooding the human brain with some random quantity of a particular molecule which targets sometimes several kinds of receptors. If you know a bit about the brain, don’t tell me you don’t find it surprising that such a treatment could work.

    Yet some patients do get better. Ok it usually takes weeks – even if the patient experiences the side effects a few hours after beginning the treatment – but they do get better. Oh god we’re so lucky to have those drugs. I mean, imagine if we didn’t. Wait… there was a time when we didn’t. How exactly did human societies survive for thousands of years without the psychopharmaceutical industry? All those depressive people and psychotic people unable to recover because we couldn’t give them prozac or abilify… Wait… Could it be that most of them recovered without taking anything? Could it be that the brain has evolved somehow several means to avoid being stuck in depression or psychosis? No surely if mental issues are so prevalent today, it must be that there were so disabling in the past that evolution took care of it… Oops.

    What about the studies? After all they do show a dramatic beneficial effect. Wait. No they don’t. Most of the time it’s just slightly better than a placebo. But the main problem with those studies is simple, they’re total bullshit. To convince yourself, I challenge you to design a study about the effect of some drug on patients suffering from some DSM-approved pathology. First you need to match a drug with a pathology. Good luck. I challenge you to find one pathology listed in the DSM that we can explain from a molecular point of view. So what do you do? You pick one drug that affects the brain because it targets a bunch of receptors. At least it should have an effect. Nothing wrong with that but clearly not the best way to start. Now comes the funny part. You need to constitute 2 homogeneous groups of people suffering from your pathology. Good luck. Because remember, the only way we can label patients today is through the eye of a psychiatrist. So you contact your team of psychiatrists and ask them to provide you with some patients suffering from pathology X. Shouldn’t be that difficult, right? Wrong. Because any sensible psychiatrist will tell you that all patients are different, that there is a spectrum of mood and psychotic disorders. She would also tell you that the DSM diagnosis can evolve. She would also admit that she may not agree with a colleague. If you were rigorous, you would stop here. But you really want to help humanity. So you decide no longer to target a pathology but rather symptoms. You no longer target bipolar disorder with psychotic features, you target psychosis. You no longer target major depressive disorder, you target depression. You will call your drug antipsychotic or antidepressant. So you have your 2 groups of patients presenting some symptom. You need now to decide what quantity of the drug you should give to the lucky group. Good luck. Of course you could decide to recruit more patients to constitute other groups and give each group a different dosage. But who cares since what you’ll end up doing is convinced every psychiatrist that when the patient doesn’t improve, they should increase the dosage. Who said the brain was complex? Who said that targeting 50% of some category of receptors could have a totally different effect than targeting 75% of those same receptors? But let’s forget this. You need now to measure the outcome of the experiment, your carefully designed double blind study. Of course your drug has so many side effects that you’re pretty sure patients and psychiatrists will know whether they were in the placebo group or not. But who cares? After all, evaluating the mind is just the most subjective measurement we can imagine. But let’s forget this. So how long do you wait before asking your team of shrinks for news? Let’s say several weeks. If you’re lucky, you will measure a positive effect. If not, well, you don’t need to publish the study, right?

  26. windriven says:

    @mouse

    Thanks for your thoughts. I’m shocked and saddened that you had a similar experience. Glad to hear that it didn’t leave a debilitating scar.

    My daughter came out of it all just fine too. But I wish that she had had someone to talk to at the time. evilrobot hit it perfectly saying that she didn’t need a massive intervention, just a little TLC from someone with some experience.

  27. Coot says:

    What about the studies? After all they do show a dramatic beneficial effect. Wait. No they don’t. Most of the time it’s just slightly better than a placebo.

    That’s what the studies are designed to do.

    To show a statistically stronger effect of the treatment verses a placebo you need more power, which means more subjects exposed to an unproven treatment.

  28. Chris says:

    windriven:

    My daughter came out of it all just fine too. But I wish that she had had someone to talk to at the time. evilrobot hit it perfectly saying that she didn’t need a massive intervention, just a little TLC from someone with some experience.

    Which is exactly what I got after the death of my mother. I was taken by my stepmother, and it proved a way to get through those dark years between twelve and fifteen.

    My mother-in-law was told to provide the same for her kids after her husband died. But she was having a hard enough time dealing with things herself (which involved moving across the USA and back to Canada to live with her mother). Fortunately the son did okay, her daughter: not so much.

    Her son and I both hate the movie “Terms of Attraction” with a passion. It was advertized as a comedy with Jack Nicholson and Shirley McClain (sp? who cares), but turned out to be a stressed drama where the mother of small children dies. A horrible terrible misdirection. When I went into the theater lobby to get napkins for leaking eyes, and told the clerk that all the folks crying in the theater had a high probability of losing a parent in childhood.

    I’ve taken my oldest to a psychologist after he gave up in tenth grade and refused to do anything. He was being bullied. Unfortunately he refused to talk to the psychologist, so he was let go. It still worked, he started to do homework and participate in school. For him, it is little growing step all the time (he has developmental issues).

    Many times it is the talking that is needed. Though I understand one of our cats may need Prozac to keep her from peeing all over the house. She belongs to my son who moved where he could not have pets, and it doesn’t help she has always been a bit psychotic.

  29. evilrobotxoxo says:

    @zplat: as a psychiatrist, I could argue that we know exactly what we’re doing, but I could argue equally well that we have no idea what we’re doing. It depends on how you look at it. We have a lot of knowledge about what effects the drugs have, and we can (usually) explain the mechanism at the molecular level, but I agree that we generally can’t explain the system-level mechanism in a satisfactory way. I agree that it is amazing how well psychopharmacology can work given how unlikely it would be to work. I think that’s particularly true for oddball drugs like lithium.

    I challenge you to find one pathology listed in the DSM that we can explain from a molecular point of view.

    The short answer to this is Rett syndrome, which is caused by MeCP2 mutations. The longer answer is that psychiatric pathology, in general, does not occur at the molecular level, it occurs at the level of neural systems. Expecting a molecular mechanism of psychiatric illness is like expecting a molecular mechanism of atrial fibrillation. I think that the fantasy that psychiatric pathology should have identifiable molecular substrates has been one of the major impediments to progress in the field.

    What about the studies? After all they do show a dramatic beneficial effect. Wait. No they don’t. Most of the time it’s just slightly better than a placebo.

    That statement is true for trials that use antidepressants to treat a depressive episode. However, antidepressants show a robust effect in preventing relapse of depression, as well as for treating certain anxiety disorders. Also, antidepressants basically have the smallest effect sizes of any drug class used in psychiatry. If you look at antipsychotics for psychosis or mania, benzodiazepines for anxiety, stimulants for ADHD, or mood stabilizers for bipolar disorder, you actually do see dramatic beneficial effects that far exceed placebo. Of course, there are plenty of other problems, e.g. side effects and a significant number of treatment refractory patients.

    All those depressive people and psychotic people unable to recover because we couldn’t give them prozac or abilify… Wait… Could it be that most of them recovered without taking anything?

    No, unfortunately that was not the case. In the early 1950s prior to the introduction of chlorpromazine (the first antipsychotic), so many mentally ill people were institutionalized that the state hospital system was apparently eating up half of the state budget in some states. The effectiveness of antipsychotics is what enabled most of these people to live in the community, which triggered deinstitutionalization and the entire mental health care delivery system being shredded. Another factor is that people had much stronger family and community support structures in the past, and they still do in some cultures today. I used to treat a first-generation immigrant who had severe treatment-refractory psychosis but lived with his family, worked a job in the family restaurant, and was integrated into an immigrant community where people kept an eye on him. Because of those supports, he did much better than typical Americans whose actual pathology was a lot less severe than his.

  30. Chris says:

    evilrobotxoxo:

    I used to treat a first-generation immigrant who had severe treatment-refractory psychosis but lived with his family, worked a job in the family restaurant, and was integrated into an immigrant community where people kept an eye on him. Because of those supports, he did much better than typical Americans whose actual pathology was a lot less severe than his.

    Hooray for support systems. Unfortunately many human families fail to provide those. Even when we try, and we did try, and if it meant someone driving three hours away to another state, we fail. The results are under a beautiful rhododendron at the cemetery up the street. Trust me, the family tried, and failed. Apparently one of the key ingredients is that the person is willing to listen to advice that they do not agree with (the person decided the real psychiatrist who worked at the county psyche ward did not know anything, but a homeopath was more qualified… um, it didn’t work very well).

    Unfortunately the patient has to agree with the family and the therapist. Been there, done that.

    Then there a these things known as “companion animals.” Apparently co-evolution with certain critters has its drawbacks.

    And that includes younger son’s psycho cat. If she keeps up her inappropriate urine deposit behavior, dear hubby has threatened to toss her out of a second story window. I don’t think the psychological health of the college age children will handle that very well. Though I would insist that dear hubby clean up the mess. In the mean time I hope that medication from the vet will help. Until then I really love the enzyme cleaners designed for pets. At least I know they work.

  31. Chris says:

    evilrobotxoxo…. “as a psychiatrist”… aaah! Wait, Evil Robot kiss hug kiss hug !?

    What!?

    Oh, wait, humor. I know about that. It sometimes actually works. It is one of the reason I am slightly sane. ;-)

  32. zplat says:

    I could argue that we know exactly what we’re doing

    Sure, it would make for a fun read. Believe me, if you want your most educated patients to trust you, don’t do that.

    The longer answer is that psychiatric pathology, in general, does not occur at the molecular level, it occurs at the level of neural systems.

    Yet psychiatrists prescribe molecules. So they must think it will affect the activity of those neural systems. And I think we agree it does. Try ejaculating when you’re given risperidone for instance. The problem is that we don’t understand how we can fix the activity of those neural systems with molecules. Actually we barely understand what is wrong with the activity of the brain when someone is depressed for instance. So how can we expect to fix it?

    No, unfortunately that was not the case.

    According to some statistics about 3% of the population will experience psychosis in their lifetime. Are you trying to tell me that before the invention of antipsychotics, all those people were condemned to be locked up or taken care of by their family until their death? Please be serious. I’m ready to accept that a few patients may benefit from taking antipsychotics – even if we don’t know the mechanism and the studies are crap – but I hope you don’t tell all your psychotic patients that if they were born one century ago they would have suffered from psychosis their whole life. There are several people in my family who had one psychotic episode, didn’t take any drug and never relapsed. And what about people experiencing depression? Same thing? Stuck in depression until they die?

    What about the small paragraph where I question the validity of the studies?

    You’re a psychiatrist and I’m sure you think prescribing drugs is a big part of your job. So I understand it may be hard to swallow. I don’t expect to convince you.

  33. evilrobotxoxo says:

    Yet psychiatrists prescribe molecules. So they must think it will affect the activity of those neural systems. And I think we agree it does. Try ejaculating when you’re given risperidone for instance. The problem is that we don’t understand how we can fix the activity of those neural systems with molecules.

    Prescribing small molecules is one of the things we do, and sometimes it works well and other times it doesn’t. The problem, however, is not that we don’t understand how to fix neural systems with molecules. It’s that fixing the nervous system by bathing the entire body in a small molecule is a fundamentally impossible thing to do. For example, risperidone’s primary mechanism of action is blocking D2 dopamine receptors. The antipsychotic effect is mediated by D2 receptors in one part of the brain, but the brain has D2 receptors all over the place, and no amount of medicinal chemistry knowledge or understanding will allow you to target some and not others. The problem isn’t just a problem of knowledge – practicality and technological limitations also impose some pretty serious constraints.

    According to some statistics about 3% of the population will experience psychosis in their lifetime. Are you trying to tell me that before the invention of antipsychotics, all those people were condemned to be locked up or taken care of by their family until their death?

    I didn’t say anything that remotely resembles that. About 0.9% of the population develops schizophrenia, which by definition is chronic psychosis, so you’re correct that it’s a minority of the total number of people who have had psychotic episodes. Even in the pre-antipsychotic era the state hospital population was nowhere near 0.9% of the total population, so I’m not trying to imply that all schizophrenics required lifetime institutionalization before antipsychotics. However, the state hospitals had a hell of a lot more patients before antipsychotics than they do now.

    What about the small paragraph where I question the validity of the studies?

    The problems with drug trials are numerous, and it prevents us from getting good quantitative estimates of how effective the drugs are, but for most of the major drug classes (except antidepressants) we can say that there are mountains of data showing that they’re generally very effective.

    You’re a psychiatrist and I’m sure you think prescribing drugs is a big part of your job. So I understand it may be hard to swallow. I don’t expect to convince you.

    I’m primarily a researcher, and my research focuses on developing gene therapy-based treatments to replace pharmacology. My clinical practice is focused entirely on interventional approaches to psychiatric illness, either transcranial ones or neurosurgical approaches. Basically, my entire career is dedicated to non-pharmacological approaches. And even I, of all people, find myself defending psychopharmacology to you.

    Let me turn the tables: you’ve had an inpatient psychiatric admission, and you’ve taken psychiatric meds before. That easily gives you more insight into mental illness than 90% of the population. However, have you ever considered the possibility that you have a lot more insight into your own particular condition and reaction to medications than into mental illness and psychopharmacology in general?

    Anyway, that’s what I had to say. I’m under deadlines with other stuff, so this will have to be my last response.

  34. zplat says:

    However, have you ever considered the possibility that you have a lot more insight into your own particular condition and reaction to medications than into mental illness and psychopharmacology in general?

    I wouldn’t be here commenting if I had suffered from depression in the past, took some prozac and got better. I got interested in psychiatry because my life is a nightmare although I’ve met a dozen of psychiatrists and I’ve been prescribed so many different drugs I don’t remember their names. But I’m not saying that psychopharmacology is a scam because I don’t feel any better. I say that psychopharmacology is a scam because there are too many issues with the studies.

    When I see that quetiapine is approved for the treatment of schizophrenia, bipolar disorder, and major depressive disorder, it only confirms what I thought: you can prove anything with crappy studies.

    Good luck with your research.

  35. Alia says:

    @zplat – if I may add something from historical perspective – if we go back deeper than 20th and 19th centuries, you can find a lot of examples of various mental disorders in the documents from those times. Only in Middle Ages it wasn’t psychosis, it was possession by evil spirits (or on the contrary, visions sent by God). And depression symptoms could be perceived by contemporaries as ascesis. And then there are records of people who were so dangerous that they had to be put in chains. Of course, if you were rich enough and aristocratic enough, you could get away with almost everything – Elisabeth Bathory, anyone?

  36. Coot says:

    “I say that psychopharmacology is a scam because there are too many issues with the studies.”

    All studies have issues and limitations. Still there is advancement in our understanding of mental disorders and ways to help patients.

    The black PR against psychiatry is hate speech with social consequences and we must begin to stand up to it. The pharmaceutical companies have pulled out of researching novel psychiatric medications. States have closed hospital units and mental health centers. People we’ve always cared for are now bounced from one inadequate setting to another. Many are in jail.

  37. zplat says:

    The black PR against psychiatry is hate speech with social consequences and we must begin to stand up to it.

    If people don’t understand the difference between criticizing psychopharmacology and criticizing psychiatry, that’s not my fault.

    The pharmaceutical companies have pulled out of researching novel psychiatric medications.

    Yeah, I wonder why. There is a big market. That’s weird. Maybe because “fixing the nervous system by bathing the entire body in a small molecule is a fundamentally impossible thing to do” (evilrobotxoxo)

    States have closed hospital units and mental health centers.

    We don’t need them, we have drugs. Q.E.D.

    Many are in jail.

    I confirm. I was put in jail once and I was far from being the only one with mental issues.

  38. Coot says:

    “If people don’t understand the difference between criticizing psychopharmacology and criticizing psychiatry, that’s not my fault.”

    I guess it is nice that you aren’t condemning psychiatry as a whole, just the use of medication for psychiatric disorders. Still, you have no rational basis for claiming that medications are never going to help psychiatric disorders.

  39. zplat says:

    Still, you have no rational basis for claiming that medications are never going to help psychiatric disorders.

    I’ve never said that. I can’t predict the future. I’m not Kurzweil.

    I’m not stupid. I know I’m basically saying that the vast majority of psychiatrists, the ones who prescribe drugs, aren’t that different from homeopaths. So I don’t expect people on this blog to agree with me immediately. If I wanted to talk with people who agree with me, trust me I could.

  40. medicalrevolt says:

    Very well said. As a physician (internal medicine) I have always been frustrated with out unscientific psychiatry is. 3 psychiatrists will give you 3 different diagnoses of the same patient. Your summary put it in great perspective.

    Unfortunately the brain is still totally mysterious and neurology claims all of the demystified parts for itself leaving nothing but unexplained pathology and behavior for psychiatry. After reading this piece I can see how where psychiatry is now is akin the the old unbalanced humors approach to medicine. As they tried to pigeon hole every disorder into a small number of humor imbalances they did categorize and learn about disease. Psychiatry is doing much the same trying to pigeon hole behaviors into a limited number of diseases and one day, like with humors, we will likely learn those categories were completely off base but we hopefully will have learned a lot in the process. I just hope we can curtail the pharmacological experimentation before then

  41. Coot says:

    zplat, if you concede that medications may help psychiatric disorders at some point, then there is no need to campaign against the use of psychiatric medications generally.

  42. evilrobotxoxo says:

    @medicalrevolt: the brain is not “totally mysterious.” At the biophysical level, brain function is more or less fully understood, and it has been since the 1960s. There is a lot that we still don’t know, but there is no evidence that there are any fundamental mysteries remaining. Just a lot pieces to fill in. I have a PhD in neuroscience, and you obviously don’t, so stick to what you know and don’t speak for my field.

    Regarding psychiatry, there is nothing less scientific about our diagnostic framework than there is about concepts like “shock” or “heart failure” that internists use. Each of those is a clinical syndrome that corresponds to a particular class of physiological disturbance that can be caused by multiple distinct etiologies. Despite the fact that these conditions don’t reflect a monolithic underlying cause, they’re still clinically useful constructs because they actually do reflect something meaningful about the underlying physiology. Diagnostic constructs like “schizophrenia” or “bipolar disorder” are no different. As far as “pharmacological experimentation” goes, most of the main medication classes we use have NNTs that compare favorably to most medications prescribed by internists. As an internist, you may be frustrated by how unscientific you think psychiatry is; as a scientist, I’m frustrated by how unscientific all of clinical medicine is. You are wrong if you think psychiatry is that different than what you do.

  43. zplat says:

    I just hope we can curtail the pharmacological experimentation before then

    Glad to see that there are scientists among physicians.

    how unscientific all of clinical medicine is

    Nice. You lost all credibility.

    then there is no need to campaign against the use of psychiatric medications generally.

    I’m not sure to understand what you mean by that and I’m frankly tired of repeating myself. So yeah, whatever.

    There is one thing I would like to add. There are currently people who are forced to take those drugs. Don’t you think they at least deserve we pay a close look to the studies in question?

  44. Jay says:

    This post is much too kind to psychiatry. Robert Spitzer, one of the most celebrated architects of the DSM-III and its successors, said that the DSM has been based on “very little systematic research, and much of the research that existed was really a hodgepodge—scattered, inconsistent, and ambiguous” and that even today reliability problems have not been solved for clinicians in treating diagnoses.

    I must say I expected a bit more from this blog, given the array of “treatments” foisted on vulnerable patients by practitioners in this field — from lobotomies, to ECT, to the origins of reparative therapy, and on and on … not to mention the drugging of millions of people for alleged illnesses that may be emotional trauma. There are certainly individuals who exhibit signs of severe problems with mental health, but the subjectivity required for assessing whether patients need psychiatric care (or its even less scientific cousin, psychological “counseling”) permeates this field. Thomas Szasz warned of this years ago before many of these bloggers were born.

    The difference between much psychiatry and unscientific alternative treatment is hard for me to see. Science-based they are not.

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