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A Top Psychiatry Expert Says Psychiatry's Guidebook Has Science Problems

The US government's top psychiatric expert says it is focused too much on symptoms, and not enough focus on science.
May 9, 2013, 7:00pm
Image: Richard Masoner/Flickr

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is psychiatry's bible. Published by the American Psychiatric Association, it's used by everyone in psychiatric medicine, from physicians to health insurance companies, as a guide to diagnosis and classification of everything in the mental health spectrum.

Now, as the newest version, DSM-5, nears publication, National Institute of Mental Health director Dr. Thomas Insel says it is focused too much on defining symptoms, and not enough focus on science. From the New York Times's report:

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While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best tool now available for clinicians treating patients and should not be tossed out, he said, it does not reflect the complexity of many disorders, and its way of categorizing mental illnesses should not guide research.

“As long as the research community takes the D.S.M. to be a bible, we’ll never make progress,” Dr. Insel said, adding, “People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.”

The DSM has long had critics, as anything considering a "bible" would, but it's interesting that Insel is dropping this bomb right now. While Insel thinks the book is still valuable, he does think that it should be more driven by biology, genetics, and neuroscience.

Motherboard's Laura Cameron recently spoke with Dr. Ray Blanchard, the psychiatrist who headed the sexual paraphilias sub-working group for DSM-5. One fascinating thing about that chat was Blanchard's discussion of terminology; he was very adamant that words like "sissy" are of valid use, which is probably a fair point. But in talking about transsexualism, Blanchard (at least in this lone interview) was largely focused on discussing the terms themselves.

Clearly, discussing terms is a large port of the point of the DSM—it's basically an encyclopedia of psychiatry, after all—and I wouldn't want to distort Blanchard's views based on one chat he had. But when it comes to specific cases like PTSD and ADD/ADHD, you get the picture that the DSM's role as guidebook is to connect patient's symptoms to disease, and disease to medicine.

That's probably an obvious point, but it's what Insel appears to be concerned about. If we take someone's symptoms, give them a name, and then later add in what treatment works, now we've got a nice, contained set of terminology and definition. But what about the root causes of symptoms? More importantly, how can we be sure that similar symptoms are caused by the same thing if we don't know the root?

I believe that's Insel's point: We can't assume that just because something fits a definition, we know exactly what we're dealing with. So we don't need to throw out the DSM, but when so many health professionals and patients rely on it, it is important to make sure it's always improving. Funny, then, that Insel's comments right before the latest version, which has taken years to update, is published.

@derektmead