Modern Psychiatry: Still in the Dark Ages?
By Alen J. Salerian, MD
Richmond Times
February 24, 2009
Sometime in the near future, modern psychiatry’s unborn holy book, the DSM-V, the Diagnostic and Statistical Manual of Mental Disorders, will arrive. In fact, an early draft of the fifth edition of this guidebook of diagnostic criteria for mental disorders, which mental health professionals, researchers, health insurance companies, and pharmaceutical companies use as the basis for their work, is expected to be released later this year for comment.
The bad news is that DSM-V, as its heritage, is cursed with the same bad genes that handicapped modern psychiatry during the past century: a paucity of science.
All scientific arguments must be transparent and open to scholarly scrutiny. If that is true, why have the gurus who are revising the guidebook — the American Psychiatric Association — mandated that the revision process be carried out in secret? Psychiatrists working on the new fifth edition have been required to sign a confidentiality agreement. The total secrecy surrounding the birth of DSM-V is blatantly unscholarly.
The bigger concern, however, is the great likelihood that DSM-V will be an improved version of a system that has already proven to be broken. Regardless of how much improvement can be generated, it is not possible to upgrade DSM-V into a workable guidebook as long as it is based upon a descriptive approach to the definition of very complex neuropsychiatric disorders.
IT IS AS IF a bunch of high school students were to write a diagnostic manual on “how to fix cars”: The book says if the smoke is too black or too thick and comes from the left side, this may suggest a flat left front tire. But there is no discussion about the visual, manual, or mechanical evaluations of different body parts and not even a suggestion that someone must at least lift the hood to check the engine.
Thanks to advances in neuroscience, there are plenty of tests that are crucial in psychiatric diagnosis, including neuroimaging studies (PET or MRI scans of the brain) or laboratory studies.
DSM-IV never included any diagnostic tests. This itself presents a huge problem for modern psychiatry. That is, according to the guidelines of DSM-IV, a psychiatric diagnosis is made without any logical discussion about neuroanatomy, neurophysiology, or highly complex and relevant neurotransmitters such as serotonin, dopamine, glutamate, histamine, acetylcholine, or testosterone that influence human mood and behavior and hence all neuropsychiatric conditions.
The result seems devilish and intellectually impossible. How can a scientific discipline declare a mother and father guilty of inflicting consciously or unconsciously a horrific misery, “depression,” or “schizophrenia” as modern psychiatry did throughout the 20th century?
The very people who came up with the absurd ideas of blaming bad mothers and fathers for psychiatric disorders were also the same people who came up with DSM-I, II, III, and IV — and are now getting ready for V. How long and how many centuries will it take for American psychiatry to take corrective action to catch up with science? Is this a measure of progress for psychiatry or medicine? And if it is, what is progress? How could it be justified or still defended that modern psychiatric terminology does not have any connection to neuroanatomy, neurophysiology, and neurotransmission? How can American psychiatry get away with such nonsense and at the same time promote the idea that until the new holy book is born, secrecy is the best thing? And how can American psychiatry name various psychiatric disorders with pejorative terms such as “borderline personality?”
THE BEST REASON to declare the current DSM system dead is that it is a barrier to progress in the treatment of serious neuropsychiatric disorders. The difference or conflict between modern psychiatry and scientific knowledge partly explains why progress in neuroscience, for example in the treatment of schizophrenia, has been excruciatingly slow when compared with other equally destructive and progressive disorders, such as AIDS, tuberculosis, syphilis, diabetes, or hypertension.
Many schizophrenic symptoms can be logically explained consistent with our current knowledge of brain physiology and neuroanatomy — e.g., symptoms such as hallucinations, paranoia, delusions, agitation, or intellectual decline. Science says such symptoms are rooted in neurotransmitter dysfunction of specific brain regions such as amygdala, hippocampus, hypothalamus, or the brain cortex. But none of these relevant data can be found anywhere in the DSM system.
What modern psychiatry faces today is not much different from Galileo Galilei’s conflicts with the church during the dark ages. How can we address problems with a complex illness like schizophrenia without offending the established powers of APA, NIMH, and even the judicial system, which heavily relies on DSM-based diagnoses incompatible with science?
The good news is there is no reason to delay progress. It is possible to develop a simple and biologically sound system that will be the premise for defining psychiatric disorders. Basically, the mental health professions should adopt a medical approach.
The truth is, we have all the knowledge to be able to do it, yet our current bureaucratic and institutional systems must be ready for a paradigm shift. The truth is also that until the world of psychiatry changes its approach to diagnosis of mental disorders, we will still be locked in the dark ages of science and medicine.
Alen J. Salerian, a psychiatrist, is the medical director of the Washington Center for Psychiatry. Contact him at (202) 244-3815 or rcolbert@salerianbrain.com .