bookofwoe

The baddest guys are the American Psychiatric Association. The APA owns and operates the DSM. They made 110 million dollars off the last one. They also own the names of mental disorders and the criteria by which they are known. It is a unique arrangement in medicine--a private guild in charge of a public trust, in this case one that determines treatment dollars, research priorities, drug approvals, educational services, courtroom verdicts, etc. And they prove themselves to be, how should I put this?, not up to the task.

Pharma is in there too, although some might think I go too easy on them. I figure they're just doing what profit-amking corporations do, which is to sail the corporate ship on the prevailing winds. Or, to switch metaphors, the APA alley-oops them the diagnoses, and Pharma slam dunks them.

And the institution of psychiatry, which is separate frim the APA, comes in for some criticism too. It's a profession with an inferiority complex, and the DSM, at least since 1980 has been its attempt to establish its medical cred.

Right now, we identify illnesses primarily through a combination of clinical signs and symptoms and biochemical findings. Psychaitry's got the first two, and probably does a better job of organizing them than othe branches of medicine. But it doesn't have the third. So the obvious solution, and they are working on it, is to identify the brain pathologies involved in mental disorder. But don't hold yourbreath. The brain's pretty complicated. And what we know so far doesn't seem to map very well onto DSM disorders.

In the meantime, two suggestions. First, that the DSM, whoever produces it, do a better job of explaining to the public what it is, which is a compendium of expert consensus about how to organize our knowledge about psychiatric suffering. It is not a collection of diseases that can be diagnosed like cancer or diabetes. Second, that psychiatry focus more on what it is really good at, for now, which is treating symptoms. Psychiatrists don't treat mental disorders, at least not in the same way that endocrinologists treat diabetes or gastroenterologists treat ulcer. That's why you have depressed people on antipsychotic drugs, anxious peopl eon antidepressants, and so on.

I would suggest that these changes would make for a much more modest psychiatry. That would be good for all of us.

The official reason is that Asperger's is not different enough from autism to warrant its own diagnosis. The way psytchiatrists say this is that people with Asperger's are on the autism spectrum. The unofficial reason is that Asperger's had gotten out of hand. It was being used by too many clincians to give a label to too many people who were just odd or awkward. That had some bad effects: increased costs for special services. It also made the DSM look bad, if all of a sudden all these people had a disorder that didn't exist in 1994. So they had to find a way to rein it in.

And here it is (or do I need to post it elsewhere?)

https://twitter.com/bookofwoe/status/329264598916145155

The personality disorders are the big mystery of DSM-5. There was an attempt to change them radically, but it caused a mutiny in the ranks. By the time it had been straightened out, the APA had pulled the draft off the web, and there were no further updates. My udnerstanding is that they went back to something very much like the DSM-IV version, but we won't know for sure until May 22.

What happened with the personality disorders is in some ways emblematic of wht happened with DSM. Experts have long agreed that sorting mental disorders into categories like major depression, anxiety disorder, etc. , is not such a great idea because mental disorder exists on a spectrum. This is especially true in personality disorder; it is impossible to say where a personality trips over the line from eccentric or difficult to sick. So the committee in charge of the PDs took it upon themselves to create the dimensions that could place people along the spectrum. But between the lack of good science, the haste with which it was done, and the fact that many careers would disappear if narcissistic personality disappeared from the DSM, whcih was one of the proposed changes, the attempt met with stiff and bitter resistance. Even some proponents of changing the approach came out aginast the draft. The result: chaos, friction, and a section probably no better than what came before.