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Updated: February 16, 2013 00:07 IST

In search of a revolutionary road

K. S. Jacob
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Psychiatric diagnoses continue to lack the predictive power required of hard science. A new framework is needed to understand mental health, distress and disease

The American Psychiatric Association (APA) will release the fifth edition of its Diagnostic and Statistical Manual (DSM-5) in May 2013. DSM-5 has been years in the making. The process included planning sessions, international research conferences, review of literature, a series of monographs, secondary analysis of data and field trials involving hundreds of scientists and clinicians, drawn from many countries and disciplines, and feedback from the public. Many interest groups — neurologists, psychologists, insurance and pharmaceutical industries, legal and forensic fraternity, military veterans and anti-psychiatry groups — have been watching the process and outcome closely as the DSM has a wide impact. The Indian Psychiatric Society also submitted its views to the APA.

International standard

The DSM-5 has pursued the basic framework adopted by its forerunners, DSM-III and its successors DSM III R, IV and IV TR. DSM III, with its atheoretical approach, objective diagnostic criteria and specific exclusions, was revolutionary at the time of its introduction in 1980. Its focus on standardised diagnosis and on improving inter-rater reliability had a major impact on psychiatric practice and research. It soon became the international standard.

The absence of laboratory tests to diagnose mental disorders forced psychiatry to focus on clinical presentations for this purpose. The lack of pathognomonic symptoms required the discipline to rely on identifying collections of symptoms to define clinical syndromes. Psychiatric classifications include medical conditions (e.g. delirium, dementia and psychiatric manifestations of medical diseases), severe mental disorders (schizophrenia, bipolar disorders, psychotic depression, and stupor) and stress-related conditions (e.g. depression, anxiety and adjustment disorders).

The DSM laid out objective criteria for diagnosis. It offered differential diagnosis in order to distinguish similar conditions. It allowed psychiatrists working around the globe to read from the same page. It facilitated collaboration and comparison. It improved communication, standardised research, increased, and improved the evidence base. A unified language also helped mental health activism.

Despite major advances and significant progress, the DSM has many critics. Most detractors are free with their criticism, without providing comprehensive solutions to the complex issues facing people with mental illness. Defining mental illness is no simple task. A single definition to partition health, illness and disease has proved to be extraordinarily difficult. The diversity of and heterogeneity within these conditions are major challenges. Typically, patients emphasise distress and suffering, while psychiatrists diagnose and treat “diseases.” Mental disorders include both disease and illness. Nevertheless, diagnostic criteria for psychiatric disorders did not bridge the classical disease-illness divide between physicians’ perspectives and patients’ subjective experience of sickness. In fact, the DSM resulted in language, concepts and frameworks, which contrasted starkly with those held by patients, impeding understanding of the illness experience and diminishing the role of patient narratives. In addition, DSM could not overcome the fact that different etiology and pathology can result in similar clinical presentations, and that a particular cause can produce diverse clinical manifestations. Research and specialist interests also increased manifold the number of diagnostic categories.

Little regard for context

The difficulty in separating disease from distress is a major challenge. The DSM system emphasised symptom counts to identify psychiatric categories, with little regard for the context (e.g. psychosocial stress, personality, and coping). This strategy improves reliability of diagnosis for non-psychotic conditions associated with psychosocial adversity, but also includes people with normal responses to such difficulties. Psychiatry tends to reify diagnosis, making abstract concepts concrete. Psychiatric practice transmutes clinical syndromes (collection of symptoms) into diseases.

The DSM III also suppressed etiological debates about mental disorders and placed them on the back burner. The biomedical model, which undergirds the approach, became dominant, annihilating psychological, behavioural and social conceptualisations. However, the APA argued that reliable diagnoses would result in the recognition of underlying neurobiological substrates and facilitate etiological research; it would lead to the development of new and more effective treatments.

However, the frequent revisions of the DSM, with minor changes often based on limited evidence, also prompted debates on the motivation of the APA. The numerous minor and major disagreements with World Health Organisation’s International Classification of Diseases (ICD) -10 diagnostic categories supported the argument that most changes were arbitrary as there was no agreement among international experts. The DSM had to contend with many charges including medicalising normal reactions, lowering diagnostic thresholds to create spurious “epidemics,” creating new categories without evidence, using medication responses to define categories and playing into the hands of the pharmaceutical industry.

Challenges to diagnosis

Defenders of the DSM argue that its primary purpose is to enable psychiatrists to reliably identify individuals who seek clinical attention, and to facilitate communication among clinicians and researchers. The field of psychiatry has to grapple with the current state of knowledge with its inherent limitations. The lack of laboratory diagnosis, poor understanding of genetic basis and psychological vulnerability, and the need to provide categorical diagnosis for phenomena which lie along a spectrum (e.g. depression, anxiety, cognitive impairment and substance misuse) are difficult challenges.

The most ardent supporters of the DSM acknowledge its imperfections but argue that it reflects our current understanding and state of the science. They contend that DSM-5 is not an attempt to define normal and that being normal is not the same as not having a DSM-5 diagnosis. They argue that having a psychiatric diagnosis is not the same as being insane or crazy, stigmatising labels, which do not apply to the vast majority of people with a DSM diagnosis. They suggest that prescribing medication for any condition in preference to time and labour-intensive psychological interventions is dependent on many factors, including the economic realities of medical practice, and does not necessarily imply medicalising normality.

Pressure from user groups

The use of a single set of criteria, useful to psychiatrists working in specialist settings, in other locations (e.g. definitions for legal use and for reimbursement, in primary care and across cultures) is not without problems. There was also pressure from patient and user groups, as any changes to the DSM-IV categories in the new revision would have affected their claims for disability support and health insurance. Consequently, there were demands to enlarge and to reduce the diagnostic net from different quarters.

A close examination of the DSM-5 suggests the maintenance of status quo. Psychiatric diagnoses and theories, with their technical language, operational criteria, elaborate classificatory systems and empirical data continue to lack the predictive power required of hard science. Its diagnostic systems and models do not explain many aspects of mental health and illness. Human cognition, emotion and behaviour are complex, interconnected and under a variety of influences (e.g. genetics and biology, psychological, social and cultural forces), whose effects cannot be teased out under controlled experimental conditions.

Nevertheless, psychiatric treatments help millions of people lead productive lives. The DSM process and consultation was elaborate and transparent, seeking opinions and evidence from people with diverse backgrounds. Despite its shortcomings, it does reflect the current state of the science. Psychiatry, at this moment in time, has been compared to biology before Darwin and astronomy before Copernicus.

Thomas Kuhn in his book The Structure of Scientific Revolutions described three stages: (i) normal science (routine scientific work) within existing paradigms and a dedication to solving puzzles, (ii) serious anomalies produced by research, which leads to a crisis, and finally (iii) resolution of the crisis by the creation of a new paradigm. Psychiatry today, with its attempt at solving the clinical puzzles and its many anomalies, is awaiting a paradigm shift, which will not only clarify these complex issues but will also provide for a new framework, insight and understanding. Psychiatric research, despite its current attempts at testable conjectures and refutations, is still within a paradigm that seems inadequate for the complexity of the task. Psychiatry awaits its new dawn.

(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore. The views expressed are personal)

More In: Lead | Opinion

In fact, Ashis Nandy's 1983 article "Towards an Alternative Politics of Psychology"--
published in the International Social Science Journal, v35 n2 p332-38 1983--is most
relevant to working out a paradigm shift. However, K. S. Jacob's hopes regarding a
paradigm shift to make psychiatry an exact science are completely illogical because
humans will always exercise their will and could not be mechanically interpreted.

from:  Kapila
Posted on: Feb 18, 2013 at 11:00 IST

My reply is to Mr.(?)Dr.chandy who says Psychiatry in non science.No doubt Dr.jacob has
opened up a debate rather than conclusions.Medical conditions fall under categorical vs
Dimensional area.For e.g we all know rheumatic heartdisease ,rheumatoid illnesses have no
single point of referrence for diagnosis.There was an article years ago int he Archives of
general Psychiatry regarding this debate.IT is getting jargonish , i am sorry.Also Mr.iyer there
are psychiatrists who givethe benefit of doubt about bach flower remedies.In General
Medical ailments too native healing /herbal medicines are followed but no one expects the
Physicians nod .Psychiatry is still evolving ,it is hard to do research on a living brain which is
why despite many advances neurologists have very limited number of pharmacological
preparations for many neurological conditions.

from:  Seetha
Posted on: Feb 17, 2013 at 17:19 IST

If I may venture a layperson's prediction: DSM-5 will NOT bring about the desired "paradigm shift (to) clarify (the) complex issues (relating to mental health)". It will NOT provide any needed "new framework, insight and understanding". It is true enough that "psychiatric research, despite its current attempts at testable conjectures and refutations, is still within a paradigm that seems inadequate for the complexity of the task" (of exploring the complexities of the human mind). Psychiatry is, I'm afraid, still as far as being a 'science' as is economics, that 'dismal nonscience'.

from:  G.S. Chandy
Posted on: Feb 17, 2013 at 11:13 IST

Points made by Dr. Jacob are quite true. The larger issue is that despite impressive advances over the past 100 years modern (western) medicine is very young. And, it is susceptible to several culturally-rooted blind-spots that are present in western society. These pose serious limitations to the growth of medical understanding, especially in psychiatric medicine. In contrast, in India and other parts of Southern and Eastern Asia, the foundations for the scientific practice and growth of psychiatry are much better, due to the much deeper and longer pursuit of the understanding of 'human consciousness' in these cultures. Ironically, the few western psychiatrists who have been more receptive to non-western hypothesis in psychology and psychiatry are systematically ignored by the so-called 'mainstream'. Perhaps the best example is that of the late Dr. Ian Stevenson (a Canadian psychiatrist) and his former colleagues (including Dr. Jim Tucker) at the University of Virginia.

from:  R. Venkatesh
Posted on: Feb 17, 2013 at 09:01 IST

I practise Bach Flower Remedies,an alternative healing therapy. My most recent success was in August'2012 when 60 children were rehabilitated from Assam in a western suburb in Mumbai. The parents of these children were brutally murdered in front of their eyes. I prescribed Bach Flower remedies through the NGO and met with considerable success. The children's childhood and innocence was restored. When i broach this subject with psychiatrist they do not like it. After all, I am a layman, an aam admi and what do i know about medicine. That is the problem with MNCs, off course, psychiatrist problems do not fall into a straightjacket. At the end of the day we have to ask ourselves, does all the medication really help the patient or does he/she continue in the vegetative state wallowing in their self-pity. Off course the trauma of these children will haunt and revisit them, but then the subtle flowers do work in their own way to stabilize the victim(s) emotionally. Doctors listening?

from:  Venkatesah Prasad Narayan Iyer
Posted on: Feb 17, 2013 at 08:29 IST

Not sure of the relevance of this article in a newspaper. Full of jargon, surely this is
something for a medical journal rather than a national newspaper? Is a discussion on the
merits of DSM-5 vs earlier iterations of the same relevant?

from:  Jo Nair
Posted on: Feb 16, 2013 at 16:56 IST

Psychology had its newton in Freud and it
is still waiting for its Einstein. The
most intense challenge as you pointed in
defining what Is normal. In age when our
experiences are getting so diversified
through internet and media, when our
culture Is undergoing such a paradigm
shift. It will become very difficult to
find right correlation between cause and
effect.

from:  Abhisek
Posted on: Feb 16, 2013 at 15:04 IST

A masterpiece! Paradoxically, psychiatry is still not handled in a decent manner in India where most of the cases are derogatorily called " mental " and doctors instead of doing CBT just dispense medicines

from:  Dipak Rai
Posted on: Feb 16, 2013 at 13:02 IST

A very well written article on the current need of the hour in the field of mental
illnesses. Lack of good diagnosis techniques as well as a lack of expert doctors in
comparison of the number of cases that require attention is indeed needed to be
looked into. There are a lot of patients(and their families) who suffer immense
mental distress on account of absence of good medical help from an expert. Also,
the stigma associated with mental disorders makes people conceal the problem
instead of dealing with it. There needs to be created a greater awareness in general,
and more work needs to be done for a better diagnostic approach in particular.

from:  Abha Verma
Posted on: Feb 16, 2013 at 11:49 IST

Dr,Stanislav Grof has been doing excellent work in the field of
Transpersonal psychology! He has tried to integrate western medicine
with yoga.

from:  Umesh Bhagwat
Posted on: Feb 16, 2013 at 05:11 IST
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