On Monday, David Brooks weighed in on the debate about the merits of the latest edition of the DSM-5, psychiatry’s primary diagnostic manual for mental disorders. As often happens when a columnist parachutes into a complicated scientific subject, he made a muddy topic even muddier with superficial generalizations.
His column, headlined “Heroes of Uncertainty,” is oddly contradictory, beginning with a sweeping attack on psychiatrists’ work and concluding with a sweeping defense of it, both of which are off the mark. Brooks seems to grasp fundamental problems with the DSM-5, but the conclusions he draws from that knowledge betray misunderstandings of the underlying science and scientific process.
He explains, for instance, that, “Mental diseases are not really understood the way, say, liver diseases are understood, as a pathology of the body and its tissues and cells” and that, “What psychiatrists call a disease is usually just a label for a group of symptoms.” True enough. However, these facts lead him to claim that:
The problem is that the behavioral sciences like psychiatry are not really sciences; they are semi-sciences. The underlying reality they describe is just not as regularized as the underlying reality of, say, a solar system.
That’s wrong. Psychiatry is not a semi-science. It’s just a really immature science, and most practitioners are well aware of its limitations. They’re not focusing on symptoms for fun. They’re doing it because, until we have a better understanding of the brain, and better tools to diagnose its afflictions, it’s the best anybody can do, and it’s often effective. Moreover, there is every reason to believe that the “underlying reality” of the mind is just as “regularized” as the solar system, and for the most part, psychiatrists are as eager as anybody to figure out how it all works.
Brooks’s misinterpretation probably resulted from the acrimonious, and often misunderstood, debate within the medical field about the DSM-5’s value and usefulness. A few weeks before its release, Dr. Thomas Insel, the director of the National Institutes of Mental Health, wrote a blog post declaring:
We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data—not just the symptoms—cluster and how these clusters relate to treatment response.
That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories—or sub-divide current categories—to begin to develop a better system.
As long as the research community takes the D.S.M. to be a bible, we’ll never make progress. People think that everything has to match D.S.M. criteria, but you know what? Biology never read that book.
These comments fostered a few misunderstandings, however. First, there were the inaccurate headlines about the NIMH “abandoning” and “rejecting” the DSM-5, which led Insel to clarify his position. In a joint statement with the president-elect of the American Psychiatric Association, which publishes the DSM, he explained:
[The manual] represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care.
And testifying to the fact that psychiatry is an immature field of science, rather than a “semi-science,” Insel added:
All medical disciplines advance through research progress in characterizing diseases and disorders. DSM-5 and RDoC represent complementary, not competing, frameworks for this goal.
Nonetheless, Insel’s charge that the research community treats the DSM like a “bible” has lingered. Myriad news articles have blindly repeated the assertion, but careful readers might note that reporters never actually quote psychiatrists calling it that. On the contrary, Dr. Richard A. Friedman, a professor of clinical psychiatry at Weill Cornell Medical College, noted in an op-ed for The New York Times, “Most of my colleagues laugh at the notion that the manual is a ‘bible.’”
In reality, Friedman explained, most psychiatrists are as eager as any other doctor to move away from symptom-based diagnoses. They understand that as their field matures, it will look more and more like internal medicine. Friedman referred to discovering the neural basis of mental disorders as “the holy grail of psychiatry.”