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.”
Yet after maligning the adolescence of psychiatry in his column for the Times, Brooks censures this desire to come of age. Accusing psychiatrists of “piggybacking” on the authority model of biology and physics, he makes a bizarre case for the status quo:
All of this is not to damn people in the mental health fields. On the contrary, they are heroes who alleviate the most elusive of all suffering, even though they are overmatched by the complexity and variability of the problems that confront them. I just wish they would portray themselves as they really are. Psychiatrists are not heroes of science. They are heroes of uncertainty, using improvisation, knowledge and artistry to improve people’s lives.
Well, yes and no. As Brooks writes a paragraph later:
The best psychiatrists are not coming up with abstract rules that homogenize treatments. They are combining an awareness of common patterns with an acute attention to the specific circumstances of a unique human being. They certainly are not inventing new diseases in order to medicalize the moderate ailments of the worried well.
But that’s just the best of them. The worst take advantage of the uncertainties in their field to rack up patient visits, dole out prescriptions and pad their wallets. There are also the lazy ones, who don’t heed their field’s shortcomings and disrupt their patients’ lives in the process.
Maia Szalavitz’s first-person account of dealing with psychiatrists, published May 17, shows, as the headlines notes, “what’s right—and wrong—with psychiatric diagnoses.” Szalavitz, who covers neuroscience for TIME.com, spent decades going in and out of psychiatrists’ offices and received at least five different diagnoses for mental illnesses based on DSM criteria. None really fit, however, and some exacerbated her anxiety. The appropriate diagnosis, Szalavitz now believes, would have been Asperger’s Syndrome, and it would’ve helped, but it didn’t exist when her problems emerged and it doesn’t exist any more, having been folded into autism spectrum disorder in the latest edition of the DSM.
Refining the current diagnostic system will be difficult, to be sure—so difficult that nobody’s sure how long it will take—but few doubt that it can be done. Still, Brooks suggests that psychiatrists should stick with what they’ve got.
The solution he sees is not scientific progress in psychiatry, but rather admitting that it is a “semi-science” and accepting that that’s the best we can do. In his words:
The desire to be more like the hard sciences has distorted economics, education, political science, psychiatry and other behavioral fields. It’s led practitioners to claim more knowledge than they can possibly have. It’s devalued a certain sort of hybrid mentality that is better suited to these realms, the mentality that has one foot in the world of science and one in the liberal arts, that involves bringing multiple vantage points to human behavior.
Wrong again. Yes, there will always be some artistry involved in medical practice, but psychiatry is not like economics, political science, and other behavioral fields. It is a hard science in the very early stages of development, and its diagnostic methods will improve. Brooks’s failure to understand that caused his blanket attack on psychiatrists, and his blanket defense of them, to be sorely misguided.
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