Psychiatry’s existential crisis

dsm_iv_21Simon Baron-Cohen, the Cambridge psychologist best known for developing the hypothesis that autism is caused by delays in the development of theory of mind, has an op-ed piece in today’s New York Times about the challenges facing the DSM committee as they proceed with developing DSM-V.  Apparently, the committee is considering subsuming autism and Asperger’s syndrome under the single diagnosis of autism spectrum disorder.  Baron-Cohen urges the committee not to do so.

What is notable about his argument is not that autism spectrum disorder does not exist, but rather that we know too little about it to be certain that this is a better way of characterizing the situation.  Without a firmer grasp of the relevant details, Baron-Cohen argues that we should not make changes in the DSM that may have far ranging consequences.  After all, DSM “is the bible of diagnosis in psychiatry, and is used not just by doctors around the world but also by health insurers.”

Later in his article he gets to the meat of the matter:

Part of the reason the diagnostic manual can move the boundaries and add or remove “mental disorders” so easily is that it focuses on surface appearances or behavior (symptoms) and is silent about causes. Symptoms can be arranged into groups in many ways, and there is no single right way to cluster them. Psychiatry is not at the stage of other branches of medicine, where a diagnostic category depends on a known biological mechanism. An example of where this does occur is Down syndrome, where surface appearances are irrelevant. Instead the cause — an extra copy of Chromosome 21 — is the sole determinant to obtain a diagnosis. Psychiatry, in contrast, does not yet have any diagnostic blood tests with which to reveal a biological mechanism.

His comments mirror my own from a previous post,

The field of psychiatry struggles to help patients, but the truth is that the neurosciences have yet to reveal the causes of psychiatric disorders.  Without objective criteria to guide them, physicians fall back on descriptors which are imprecise and therapies which do not treat the underlying (and still unknown) pathology.

The dilemma is what to do now.  Although the issues of autism and it’s kissing cousin Asperger’s syndrome serve to highlight the problem, the larger issue that looms relates to psychiatry as a whole.  There is little question that psychiatric diseases exist and that people suffer terribly from them.  But lacking proper diagnostic and therapeutic tools, psychiatry as a discipline seems to flail around, with the debates over the new DSM-V being symptomatic of existential crisis that plagues the field.

It is easy to offer advice from the sidelines, but the truth is that I can only empathize with the challenges that the crafters of DSM-V must be going through as they consider these issues, and the public debate, sometimes quite heated (see here and here), that accompanies it.  Patients will be affected by whatever decisions they make [It bears reflection that the pharmaceutical companies have a substantial vested interest in the outcome as well.]  Unfortunately, the situation that we are left with is one in which there is no good solution absent stronger science.  If anything, the situation points to the importance of continued research into the neuronal substrates of mental illness in an effort to provide just the sort of tools that the DSM-V committee lack.

[In case you didn’t know, according to wikipedia, Simon Baron-Cohen is a cousin of the Cambridge educated actor-provocateur Sasha Baron-Cohen.  One can only imagine what gets discussed at family gatherings.]


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  1. Pingback: Public expression and DSM-V « Neuroethics at the Core

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