Wednesday, May 8, 2013

The APA’s response to the NIMH announcement: a Spin-to-English translation

Statement by David Kupfer, MD

Chair of DSM-5 Task Force Discusses Future of Mental Health Research

The promise of the science of mental disorders is great.
Hey – look over here, to the wondrous FUTURE! SCIENCE! Pay no attention to the present exposure of our diagnoses and model as a sham!
In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant.
OK, we admit it. Our diagnoses are invalid. Our model is false. Oops.

But still…the FUTURE!
We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.
We haven’t actually been telling people this at all. We and our friends at the pharmaceutical corporations have been leading people to believe for decades that our diagnoses reflected brain disorders for which we had scientific evidence. The chemical imbalance myth? Ours. And we’ve grown rich and powerful in the process. Where would we be if we’d been open all along about how unscientific our diagnoses are?
In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia.
Please continue to ignore that the biomarkers we’ve encouraged you to believe in for the past several decades don’t exist. You know that clinical experience you reject when anti-vaccination activists try to use it? Well, that’s what we’ve got. Oh, and some other empirical research we don’t have to tell you about. But it’s growing. And by growing, we mean unreplicated.
This progress will soon be recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
What progress, you ask? The progress we just mentioned. Isn’t that enough?
The new manual, due for release later this month, represents the strongest system currently available for classifying disorders. It reflects the progress that we have made in several important areas.
• A revised chapter organization signals how disorders may relate to each other based on underlying vulnerabilities or symptom characteristics.
• Disorders are framed in the context of age, gender, and cultural expectations, in addition to being organized along a valuable developmental lifespan within each chapter.
• Key disorders were combined or reorganized because the relationships among categories clearly placed them along a single continuum, such as substance use disorder and autism spectrum disorder.
• A new section introduces emerging measures, models and cultural guidance to assist clinicians in their evaluation of patients. For the first time, self-assessment tools are included to directly engage patients in their diagnosis and care.DSM, at its core, is a guidebook to help clinicians describe and diagnose the behaviors and symptoms of their patients. It provides clinicians with a common language to deliver the best patient care possible. And through content such as the new Section III, the next manual also aims to encourage future directions in research.
None of this addresses the basic invalidity of our diagnoses in any way, but it is a lot of words. And our references to disorders and clinicians sound sciencey, don’t they?
Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders.
If we keep saying things like “continued progress,” will you keep believing us?
But they cannot serve us in the here and now, and they cannot supplant DSM-5.
DSM-5 is the best currently available invalid, pseudoscientific manual. I think we can all agree that we need an invalid, pseudoscientific manual, and ours can’t be beat.
RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field.
You know – those breakthroughs you all thought happened decades ago and formed the basis of our model.
In the meantime, should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.
Look, we need you to keep believing this isn’t quackery. Our profession’s status, millions in grant funding and proceeds from our book, and billions in drug sales depend on it. Please continue to believe that there’s no alternative to our pseudoscience.

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