Mood Swings

A psychiatrist surveys the mind and the wider world

DSM and disease: Telling the whole truth

why the concept of disease should not be lost in DSM
Christopher Lane, Ph.D.
This post is a response to The More Things Change . . . The Uphill Struggle to Revise and Reform the DSM by Christopher Lane, Ph.D.


I thank Christopher Lane for his comments on my posting regarding the term "disorder." I elaborate here on topics he raised.

The concept of "disease" does not take us back to Galen and brethren; on the one hand it takes us back to Hippocrates, who took the concept of disease seriously in a clinical sense, prioritizing clinical syndromes as the source of knowledge (not biological theory, unlike Galen); on the other hand, the concept of disease is thoroughly modern. Consider the rest of medicine, and tell me that there is no such thing as disease. If not the diseases of cancer and coronary artery disease and stroke, what are the ethereal conditions that kill people right and left?

I agree with Prof. Lane that we need to be honest about where we are ignorant and where there is not evidence of disease; the most honest approach would be to delete such conditions from DSM, or to give them a non-disease label. But we also need to be honest when we have knowledge of disease. This is a step Prof. Lane appears unwilling to take.  The humble spirochete, cause of half the world's psychosis before penicillin, would beg to differ. Skepticism about disease seems to me to represent a misunderstanding of science, common among academics who have not engaged in science. In science, ignorance is the flipside of knowledge; one can never say one knows without also implying what one does not know, and vice versa. This should not pose any reason for concern by Prof. Lane or by those patients who have previously received those other labels, if they accept and appreciate science. A century ago, all Americans were diagnosed with labels which are mostly out of use today; people are not now unhappy that their great-grandparents had been diagnosed with pleurisy, or ague, or catarrh, or King's evil, or phthisis - and given treatments now known to be ineffective, such as bleeding. This is the nature of science, to make errors, and to approximate the truth by correcting those errors. Yet postmodernist ideology rejects science and the concept of truth, an approach feasible in literature and philosophy, without harming anyone but college sophomores, but, if applied to medicine and psychiatry, deadly to the general public.


Calling the whole thing off would mean a wholesale rejection of science. This option takes us way back - before Galen, before Hippocrates  - to the Ice Ages.


Lastly, the allusions to Pharma and Psychiatry are stale; one should be clear: the APA archives show, as historian Edward Shorter and others have reported, that there is no link, direct or indirect, between Pharma and the basic structure of today's psychiatric nosology, as set in DSM-III in 1980. There was just no interaction between the DSM-III task force and pharmaceutical companies.  Allen Frances' frantic anti-Pharma lucubrations should resolve any doubt whether he allowed Pharma to influence DSM-IV. And today, the DSM-5 task force itself includes only persons with no Pharma connections for five years or longer. But there is no need for direct relationships. Pharma will devise its marketing strategies no matter how DSM is organized. We should neither gerrymander our diagnoses, as Frances wants, to try to outwit Pharma (that's a losing battle), nor should we just give up.

I have a simple suggestion: tell the truth, based on our best scientific knowledge to date.


Let's do that, as has been done in the rest of medicine, where Pharma is equally or even more involved with academia, and then we will be able to treat disease (yes) and save lives, which, after all, is what being a physician is all about. In psychiatry, no less than in cardiology, we must deflect the transient postmodernist weltanschauung  of contemporary academia and get on with our real work: to understand disease where it is present; and to understand non-disease - the psychological problems of life and living - when it is present. Scientific psychiatry means taking on both tasks, not just one or the other.

 

 

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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