Mood Swings

A psychiatrist surveys the mind and the wider world

The DSM Debate: Trotsky Was as Wrong as Stalin

A reply to Dr. Frances
Allen Frances, M.D.
This post is a response to Pragmatism In Psychiatric Diagnosis by Allen J. Frances, M.D.

When Leon Trotsky opposed Josef Stalin, it was a disagreement among believers.  One believed in more Communism of a certain kind, another in more Communism of another kind. So it is with Dr Frances and his opponents: they are all pragmatists of various stripes criticizing each other. They all fail to value science sufficiently, as any credible medical profession should. 

Dr Frances explicitly supports "pragmatism" over science as a basis for defining psychiatric diagnoses.  He criticizes DSM-5 for valuing science somewhat more than DSM-IV, under his leadership, did, because of the presumed "practical" harms of overdiagnosis, mislabeling, overtreatment, and other baleful practics of our presumably incompetent profession. 

Here is the core of the debate among DSM leaders:

My colleague wants just pragmatism, and nothing else, as the core of DSM-5; DSM-5 leaders want mostly pragmatism, but sometimes science, as the core of DSM-5.

I think they are both wrong, and the world deserves more respect, with science placed above all other considerations in DSM revisions. 

I know, obviously, that there can be differing interpretations of scientific data, but our best science is always better than our best "pragmatic" guesses.  

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My colleague's nihilistic approach to science becomes clear when he denies the relevance of psychiatric data that are very definitive. In DSM-IV, my colleague instituted an exclusion criterion for diagnosis bipolar disorder if antidepressants were present during a manic episode.  The science now clearly shows this is wrong. For example, there is a nearly 200-fold increased likelihood of antidepressant-related mania if one has bipolar disorder versus non-bipolar depression. A 200-fold effect is huge; cigarettes increase the risk of lung cancer only 10-fold. (We have debated these matters on prior blog posts).  At least DSM-5 has bowed to this clear scientific evidence to remove the antidepressant exclusion for diagnosing bipolar disorder, a scientifically false criterion that has harmed many patients.  My colleague continues to oppose on this change based on idiosyncratic "pragmatic" grounds. 

My colleague should start smoking cigarettes immediately, given his philosophy.

Trotsky and Stalin were both wrong because Communism was wrong, presumably.  My colleague's loud attacks on DSM-5 impress me as much as Trotskyism: pragmatism is harmful whether there is a huge amount of it (as in DSM-IV) or a whole lot of it (as in DSM-5).

I agree completely with the goal of reducing the number of psychiatric diagnoses: I would take them down from the hundreds in DSM-5 or DSM-IV to just about a dozen; making diagnoses dependent on good scientific evidence would be the best way to make this change, not an idiosyncratic "pragmatism" that depends on the opinions of the pragmatizers. 

If one really wants to help patients and the public health, making science the most important criterion in any medical profession would seem to be an obvious necessity.  The DSM revisions have failed us all and produced many harmful outcomes because of this denigration of science. 

We will never progress in psychiatry unless we get more scientific about diagnosis, not less so.

Our patients and the public health deserve better. 

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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