The death of psychiatry?

A while back I wrote a post on why I believe that a lot of what’s been classified as mental illness is nothing of the sort (see here). I argued that the psychiatric diagnostic manuals, like the DSM-IV, are nothing but descriptions of symptom clusters, and do not explain the underlying aetiology of psychological dysregulation.

Turns out I’m not the only one. A few weeks ago, with reference to the soon to be published DSM-V, the director of the National Institute of Mental Health (NIMH) in the US said pretty much the same thing. The NIMH have decided to ‘drop’ the DSM-V as a classification tool for all future research funded by their organisation. Instead, they plan to develop a classification criteria that examines the underlying biology, as well the brain circuitry, cognitions, genetics and degrees of functioning associated with a specific dysregulation. In other words, they’re trying to develop a set of  classification and diagnostic criteria that will take into account not only the expressed symptoms of a disorder, but the underlying reasons why it’s occurred in the first place and, in doing so, open the way for more effective, targeted treatment.

But I’m getting ahead of myself. Let’s take a step back and look at the (largely psychiatrically-led) journey to this point. Although the roots of psychology go back a long way (Freud pretty much rehashed Aristotle), modern psychology began with Sigmund Freud and his contemporaries. Freud was a medical doctor (the difference between psychiatrists and psychologists, is that psychiatrists study medicine before psychology – psychiatry is a branch of medicine), and it has remained the ordained thinking within the medical profession that those working with mental disorders should also be medically trained. Consequently, as diagnostic manuals were developed, they were done so using a typical medical model (or at least the model of the early 20th century) – observation of symptoms and their categorisation into observable clusters. Alas, whilst the rest of medicine went on to refine classification systems to include substantially more than the expressed symptoms (including understanding of the aetiology and increasingly accurate tests for these underlying causes), psychiatry stayed faithful to the old school. As such, the American Psychiatric Association’s Diagnostic and Statistical manual version 5 (DSM-V) is the latest incarnation of an increasingly large collection of symptom clusters.

The problem with this system is that it does very little to help identify the actual causes of psychological dysregulation and, using these classifications, the only way to determine the effectiveness of a treatment is to see if the symptoms reduce following its delivery. Thus, psychological dysregulation has become mental illness and, as the classifications have become more numerous, the already existing stigma regarding ‘mental illness’ has burgeoned. Further, although there are undoubtedly a range of biological issues that can result in psychological dysregulation, depression and anxiety, the most common ‘mental illnesses’ appear to be normal human reactions to abnormal states (i.e., evolved neurobiological responses to certain environmental stimuli). Instead of understanding more about the states that provoke these largely survival-based responses, and the best ways of reducing their impact, the research emphasis has often been on the diagnosis and treatment (often using medication) of these problems. It’s not surprising, therefore, that many people are terrified of seeking treatment for anxiety or depression, because of the weight they carry. It’s also not surprising that most researchers, bound within these classification schemes, have spent their time looking for better ways of reducing the symptoms, rather than properly understanding the underlying causes.

Psychologists have made their share of mistakes as well. Early behaviourists were convinced that all human behaviour could be described through simple operant conditioning processes. Nevertheless, psychology (the study of the mind) has long been concerned with understanding the human condition by better understanding the ‘software’ platform that makes up ‘us’. Combined with recent advances in neuroscience (understanding the ‘hardware’), psychologists and neuroscientists are starting to identify the underlying systems that are activated during psychological dysregulation. Recently, the idea of a ‘connectome’ has been proposed: effectively, the entirety of all the synaptic and other neurological connections that make us who we are. Unlike the genome, which sets up the initial conditions for our brain, the connectome is the result of the ever-evolving response of our brains to the myriad experiences of life. It’s been suggested that were we ever able to measure it accurately, we could preserve a person’s ‘self’ indefinitely, as uploaded consciousness to a powerful computer platform. This might take a while so, in the meantime, neuroscientists and psychologists are attempting to identify the various components that make us tick, and to understand how they can go wrong. Using this focus, researchers recognise that the neural circuitry that underlies psychological dysregulation is insanely (forgive the pun) complex, and that it isn’t particularly useful to simply give it a classification. Worse, to assume knowledge of a complex system and then to attempt to correct that system using pharmacological agents (without full knowledge of the system of how those agents disrupt it), is downright irresponsible. Perhaps, eventually, with enough understanding, and carefully delivered drugs to specific brain systems, a pharmacological approach will be justified. Presently, not so much.

A short side-step. Many people have had extensive benefit from modern psychotropic medications (including antidepressants). This is both a good and bad thing. The benefit is great, but the assumption that the aetiology is understood because we know which neurotransmitters are stimulated by a medication is false. In fact, recent research has highlighted the fact that, if antidepressants work at all (and there’s some very convincing epidemiological research that suggests the effect is placebo), they do so in ways that aren’t related to serotonin reuptake inhibition…

Anyway – the psychiatric model appears less and less relevant in the increasingly knowledgable world. Instead of assuming we understand the conditions we’re trying to treat, and then treating them badly with medications, the effects of which are not properly understood, psychologists and neuroscientists are working to remove our preexisting assumptions and replace them with a more complete understanding of the underlying systems. This is the aim of the new strategy by the NIMH, with the eventual goal of treatment that is truly effective.

It’s important that psychologists don’t fall victim the same hubris of the psychiatric profession. Truth be told, currently, the best we have are low-bandwidth ‘software patches’. Yes, the various forms of psychotherapy are delivered through the medium of language and, currently, language is extremely low bandwidth – we can only get across a tiny amount of information through written or spoken communication and, a lot of the time, the content is unreliable (whether it’s understood is dependent on the client’s ability to understand, something that, ironically, can be reduced by the dysregulation we’re trying to treat). Consequently, research into the most effective delivery systems, given the narrow bandwidth of the medium, is a lot more important than trying to come up with overly simplistic diagnostics. My money is on a better understanding of the underlying processes.

In the meantime, psychiatry may well be a dying profession. Relying on outmoded classifications and poorly understood pharmaceuticals isn’t much of a business model in the rapidly evolving world of psychoneurobiology. My prediction is that 20 years from now, psychology  will have taken over the psychiatric niche. Using a strong neuroscientific base, combined with complex imaging technology and massive processing power to identify a person’s connectome, psychologists of the future might be able to identify specific dysregulation and intervene by modifying the source directly (instead of relying on slow, unreliable language-based therapy). Until then, thanks to forward-thinking institutions like the NIMH, we might learn a bit more, rather than relying on out-of-date, and stigma provoking ‘diagnoses’.