Written by Willa Goodfellow

March 2020

Blowing Up the DSM

How do we get from a public DSM book-burning to a new, biologically informed system to describe mental illnesses?

Editor's Note   This article was the consensus winner of our 2019 essay contest. We hope you agree that the humor, passion, and independence in Willa's writing is as compelling as it is insightful. Congratulations Willa, and thank you to the many other worthy submissions that we, unfortunately, did not have the space to feature.

About the Author   Willa Goodfellow is a mental health journalist and Episcopal priest. She blogs at Prozac Monologues and tweets @WillaGoodfellow. Her book, Prozac Monologues: A Voice from the Edge will be published in August 2020 by She Writes Press. She lives with Bipolar 2.

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It’s a thing they say in the psychiatry biz: Nature does not sort by DSM categories. So, when are they going to blow it up? The DSM, I mean. We’re stuck with nature.

 

On the eve of DSM-5’s publication in 2013, Director of the National Institute of Mental Health Thomas Insel climbed the mountain and saw what lay on the other side. The DSM lay in the bonfire, while scientists write a new classification system, based on what is going on inside the brain.

 

In his (in)famous blog post, ”Transforming Diagnosis,” Insel noted that the increasing amount of genetic and brain mapping data we have about mental disorders do not match up with the DSM categories. People with different diagnoses have similar genetic markers, and people with the same diagnosis have differently-wired brains.

Here are a few examples:

 

  • Some people with depression do better with antidepressants, some with cognitive behavioral therapy. A research study using PET scans discovered that the brains of people who do better with medication are wired differently from the brains of those who do better with cognitive therapy. These treatments are not interchangeable.

 

  • The DSM cannot predict response or lack of response to lithium, the “gold standard” treatment for bipolar. Genetics can.

 

  • Even EKGs and measures of inflammation have been able to distinguish between people with bipolar and people with major depression. Yes, blood tests. Yes, inflammation.

 

The DSM was supposed to be a tool for research, so that scientists could compare apples to apples and oranges to oranges, mood disorders to mood disorders, cognitive disorders to cognitive disorders. As the science has progressed, it has become clear that it doesn’t do its job well enough to produce treatments that are safe and effective, often because nature does not recognize what the DSM calls apples. Because of this, Insel announced that NIMH funding would be redirected away from research based on the DSM’s symptom silos and toward studies of biomarkers, what is going on inside the brain.

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This announcement was greeted with wailing and gnashing of teeth. More money going to basic brain-based research would mean less money going to research on treatments for people with existing diagnoses. The wailers and gnashers also claim that a more scientific approach to mental illness would replace humanistic approaches.

 

Personally, I think a better understanding of what is happening inside my brain might protect me from the pain and suffering caused by my having been slotted into the wrong symptom silo. The National Alliance on Mental Illness’s Peer to Peer class devotes one session to people identifying their diagnosis. This exercise invariably turns into an accounting of a series of diagnoses, along with a history of medications that were ineffective and/or dangerous. What could be more humane than abandoning a system that isn’t working in favor of a more promising direction?

 

So, how do we get from a public DSM book-burning to a new, biologically informed system to describe mental illnesses? That’s a long journey, and there are many steps on the way. 

 

  1. How about we start with universal health care? If we don’t need insurance, then we don’t need insurance codes. If we don’t need insurance codes, we can start treating people’s pain instead of their diagnoses.

  2. Give the disciplines of psychology and psychiatry each its own diagnoses and treatment protocols. Psychology is primarily a relational discipline and treatment modality. Psychiatry addresses physical processes with technical means, medication and those things they do with electricity and magnetism. Most conditions fall under both fields. As now, these conditions will be treated concurrently, though under different diagnostic schema and with different treatments.

  3. Turn the diagnoses of psychology into a narrative-based system, asking the question, What happened to you? The goal will be to heal trauma, develop coping mechanisms for continuing effects, and learn management skills for brain dysfunctions. Current examples include: DBT (dialectical behavioral treatment), CBT (cognitive behavioral treatment), and IPSRT (interpersonal social rhythms therapy).  A branch of NIMH will continue to study which of these and others are “evidence-based,” and how they do indeed remediate certain brain dysfunctions. 

  4. Work toward a brain-dysfunction-based diagnostic system for psychiatry. What is actually going on inside the skull, the circuits, the chemistry? Give it new names like Executive Function Dysfunction, Flattened Cortisol Curve, Wonky Wiring… Forget the symptom silos that lump together those with hypersomnia and those with hyposomnia. Forget funding the search for one pill to fix them both. Can TMS (transcranial magnetic stimulation) switch on circuits that don’t currently [sic] work well? How can we best stimulate BDNF (brain-derived neurotrophic factor) and what are the downstream consequences when we do? Where does inflammation come from/what does it do/how can we remediate its deleterious effects?

  5. Where do the pills come in? Oh dear, where do the pills come in? Sure – We still need the pill pushers. They will be the psychiatrist/practitioners, applying what the psychiatrist/researchers discover, as the system works now, but presumably with better results that target specific brain issues rather than the current rickety constructs.

The pushback against my modest proposal will come from DSM IV fans and the folk they can gin up with their hysteria – the same folk who made it impossible for DSM-5 revisers to do their job. Well, they’ll be dead soon.

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