NIMH Backing Away From DSM

Kermit Cole
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Calling for a complete overhaul of research into psychiatric diagnosis, Director of the NIMH Thomas Insel writes that “Over the past 18 months, we have tried to define several major categories for a new nosology… It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data.” Insel cites the current paradigm’s “lack of validity”, saying that “symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

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From Insel’s post:

“The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]

20 COMMENTS

  1. The good news: a) Insel clearly admits DSM is NOT valid – that DSM “disorders” are NOT just like other medical dx’s; b) He admits psychiatry DOESN’T have the physical data to define mental problems the way medicine does elsewhere, and that psychiatry SHOULD have that; c) He admits this will take a decade to remedy – gives us time to make our own headway, and in the meantime, he himself is exposing psychiatrys emperor as having no clothes (which should make our task easier)

    The bad news: a) he doubles down on the medical model orientation; b) psychiatry can now dribble out PR to a breathless public about the “exciting breakthroughs” this new “research “ will produce – making a splash even though nothing immediately useful exists yet (just like psychiatry does now with the latest “genetic discoveries”) – it is more money and grist for the PR mill to shape public perceptions in favor of the medical model.

    Viewed rationally, Insel’s open acknowledgement of DSM’s invalidity should be a shot through the heart of virtually all medical model psychiatry. After decades of pretending to be scientific, the biggest cheese of them all is admitting that the very framework of all psychiatry’s clinical trials and journal articles is hopelessly flawed – kind of like centuries ago, admitting that alchemy was barking up the wrong tree. How can all these “experts” in white coats with confident demeanors explain this big “oops”?

    Of course they will try, with the same PR machinery that’s given psychiatry and the medical model a virtual lock on our culture’s view of our emotional lives. They’ll still have the $60 billion/year promo budgets to throw at this.

    But I am still very hopeful: we will make headway by being rational, and Insel’s admission makes our point that much easier to make. And ten years from now, there’s every chance that NIH will have egg on its face again, when it has to admit there are STILL no workable “biomarkers” and pathophysiologies for mental problems.

  2. For me, whatever NIMH decides to do with its new proposed nosology is ultimately beside the point …. it will still be rooted in the biomedical model.

    More importantly, it represents a crack in the long-time collaboration between the FEDS, in the institutional presence of NIMH (and SAMHSA), and the APA. The fact that NIMH, which sees itself as a research entity, is actively considering its own alternative to the DSM indicates that the fierce criticism directed at the DSM is beginning to take a serious toll on the DSM’s credibility and its utility to the Federal Govt. Very good news, which needs to be summarily exploited.

    I’ve already posted suggestions for immediate f/u on the Boycott DSM-5’s FB page; I make them again below. For starters, go to NIMH’s FB page, locate the comment box for Insell’s article and comment away.

    I’d also suggest reading the article I posted on MIA on 2/26, where I discuss disrupting the APA’s relationships with Big Gov, Big Pharma & Big Insurance. looms like we have an opening to start with Big Gov.

    More on NIMH’s decision to distance from the DSM.

    My FB comments to Dr. Tom Insel, Dir of NIMH + a reference to my 2/26 MIA article which discusses the need to disrupt APA’s relationship with the FEDS.

    Dr. Insel. NIMH appears to have opened the door to re-examine its relationship with the APA and its DSMs. Those of us who are boycotting the purchase and use of the new DSM welcome your initiative. In truth, we do not share your apparent enthusiasm for the bio-medical model, despite the admitted continued absence of biomarkers, and we urge you and the NIMH to devote greater attention and resources to psychosocial treatment interventions that forego reliance on psychoactive medications. In the struggle for a treatment system that does no harm, Jack Carney, DSW, Coordinator, Committee to Boycott the DSM-5.

    First chinks in the armor. If pushed hard enough, NIMH might start re-thinking its relationship with the APA. Ignore the pundits + NIMH’s own hyperbole — this represents an opportunity; should be exploited. Have written exactly about this in my MIA post of Feb 26 ….

    The Politics of Systems Change: Lessons Learned from the Launch of the DSM-5 Boycott
    https://www.madinamerica.com/2013/02/the-politics-of-systems-change-lessons-learned-from-the-launch-of-the-dsm-5-boycott/May 3, 2013
    Jack Carney, DSW

    I encourage everyone on this list serve to address your comments re NIMH’s initiative to Insel, which might provide an opening to further weaken the APA and its relationship to the Federal Government.

    Here’s a link to Insel’s article.

    http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml#1

  3. This causes me to envision a future in which junk science points to dubious theoretical causes of mental illness which then leads to treatments approved for use not because they reduce symptoms but because they address a theoretical cause. I can imagine kids being given drugs that alter their genes and DNA, for no other reason but to treat some imaginary genetic cause that a group of “scientists” concluded might be the cause of “bipolar disorder”

  4. “RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning.”

    Now this poses an interesting question.

    Dr. Insel has acknowledged our current system of diagnosis is not valid, but a presumbably more valid (or precise) system is a decade or more in the future.

    So what does that mean for the current practice of diagnosing and treating so-called mental illness? Should people continue to do something that isn’t valid just because a valid alternative doesn’t exist yet? Why should insurance companies pay for treatment based on diagnoses that the nation’s Top Doc has declared fradulent?

    Pandora meet Dr. Insel.

  5. Finally the one at the top of the world’s leading research organization admits that the underpinning of almost all psychiatric research to date is invalid. If the diagnostic categories on which all the research is based are invalid, and also not reliable (as the field trials for DSM V showed), we will have to throw it all out and cannot trust any of its claims. It is as if Insel is saying to the profession: unless you can prove that bloodletting is curing something you can really objectively measure, you have to stop it.
    So since it is impossible to show objectively e.g. that Zyprexa has an effect on anything since psychotic symptoms are not observable in the sense Insel insists, we cannot continue using this medication against socalled schizophrenia.
    Insel wants to go for genetics and imaging. Genetics has been promising results right around the corner for 40 years and still not found anything that has been replicated. Imaging is at such a simple stage that the smallest unit of measure is approximately 1 cubic millimeter. In this cubic millimeter there will be approximately 1 000 000 000 neural connections that will continuously evolve and program themselves based on input to the brain. In other words: When we see the activity of this network it shows up as only one pixel of MRI. A network this size has the complexity the connections between all the computers on the internet. And this shows up as only one pixel among at least 1 000 000 pixels. So it is clearly an impossible task with todays technology to even come close to understanding the complexity of even one cubic millimeter of the brain since the whole network shows up as only one pixel.
    For the sake of argument though, we could imagine that we could scan all of the 1 000 000 000 connections, know the exact electrical state, which by the way is not a one or zero like in a computer, but varying continuously so as to produce millions of possible voltages for each connection. Add in a few hundred different neurotransmitters at various concentrations, and one has recorded the state of the system. In the next millisecond the whole system has changed and we have to mearure it all again and try to make sense of why it changed, and what we can do with it to change in a better way.
    But let us imagine that we could follow all these changes in all these connections. Would we be any wiser by knowing all this biological data? How would we find the program of this circuit, especially since every cubic millimeter of every human would be different due to the different input each individual has had. Clearly impossible.
    But if it proves to be possible, would we be able to help the patient biologically? Would we send in nanorobots to rebuild a better micro network unique to each patient? And how would we rewire these extremely complex systems? Clearly impossible!
    So Insel has embarked on a quest that could clearly be termed “mission impossible”.
    But is there an alternative?
    Yes, actually. We are dealing with a very responsive intelligent self programming system, that is designed to be programmed by its inputs. The brain gets input through all sensory systems and automatically learns complex tasks such as language and motor movements. So we already have a relatively simple input system. We also have an output system in the form of speech, movements etc. So with some experimentation with varying input, mostly in the form of language, but also tailored experience, we can reprogram the system. This has actually been done. It is called psychology.
    I am a clinical psychologist, and I experiment on a daily basis with these unique brain systems in the form of psychotherapy, more specifically cognitive behavioral therapy. The basis for this kind of research was laid in the 1950s by BF Skinner. He took the stance that we may only observe the input to the system (human with its brain) and the output. We could not know the intricate patterns within the brain. Insel seems to think we know, although we are not in any way able to see the 1000 000 000 connections in the MRI pixel.
    From an information processing point of view, Skinner was on the right track. By experimenting with input and watching output (language and behavior) in more and more complex ways, millions of suffering human beings have been helped by what may be termed psychological reprogramming through therapy. This morning I had the pleasure of doing follow up on a young woman who for years had been tormented by horror film images that she could not get out of her head. Three months ago I had taught her a technique that she could use to take control over these images. I had told her that she could imagine the horrible picture/film clip right in front of her, send it away at high speed, all the way to the mountains, and then taking in a picture of herself smiling broadly because she was not plagued by the images again. This image would rush in from the mountains in less than a second and stop right in front of her. She had repeated this technique 5 times with a half minute break between each.
    Since that moment, the images had not bothered her at all. She was already on an antidepressant when she came to treatment. It had not helped. But the reprogramming did the trick in approximately 5 minutes. 10 years of suffering disappeared by using a simple technique. Other patients need more time consuming reprogramming in the form of exposing themselves for what they are afraid of, repeatedly over several weeks. OCD symptoms such as fear of germs and compulsive washing, is often easily treated like this. Years of suffering is reversed in a few weeks of retraining the brain. Depressed patients are trained to interpret their input (words from others, looks) in more positive ways than what they used to, and the result is side-effect free relief from depression, which often has positive effects on other areas of functioning such as relationships and sex, quite to the contrary of antidepressants.
    So by changing the input (techniques, retraining, restructuring of thinking patterns) one has been able to change the output of the brain. And one does not need diagnosis to do this. It is totally uninformative for me to know the diagnosis of the young woman. At best it will just make me have a stereotypical, usually pessimistic , reaction to her (“Oh here comes another borderliner, they are so difficult to treat”). I asked her what her problem was, and we reprogrammed that specific problem. She was also a perfect example of the self-reprogramming capacity of the human brain. Today she told me that she had rented a horror movie just to revel in how “finished” she was with the problem of scary images getting stuck, and she discovered that she had also got rid of strong reactions she used to have regarding crawling insects and maggots.
    We also discussed another problem she gets from time to time: she starts thinking of a negative possibility and then creates long chains of worry thoughts based on this, often ending up as loveless and homeless. I challenged her to catch the first negative thought, and then to use her intelligence and creativity to find what could be positive in the original negative thought. One thought was “I may do something wrong in my job and be fired”. She thought it strange to find something positive in that, but after less than a minute, she smiled and said: “Well I will get to try something new, get rid of my irritating colleagues, maybe get an opportunity for a new career”.
    Some of these suggestions may be far-fetched, but training the brain to make them, changes the circuits and increases the probability that more positive thoughts will block the negative rumination in the future.
    So every day as a clinical psychologist, I see the miracle of the programmable human brain. I find the specific problem, (what we would call case formulation) give the right input, start the right training, and the brain changes. Sometimes is almost too easy. A middle aged woman had been plagued by the thought of rats for several years. Several times a day, the words “rats” popped into her brain, and made her get scary rat images. I just told her to practice saying the sequence:” rats-stop-I am working on my anxiety and getting better!” (in a positive tonality). So she did, and the next day her 3 good things per day diary (another very good technique) reflected that she was no longer plagued by the intrusive thoughts of rats. Very specific problem, very specific retraining, and brilliant, quick result.
    Commanding auditive hallucinations that ask the person to do violent things, are often considered to be the worst of the worst of psychiatric symptoms. A woman in her fifties, taking a cocktail of 5 different antipsychotics, suddenly hallucinated a male voice saying “go and hang yourself, you pig”, over and over again. She told me about it and was extremely distressed, ready to do what the voice said, just to get it to stop. I told her: “repeat what the voice says to you, and then you say quickly in an upbeat voice: “No! I want to live”. This was a mix of exposure training, symptom prescription to take control , and classical conditioning to make the negative voice trigger her own positive thought. Within two days the negative voice had disappeared. So a simple retraining/reprogramming of a very specific symptom created a very specific relief, which also gave her a general confidence that she could handle any hallucination, and took away her fear of madness.
    So Insel may be right in one thing: we need to look at specific problems and find specific solutions. His error is to search for the solution in the wrong place, biology. Brains are programmable computers so we should try to program them! It even responds to natural language commands and can do complex self reprogramming in seconds.
    Insel is like the curious kid who tries to take the computer apart, piece by piece to try to find the nice woman in the YouTube video, or to take away the offensive remarks in the blog about him. He discovers he can take the offensive remarks away by short-circuiting the motherboard (ECT) or by injecting it with acid (medication) but destroys the computer in the process.
    The more intelligent approach to a programmable system is to re-program it! Then the nice YouTube picture could be printed, enlarged, sharpened, inserted in another picture etc. The offensive language in the blog could automatically be blocked by some simple programming statements.

    So Insel got two thirds right:
    1. Psychiatric diagnosis have no biological basis ( in other words, there is no biologically diseased brain), no validity and hardly reliability.
    2. It is better to focus on smaller units of distress, particular problems.
    3. But the solution is not in biology. Stop short circuiting the computer or flooding it with chemicals. Start programming our brains with natural language cognitive behavioral therapy.

  6. Something I have to add, it’s time for us in the survivor movement to celebrate Thomas Szasz’s legacy. NIMH has basically make it official US government policy (at least official NIH policy) the very same points he raised with “The Myth of Mental Illness”.

    Although I am a Christian and he was an atheist, I hope he was wrong on that regard and that he is somewhere having the last laugh :D.

    I have said numerous times, he was THE intellectual giant in our field. We will never thank him enough for fighting psychiatry with such intellectual clarity.

  7. In regard to whether mental & emotional confusion & distress. & psychic disturbance is biologic or not – How about it’s not either/or, but both (& a load of other things as well).

    I see it that these conditions/experiences exist on a continuum of multiple & variable; individual factors; across a range of physiological/biologic/somatic, psychological/emotional, social/environmental & spiritual areas.

    Maybe in some individuals it all is more biological, however caused & for whatever the reasons, & maybe in someone else it is more psychological, or more social/environmental, or more spiritual – & maybe in cases it is aspects of all of it?

    The problem is that there is no definite aetiology for these conditions. You can use whatever theories & frameworks that you like & make it all fit (to a degree). You can’t divorce physiology/biology from wider experience/environment; & the materialist view will state that ‘all phenomena are emergent properties of physicality’; hence the primary issues are also going to be genetics & brain function; they are not largely interested in what caused the physiological changes (beyond materialist scientific explanations), to them the primary problem/issue is with the altered biology; & that view is the consequence of a dominant reductionistic/materialist paradigm.

    You can apply similar reasoning to the other areas – If it’s the mind/psychological & emotional areas that are the primary issue; then the biological factors are more nuances or effects. The same with social/environmental concerns. Very often those that hold to these areas of psychological & environmental areas being the primary concerns, will also play down or deny all the physiological/biologic aspects to it all.

    Spirituality gets into a lot of other areas as well, especially concerning the nature of consciousness, & the ideas of it’s non-locality/primacy.

    It’s a problem that no one seems to be looking at all areas together & how everything interrelates. All the research & areas need to be considered together. Just looking at epigenetics & brain plasticity; it’s shown that life experiences alter gene expression, brain structure, functioning & development – you can’t divorce physiology from experience. By the same token, it may well be that certain gene mutation, (& inherited genes) at conception also plays some part in all this as well. It’s again not either/or, it’s all a part of the picture puzzle. Very few people, & no one it seems in the Establishment; is joining all the dots. It appears more to be about a battle of World Views/Paradigms.

    The primary focus & issue from the Establishment, & mainstream Psychiatry/Society however; has always been that the primary issue is a problem with the individual. Of course the theories have become more developed; but it all still largely consists of blaming the individual, of blaming the brain; it’s dysfunction & psychopathology. & that has largely remained the same for some 400 years. Will that & can that change? Can psychiatry & the mainstream scientific/medical establishment/community change in it’s primary assumptions about biological/materialistic reductionism/determinism? It may take another 200 years for it all to change, or it may never change at all? But until there is such a shift & change; the basic paradigm/understanding & theorised nature of the experiences of Madness, is going to largely remain the same – That it is all mental illness, a problem primarily of the Individual & their Brain/Physiology.

    I don’t know how you alter that dominant belief/paradigm??? & that is what feeds everything else; the treatment approaches, responses & understandings.

    Continuing to argue either/or, is not, I feel going to get anywhere. There needs to be a fully integrative approach; that takes all understandings into account.

    Another major issue is that psychiatric nosology; within it’s diagnostic system is describing everything in blanket terms. Take schizophrenia; it may be the case that it is a term that is describing 10 or 20 (or more) different things; & the same goes for a lot of other diagnoses. It’s not an exact science; it’s not really science at all. & labelling & carpet/shotgun drugging increasing amounts of the population (to the large exclusion of all else) is really doing very little that constructive in improving the overall health of our populations. The Pharmacological & Psychiatric Industry needs some serious Regulation. It’s Insanity itself to carry on as we are. There needs to be a genuinely comprehensive, person centred, individualised & theraputic response, using a comprehensive psychosocial approach as well as the current medical understandings. Left to their own devices; the current Pharmacological/Psychiatric/Medical Establishment; will not stop until the entire Global population is pathologised, labelled & drugged.

  8. Official APA Response to Insel’s announcement:

    : FOR IMMEDIATE RELEASE
    Erin Connors, 703-907-8562 May 3, 2013
    [email protected]

    Tamara Moore, 202-745-5114
    [email protected]

    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. 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. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting. 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.

    This progress will soon be recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 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.

    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. But they cannot serve us in the here and now, and they cannot supplant DSM-5. 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. 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.

    • Does this official response make any sense to anyone? Isn’t it an implicit acknowledgement that the DSM is a scam, only that it is better than nothing -not that I dispute the notion that a scam is better than nothing, it just seems to me that that is what the APA is saying: better have a scam than nothing-? Thoughts anyone?

      • Looks like Kermit posted this response in the news section and folks are commenting there.

        The response doesn’t really disagree with Insel’s assertion that the DSM is not valid. In fact, the response seems to confirm reliability but not validity which is what Insel stated.

        Dr. Insel has, using his blog postings, over the last year or so declared that the chemical balance theory is far too simplistic and shouldn’t be used anymore. And now says the DSM is not valid. That’s quite a year for Dr. Insel!

        There is no replacement for DSM because reductionistic biomedical conceptulizations will never capture the complexity and wonder that is the human brain. Any so-called replacement from the “establishment” will most likely be lacking. I’m incredibly curious to see what, if any alternatives, will be proposed in light of Insel’s declaration.

        • To be honest, I have been all weekend under shock, a pleasant shock, that is :D.

          When I first saw the post on Friday I said, OK, another guy who finally saw the light. I was busy at work, etc so I didn’t give much thought to it.

          Over the weekend I had time to reflect more and I said, WAIT A MINUTE. This is huge, so the medical research arm of the US government is officially admitting that the DSM is a scam? I bet there must be consequences to this. The late Thomas Szasz would have been delighted with seeing Insel saying,

          “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever”

          Boy, this has to be exploited.

          As to your final thought, I agree, psychiatry is setting itself up for failure, but that is great. If the gold standard is going to be quantitative measurements in bio-markers, we have already won. You can definitely falsify false predictions based on quantitative data, while there is no way falsify so called “consensus” from the DSM committee members :D.