Tuesday, April 20, 2010

The DSM-5: Science vs Scientism

Just a quick note before I start packing for Kansas. Nassir Ghaemi MD of Tufts (pictured here), who has helped me enormously in understanding the fine points of my illness over the years, has cited one of my blogs pieces here with approval.

In a blog post on Medscape, Dr Ghaemi neatly encapsulates the DSM-5 debate. To quote at length:

In recent months, there has been back-and-forth between the heads of DSM-III (Robert Spitzer) and DSM-IV (Allen Frances), on one side, and the leaders of DSM-V (David Kupfer and colleagues), on the other. Frances in particular has been vocal in articles in the Psychiatric Times and the British Journal of Psychiatry; his critique sums up this way: 

Changes in DSM-V should not be made unless strong scientific evidence exists to do so. A conservative baseline mind-set appears to exist such that revisions should always err on the side of not making a change unless notably strong evidence exists for change. The rationale, as Frances describes it, is partly so that the psychiatric profession is protected from rapid and unnecessary changes in nosology.

Dr. Frances does not seem to question the validity of his assumptions: Should we have a very high threshold for making changes? Should we be erring on the side of not making changes? 

As John McManamy notes, this would ensure that we would forever be mired in the "Groundhog Day of 1980", the last time anyone in psychiatry had the courage to structurally change our nosology.
Science, yes; scientism, no.  We should not let claims of science blind us to data that are good enough, or to current practice that has the virtue of not requiring change but the vice of being unscientific.  

As I noted in other pieces here, the DSM-5 is not a science project. Instead of an academic publication that maybe 30 people would read, the DSM is a real world document relied upon by millions. Ironically, in the name of science, the DSM-5 is leaving in place ancient diagnostic criteria the defies both science and reality (such as not acknowledging the depression-bipolar spectrum).

As Dr Ghaemi concludes:

Over time, revolutionaries tend to become conservatives, and reaction engenders counter-reaction. There is a psychological law of inertia, as the writer Henry Adams observed: What exists is valued simply because it exists, and much more effort is needed to push the boulder of dogma into motion than to leave it alone. Perhaps the physicist Max Planck is sadly all too right that new scientific truths are routinely resisted by prior generations, who are rarely convinced, and rather are only accepted by a changing of generations.

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