This post has taken some time to get together. In my professional life, the Americans (who, as usual, are the outliers) have decided to revise their version of the diagnostic manual. When this was first put forward, there was a hope that with the decade of the brain increasing the amount of research that there would be a paradigm shift to a biological basis for disorders. This has not happened. A more conservative approach — revising the classification using the tools of epidemiology, including cluster analysis — is an alternative, and this may be where the international (World Health Organization) sponsored classification system goes.
But in the meantime, there are those who have decided to attack the idea of psychiatric syndromes.
Dr Lucy Johnstone, a consultant clinical psychologist who helped draw up the DCP’s statement, said it was unhelpful to see mental health issues as illnesses with biological causes.
“On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse,” Johnstone said. The provocative statement by the DCP has been timed to come out shortly before the release of DSM-5, the fifth edition of the American Psychiatry Association’s Diagnostic and Statistical Manual of Mental Disorders.
Now, before we go down yet another Rabbit Hole and discuss the social causes of this, it would be good to look at some fairly recent papers. Most of these papers are brand new, and I cannot link directly to reprints, but I will link to the abstracts.
The first is a recent paper linking family risk in OCD. This is fairly complex population based work that can only be done in places in Scandinavia where everyone has had a health number since birth, dating from the 1930s. Matiax-Cors has published a multigenerational family linkage study in JAMA Psychiatry, from which this is taken.
In the article, the issue of family environment and individual environment (which is in part genetic, and in part the individual and unique experience everyone has — for even twins are raised slightly differently) are unpicked. Most of the risk for OCD — isn internal, not shared. In short, OCD cannot be explained using the tools of social psychiatry. There is some biology here, and there is a syndrome.
The second article is from the same journal. It is looking at the use of a Sodium Nitroprusside solution — completely bypassing cell receptors and interfering with the second messenger (cGMP) cycle. In people with treatment resistant schizophrenia. With good results.
Now, there are things that are much more social in aetiology — the paradigmatic socially driven psychiatric conditions are the stress disorders — and there a social, occupational and psychological consequences to having a serious mental illness. But to pretend that there is not a syndrome is nonsense.
And the word syndrome is the correct one. A syndrome is a series of symptoms that form a pattern that is coherent, repeated in multiple people, and leads to the ability to make predictions about natural history or prognosis. The syndrome Dropsy, for instance, has become various forms of heart failure and renal failure.
But all clinical medicine starts with description, and from that various hypotheses are made about aetiology. These we should hold lightly. Our theories and are classification systems are mobile — because we are continually working to find out, by all means from large epidemiologic projects to clinical trials to working with animal models — to disprove hypotheses and develop data that will allow us to develop robust theories.
And those, from the outside, who say this is a nonsense — generally are not around when people appear in despair, and you offer them the best options available. With today’s imperfect knowledge, and in their imperfect situation. It is far better to do what is available, and known to be partially efficacious (we have a deep enough database of studies in most areas to know that) in a timely manner than it is to leave a person waiting for some perfect treatment.
I’d agree with the psychologists that DSM5 is an over reach, beyond current knowledge. But the phenomenological project, the ongoing work of careful clinical description and observation remains but the only tool we have. And the art of medicine is now practiced in it’s most ancient form by that group of stigmatized, shunned and criticized doctors that I am part of, now called psychiatrists.