Scott Alexander discusses the incoherent wish for an apolitical psychiatric classification in a recent blogpost on Astral Codex Ten. His post is in response to assertions that it is better for classifications to eschew social and political influences because when they don’t do so, it results in errors like the DSM classifying homosexuality as a disorder. Alexander argues that “The people asking for apolitical taxonomies want an incoherent thing. They want something which doesn’t think about politics at all,
Both DSM and HiTOP have something in common - no mention of the brain. I don’t know how long these competing classifications (from both APAs) can keep the charade.
DSM offers some practical value as a communication tool, and it is readily accessible to the curious public. Also, the insurance companies and the CDC can collect data (thanks to the "S" in its name), and the FDA can give pharmaceutical houses a standardized language for advertising.
HiTOP can’t claim even that. The scheme is so convoluted and impractical that even seasoned psychiatrists can’t make heads or tails of it, not to mention primary care docs and OBGYNs who see most psychiatric patients.
DSM is ubiquitous but still makes a lousy taxonomy. For instance, PTSD diagnostic criteria list 20 symptoms and 4 situations, which in various combinations make 636,120 (!) possible diagnostic presentations. Lupus was called a disease with a thousand faces; how about more than 600,000? Imagine a medical disorder with the same conundrum. Or take, for instance, the DSM criteria for major depressive disorder (MDD) offering nine sets of symptoms and calling out five for the diagnosis. That makes more than 250 possible combinations, which means two people who do not have a single common symptom can still be diagnosed with major depression. How can you treat both of them with the same “FDA-approved” for major depression medications?
BTW, the third contender, RDoC, is as good as dead. The team bit off more than they could chew and got stuck in a tangle of social categories, disjointed symptoms, neurocircuits, neurotransmitters, receptors, and genes mixed with NIMH bureaucracy and politics. The statue of Laocoön and His Sons comes to mind.
All told, psychiatry painted itself into a proverbial corner. There is, however, a model that might work. It served physical medicine well for centuries. APA actively resists it despite its own statement that ”psychiatry is the branch of medicine.“ I am curious why they avoid mentioning the brain in its classification. A specific phobia, perhaps.
There is another point of confusion permeating both classifications. Despite the superficial appearance of continuity, etiology, pathology, diagnosis, and treatment are only loosely connected. We don’t treat etiology, not only in psychiatry but in the rest of medicine. The best we can do in psychiatry is to restore some missing functions and alleviate debilitating distress. The classifications should help us do that instead of muddling the picture with vague, contradictory symptoms and irrelevant categories, which continue to plague DSM.
The Comments format limits getting deeper into the medical model for psychiatric disorders. Another time perhaps.
Thanks, Awais.
Both DSM and HiTOP have something in common - no mention of the brain. I don’t know how long these competing classifications (from both APAs) can keep the charade.
DSM offers some practical value as a communication tool, and it is readily accessible to the curious public. Also, the insurance companies and the CDC can collect data (thanks to the "S" in its name), and the FDA can give pharmaceutical houses a standardized language for advertising.
HiTOP can’t claim even that. The scheme is so convoluted and impractical that even seasoned psychiatrists can’t make heads or tails of it, not to mention primary care docs and OBGYNs who see most psychiatric patients.
DSM is ubiquitous but still makes a lousy taxonomy. For instance, PTSD diagnostic criteria list 20 symptoms and 4 situations, which in various combinations make 636,120 (!) possible diagnostic presentations. Lupus was called a disease with a thousand faces; how about more than 600,000? Imagine a medical disorder with the same conundrum. Or take, for instance, the DSM criteria for major depressive disorder (MDD) offering nine sets of symptoms and calling out five for the diagnosis. That makes more than 250 possible combinations, which means two people who do not have a single common symptom can still be diagnosed with major depression. How can you treat both of them with the same “FDA-approved” for major depression medications?
BTW, the third contender, RDoC, is as good as dead. The team bit off more than they could chew and got stuck in a tangle of social categories, disjointed symptoms, neurocircuits, neurotransmitters, receptors, and genes mixed with NIMH bureaucracy and politics. The statue of Laocoön and His Sons comes to mind.
All told, psychiatry painted itself into a proverbial corner. There is, however, a model that might work. It served physical medicine well for centuries. APA actively resists it despite its own statement that ”psychiatry is the branch of medicine.“ I am curious why they avoid mentioning the brain in its classification. A specific phobia, perhaps.
There is another point of confusion permeating both classifications. Despite the superficial appearance of continuity, etiology, pathology, diagnosis, and treatment are only loosely connected. We don’t treat etiology, not only in psychiatry but in the rest of medicine. The best we can do in psychiatry is to restore some missing functions and alleviate debilitating distress. The classifications should help us do that instead of muddling the picture with vague, contradictory symptoms and irrelevant categories, which continue to plague DSM.
The Comments format limits getting deeper into the medical model for psychiatric disorders. Another time perhaps.