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.
First, I googled - [HiTOP] and [brain] - but couldn't find any connection, including a long article in wikipedia. I didn't see the link in the referenced article either and was not suprised given the origin of the proposed classification.
Second, the claims of HiTOP's acceptability to clinicians notwithstanding, the scheme lacks practical application. It's contrived and confusing. The dualism of internalizing vs. externalizing dimentions reminds of the archaic neurosis-psychosis division. HiTop is a flash in the pan, with no foundation and structure, and will be gone before most psychiatrists will learn about it.
Third, in early days, RDoC made a clear push toward classification and even as recently as 2020 had the ambitions. Read "The role of RDoC in future classification of mental disorders" written by one of its founders, Bruce N. Cuthbert, PhD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365298/
Also, the article from the 'green journal' in 2010 (authored by Thomas Insel, M.D., Bruce Cuthbert, Ph.D.,) says it all: "RDoC classification rests on three assumptions. First, the RDoC framework conceptualizes mental illnesses as brain disorders. In contrast to neurological disorders with identifiable lesions, mental disorders can be addressed as disorders of brain circuits. Second, RDoC classification assumes that the dysfunction in neural circuits can be identified with the tools of clinical neuroscience, including electrophysiology, functional neuroimaging, and new methods for quantifying connections in vivo.
Third, the RDoC framework assumes that data from genetics and clinical neuroscience will yield biosignatures that will augment clinical symptoms and signs for clinical management. Examples where clinically relevant models of circuitry-behavior relationships augur future clinical use ... analogous to what is done routinely today in many other areas of medicine."
In another article, https://www.nimh.nih.gov/archive/news/2013/dsm-5-and-rdoc-shared-interests written in May, 2013 (the birthday of DSM-5), Tom Insel wrote ""RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness."
Clearly, from the get go, RDoC saw itself as an alternative (to DSM) classification. In the NIMH vs. APA contest, the latter won and the former backed off from the original claims.
The push-back on RDoC is very fair, I am not well read in it and thus have no historical perspective. To me it seems fine to change your scope/mission statement in the process.
On the brain link, Kotov et al. (2020) literally has two sections titled "Neural substrates: neuroimaging" and "Neural substrates: neurophysiology". Kotov et al. (2021) has one section titled "Neuroscience". Does that not count as mentioning the brain?
And as far as I am aware, HiTOP is already used in practical application. Not sure what you mean by dualism of internalizing vs. externalizing, they are seperate dimensions that show some correlational pattern and thus are modeled as sharing some variance and containing some unique variance.
Thanks for this discussion! I personally think there is no reason for us to be devoted to any one particular diagnostic framework. We need to take what is valuable from any approach and use it together in a way that makes the most sense. What we might call nosological pluralism.
HiTOP and RDoC have their own advantages and disadvantages. HiTOP doesn't explicitly refer to neurobiology, but it actually has a fair bit of validity evidence, which HiTOP group presented in a series of papers in World Psychiatry. It takes time and energy, so it's not very clinician friendly at the moment, and it's unclear how well it guides treatments or changes outcomes. Likely more suitable for academic settings, but time will tell. It will be more useful for quantitatively minded psychologists. Would be a hard sell for primary care and psychiatry.
I agree about not being devoted to any particular framework, and hope I didn't come across as such. Not trying to be combative either.
I also agree that a lot of aspects are still unclear or lack stronger evidence, so time will tell indeed. In particular the usability is something I personally don't think about, since I am neither a practitioner nor a researcher, but for what it is worth, I found it not so hard to comprehend. It is a time investment though, for sure.
Psychiatrists desperately need new taxonomy; what we have are impractical at best.
Take Eating Disorders, listed as a group DSM and HiTOP classifications implying either common biology or clinical presentation. One wonders what Pica, Rumination, Anorexia, and Binge-Eating disorders have "neurobiologically" in common. The mouth, I guess. Or Unspecified Feeding and Eating Disorders, so vague that we can apply to someone who hates broccoli.
“HiTOP doesn't explicitly refer to neurobiology” because it’s divorced from it. HiTOP used a “dimensional syndromes” model [for arousal] and based all diagnoses on it – high for internalizing and low for externalizing psychopathology. Thought disorders are somewhere in the middle. It was designed by clinical psychologists for clinical psychologists who have never gone to medical school, never made a diagnosis of a medical disease, and have never prescribed medications. The HiTOP creators see the brain as one organ with one portal (higher-order cognition and, specifically, auditory) and one clinical tool – executive function. They might be right about the hierarchical structure of the brain but wrong about what it means for psychopathology. The brain has an evolutionary hierarchy, through phylogenetics, but not that moves “from narrowest to broadest dimensions,” starting with “disorders and related constructs linked to subfactors and spectra.” HiTOP is not neuroscientific; instead, it’s a mixture of conjectures based on external observations. I expect it will soon vanish.
As I mentioned, there is a (medical) model of psychopathologies, implicitly practiced daily by prescribers, albeit not explicitly articulated by governing bodies (APA, ACAP, the other APA, AACAP, NIMH, WPA, et al.) The model’s segments periodically appear in psychiatric literature but, to the best of my knowledge, were not put together as one classification. The model is based on the functional role of the neurocircuits and their malfunctions. I call mine AMPERIC (an acronym), but apparently, everyone eventually comes up with their own.
I agree, changing the scope, even the structure of the proposed project is the natural evolution of an original idea. Presently, RDoC is struggling. It's too elaborate and entangled. It will take years, perhaps decades, for all pieces to come together. The RDoC team started with a 1,000-piece jigsaw puzzle with more than half of the pieces missing. Instead, they should've tackled a 500-piece puzzle first.
HiTOP’s claim of being based on "neural substrates" is a sale pitch. Nothing in its model suggests the connection. HiTOP is written for therapists who don’t need neuroanatomy and imaging studies to write their "diagnostic formulations" and start psychotherapy. Their therapeutic targets don’t change with variations in clinical presentation.
Two main reasons (among many) prevent modern psychiatry from embracing the evolutionary origin of psychopathology. Neither one has anything to do with racism.
The first is practical. Despite clear evolutionary origin of arousal, emotions, automaticity, and reality testing, to name a few, we don't have tools to treat etiology. Instead, we treat symptoms, and the evolutionary role of menatl diseases becomes purely academic. The second is the antagonism toward the evolutionary model from the powerful psychoanalytical community, which insists that psychiatric diseases emerge from early traumas and unresolved conflicts that soil an otherwise clean (tabula rasa) baby psyche. We can't have both, can we? If mental illness is an evolutionary construct, what’s there to "analyze?" Evolution throws a monkey wrench (no pun intended) into the orthodoxy.
BTW, 'Why We Get Sick: The New Science of Darwinian Medicine' by Randolph M. Nesse and George C. Williams is an insightful book about evolutionary medicine. In addition, there are several books on evolutionary psychiatry and articles by Randolph M. Nesse, a psychiatrist.
I was intrigued by your "I disagree we "don't have tools to treat etiology." Do we have them? Please share. Perhaps (I am reading between the lines) you believe the analysts can get to the "bottom of it."
You shouldn't hang on to the word analytical as pertaining to the analytical couch. I use the term in a broader sense. You wouldn't deny that a psychodynamic (formerly analytical) mindset dominates in "any University in North America" and the Western World, would you?
I guessed from your writing that you conflate psychoanalysis and psychiatry into one discipline. They are not. The former is a philosophical, unfalsifiable, and self-referential endeavor, while the latter is "the medical specialty concerned with the study, diagnosis, treatment, and prevention of mental, behavioral, and personality disorders." according to APA, which supposedly knows. The analysts don't treat mental diseases.
I didn't read Del Giudice's book (I've read other authors on the subject and wrote one myself). However, I perused the linked review article by Scott Alexander and would characterize his (SA's) comments about evolutionary psychiatry (part II) as naïve and, at times, silly. I also read his notes on genetics and had the impression his knowledge of the subject is mainly Mendelian. He also uses quotes from Del Giudice's book. If the rest of the book is like these, I doubt I'll be reading it in the future.
I'll start with the "mindset" in the last paragraph. We are talking about psychiatry, not "general, clinical, and developmental psychology programs," right? The blog's name implies that. I recognize the communication gap in our dialogues (apparently, it's just us). I am coming in as a biological psychiatrist. Your background is different.
Psychodynamic concepts infiltrate psychiatric training and find their way into DSM. Most old-school psychiatrists were heavily psychodynamically (read analytically) trained, and psychiatric departments faculty insist on keeping dynamic therapy an integral part of residents' training. Many lament that the programs do not devote enough time to therapy. Let's ask Awais and Ronald Pies (this blog's contributor and a former editor of Psychiatric Times) if I am correct. As to psychology programs, to the best of my knowledge, they are heavily psychodynamic, even if they call themselves otherwise.
It would be hard to accurately comment on the FSD hypothesis and Di Giudici and Ellis's writings since I am unfamiliar with their work and can't rely on a third party's interpretation (e.g., Scott Alexander). However, I think I've got the gist of it. They do not discuss bona fide psychiatric diseases but "psychopathology" manifesting differently in different environments, societies, and times, and therefore, in their view, not entirely "real." Understandably, real psychiatric disorders do not depend on the environment – acute psychosis is maladaptive in any society, as well as severe Tourettes, autism, stuttering, mutism, dementia, and panic disorder.
Theirs idea is not new; yet, it misses the point. The goal of the evolutionary changes (if there is a goal) is survival and procreation. Humans have an additional complexity not witnessed in reptiles and lower mammals - society. Survival and procreation depend on standing within the group. Societies change, and the brain's (actually, its phylogenetically later structures) job is to recognize the rules of social existence – whatever they are – and quickly and skillfully adapt to them. Those who don't will lose and often perish. The factors that keep some humans from functioning within society (and causing debilitating distress) are called psychopathologies and if diagnosed and treatable psychiatric disorders. A psychiatrist's job is to recognize and correct these problems with available tools.
Now, about the tools. What you have referred to as a tool, I call internal compensatory mechanisms. I meant clinicians' tools, which presently only target the observable symptoms, not their origin, which, in my opinion, has evolutionary roots. We don't treat etiology (with a handful of exceptions) in medicine either, but it is an entirely different conversation.
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.
I feel like some things are worth pointing out:
First, HiTOP does mention the brain in their overview articles, as one stream of converging data. See for example:
https://www.annualreviews.org/doi/10.1146/annurev-clinpsy-081219-093304
https://pubmed.ncbi.nlm.nih.gov/32394571/
Second, in those articles, they also point to preliminary evidence for it being more acceptable to clinicians than are traditional diagnoses.
Third, RDoC was never meant to be a taxonomy of psychopathology but a framework for guiding research. See: https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/about-rdoc
First, I googled - [HiTOP] and [brain] - but couldn't find any connection, including a long article in wikipedia. I didn't see the link in the referenced article either and was not suprised given the origin of the proposed classification.
Second, the claims of HiTOP's acceptability to clinicians notwithstanding, the scheme lacks practical application. It's contrived and confusing. The dualism of internalizing vs. externalizing dimentions reminds of the archaic neurosis-psychosis division. HiTop is a flash in the pan, with no foundation and structure, and will be gone before most psychiatrists will learn about it.
Third, in early days, RDoC made a clear push toward classification and even as recently as 2020 had the ambitions. Read "The role of RDoC in future classification of mental disorders" written by one of its founders, Bruce N. Cuthbert, PhD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365298/
Also, the article from the 'green journal' in 2010 (authored by Thomas Insel, M.D., Bruce Cuthbert, Ph.D.,) says it all: "RDoC classification rests on three assumptions. First, the RDoC framework conceptualizes mental illnesses as brain disorders. In contrast to neurological disorders with identifiable lesions, mental disorders can be addressed as disorders of brain circuits. Second, RDoC classification assumes that the dysfunction in neural circuits can be identified with the tools of clinical neuroscience, including electrophysiology, functional neuroimaging, and new methods for quantifying connections in vivo.
Third, the RDoC framework assumes that data from genetics and clinical neuroscience will yield biosignatures that will augment clinical symptoms and signs for clinical management. Examples where clinically relevant models of circuitry-behavior relationships augur future clinical use ... analogous to what is done routinely today in many other areas of medicine."
In another article, https://www.nimh.nih.gov/archive/news/2013/dsm-5-and-rdoc-shared-interests written in May, 2013 (the birthday of DSM-5), Tom Insel wrote ""RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness."
Clearly, from the get go, RDoC saw itself as an alternative (to DSM) classification. In the NIMH vs. APA contest, the latter won and the former backed off from the original claims.
The push-back on RDoC is very fair, I am not well read in it and thus have no historical perspective. To me it seems fine to change your scope/mission statement in the process.
On the brain link, Kotov et al. (2020) literally has two sections titled "Neural substrates: neuroimaging" and "Neural substrates: neurophysiology". Kotov et al. (2021) has one section titled "Neuroscience". Does that not count as mentioning the brain?
And as far as I am aware, HiTOP is already used in practical application. Not sure what you mean by dualism of internalizing vs. externalizing, they are seperate dimensions that show some correlational pattern and thus are modeled as sharing some variance and containing some unique variance.
Thanks for this discussion! I personally think there is no reason for us to be devoted to any one particular diagnostic framework. We need to take what is valuable from any approach and use it together in a way that makes the most sense. What we might call nosological pluralism.
HiTOP and RDoC have their own advantages and disadvantages. HiTOP doesn't explicitly refer to neurobiology, but it actually has a fair bit of validity evidence, which HiTOP group presented in a series of papers in World Psychiatry. It takes time and energy, so it's not very clinician friendly at the moment, and it's unclear how well it guides treatments or changes outcomes. Likely more suitable for academic settings, but time will tell. It will be more useful for quantitatively minded psychologists. Would be a hard sell for primary care and psychiatry.
I recently wrote about RDoC's conceptual evolution as well: https://awaisaftab.substack.com/p/rdoc-more-than-a-decade-later-humbler
I agree about not being devoted to any particular framework, and hope I didn't come across as such. Not trying to be combative either.
I also agree that a lot of aspects are still unclear or lack stronger evidence, so time will tell indeed. In particular the usability is something I personally don't think about, since I am neither a practitioner nor a researcher, but for what it is worth, I found it not so hard to comprehend. It is a time investment though, for sure.
Psychiatrists desperately need new taxonomy; what we have are impractical at best.
Take Eating Disorders, listed as a group DSM and HiTOP classifications implying either common biology or clinical presentation. One wonders what Pica, Rumination, Anorexia, and Binge-Eating disorders have "neurobiologically" in common. The mouth, I guess. Or Unspecified Feeding and Eating Disorders, so vague that we can apply to someone who hates broccoli.
“HiTOP doesn't explicitly refer to neurobiology” because it’s divorced from it. HiTOP used a “dimensional syndromes” model [for arousal] and based all diagnoses on it – high for internalizing and low for externalizing psychopathology. Thought disorders are somewhere in the middle. It was designed by clinical psychologists for clinical psychologists who have never gone to medical school, never made a diagnosis of a medical disease, and have never prescribed medications. The HiTOP creators see the brain as one organ with one portal (higher-order cognition and, specifically, auditory) and one clinical tool – executive function. They might be right about the hierarchical structure of the brain but wrong about what it means for psychopathology. The brain has an evolutionary hierarchy, through phylogenetics, but not that moves “from narrowest to broadest dimensions,” starting with “disorders and related constructs linked to subfactors and spectra.” HiTOP is not neuroscientific; instead, it’s a mixture of conjectures based on external observations. I expect it will soon vanish.
As I mentioned, there is a (medical) model of psychopathologies, implicitly practiced daily by prescribers, albeit not explicitly articulated by governing bodies (APA, ACAP, the other APA, AACAP, NIMH, WPA, et al.) The model’s segments periodically appear in psychiatric literature but, to the best of my knowledge, were not put together as one classification. The model is based on the functional role of the neurocircuits and their malfunctions. I call mine AMPERIC (an acronym), but apparently, everyone eventually comes up with their own.
I agree, changing the scope, even the structure of the proposed project is the natural evolution of an original idea. Presently, RDoC is struggling. It's too elaborate and entangled. It will take years, perhaps decades, for all pieces to come together. The RDoC team started with a 1,000-piece jigsaw puzzle with more than half of the pieces missing. Instead, they should've tackled a 500-piece puzzle first.
HiTOP’s claim of being based on "neural substrates" is a sale pitch. Nothing in its model suggests the connection. HiTOP is written for therapists who don’t need neuroanatomy and imaging studies to write their "diagnostic formulations" and start psychotherapy. Their therapeutic targets don’t change with variations in clinical presentation.
I’ll be happy to expound.
Two main reasons (among many) prevent modern psychiatry from embracing the evolutionary origin of psychopathology. Neither one has anything to do with racism.
The first is practical. Despite clear evolutionary origin of arousal, emotions, automaticity, and reality testing, to name a few, we don't have tools to treat etiology. Instead, we treat symptoms, and the evolutionary role of menatl diseases becomes purely academic. The second is the antagonism toward the evolutionary model from the powerful psychoanalytical community, which insists that psychiatric diseases emerge from early traumas and unresolved conflicts that soil an otherwise clean (tabula rasa) baby psyche. We can't have both, can we? If mental illness is an evolutionary construct, what’s there to "analyze?" Evolution throws a monkey wrench (no pun intended) into the orthodoxy.
BTW, 'Why We Get Sick: The New Science of Darwinian Medicine' by Randolph M. Nesse and George C. Williams is an insightful book about evolutionary medicine. In addition, there are several books on evolutionary psychiatry and articles by Randolph M. Nesse, a psychiatrist.
I was intrigued by your "I disagree we "don't have tools to treat etiology." Do we have them? Please share. Perhaps (I am reading between the lines) you believe the analysts can get to the "bottom of it."
You shouldn't hang on to the word analytical as pertaining to the analytical couch. I use the term in a broader sense. You wouldn't deny that a psychodynamic (formerly analytical) mindset dominates in "any University in North America" and the Western World, would you?
I guessed from your writing that you conflate psychoanalysis and psychiatry into one discipline. They are not. The former is a philosophical, unfalsifiable, and self-referential endeavor, while the latter is "the medical specialty concerned with the study, diagnosis, treatment, and prevention of mental, behavioral, and personality disorders." according to APA, which supposedly knows. The analysts don't treat mental diseases.
I didn't read Del Giudice's book (I've read other authors on the subject and wrote one myself). However, I perused the linked review article by Scott Alexander and would characterize his (SA's) comments about evolutionary psychiatry (part II) as naïve and, at times, silly. I also read his notes on genetics and had the impression his knowledge of the subject is mainly Mendelian. He also uses quotes from Del Giudice's book. If the rest of the book is like these, I doubt I'll be reading it in the future.
I'll start with the "mindset" in the last paragraph. We are talking about psychiatry, not "general, clinical, and developmental psychology programs," right? The blog's name implies that. I recognize the communication gap in our dialogues (apparently, it's just us). I am coming in as a biological psychiatrist. Your background is different.
Psychodynamic concepts infiltrate psychiatric training and find their way into DSM. Most old-school psychiatrists were heavily psychodynamically (read analytically) trained, and psychiatric departments faculty insist on keeping dynamic therapy an integral part of residents' training. Many lament that the programs do not devote enough time to therapy. Let's ask Awais and Ronald Pies (this blog's contributor and a former editor of Psychiatric Times) if I am correct. As to psychology programs, to the best of my knowledge, they are heavily psychodynamic, even if they call themselves otherwise.
It would be hard to accurately comment on the FSD hypothesis and Di Giudici and Ellis's writings since I am unfamiliar with their work and can't rely on a third party's interpretation (e.g., Scott Alexander). However, I think I've got the gist of it. They do not discuss bona fide psychiatric diseases but "psychopathology" manifesting differently in different environments, societies, and times, and therefore, in their view, not entirely "real." Understandably, real psychiatric disorders do not depend on the environment – acute psychosis is maladaptive in any society, as well as severe Tourettes, autism, stuttering, mutism, dementia, and panic disorder.
Theirs idea is not new; yet, it misses the point. The goal of the evolutionary changes (if there is a goal) is survival and procreation. Humans have an additional complexity not witnessed in reptiles and lower mammals - society. Survival and procreation depend on standing within the group. Societies change, and the brain's (actually, its phylogenetically later structures) job is to recognize the rules of social existence – whatever they are – and quickly and skillfully adapt to them. Those who don't will lose and often perish. The factors that keep some humans from functioning within society (and causing debilitating distress) are called psychopathologies and if diagnosed and treatable psychiatric disorders. A psychiatrist's job is to recognize and correct these problems with available tools.
Now, about the tools. What you have referred to as a tool, I call internal compensatory mechanisms. I meant clinicians' tools, which presently only target the observable symptoms, not their origin, which, in my opinion, has evolutionary roots. We don't treat etiology (with a handful of exceptions) in medicine either, but it is an entirely different conversation.