In psychiatry, the ice is jammed up. There have been no innovative new drug classes for mood disorders in thirty years. The diagnostics of the field, as expressed in the recent DSM-5, have become a object of ridicule: Many people simply do not believe in such capital diagnoses as “major depression,” or “social anxiety disorder,” as though they were independent illnesses, comparable to measles or tuberculosis. So, in many ways, psychiatry offers the view of a field adrift, yanked loose from its moorings in science by pseudoscience.
This is a preface to a travel report. But it’s an account of a trip that shows where the entry portals to the future may lie for psychiatry.
I am just back from a meeting in Paris on “psychopathology,” a technical term for symptom-to-symptom differences from one patient to another. And here there is movement, life in a field otherwise dominated by neurotransmitter research that leads to no practical result (save references to “reuptake” in pharma advertising), and by a disease nomenclature that bears the same relationship to Nature as astrology does to astronomy.
At this meeting there were lumpers and splitters. The lumpers wanted to reduce the number of real psychiatric diseases from hundreds to a handful. The splitters wanted to disaggregate the huge diagnostic basins such as “depression” and “schizophrenia” into component parts. There is a place for both approaches, and that’s why the study of psychopathology offers hope.
Take anxiety. There are currently nine anxieties in DSM-5. Someone showed a slide of an Edvard Munch painting -- not the “Scream” but one of his other anxiety-in-Norway images --- and asked which of the nine anxieties these people have? There was laughter. Anxiety didn’t use to exist as a separate diagnosis, so common is it in all psychiatric illnesses, like “fever” in an infectious disease service. Here some lumping is needed.
And splitting! The attendees were the European crème-de-la-crème of psychopathology thinking, and when “major depression” was mentioned, there were sighs, raised eyebrows, snide asides on the order of “Where is minor depression?”
“Schizophrenia” evoked particular criticism: “You cannot do a study of ‘schizophrenia.’ The term includes very different diseases.” Adolescent insanity, the original term in the nineteenth century, still works. But schizophrenia? It’s a concept of the marketing department: A single vast diagnosis is much better for sales.
At this meeting, I had the impression of people about ready to throw their white-tipped canes away and to discover the real diseases that are out there. The field is regaining its sight.
What will replace “schizophrenia”? Lots of new thinking on this. What will topple “major depression,” like pulling down the Lenin statue in Kiev? Early days yet, but lots of interest in melancholia.
As for anxiety, Emil Kraepelin, the founder in the 1890s of modern thinking about diagnosis (before the psychoanalysts temporarily pushed him aside) was a complete disbeliever in “anxiety” as an independent disease. Much nodding as this was pointed out.
All of this new movement owes nothing to genetics or “neuroscience,” both of which have proven colossal disappointments to clinical psychiatry. Instead, people are going back to principles we’ve known for a hundred years: carefully describing symptoms in a disease-picture that is unique to that disease; verify the existence of that disease with biological markers; validate its existence with response to a specific treatment. Most of today’s “disorders” will dissolve under this approach, as indeed someone famously said of DSM, “Put it in a shit solvent and only the binding remains.”
There’s a shit solvent on the horizon. Of course, we can’t call it that. Let’s call it “science” instead.