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Missed Diagnosis

Psychiatry professor Nassir Ghaemi says the bible of his field needs an intervention

A century and a half ago, doctors who understood little about the causes of disease relied on a grab bag of quackery—bleeding, vomiting, plunging patients into cold baths—to treat its symptoms. Then the germ theory of disease and the discovery of antibiotics around the turn of the last century created a revolution, allowing doctors for the first time to treat root causes and develop permanent cures. Those breakthroughs led to all branches of modern medicine, including pharmacology, surgery, neurology, and the rest.

But, says Nassir Ghaemi, one field was left behind: psychiatry. Despite promising beginnings in the twentieth century, the field was riven by disagreements on whether mental illnesses had biological, social, or psychological causes until about 1980. It was then that doctors entered into an uneasy truce. They agreed to disagree on causes and focus only on relieving symptoms. That principle was enshrined in the third edition of the Diagnostic and Statistical Manual (DSM), the bible of psychiatry, which identified 170 mental and personality issues equally as “disorders” without regard to whether their causes were purely psychological, socially conditioned, or due to biological or genetic factors. “Despite many millions of dollars and the efforts of thousands of researchers, we have made little progress in understanding the causes of mental illnesses or identifying cures,” contends Ghaemi, professor of psychiatry and pharmacology at Tufts University School of Medicine.

Ghaemi is in a good position to make the claim. He practiced psychiatry at Massachusetts General Hospital and Cambridge Hospital before joining Tufts in 2008 as director of the Mood Disorders and Psychopharmacology programs at Tufts Medical Center. Along the way, however, he also acquired an M.A. in philosophy at Tufts in 2001, a degree that gives him a uniquely philosophical approach to his medical work. However well intentioned the détente over the causes of mental illness, Ghaemi argues, the resulting “biopsychosocial model” has led to a fundamentally eclectic, trial-and-error approach to treating symptoms, in which individual doctors decide at their own discretion whether to use drugs, psychoanalysis, or behavioral techniques.

In place of that model, Ghaemi proposes that psychiatrists should use the best scientific evidence to first determine whether there is a biological root to an illness that could be treated with a drug. If the answer is no, only then should they apply the best techniques from psychology or social science to manage symptoms. “It’s about knowing when to do one and when to do the other. That’s what makes a good doctor, and that’s what we’ve lost sight of.”

Now, thirty years after the DSM-III, Ghaemi says, the field of psychiatry is on the road to continuing the same “guessing game” with the close to four hundred disorders proposed for the manual’s fifth edition, DSM-5, currently under review for publication in 2013 (and newly retrofitted with an Arabic numeral). Like law- and sausage-making, the process to produce the bible of psychiatry is not one most people would want to see close-up. Committees full of doctors from different disciplines—some with academic and personal feuds stretching back decades—have jockeyed for their own disorders and definitions to make the cut. Add to that the pressure on doctors to secure research grants for their specialties and pressure from drug companies and insurers, who have their own interests in how disorders are coded, and it becomes clear why psychiatrists have followed a “pragmatic” approach to treating patients.

Not that good intentions haven’t also played a role in the structuring of diagnoses. In his own field of mood disorders, Ghaemi says, psychiatrists have expressed valid concern about the harmful side effects of antipsychotic drugs, especially in children. In response, the committee creating the DSM-5 invented a new diagnosis—“temper dysregulation disorder”—as a milder alternative to childhood bipolar disorder. This despite limited scientific evidence that such a condition exists as a distinct disorder. The main reason for the change, Ghaemi contends, is that antipsychotics wouldn’t be approved to treat it. “They are trying to outsmart the pharmaceutical companies—and you can’t do that,” he says. “What we need to do is tell the truth as best we see it, and then do the best research and education so people are using the best medications.”

In other words, by defining their terms on hoped-for outcomes rather than causes, says Ghaemi, the creators of the DSM have only introduced their own prejudices and may be detracting from the best possible care. “They call it pragmatism, but I call it psychiatric gerrymandering,” he says. “They are tinkering with their diagnostic definitions for their own purposes. They may be benevolent purposes, but they are not taking a straight scientific attitude to get at our best understanding of the truth.”

He’s not the only one to criticize the current psychiatric definitions. In fact, the chair of DSM-IV, Allen Frances, recently criticized his own committee in an editorial in the Los Angeles Times. He blamed them for falsely creating “epidemics” of new diseases such as attention deficit disorder, autism, and childhood bipolar disorder in the first place. “That’s a common complaint, and a valid one,” says Ghaemi. But the proposed solution—arbitrarily making new rules in the DSM-5 to reduce diagnosis of those diseases—amounts to little more than rearranging the deck chairs on the Titanic, he contends.

Some psychiatrists have argued that the current format of the DSM, however imperfect, is at least a temporary stopgap until research catches up to definitively identify sources of mental illness. Ghaemi disagrees. “If you get your clinical diagnoses wrong, you are dooming all the biological research,” he says.

Ghaemi doesn’t propose dumping the DSM; in fact, he says, the proposed fifth edition is based more on scientific research than its predecessor. Even so, he’d like to slash the number of diagnoses—say, from four hundred to fifty—and draw a bright line between those we know to be rooted in biology, such as schizophrenia and manic depression, and those that seem to have external psychosocial causes. “We need to get back to a healthy respect for science as the most important factor and make everything else secondary,” Ghaemi says. “If we just made that change, we’d be much more effective.”

MICHAEL BLANDING, a frequent contributor to these pages, is a Boston-based writer whose work has been published in The New Republic, The Nation, Consumers Digest, the Boston Globe, and Boston Magazine, where he is a contributing editor. His first book of investigative nonfiction, The Coke Machine: The Dirty Truth Behind the World’s Favorite Soft Drink (Avery/Penguin), appeared last fall.

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