Mar 02 2010
The DSM-V
The Diagnostics Statistical Manual for Mental Disorders, a much maligned document, is in the midst of its fourth major revision (the DSM-IV will be replaced by the DSM-V). This process has been going on for over a decade. The revisions are now being made public in order to have a two year period of public comment and debate about the details of the revisions.
This has led to a new round of criticism of the DSM, and through it psychiatry, from those who either do not sufficiently understand, in my opinion, the nature of psychiatric diagnosis, and from those who are anti-psychiatry because of ideology (Scientologists, for example).
At the extreme end of criticism are those who deny the very existence of anything that can be called mental illness. I have already dealt extensively with their arguments, and won’t repeat them here. But even those are not so extreme fall into some of the same logical fallacies when criticizing mental diagnoses. Recently George Will, for example, wrote an editorial which I think confuses medical diagnoses with taking moral positions (I will get to his commentary below).
Diagnosis in Psychiatry
I do acknowledge the extreme difficulty of establishing discrete diagnoses in psychiatry. The brain is the organ of mood, thought, and behavior, and it interacts in complex ways with the environment. So it is very difficult to tease apart those manifestations that should be considered a symptom of dysfunction from those that simply represent the range of normal variation or the effects of the environment.
Further, when there is demonstrable pathology we tend to think of those disorders as neurological, not psychiatric – even when they have overtly psychiatric manifestations (mood, thought, and behavior). If someone becomes psychotic (develops delusions and hallucinations) and is found to have a brain tumor, most people have no problem understanding that the tumor caused the psychosis – that this is a disease that needs to be treated. However, if another person becomes identically psychotic and no underlying pathology is found, suddenly this is a psychiatric disorder (not a neurological disease) and many people wring their hands about whether or not it is a real disorder, how to define it, and if it should be treated at all.
The challenge of psychiatric diagnosis also suffers from the fact that mood, thought, and behavior exist on a continuum – a Bell curve of variation. So there is often a demarcation problem – between healthy variation (the term “normal” is too problematic to use effectively), and mental disorder. Take any mental trait, such as anger. Some people are more angry than others. What if someone had no control over their anger and were perpetually on the verge of rage – triggered by the slightest perceived offense? It seems reasonable that at some extreme of anger we can meaningfully call this a mental disorder and explore ways to treat it. But there is no sharp line between healthy anger and a dysfunctional loss of self control.
This, of course, is the exact challenge of the DSM – coming up with reasonable criteria to designate when there is a disorder and some scheme of categorization. The definition of “disorder” that guides this process is the lack of a trait or ability usually possessed by people that leads to a demonstrable harm (like self-control).
Psychiatry also has a lot of historical baggage to contend with. In the dark ages of psychiatry, which we are barely out of in historical terms, diagnoses were not cleanly separated from the current fashionable moral judgments of the time. And so homosexuality was considered a mental disorder for a time. Treatments were likewise crude, even cruel. But it is a fallacy to blame the modern profession of psychiatry for the sins of the past – sins from which they have already redeemed themselves. It must also be noted that psychiatry was largely reformed from within.
Mental Illness and Morality
In his editorial, George Will argues that the DSM, including many of the new diagnoses being contemplated, represents medicalizing character traits, in order to exempt them from moral consideration. He commits many of the errors of mental illness denialists, however, in forming his arguments. He writes:
Today’s DSM defines “oppositional defiant disorder” as a pattern of “negativistic, defiant, disobedient and hostile behavior toward authority figures.” Symptoms include “often loses temper,” “often deliberately annoys people” or “is often touchy.” DSM omits this symptom: “is a teenager.”
Clearly Will thinks that a “normal” teenager might earn for themselves the label of “oppositional defiant disorder” – ignoring the crucial aspect of diagnosis that these traits must exist to an extreme degree, sufficient to cause demonstrable dysfunction. Therefore your average disobedient teenager would not (should not) be diagnosed. But a child who was unable to function at school because of frequent hostile disobedience might.
My wife, who is a counselor, actually worked with oppositional defiant children for a few months (those severe enough that they were enrolled in a special school) – they quickly burned her out (quite a feat, as she is a very tolerant person) and she decided to change jobs. There is no way to quantify severity of a mental disorder like this, and so some judgment is always required. But when you see the extreme cases you know what oppositional defiant disorder means, and you won’t confuse it for average teenage behavior.
He continues:
This DSM defines as “personality disorders” attributes that once were considered character flaws. “Antisocial personality disorder” is “a pervasive pattern of disregard for . . . the rights of others . . . callous, cynical . . . an inflated and arrogant self-appraisal.” “Histrionic personality disorder” is “excessive emotionality and attention-seeking.” “Narcissistic personality disorder” involves “grandiosity, need for admiration . . . boastful and pretentious.” And so on.
If every character blemish or emotional turbulence is a “disorder” akin to a physical disability, legal accommodations are mandatory. Under federal law, “disabilities” include any “mental impairment that substantially limits one or more major life activities”; “mental impairments” include “emotional or mental illness.” So there might be a legal entitlement to be a jerk. (See above, “antisocial personality disorder.”)
The DSM actually differentiates between a personality “trait” and a personality “disorder”. A disorder is no mere “character blemish” – it is a gross disfigurement. This is a crucial concept missing from Will’s editorial and highlights the danger of criticizing an entire profession without sufficient expertise to do so. Also, the personality disorders are considered the least “illnessy” of the mental illnesses. In fact they are described in the DSM and are part of psychiatric assessments so that their traits can be differentiated from more hard core mental illnesses, like schizophrenia or bipolar disorder.
Will continues with this fallacy a bit more, then turns to a new one:
Extremely irritable or aggressive children are frequently diagnosed as bipolar and treated with powerful antipsychotic drugs. This can be a damaging mistake if behavioral modification treatment can mitigate the problem.
Does Will really think he has a better grasp on the evidence for the relative safety and effectiveness of medication vs behavioral therapy for a variety of mental disorders than trained experts? But that aside, this hits upon one of the features of the proposed DSM-V revisions (albeit controversial even within psychiatry). New diagnoses were carved out in the DSM-V for the stated purpose of differentiating them from more severe disorders that are more likely to be treated medically.
Will links to this article in the Washington Post (apparently the spur for his editorial) which states:
Others expressed concern about the proposals to create new conditions such as “temper dysregulation with dysphoria,” or TDD. Supporters say it is intended to counter a huge increase in the number children being treated for bipolar disorder by creating a more specific diagnosis, though critics argued that it would only compound the problem of overtreatment.
I don’t know what the net effect will be of making a new category of TDD – it seems to be a matter of debate among those revising the DSM. But at least Will should understand and acknowledge that stated purpose by supporters – to create a less severe diagnosis and decrease the number of people who will quality for the more severe diagnosis and therefore likely get treated. Will assumes that labels lead to increased treatment, but the opposite may be true depending on how they are applied. At the very least this topic is more complex than Will’s simplistic formulation.
Finally we get to the core of Will’s point:
Furthermore, intellectual chaos can result from medicalizing the assessment of character. Today’s therapeutic ethos, which celebrates curing and disparages judging, expresses the liberal disposition to assume that crime and other problematic behaviors reflect social or biological causation. While this absolves the individual of responsibility, it also strips the individual of personhood and moral dignity.
This one paragraph could be the subject of a separate post, but I will try to summarize my points quickly. First, it must be realized that within medicine it is absolutely necessary to focus on curing and to “disparage judging”. Physicians need to be non-judgmental toward their patients, and should never impose their morality, religion, or politics onto their patients. That is a core principle of medical professionalism.
I will give Will the benefit of the doubt and assume he is not denying the necessity of this professional ethic. Rather, he seems to be lamenting the extension of this attitude into the realm of broader society – claiming that it is a “liberal disposition.” I don’t want to venture into a political argument on this blog, but I will just say that I see his point and will assume for the sake of argument that it is part of liberal political philosophy, in the name of social justice, to emphasize the situation and conditions that lead to individual behavior. Meanwhile, conservative philosophy emphasizes individual responsibility. This appears to be the lens through which Will is viewing the DSM.
But I think it is fallacious to criticize the DSM for trying to understand the human condition, simply because some may use that knowledge to bolster a political position with which Will disagrees. Rather, it would be more appropriate to simply argue that understanding the biological cause of behavior does not and should not absolve one of personal moral dignity or responsibility. Will instead has decided to attack the notion that behavior is biologically caused.
This relates to the deeper question of free will. Again, I will not delve into this complex issue, but briefly – if we take the premise that the mind is the brain, and the brain, as a materialistic physical entity, is deterministic, then we can conclude that all behavior is ultimately caused. Depending upon how one defines free will, it can therefore be argued that free will is ultimately an illusion as behavior is deterministic.
My take has been that, while this is true, we are still capable of making choices based upon internal reflection, and I call this free will (acknowledging that it is ultimately deterministic). But in any case, even those who deny the existence of free will acknowledge that we still need to have laws that hold individuals responsible for the choices they make. From a societal and legal point of view, we still need to act as if we possess free will – because those laws and moral boundaries are part of the environment that feed back on our behavior.
Will is in the curious position of making the same mistake that many of the liberals that he criticizes make – denying the underlying science rather than the inappropriate moral connection. It is better to assess the science for its own sake, and in this case not just the basic science but the medical utility of the DSM – and then separately argue that simply because a behavior can be meaningfully called a disorder that does not mean we do not hold people responsible for their behavior.
Admittedly this creates another demarcation problem – because we do draw a fuzzy line beyond which we mitigate guilt due to mental illness. This is now a legal question – the insanity defense. We recognize that someone’s mental function can be so compromised that they should not be held responsible for their behavior while in that state. There are established criteria for such a defense, and like many legal criteria they are complex and blurred at the edges, but can be reasonably applied in the real world. It would be a slippery slope argument to imply that any acknowledgment that extreme mental illness mitigates guilt leads to the medicalizing of all morality.
Conclusion
The issues raised by Will and other critics of the DSM and its current revision are complex. There may be problems with the current revisions – I would expect any such process to be messy and involve many controversies and trade offs. But I don’t think that Will and others with similar criticisms are hitting upon the true complexities of making mental diagnoses.
Most often criticisms of the DSM stem from looking at the list of symptoms that comprise the diagnostic criteria for a particular diagnosis and then not putting them into their proper context. This results in confusing healthy human variation with the extreme traits that constitute a disorder.
30 Responses to “The DSM-V”
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It is fitting that you should write about this after your armchair skepticism post. Will seems to fancy himself an arm chair climatologist and an armchair psychologist. I think I would be more trusting of the armchair student of the subject that doesn’t require mastery of calculus or neuroscience.
I’ve gotten into similar discussions in my law classes because of the topic of emotional harms in tort. My position has been that emotional harms are physical harms and if a plaintiff can show that they suffered real emotional harm because of the negligence or recklessness of another, then those should be compensable just as if they were physically hurt (again, because they were).
Another classmate referred to them as “Crybaby harms.” Oh well.
Dr. Novella:
I’ve seen you make comments like the following one before, and I’m always intrigued by your presumed position that “free will” is likely an illusion.
I realize my comment is tangential to the main point of your article today, but I would like to hear more from you on this subject of free will. At first glance, your argument seems to have a huge unfalsifiable component to it, which is a characteristic you have so well analyzed as unscientific when it is part of someone else’s mindset.
It is possible that I am grossly misunderstanding your position. But in any case, I would love to hear you elucidate and debate the subject of free will.
Jim – as I said – complex topic beyond the scope of this post. This is a separate argument, and I am not comfortable with the conclusion that free will is an illusion – that is why I added the caveats. But some argue that it is.
My point is – that even if you are someone who takes the extreme position that free will does not exist, you can still believe that we need laws and need to attach consequences to our moral choices.
The Advocate (a gay news source) had it’s round with the DSM-V with an undereducated sexologist commenting on paraphilia. The sexologist in question didn’t bother to look up the new criteria for a mental disorder and made huge claims about what could be diagnosed as a mental disorder.
Speaking of which, I found the rationale behind the new recommendations for mental disorders fascinating as the committee responsible for the recommendation had the following to say:
“It may be timely to reconsider the term “mental disorder”, given our growing knowledge of the psychobiology of these disorders. In considering new disorders for DSM-V, we need to consider their relationship with diagnostic “near-neighbors”, and the overall benefits vs harms of an addition.”
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=465#
I’d offer “psychobiological disorder” as a replacement term, in the paper they wrote to discuss these recommendations they suggest “psychiatric disorder.” Their reasoning is as follows:
“It is relevant to address the question of whether the term
‘mental disorder’ is optimal. ‘Mental’ implies a
Cartesian view of the mind–body problem, that mind
and brain are separable and entirely distinct realms,
an approach that is inconsistent with modern philosophical
and neuroscientific views (Fulford et al. 2006).
The term ‘ psychiatric disorder’ may be preferable insofar
as it emphasizes that these conditions are not
purely ‘mental’ and that the line between ‘ psychiatric
disorder’ and ‘other medical disorders ’ is not distinct.
However, mental health clinicians other than psychiatrists
have also criticized this term as it may suggest,
incorrectly, that only psychiatrists are trained in
the diagnosis and management of these conditions
(Spitzer & Williams, 1982). Such criticism may be
sufficient to warrant retaining ‘mental disorder’,
and indeed the authors of this article could not come
to a consensus on this matter. One potential compromise
is to recommend the awkward term ‘mental/
psychiatric ’. A more conservative approach would be
to retain the term ‘mental disorder ’, in keeping with
DSM-IV, but to emphasize in the text that these are
brain–mind disorders.”
Stein DJ et al: What is a Mental/Psychiatric Disorder? From DSM-IV to DSM-V; Psychological Medicine (2010; in press)
“free will” is a pretty vague term. I think it would be difficult to make the case that human action is outside of the determinism implied by cause and effect. People react to events all the time and their reactions are mostly predictable.
The complexity of the human mind and its plasticity (and resulting variability) certainly allow enough variables to make 100% prediction unlikely, especially in the real world. Hypothetically, if we could model the activity of every single neuron in someone’s mind as well as every bit and byte of information their senses received in a uber-supercomputer then we could strip away a person’s free will. Realistically this task is probably impossible, there’s just too much information and too many variables.
The point is that free will arises from complexity, which makes human action and thought potentially unpredictable (though this clearly not always so). It does NOT arise from some mystic or animistic force. It’s the same as climate modeling (that tired old butterfly). Just because we’ll never be able to model our climate with 100% accuracy doesn’t mean that a supernatural force is at work.
Somewhat ironic to be decrying the medicalization of behaviors while supporting their criminalization. With a medical model there is at least a hint of a possible path to recovery rather than the “lock-em-up” criminal justice approach which we know doesn’t work and which costs a gigantic amount.
Daedalus, I wouldn’t be so quick as to say it doesn’t work, at least in curbing some people from certain behaviors. While anecdotal, having received fines for speeding I’m more cautious when driving, especially around the areas I received the tickets. I have a lead foot, but I also now control my speed around the bend on the 290, and Millersport Highway (the misnamed 35 MPH road). It probably doesn’t work for everyone, hence, seeing people in the court for their 7th violation in three years, but it does influence some people. I agree though, we should employ more of our knowledge from psychology when accessing our existing penal system.
One point of curiousity I had:
The article states “The part of the brain that stimulates anger and aggression is larger in men than in women, and the part that restrains anger is smaller in men than in women.”
Is he referring to the amygdala, and is there a sexual dimorphism in this part of the brain?
I think you’re not giving Will enough credit. The problem with the DSM is that the disorders are vaguely-defined enough that they can be misapplied. Given that the people applying it are human beings, many of them are going to make mistakes or be less than completely competent.
To draw from my own experience, the school psychologist that visits schools in my system came in to look at my daughter, who dislikes sitting still in circle time and doesn’t make friends easily. After half an hour of observing her in class, she suggested that my kid has autism spectrum disorder. This is absolutely nonsense, and anyone who knows anything about my daughter or autism should not have even brought it up. But she did, because enough boxes were checked on her diagnostic. Things like “doesn’t make eye contact” that are characteristic of many perfectly normal kids, or vague things like “weird behaviour”.
Having a look at the complaints she had concerning our kid’s behaviour, my wife and I jokingly spent the rest of the week diagnosing everyone in our environment with Asperger’s Syndrome when they did anything on the list. Apparently 100% of the population is on the autism spectrum.
Anyway, the school administrators (thankfully) had the same opinion as we did about this psychologist’s assessment, and they took her off our daughter’s case. But if we didn’t know better, or the administrators were not the people they are, we could have ended up misdiagnosing our daughter and having her pigeonholed. She would be treated as having an uncurable disorder, when all she really has is some social awkwardness that she is quite clearly growing out of, if a little more slowly than her peers.
The problem with diagnosis is that we trust people to diagnose, and they might be predisposed to over-diagnose. How can you argue with a psychiatrist or a psychologist? After all, they’ve got the qualifications, and people say things like this:
“Does Will really think he has a better grasp on the evidence for the relative safety and effectiveness of medication vs behavioral therapy for a variety of mental disorders than trained experts?”
I think that what is often lost in this discussion is how seriously normal functioning is often affected by a disorder or mental illness. While one hopes that diagnosis precedes treatment, much of what is achieved in the diagnostic process is giving a person a label or status so that the many local, state and federal government agencies can adequately respond the circumstance the individual finds themselves in. Much of the controversy over changes in the DSM is directly related to the effects on the lives a change in a diagnosis can have. A diagnosis can impact income, benefits, housing, educational opportunities and safety assessments; and will have a much more substantial influence on how people are able to lives their lives than a change in the diagnostic criteria in any other medical field I can think of. The stakes in these changes are very high for many people.
I’m a social worker who has worked in the child protection field for twenty three years and what a person’s mental health diagnosis history is can have a significant impact on my decisions regarding removal of children from a home. Often a diagnosis is accompanied by specific behaviors that can be easily quantified as presenting risk to a child. However that is not always the case and sometimes social workers and the courts make important and life changing decisions based on a diagnosis or an evaluation from a mental health provider that is informed by the DSM.
MKandefer, it is my understanding that a very large number of first time incarcerated individuals are there for non-violent drug abuse, and that after they leave prison they are more violent and more likely to commit violent crimes.
Incarceration is gigantically more expensive than outpatient drug treatment. Is it more “effective”? I guess that depends on how you define “effective”. If by “effective” you mean provides a lot of jobs for prison guards and a lot of money for prison construction programs, then it is more “effective”. Outpatient drug treatment is completely ineffective at providing jobs for prison guards.
Very interesting post, thanks. In my class, each year I have several mentally ill students so this was very informative. I do hope at some point you’ll do a post on the possiblity of Aspberger’s disappearing from the DSM, would love to hear your take on it.
Steve
I do not practice in a Psychiatric field, but all forms of medicine impact or are impacted by psychiatric diagnoses. DSM is a tough nut to crack. We all like hard science diagnostic studies. CBC, Radiographs, MRI, ETC… Still you realize over time that interpretation is the norm rather than rock solid testing. DSM IV or V attempts to classify a very subtle subject. What problems I have with psych are personal experience and not very scientific. To me, there is to much wiggle room in treatment and diagnosis. I hope DSM V addresses this, but I feel that it will be even more of a guideline, instead of a yardstick. My impression of DSM-IV is that it has become a billing tool rather than a actual classification device. I am not certain comittee approach is the way to go. Psuedoscience preys upon these weaknesses. I don’t see any easy answers, just I was hoping for more out of a revision.
Dr. Novella,
Please, please, debunk this article in a blog post: http://www.arachnoid.com/psychology/index.html (Is Psychology a Science?)
With this post, you’ve already debunked his fallacious reasoning concerning the DSM, but he still has several arguments in which he goes into the “Architecture of Science.”
It’s written by a former NASA engineer, and he’s somewhat of a skeptic(he uses F.C. to bolster his argument that Psychology isn’t science), and ostensibly understands science. So naturally, people see this guy as some kind of authority on the topic and continually use his article as evidence that Psychology is a “religion.” It’d be tremendously useful to be able to link to a concise article in which you debunk his assertions.
Will shows ignorance of the legal system, too.
The legal system does not, in reality, “absolve[] the individual [with mental illness] of responsibility” for the person’s actions. As Dr. Novella argues, the legal question of insanity is a completely different question from the DSM diagnoses. In most states (if not all), legal insanity sufficient to avoid responsibility for criminal conduct requires the defendant to prove (1) that he/she has a diagnosed mental illness, and (2) that the diagnosed mental illness made him/her actually unable to distinguish right from wrong or, in some states, to resist the impulse to act.
The insanity defense is rarely asserted, and even more rarely successful. Last I heard, statistics showed that those who successfully assert the insanity defense spend more time “locked up” than do defendants who are convicted of similar offenses. A person found not criminal responsible by reason of insanity is usually restrained indefinitely, and has to prove that he/she is ready to be released safely into society before being allowed some freedom.
Therefore, those who successfully assert the insanity defense are held responsible for their actions to a higher degree than those who don’t assert it or are unsuccessful, at least if you consider being restrained against your will to be an accurate measure of society holding someone responsible for his/her actions.
George Will’s belief that oppositional defiant disorder should be changed to teenager as a category, simply changes the sematics.
The characterization remains the same. Within the context of the culture at large, the opposite of this phrasing would be harmonious, compliant order. I wish I could have invited George Will to view the testing situations with diagnosed oppositional defiant disorder. Trying to test the client is like watching an angry cat with its fur flying in different directions.
People like George Will make me sad and angry. They seem to feel that a mental illness is the same as a character flaw, and if only we’d try harder, we could be “normal” – however they define “normal”, which usually means “just like me”. It’s blaming the victim, nothing more.
HHC,
Your comment reminds me of my usual response when people say that they don’t believe in ADHD or that it’s only an excuse. I offer to let them stay with me for a week off-meds. I would strongly advise against anyone actually taking me up on that offer. Not being able to see the floor because of the mess, constantly losing car keys and important documents, and getting distracted by interesting blog posts when I should be doing more productive things generally do tend to have fairly negative effects on one’s life (well, maybe except the part about the blog posts).
I think that some of it is the desire to cling to the idea that there must be some sort of “mind” that is separate from the brain, that our thoughts, cognition, etc couldn’t possibly be the result of the electrochemical impulses of a hundred billion neurons…it’s a scary concept, and I can understand why even Dr. Novella doesn’t want to discuss the topic. But I think that people do want to believe that even though the liver or kidneys or thyroid or ovaries or bowels could malfunction, resulting in obvious illness, such a thing could not happen to the brain.
Or perhaps it’s the desire to believe that such a thing could not happen to them, or a complete lack of experience with people with neuropsychiatric disorders (I actually prefer that term to psychobiological). There is an understandable desire to view things through our own experiences, and if those experiences do not involve such illnesses or interacting with people with such illnesses, then it can be very difficult for people to grasp the severity involved. Thus people like Will can make fun of various diagnoses without realizing that there are actually people who have these symptoms to the extent that it interferes with their daily lives.
It is also odd to see Will once again deriding scientific evidence-based information, as he repeatedly does with regards to his denials of the basic consensus regarding climate change in many of his columns. Will has been fairly candid about his distaste for anti-intellectualism, and is often regarded as being fairly well-educated and as one of the pre-eminent intellectual conservative writers (I am not conservative by any means, but I do respect Will’s intelligence when he writes about subjects he actually understands, even when I disagree with him). His bashing of scientific evidence-based decisionmaking with regard to the environment and psychiatric diagnosis and treatment is rather puzzling. It’s as if he grasps the concept of scientific expertise and such, but he simply wishes to ignore it, or decide not to dig too deeply into it, if he fears that doing so might lead him to conclusions that he finds politically objectionable.
And of course, if there’s one thing that I really wish weren’t so heavily politicized, it’s healthcare, especially mental health.
everyone also has to keep in mind that the DSM V is not written for lay people. No one ever expects a lay person to pick up a statics textbook and design a bridge, but because the language of the DSM is more accessible it invites lay people to analyze it.
If George Will could have written a different article, then he has free will.
(A relative of mine has been instrumental in the production of the DSM, so the following comments should not be taken as critical of anyone’s intelligence, honesty or morality as he gets high marks on all accounts)
The use of the term expert in regards psychiatry (and climate science for that matter) might be somewhat inappropriate–
An expert has great knowledge and can demonstrate skill– the word expert implies proficiency.
An expert bridge builder can build a bridge. I’m not sure that psychiatry (or climatology) have produced results that warrant the same level of acknowledgement of expertise as other sciences (physics or chemistry for example).
It would seem that the level of trust of an expert would require a judgement of the meaningfulness of the expertise– and this would involve a dispassionate view of the actual results of the demonstrations of the expertise.
If an expert psychiatrist can diagnose and treat a patient, alleviating their problems, wouldn’t that warrant some level of expertise? I see that as no different than an expert endocrinologist diagnosing and treating diabetes, or an expert cardiologist diagnosing a heart defect.
I’m not sure what would qualify one as an expert climatologist. It’s not a field that I’m overly familiar with, but someone who can collect data, examine evidence, make testable predictions, just like any other scientist. Many NASA scientists spend their entire careers studying the climate of our planet and of other planets. I don’t know at what level you would consider them to be an expert, but if they can built a climatological model of some sort and test it out, that could be a sign of expertise
Actually, you mention physics and chemistry….well, related to that is biology. Medicine can be considered as a subset of biology (although actually it does borrow quite a bit from chemistry and physics as well….most cellular biology involves chemical processes). So you could go one step further and look at research psychiatrists whose expertise has led to discovering correlations between activity in certain regions on the brain and certain neuropsychiatric conditions (Zametkin and others come to mind).
You could also consider the expertise needed to make a complicated differential diagnosis based upon a patient’s symptoms. You need to know what information to ask, how to ask for information from some patients, etc. There’s a level of expertise in being able to know which drug (or class of drugs) is most likely to be effective in treating a patient who has a certain amount of symptoms.
I’m always amazed at how people with no expertise in psychology have the arrogance to speak about the issues like they know what they’re talking about. I go to a doctor for medical issues, but apparently I should go to a journalist for psychological advice. How does that even begin to make sense? Good news for me though; I’m getting my degree in political science -just like George Will. You know what that means: license to be an expert in everything!
Will’s teenager remark should be refined to “teenager wearing a gang jacket.”
It must also be noted that psychiatry was largely reformed from within.
Could you explain this? I must misunderstand, because I find it hard to believe that reform around things like “self-defeating personality disorder”, “ego-dystonic homosexuality”, and the inclusion of “PTSD”, among others, as well as current debates around changes to ADHD and GID, for example, are not to a significant extent a function of public lobbying and broader shifts in attitudes towards the behaviors symptomatic of these diagnostic categories. Even if reform appears largely determined by clinical studies demonstrating the validity of a diagnostic category, clinical studies are not conducted in a vacuum, and either we must conclude (1) that public dissent around the inclusion of homosexuality (or any other example) co-occurred with studies showing that it did not warrant being called a disorder, simply out of coincidence; or (2) greater clinical attention, the search for evidence, does not occur independently of shifting public values about what warrants attention. I believe (2) is more likely, and that it is supported by the historical evidence.
Unless (1) you are hedging your bets behind the qualifier ‘largely’; or (2) you mean the literal task of reform was conducted by people in charge of editing and putting together DSM revisions, namely, the Task Force and Work Group are at the helm, at which point the claim that reform was internal is trivially true. (In other words, how could reform be ‘external’? Unless dissenting positions stage a coup and take over the APA printers, it is always possible to say DSM reform occurs from within).
As always, let me know if or how I’ve misread.
Hyperion-
You make good points–
My point is that if we ask a physicist ‘what will happen in this set of circumstances?’ the answer will probably be correct.
If we ask a climatologist– I’m not sure how accurate any of the models are (this is not a slight on what they do know or the work they have done, more a comment on what I perceive as the ‘state of the art’)
Similarly with psychiatry– I’m fairly certain that a doctor will fix the broken arm to health– I don’t have the same confidence with the ‘depressed’…
@siodine:
I’m catching up on podcasts, and yesterday I happened to listen to a Science Friday about Clinical Psychology. It demonstrated that, not only is Clinical Psychology NOT science, it is, in fact, often ANTIscience. Therapists and Therapy educators said things like “you can’t use science to evaluate the effectiveness of talk therapy.” Those statements did encounter opposition, but at least 2 of the three panelists said things like that more than once. While, at the same time, ALL of them insisted that Clinical Psychology is and must be scientific. It reduced my faith in the profession, which was already low.
I discovered the profession of “neuropsychology” a couple of years ago, and I was thrilled to find that they are forced to consider and explain reality, which sets them apart from all of the generations of clinical psychologists to this point. You might get an effective psychologist. You might even get a scientific psychologist. They might even be the same person. But odds aren’t good on any of those.
I thought your description of mental disorders as “gross disfigurement” really brought the point home for me. By analogy, we can consider birth defects. I expect we could expect to find a continuum all the way from “normal” facial features to cleft palates, with ugly noses somewhere inbetween. At some point, you have to draw the line between normal variant and birth defect. I guess George Will would argue that cleft palates are a non-existent diagnosis used as an excuse to get free nose jobs.
@BubbaRich
You’re conflating the field of Psychology with the practice of clinical psychology.
On George Will’s political spectrum, TDD, or Very Unhappy Camper would be at one end of the continuum, and Overtly Stimulated by “Psychobunnies,” TDE(euphoria) at the other end.