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Friday, 28.07.2017

Comment by Jose de Leon

Comments by Jose de Leon on Thomas A. Ban’s RDoC in Historical Perspective and on Following Comments by Bernard Carroll and Samuel Gershon

Thomas A. Ban started his commentary on the RDoC by referring to an article published by Luhrmann, an anthropologist, on January 17, 2015, in the New York Times (NYT) that did not reflect favorably on contemporary psychiatric nosology (http://www.nytimes.com/2015/01/18/opinion/sunday/t-m-luhrmann-redefining-mental-illness.html?_r=0). This time, the NYT comment was published without any reply from a psychiatrist. Jeffrey Lieberman, past president of the American Psychiatric Association (APA) and chairman of an academic department in New York, had to ventilate his frustration in Medscape (http://www.nytimes.com/2015/01/18/opinion/sunday/t-m-luhrmann-redefining-mental-illness.html?_r=0). The attentive reader will observe that I used the words “this time”. I personally believe the NYT has been presenting a progressively worse view of psychiatric nosology since the spring of 2013 when the DSM-5 was published. I suspect that any objective observer would agree that psychiatry’s prestige as a scientific enterprise has coursed downhill for the past two years.

In my view the anthropologist’s article in the NYT was the third step in this downhill process. This course started with a comment on April 29, 2013, by Thomas Insel, Director of the National Institute of Mental Health (NIMH), who explained just before the DSM-5’s official publication in May 2013 that it lacked “validity” (http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml). Not surprisingly, May 7, 2013, brought a comment in the NYT titled “Psychiatry’s guide is out of touch with science, experts say (http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html?pagewanted=all&_r=0). To try to address that marketing catastrophe, Insel and Lieberman published an online article together (http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-interests.shtml).

The second step was the NYT column entitled “Heroes of Uncertainty” by David Brooks, a political columnist, which appeared on May 29, 2013 (http://www.nytimes.com/2013/05/28/opinion/brooks-heroes-of-uncertainty.html?_r=0).  I am surely biased as I earn my salary by treating the most difficult psychiatric patients in the public system of a state with 4 million people, but I thought the description in “Heroes of Uncertainty” fairly accurately describes1 what I do for a living and is a pretty good depiction of what many excellent psychiatrists do every day in my state’s public system. I consult with these psychiatrists, who work with limited time, resources and access to medical records, but are able to treat very difficult patients. This time Lieberman was given the opportunity for a brief rebuttal to Brooks by the NYT (http://www.nytimes.com/2013/05/30/opinion/psychiatry-on-the-scientific-spectrum.html?r&_r=0). Moreover, he expanded his view in the APA newspaper Psychiatric News on July 1, 2013, with an article titled “Psychiatry: Nothing to Be Defensive About” (http://psychnews.psychiatryonline.org/doi/abs/10.1176/appi.pn.2013.7b19) One of Liebermann’s major concerns was that Brooks questioned the scientific status of psychiatry. Brooks stated, “The recent editions of this manual exude an impressive aura of scientific authority…The problem is that the behavioral sciences like psychiatry are not really sciences; they are semi-sciences.” Since Brooks is not an expert in scientific methodology, his definition of psychiatry as a “semi-science” does not appear “scandalous” to me; my view on the application of scientific methodology to medicine and science has previously been described in detail.1 Following Paul McHugh,2 I believe that psychiatry is 150 years behind medicine and, following Karl Jaspers,3 I think that psychiatry is a hybrid discipline combining the methodology of the natural sciences (explaining) and of the social sciences (understanding). In my opinion, psychiatry is not only neurology and not only abnormal psychology4 since it includes disorders that can be called “neurological” and follow the medical model (e.g., Alzheimer disease) and also the psychological abnormalities that McHugh5 describes in three of his four perspectives in psychiatry, namely “behaviors”, “dimensions” and  “self and life story”. His fourth perspective is “disease”, which applies to Alzheimer disease.4 Supported by the wisdom of Jaspers and McHugh, I feel comfortable disagreeing with Lieberman about the “scientific” status of contemporary US psychiatry. Moreover, from the practical point of view, I believe that US psychiatry has to be “defensive” about many things. I titled an editorial in a psychopharmacological journal “Paradoxes of US Psychopharmacology Practice in 2013: Undertreatment of Severe Mental Illness and Overtreatment of Minor Psychiatric Problems.”6

Like Ban, I am a European psychiatrist transplanted to North America; therefore, my views on the interaction between psychiatry and psychopharmacology are very similar to his, and I consider his approach of using clinical symptoms7-9 to be one of the main ways that psychiatry can move forward with the “fantasy” of personalizing psychiatric treatments.10 To criticize the RDoC, Ban uses a historical approach going back 150 years to Griesinger, while my historical approach11 looks back only 100 years by proposing that Jaspers’s words for Wernicke’s approach, “brain mythology”, apply to the RDoC, as well. The RDoC appear to forget that some of the so-called disorders of the DSM-5 have no clear boundaries with normal human behavior, and can simply be defined as “abnormal psychology”; these disorders do not follow the medical model which was the “ideal” of Kraepelin12 and the US neo-Kraepelinians.13 In summary, I do not have Ban’s wisdom, but I cannot find any statement in his comment with which I can disagree.

I started to admire Carroll and Gershon 30 years ago, during my psychiatric training; therefore, I am not sure I can do a good job of critiquing them. Moreover, I totally agree with them that the RDoC are an absolute catastrophe for research in severe mental illness, including schizophrenia, bipolar disorder and severe depression. To conclude, Kraepelin,14 100 years ago, tried to save psychiatric nosology by developing a Research Institute using the neurosciences of his time; he failed but at least he had a thorough understanding of clinical and historical issues in psychiatry during his time,15 while the NIMH leaders do not appear to have mastered clinical issues and have no historical knowledge. They combine Kraepelin’s marketing of curing mental illness16 with Wernicke’s “brain mythology”. It appears that they have not read the Harvard philosopher George Santayana, “Those who cannot remember the past are condemned to repeat it.”17

 

References

1. de Leon J. Is psychiatry scientific?  A letter to a 21st century psychiatry resident. Psychiatry Invest 2013; 10: 205-217. pdf available  http://www.ncbi.nlm.nih.gov/pubmed/24302942

2. McHugh PR. Striving for coherence: psychiatry's efforts over classification. JAMA 2005; 293: 2526-2528.

3. Jaspers K. General Psychopathology. Translated from the German 7th edition by Hoenig J and Hamilton MH. Manchester: Manchester University Press, 1963. 

4. de Leon J. Is Psychiatry only neurology? Or only abnormal psychology? Déjà vu after 100 years.  Acta Neuropsychiatrica (in press).

5. McHugh P, Slavney PR.  The Perspectives of Psychiatry.  2nd edition.  Baltimore:  The Johns Hopkins University Press, 1998.

6. de Leon J.  Paradoxes of US psychopharmacology practice in 2013: Between undertreatment of the severe mentally ill and overtreatment of minor psychiatric problems (editorial). J Clin Psychopharmacol 2014; 34: 545-548.

7. Ban TA. Neuropsychopharmacology and the forgotten language of psychiatry.  International Network for the History of Neuropsychopharmacology (INHN) E-Book, 2013. http://inhn.org/previews/neuropsychopharmacology-and-the-forgotten-language-of-psychiatry.html

8. Ban TA. Prolegomenon to the clinical prerequisite: psychopharmacology and the classification of mental disorders. Prog Neuropsychopharmacol Biol Psychiatry 1987; 11: 527-580. 

9. Ban TA. Towards a clinical methodology for neuropsychopharmacological research. Neuropsychopharmacol Hung 2007; 9: 81-90.

10. de Leon J.  Focusing on drug versus disease mechanisms and on clinical subgrouping to advance personal medicine in psychiatry.  Acta Neuropsychiatrica 2014; 26: 327-333 

11. de Leon J.  DSM-5 and Research Domain Criteria: One hundred years after Jaspers’ General Psychopathology. Am J Psychiatry 2014; 171: 492-494.

12. Kraepelin E.  The manifestations of insanity. Hist Psychiatry 1992; 4: 509-529.

13. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970; 126: 983-987.

14. Kraepelin E. The German institute of psychiatric research. J Nerv Ment Dis 1920; 51: 505-513.

15.  Kraepelin E. One hundred years of psychiatry. New York: Philosophical Library, 1962.

16. Insel TR, Scolnick EM. Cure therapeutics and strategic prevention: raising the bar for mental health research. Mol Psychiatry 2006; 11: 11-17.

17. Santayana G. The Life of Reason: Or, The Phases of Human Progress, 5 vols. Available free online from Project Gutenberg (http://www.gutenberg.org/etext/15000) 1998.

 

Jose de Leon

April 30,, 2015.