So why, you might ask, this sudden pessimism on the part of psychiatrists? (Or is it just honesty? Remember depressives are better at reality testing than non-depressives, which implies that pessmism is more trustworthy than its opposite.)
The answer is simple. It’s safe for psychiatrist to come clean about how bankrupt the scientific and intellectual underpinnings of their discipline are because they think they have something with which to replace it. Actually, they have two things: a new DSM and a new project initiated by the National Institute of Mental Health. DSM-5 and RDoC actually have very little in common, although no one quite wants to admit it, preferring instead to pretend that the APA and the NIMH are singing kumbaya together. But they do share this sudden antipathy toward psychiatry up to this point, and they’ve both pointed the finger at the same culprit: the DSM-IV.
So this convention is very much a DSM-IV hatefest. The book not only reflects the lack of what Insel calls Science; it is one of the big reasons why psychiatry is so benighted, and its continued use can only further benight the profession.
So far, it’s hard to disagree with them. But in their view, the DSM-IV fails because it is a phenomenological account of human suffering, i.e., because it looks to the actual lived experience of distress in order to understand it. It’s important to see that their beef isn’t with the quality of that account. It’s not like they’re saying that the DSM-5 needs to provide a better phenomenology than the DSM-IV. It’s that it should pay as little attention to people’s experience as possible, and only until neuroscience makes it unnecessary. Evidently, the mistake Bob Spitzer made in formulating DSM-III (and DSM-IV is really only a modification of Spitzer’s approach) was in not sufficiently eliminating the human. Spitzer, they think, didn’t throw the Freudian baby–the idea that our suffering has some kind of meaning, that its specifics are important–out with the bathwater of Freud’s metapsychology.
Of course, neuroscience was just a twinkle in psychiatry’s eye when Spitzer was in charge, and not much more than that when Al Frances came along. But now, what with those fMRI and PET scans, with genetics and genomics and all the other biochemical techniques at their disposal, psychiatrists are ready to try to cut out the middleman–that’s you and me and our lived experience–entirely. They want to drill down to the deepest level of all, the molecular world where, in their view, we are assembled into selves. Why bother listening to patients, what with the vagaries of their language and all the deceptions and evasions in whcih they engage (not only because they are sick, mind you, but because they are human and therefore incapable of reporting accurately what’s going on in their amygdalas and their DNA), why bother trying to make sense out of what they tell you when you can just look at the readout or the brain image and find the pathology there? Why bother wondering if a person is schizophrenic or bipolar, if he has depression or anxiety, if what we think today is Asperger’s disorder really is mild autism when the answer is really none of the above, when the answer is that this person’s ventral medial prefrontal cortex and the circuits it feeds have gone haywire. What difference does it make how that pathology manifests. I mean, do we really care what kind of pain a cancerous tumor causes, or whether it causes pain at all?
