While there are no biological tests in psychiatry?
I asked this to my supervisor once who used to be a psychiatrist. Following a short blank stare, the answer was: well, brain is not kidney. You cannot just extract a sample of brain tissue to garnish your petridish. And it immediately felt like a brainless question.
The idea of mental disorder is at the centre of scholarly and public discussions about which mental disorders should be classified as pathological vs which should be classified as normal suffering or life challenges, with implications for psychiatric diagnosis, research, and policy. Despite the fact that both normal and disordered conditions may require treatment, and that psychiatry serves purposes other than disorder treatment, there is widespread concern that erroneous disorder attributions are biassing prognosis and treatment selection, creating stigma, and even interfering with normal healing processes. However, there is no consensus on what constitutes a “mental disease.”
“Psychiatric diagnosis is unquestionably imperfect, but so is diagnosis in general. Regardless of existing limitations, psychiatric diagnosis is valuable and necessary. There will be no paradigm shifts until we get a lot more information. If you state otherwise, patients will be mislead and confused.”
The DSM and ICD diagnostic criteria are currently the principal arbiters of what is disordered vs. nondisordered in most clinical practise and research. They are not, however, final arbiters in terms of concept. The criteria are revised on a regular basis in order to increase their accuracy in detecting disorder and to eliminate false positives, meaning that there could be “errors” in the criteria. Furthermore, both the general public and critics within the mental health professions challenge the validity of the criteria for defining mental diseases, and these conflicts appear to be based on a shared notion of sickness rather than being entirely random.
Although several biochemical abnormalities can distinguish individuals with mental illnesses from healthy volunteers, only a few of these have led to clinically effective testing. The lack of a biological ‘gold standard’ definition of psychiatric illnesses, a plethora of statistically significant but minimally differentiating biological findings, ‘approximate replications’ of these findings in a way that neither confirms nor refutes them, and a focus on comparing prototypical patients to healthy controls are all factors that contribute to the delay. In order to overcome these challenges, a new approach will be required. Rather of aiming for biological tests that can ‘diagnose’ DSM-defined disorders, researchers should focus their efforts on identifying physiologically homogenous subcategories that cut through phenotypic diagnosis, obviating the necessity for a gold standard.
Mental health in crime research
I received this book as a remuneration for editing an article for SAGE Open Medicine. It was more of a surprise than a remuneration, I was told only after submitting a decision that I am entitled to a hardcover title from their library. And such a hardship it was to choose one from the SAGE Ocean. I still keep asking myself how did I end up finding a book whose theme couldn’t be more remote from the subjects that occupy most of my time. Maybe my subconcious mind had something different in mind…
My relationship with psychology research started with a brief course on lifestyle medicine. This perhaps in the simplest terms points to a subdomain of medicine that tries to understand why do people consciously make unhealthy decisions that affact their health. The most commonly investigated areas in this discipline are dietary preferences, physically activity, smoking and drinking behavior, not missing medications and medical visits, and the like. I also happened to work on a few data projects that required me to inspect the issues from a behavioural perspective e.g. neighbourhood crime and safety, child abuse and intimate partner violence. Extremely trecherous constructs whose variance always remained largely unexplained. My common sleight-of-hand to trick the reviewers was that a certain extent of every behavioral trait is determined biologically, so it is a good practice to avoid explaining them using the social conditions alone. That was a good point (!), for eventually driving me to the clinical criminology literature. The question was can the level of crime and violence in any society be reduced through tweaking the socio-political conditions. The literature is still too blurry to answer this, and the arguments by Robert and Henry little too biased. But the book was a good starting point. Thanks SAGE. The book claims at the outset that the link between mental illness and criminal activity is a myth. Their thesis is a difficult one to disprove right away due to the absence of any direct evidence. But there is no shortage of studies showing the importance of the predisposing factors which in the course of time set in motion a chain of social and behevioral forces that eventually lead to the execution of a crime. Two quick examples: 1) I found at least 10 review studies on addiction pharmacogenetics confirming the genetic susceptibility to drug addiction, as well as the effectiveness of pharmacotherapy on several SUDs. And a few thousands on the link between SUDs and violence. 2) About 8 clinical studies that used neuroimaging techniques to establish a connection between brain disorder and acquired pedophilia. And from there anyone using minimal reasoning will be able to deduce the connection between the two. DSM-5 There are numerous studies showing the molecular basis behind the complex psychological traits. In the language of ScientificAmerican <And if hormones are the story’s main characters, then its hero may be oxytocin—a neurotransmitter that some scientists call the “love hormone.” Researchers have shown that oxytocin, made in the hypothalamus, is involved in human trust, bond formation, generosity and, of course, empathy.> Synthesis of oxytocin is strongly dictated by genetic factors, hormonal imbalances, and nutritional deficiencies. All of the three are very easy to wrong, and if they do the individual will struggle with the aforementioned: ‘human trust, bond formation, generosity and, of course, empathy’, a difficult-to-diagnose predisposing factor *which in the course of time can set in motion a chain of social and behevioral forces that eventually lead to the execution of a crime.* Epidemiology at its core is all about pinpointing the true-positive dots and lines that connect them. Maybe the same goes for forensic science. And the respective institutions share the same tragedies. Our healthcare and criminal justice systems couldn’t be more similar in their approaches as they both are too focused on treating the outcome, and too ignorant of the predisposing conditions, perfectly echoing the regrets of a healthcare researcher: “What is the point of the treating a patient for a diseases only to send him back to the environment that caused the disease in his system in the first place.” Maybe someday our institutions will find a way to disillution themselves and start working in the right direction. Genetic susceptibility to drug addiction. There is no single cause behind any behavior, but a groups of risk factors. Not all types of mental disorder are linked to criminal proclivity. People with mental illness are more likely to be a victime rather than a perpetuator
DSM-5 Critics
Even if the DSM-5 is deserving of contempt, the NIMH’s surprise denunciation was an unjust and erroneous attack on all psychiatric practise. The National Institute of Mental Health (NIMH) promoted its new research agenda in support of its petition to Congress for greater money for brain research. The statement left out the fact that the National Institute of Mental Health will not be able to make any significant advances in clinical care this decade. The National Institute of Mental Health was phasing out current mental diagnoses, but there were no alternatives.
The British Psychological Society then added to the hilarity by suggesting that we replace our current psychiatric diagnosis system with a psychosocial paradigm.