What do we want our diagnoses to do?

La entrada de Ghaemi es certera y simpatizo con su crítica de la perspectiva postmoderna (sui generis - ya que no creo que a Allen Frances, el artífice del DSM-IV, se le pueda etiquetar de postmoderno). Su crítica es al "Anything goes" de Feyerabend y no creo que le hace justicia a Frances que ocupa un espacio menos relativista en lo concerniente a la psiquiatría clínica... Me temo que aquí hay rencillas o resquemores anteriores que salen a la luz, ya que mi lectura de Allen no es la que ofrece Ghaemi. Y sin embargo, este hombre - joven - del que hablaba el otro día en una reunión interesantísima con varios discípulos de Félix Letemendia, es uno de los pocos psiquiatras norteamericanos con cosas interesantes a aportar en Psicopatologia (así con mayúscula).

En otro momento escribiré acerca de Letemendia, que se formó con López Ibor el viejo, con Martín Santos (que era donostiarra como él) y, por supuesto, con Castilla del Pino.



What do we want our diagnoses to do?: "

In debates with some leaders of DSM-IV, it has become clear to me that they are postmodernists who view science as hardly more valuable than stargazing. Which is not to say that science is simplistically "true." There is some arbitrariness to science; there are hypotheses that need to be confirmed or refuted; scientists hold to their ideas beyond the data, against the data, frequently; scientists are humans. But science is, and has been, a self-correcting endeavor. Truth is corrected error; falsehood is accepted and studied, not proclaimed and rejected. Science is not religion.

But some of the leaders of DSM-IV have drawn postmodernist conclusions, and decided to replace science with "pragmatic" opinions, a psychiatric gerrymandering of diagnoses to the tastes of those sitting around the DSM table. This has produced a scientifically poorly-founded nosology; a diagnostic system that is "abused" because it easily is abusable.

The key is to ask the question: What do we want our diagnoses to do? It seems to me that there are two opposed answers: One answer is to find out the truth about mental illness; to understand it well so that, if present, it can be treated correctly. Another answer, based on a rejection of science and a cynicism about mental illness, is to view nosology as having only one purpose: to get along. In the case of psychiatry as a profession, it is a means for everyone to make a living. The authors of DSM-IV will proclaim this "pragmatic" goal as something that sounds more benign: to produce good outcomes in the real-world of practice. But what does this mean when science counts for little and you don't think you are actually capturing real diseases? In other words, what does it mean when there are no right answers? It means getting along. The problem is: people will not necessarily accept the made-up answers of DSM-IV, and they will use DSM in whatever way they think produces good outcomes in the real world. And we will disagree on what those good outcomes are.

There is, in the postmodernist DSM-IV worldview, no adjudication by truth. Thus, everyone does whatever they want. But many deny truth. It seems to me a bit embarrassing that physicians should do this, that anyone would practice medicine while explicitly denying value to scientific truth. Such practice seems hard to justify when one is practicing surgery or prescribing medications that can harm. But so it seems to be with some psychiatric leaders.

So let's take a step back, and think through, again, these two opposing perspectives.

There are two basic concepts of mental illness that underlie our debates about DSM. One approach is "pragmatic" and postmodernist: it focuses on the results of varying definitions, and tries to pick a definition that produces more good than harm. The other approach is called, in philosophical lingo, "scientific realism": it seeks to define the truth, as far as our science allows us, of the definitions of disease, come what may regarding consequences of such definitions. In the first definition, to put it concretely, if disease X leads to use of drug Y, and we do not want to encourage use of drug Y, we will define disease X in a very restricted way so as to make it hard to diagnose. In the second approach, we define disease X the way the best scientific research suggests we should, irrespective of how it impacts use of drug Y.

These differences explain the different goals of each group for our diagnostic system (or nosology). For the pragmatic/postmodernist, the primary goal of our nosology is to produce good consequences in the real-world of medical practice. So, based on our best current knowledge at the present time, these nosologists would nip and tuck (gerrymander might be the best word) our diagnostic definitions until they seemed to produce the best consequences. One looks around at the drugs that are out there; we examine how clinicians appear to be behave; we look at what patients want; we judge how the pharmaceutical and insurance companies will likely influence practice; we assess the goals of the government. Then we make up our criteria to try to produce the best consequences. Allen Frances, the leader of DSM-IV, has recently admitted explicitly that this was the process. The problem is the same as with utilitarianism in ethics; all this decision-making implies that we have sufficiently solid knowledge upon which to make our judgments. This is one limitation, but there is an even greater one. Even if all our practical judgments are correct, this approach would at best provide a serviceable nosology for today, this year, this era. It would not help promote a better nosology tomorrow, next year, for the next generation. This is a stagnant, static approach to nosology. In contrast to the claims of the founders of DSM-III, it has no inherent motor that might drive it forward; no progress can be assumed; there is no incremental advance.

Reliability becomes an end in itself, rather than a way-station to validity. All we have is a common language, a discourse in the sense that Foucault meant it, a pure fiction that represents the hegemony of our society. We may view this hegemony as benign; we may try to rig it so that the pragmatic results are 'good,' in our opinions. But it still is a fiction, one that has absolutely no correspondence with any reality or truth independent of our social structures and personal preferences.

Of course, postmodernists have no problem with these implications. They attack progress as a chimera; there never has been progress, they claim, and so we lose nothing by giving up our illusive hopes for it in the future. There is no reality of mental illness - or anything in fact - outside of our social and economic and human discourses; our civilizations create everything; everything is socially constructed, even the hardest science. Without society, there are no atoms, no electrons, no trees, no nature, and of course no schizophrenia. We can relabel and interpret all those things in a different way, and they would then be those different 'things.' Things do not exist; we do.

This is the 'pragmatic' postmodernist reality of psychiatric nosology today; and it will be the same reality tomorrow because such postmodernism has no future to build, for it has no criteria for what is better in any objective sense; postmodernism has only a past to attack, and, in the case of psychiatric nosology, a present to defend.

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