I think it will be hard to expand psychiatry to that level while keeping it professional. The fundamental issue is that people ascribe personality flaws to others instinctually and also have strong feelings around being subjected to such treatment, in a way that they don’t have around sprained ankles. In everyday life it’s called badmouthing or trash-talking. It’s a part of human nature.

Doesn't that presume that human psychology (cognitive functioning) is uniform at a level that would obviate the need even for personalities and styles?

Our physiological system does have that uniformity across the population but our psychological system does not seem to. Isn't it then misguided to try characterizing small deviations when we don't even have a uniform "background" to subtract?

There isn't one because a sprained ankle is a binary diagnosis.

One of the biggest problems with psychiatry is that every diagnosis is a spectrum, and over time it's become more and more obvious that the boundaries for what is considered "neurotypical" are way too narrow.

Depression being a chemical imbalance was a complete lie to sell more medication, and how prolific this type of occurrence is within the industry is not hard to see.

At the very least, a plurality of phycological diagnoses are manifestations of physical behavior: diet, exercise, exposure to sunlight, etc

We're so overprescribed on medications to try to feel a certain way within far too narrow of a spectrum.

Why do you presume that there has to be an equivalent to a sprained ankle? Maybe the answer to your question is yes, only the catastrophic is worth addressing.

https://journals.plos.org/plosmedicine/article?id=10.1371/jo...

Why does psychiatry need to have an ‘equivalent’ of a sprained ankle?

Most people recognise a sprained ankle, at least mild ones, as a self limiting illness. An issue with psychiatric diagnoses is that they are often not taken to be self limiting and often become a large part of a patients self image. While sometimes this can be helpful and help inform treatment it can also be harmful and I have seen this harm first hand in patients I see.

> What’s the psychiatric equivalent of a sprained ankle?

Not sleeping a night.

> What’s the psychiatric equivalent of a sprained ankle?

A concussion? Obviously it’s not considered a psychiatric condition but concussions check a lot of the right boxes abstractly.

But conceptually in the DSM most disorders are defined by whether they cause hardship in the patient's life. Whether that means some disorders would not have to be considered disorders in an ideal society is irrelevant for this context, because people need help navigating the society we have.

How else would you do it? Unlike an e.g. viral infection there is no positive test you can look at. Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment. I don't think you can be totally objective about this, and you get into things like if i.e. autism is mild is it a disorder? It's pretty clear to me it should be considered as such after a certain level of severity, but maybe it shouldn't always be if it has minimal impact on the person

A "disorder" is just a collection of symptoms that have been empirically shown to benefit from certain treatments. If someone doesn't think they have those symptoms then they can just not seek a diagnosis or treatment. Nobody is forcing a diagnosis on somebody who doesn't want it.

>What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm

What's the alternative then? What would "empirically" determining what a "disorder" is look like?

>…by Americans

Most of the world outside of the US uses the ICD, not the DSM.

Agreeing that social science is harder than most, I see these definitions as “circle around a set of presentations / symptoms / behaviours “. As somebody who has several circles around them, it doesn’t bother me overly. Historical enforced procedures / incarcerations did, but I understand value of “common language”. In a wildly different area that may or may not resonate with HN, I find similar value in PMP or ITIL - it’s not the One True Way, it is not necessarily a permanent scientific best approach… but it does give people of today a way to communicate with each other across domains, companies, cultures and experiences .

> The DSM in many ways represents the worst of so-called social science.

No. You need to read the thing.

The DSM only aims to be a tool to help standardize communication of often nebulous and otherwise ill-defined entities. It says so in the introductory pages.

People shouldn’t treat it like a biology textbook, it’s a self-described ontology at most.

> What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm…by Americans.

I've seen that used before to dismiss the severity of conditions like autism and especially ADHD. It's often coming from a well-meaning place, and sometimes it's just a comforting story people tell themselves in order to not feel as deficient ("The problem isn't me, it's the system!").

It's also absolutely true that the demands society places on all of us are unnatural and often excessive, but the fact is that even absent all external expectations some people with mental illness will be unable to accomplish what they themselves want and should be able to accomplish.

Even the most utopian, accepting, accommodating society it wouldn't be enough to make up for some people's inability to function.

I feel the same about a lot of the "super power" talk when it comes to mental illness. There are advantages and disadvantages to just about anything, but on the whole conditions like ADHD or autism tend to do way more harm than good.

“Empirical evidence” and “what is determined as undesirable, maladaptive, or outside the social norm” are not mutually exclusive.

My inability of being in nature without a feeling of being tortured comes from my brain not working correctly and it's not "undesired behavior". Luckily, my ADHD meds are able to fix that.

Without a clear and agreed behavioral model, I don’t see how disorders can be properly defined.

The exercise and food science people are the worst of social science buddy. Or just “social” something, because it’s not science. “Science-based” always makes me laugh.

The DSM only matters if somebody is actively seeking treatment for something that they have a problem with in their own situation. So what’s in there is totally irrelevant for the public at large. It’s only if somebody shows up and says there’s something going on that they don’t like. It’s really just billing codes, man. The reality is far different anyway, and it just gets distilled down to these primitive codes.

I think this is not a valid criticism.

By this criteria, you can then say many other non-psych conditions are not disorders.

What classifies as a disorder other than making life worse for someone?

There is no universal book given by a holy entity that we can read to classify something as normal or a disorder.

Why do we have arbitrary cutoffs for cholesterol, blood sugar, blood pressure, etc?

The DSM isn't about understanding how the brain works, it's about correlating sets of symptoms to treatments. If your issues are characterized by this broad set of symptoms, then likely you'll benefit from these sorts of treatments, and etc. We don't have a good understanding of how the brain works, but we're pretty confident that people with schizophrenia often benefit from antipsychotic medications.

It's hard to tell honestly. I studied psychology for two years in uni, and I dropped out rather disillusioned about the field. Some of my least favorite aspects included:

  - Acknowledgement by our professors that P-hacking (pruning datasets to get the desired results) was not just common, but rampant

  - One of our classes being thrown in limbo for several months after we found out that a bunch of foundational research underpinning it was entirely made up (See: Diederik Stapel).

  - Experiencing first-hand just how unreproducible most research in our faculty was (SPSS was the norm, R was the exception, Python was unused).

  - Learning that most psychology research is conducted on white psychology students in their early/mid-twenties in the EU and US. But the findings are broadly generalized across populations and cultures.

  - Learning that the DSM-IV classified homosexuality as a mental disorder. Though the DSM-V has since dropped this. 

The DSM-V is still incredibly hostile towards trans people through a game of internal power politics and cherry-picked research. It's really bad honestly.

Though I do generally hold psychologists in high regard (therapy is good), I'm not particularly impressed by psychology as a science. And in turn don't necessarily trust the DSM all that much.

This is the wrong question… The DSM is just an ontology that aims to standardize communication of otherwise ill-defined or nebulous clinical entities. It provides language for medical professionals of various backgrounds to understand each other across cultures. That’s all it is.

I took the liberty of indulging in some reading.

I must admit, it feels a bit strange. The truth is that I learned my first steps in programming by working through large, formidable books. In fact, my very first programming book was Assembly Language for Intel-Based Computers by Kip Irvine. After that, I read even larger books, many of them multiple times.

I have always been fond of reading well-written books by knowledgeable professionals. After reading such works, you come away with real understanding, greater clarity, and often new creativity. Books are valuable, and I have always respected a good one.

Yet the DSM-5-TR is quite the opposite. The Preface clearly states that the work is intended for everyone:

“The information is of value to all professionals associated with various aspects of mental health care, including psychiatrists, other physicians, psychologists, social workers, nurses, counselors, forensic and legal specialists, occupational and rehabilitation therapists, and other health professionals.”

I happen to be a social worker, and I have read a lot of books. I know how to study. I carefully looked up any words I might have misunderstood and used the dictionary freely.

But despite all my efforts, I often failed to make sense of what I was reading. One would expect a theory followed by a conclusion, or an observation leading to a conclusion, or a theorem that is then proven. Unfortunately, that structure is missing here.

A typical DSM entry begins with a statement presented as fact, only to be followed by other statements that seem to contradict it.

Take, for example:

“The prevalence of disinhibited social engagement disorder is unknown. Nevertheless, the disorder appears to be rare, occurring in a minority of children, even those who have experienced severe early deprivation. In low-income community populations in the United Kingdom, the prevalence is up to 2%.”

This kind of contradictory phrasing is standard in the DSM.

Again, the DSM is publicly available, and anyone can read it here: https://www.ifeet.org/files/DSM-5-TR.pdf

I would have expected more precision from a scientific book.

  1. We don't know actual prevalence
  2. But believe it is low
  3. Upper bound in some community is 2%

The brain is certainly difficult to study, but does it not stand to reason that there should be a collection of the current understanding of how to treat things when they go wrong? No one is calling the DSM V the final, definitive, work, there's a reason it's numbered.

Nearly all of it, because that's the case for the overwhelming majority of the social sciences.

When you do not have an objective metric to measure, prove, or hypothesize (as in physics, chemistry, etc), you're basically doing statistics on whatever arbitrary populations and bounds you choose with immeasurable confounders. That's why the replication crisis and p hacking are intrinsic properties of the social sciences

> So these folks are implying that the rework of the DSM-4 into DSM-5 was tainted in some way by association of the authors with pharma or other industries?

Yes

This has been known to economists for a long time

Medicine generally has had its progress (as a general good) held back by misaligned incentives for a long time

See "neglected tropical diseases"

As true in psychiatry as anything else

I'm pretty sure we have tablets from Babylon wherein homeowners are complaining that the building code was ghost written by the mud brick lobbyists.

" The FASB was conceived as a full-time body to insure that Board member deliberations encourage broad participation, objectively consider all stakeholder views, and are not influenced or directed by political/private interests "

It clusters symptoms "without underlying cause" because we don't know the underlying cause. If we wanted to go for a fully "physical mechanism" approach to mental health, we could just end any treatment attempts and say "come back in a few decades or perhaps centuries".

But we do know that certain symptoms tend to show up in clusters, and that patients in certain clusters tend to respond to certain drugs with an above-placebo level of effectiveness.

The same is true for a runny nose: It can be caused by any number of viruses (there is no such a thing as "the" influenza virus or "the" common cold virus), or allergies, or irritants like pepper spray, or a problem with the body's ability to regulate itself, or something else entirely – but going through the effort to test for every virus, allergen, irritant, and whatnot is wasteful, if all the patient needs at that moment is some nasal spray to breathe properly again. Incidentally, a runny nose is (or perhaps: was) not a common symptom of Covid, so unless other symptoms more indicative of it show, there may not a good reason to test for it, or prescribe medication specific to it.

If more symptoms accumulate over time, or the symptoms don't go away, you then probably can go back to your doctor, will get a different diagnosis and possibly a different prescription. The same is (or at least: should be) true for mental issues, where you might switch treatment over and over until something is found which actually helps your symptoms. Is this a flawed process? Frustrating? Absolutely. But is it "worthless"? I don't think so.

> it’s worthless

Hundreds of millions of people whose lives have been saved or improved thanks to broader recognition and treatment of their disorder would disagree.

While I agree that DSM is likely a bunch of nonsense:

> As long as they don’t provide physical mechanisms for disorders, it’s worthless

This reasoning will dismiss too many things.

We don't know the physics of almost anything, it's all progressive levels of approximation.

For the longest time we knew nothing about the physical mechanisms of anesthetics, or how a plane wing works.

Science doesn't need the mechanism. It needs predictive power. Observations, hypotheses, tests and thesis.

You are wrong. Medicine does not need physical mechanisms for any diagnosis or therapy. It is preferable but not obligatory. A mere grouping of a symptom cluster forms a diagnosis as well as a therapeutic target.

Ahahah I know what you did here.