The writer Pete Earley and his son, Kevin, who has been treated by seven psychiatrists. Only a few have agreed on Kevin's diagnosis.
I asked my doctor: "What caused my son to get sick?"
"I don't know," the doctor replied.
"Will it happen again?"
"It might, but it might not."
"Can you tell me what is wrong with him?"
"I'm not certain."
Since my adult son's first psychotic episode in 2002, during which he spent five days walking aimlessly in New York City convinced that God had given him divine orders, he has been hospitalized four times and been treated by seven psychiatrists. Only a few have agreed on his diagnosis.
I have been told my son has bipolar disorder, schizoaffective disorder, or possibly early stage schizophrenia. His most recent diagnosis is bipolar disorder with psychotic features. He has been prescribed a cornucopia of medications. One psychiatrist put him on an anti-psychotic that the next doctor called a placebo. Another prescribed a medication that made his condition worse.
Unlike many other physical ailments, there are no acceptable scientific tests that can pinpoint mental disorders. A blood test won't tell doctors which of my son's diagnoses, if any, are accurate. Instead, psychiatrists must rely on a patient or family members to describe symptoms of the illness to make a diagnosis. The doctor then consults psychiatry's "bible" - the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) - to determine which diagnosis best fits the patient's symptoms. This process can be ripe for error, especially if a patient doesn't believe there is anything wrong, a common reaction during a psychotic break.
First revision since 2000
The APA recently released a new DSM, the first revised edition in 13 years, and like its four predecessors, it has sparked fiery debate. Panels of experts were chosen to decide what constitutes a legitimate mental illness. A campaign to add "sexual addiction" - remember Tiger Woods? - to the manual was rejected because the experts decided there wasn't sufficient evidence to show that individuals can become addicted to sex in the same physical way that happens with alcohol or drugs.
The update also attempts to refine when an unruly child is simply being headstrong and when he is exhibiting oppositional defiant disorder.
It's easy to poke fun at psychiatrists arguing about whether watching Internet pornography should be classified as a mental disorder if it becomes so obsessive that it disrupts someone's life. Critics are quick to point out that the manual once listed homosexuality as a mental disorder.
Patients deserve better
Some charge that pharmaceutical companies, which often have financial ties with psychiatrists, exercise undue influence by conjuring up more and more disorders with the APA's cooperation so they can profit from medications sold to a gullible public through countless television ads. Sales of the manual at $120 each are also one of the APA's biggest moneymakers.
Despite these criticisms, the manual plays a critical role. Diagnoses based on DSM criteria often help doctors determine which medications to prescribe. Insurance companies rely on the manual to accept or reject claims. In court, defense attorneys and prosecutors call expert witnesses who argue about an accused criminal's sanity based on their interpretations of the DSM.
Most revisions in the new manual are insignificant, according to Thomas Insel, director of the National Institute of Mental Health. He dropped a bombshell recently when he largely dismissed the DSM for lacking "validity" because it is based on opinions rather than science.
The manual is "a dictionary, creating a set of labels and defining each. ... Patients with mental disorders deserve better," he wrote in a blog item.
Insel announced that the National Institute of Mental Health will no longer pay attention to the DSM when it conducts research. "Mental disorders are biological disorders involving brain circuits," he declared. The institute will focus its research on identifying which of the brain's circuits are responsible for thoughts, emotions and behavior, and what causes them to go haywire.
Insel's criticism struck a chord with parents like me. Studies show that individuals with severe mental disorders die 25 years earlier than their peers. Those are our sons and our daughters.
For too long, psychiatry and the pharmaceutical industry have focused on finding ways to alleviate symptoms of severe mental disorders, such as bipolar and schizophrenia. We need a cure. Insel's focus on neuroscience is our best hope for unlocking the brain's mysteries.
When that happens, the DSM should become obsolete.