Comment by haberman | Hacker News Reader

Comment by haberman | Hacker News Reader

This is promising. If you read the DSM (the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association), it reads a lot like a fuzzy pattern-matching algorithm:

    (A) Characteristic symptoms: Two (or more) of the following,
        each present for a significant portion of time during a
        1-month period (or less if successfully treated):

        (1) delusions
        (2) hallucinations
        (3) disorganized speech (eg. frequent derailment or incoherence)
        (4) grossly disorganized or catatonic behavior
        (5) negative symptoms, ie., affecting flatting, alogia,
            or avolition.

    Note: Only one Criterion A symptom is required if delusions
    are bizzare or hallucinations consist of a voice keeping a
    running commentary on the person's behavior or thoughts,
    or two or more voices conversing with each other.

What is a "delusion?" What is "bizarre?" There is a lot of subjective judgment here, and just generally speaking this feels more like alchemy than science.

I don't mean to criticize this approach too much though, because without a more detailed understanding of the underlying mechanisms and causes, this approach is the best possible way of at least clustering mental problems into groups. That at least allows people to share data about what treatments have worked for people in each cluster.

But if we can get a better understanding of the true underlying causes, and isolate the causes with better granularity, it should put us in a much better position to (I hope) provide much better and more specific treatment.

It's worth remembering that the DSM is not intended for use by the average person. It can and will use technical terms - like "delusion" - that users of the manual are expected to understand as technical terms.

Fair enough. It still seems safe to say that diagnoses based on criteria like "meets at least two of these five symptoms" are less than an exact science.

All models are wrong, but some are useful. This model has proven useful.

These symptoms do cluster. Most people never ever experience halluzinations, but then they also experience delusions or other psychotic problems, relatively specific social problems, paranoia, etc.

In some sense this is a human-readable equivalent of logistic regression. Because schizophrenia isn't as well understood as some other diseases, you can only make "exact" models about meaningless abstractions, or create fuzzy models which allow meaningful treatment decisions.

All of this is exactly what I was meaning to say with my initial comment.

Current models are fuzzy, but in the absence of better information they are the best we can do, and they are useful.

> All models are wrong, but some are useful. This model has proven useful.

The model is clinically useful, but the assumption (which the DSM does not itself advertise or support, which is made implicitly when its categories are used as the basis for research) that the diagnostic categories in the DSM represent commonality in origin is an impediment to research.

While many people have overstated the NIMH move away from DSM categories as a basis for research funding as something like an indictment of the DSM in its intended role or, even more hyperbolicly, a rejection of psychiatry as a field, it is an important move that recognize that the DSM categories' utility in their intended purpose does not imply that they represent real commonality.

Yes, exactly this. DSM criteria do predict effective treatment, negative consequences for the patients (both with and without treatment), and help plan for the costs of these conditions. These factors are clinically relevant.

Neuroscience tries to get a firmer grip on how the brain works, and what goes wrong when it doesn't. This research hardly touches the clinical practice as of yet, but ultimately diagnostics and treatment might improve largely.

Your points are well made. They're perhaps more applicable to Borderline Personality Disorder.

There are problems with having to match X of Y symptoms. Bob might be a close fit for 3 symptoms, and a weaker fit for 3 others, and not at all for the last 2. But, once Bob has the diagnosis, people interacting with Bob might not know what symptoms Bob matches and they might make assumptions - "People with your diagnosis do that because SYMPTOM".

It can be very frustrating.

What you have to recognize is that these critera are constructing a definition of the disease. It's not like the disease exists as some platonic object, and these criteria are simply the scientific way to test for it.

Hmm ... what we mean by `exactness' - in physics, for instance - has been changing ever since the advent of quantum mechanics about a hundred years ago.

There are two points to consider: (a) the principle underlying the hypothesis is sound vs. is not, and (b) the computational model of the hypothesis is deterministic vs. probabilistic. These two have to be considered separately when performing an evaluation/verification.

So where is the technical definition of "delusion" that the DSM is using?

In the glossary.

Really the issue is that psychology is in its infancy. Diseases that are well understood are defined and diagnosed by their root cause - the presence of a certain pathogen, a dysfunction of a certain organ. But when medicine doesn't understand the cause of a disease, psychological or otherwise, all that can be diagnosed is a cluster of correlated symptoms.

Take, for example, Irritable Bowel Syndrome - no one exactly knows what causes it, or if it's even a single disease, but there are a cluster of symptoms that indicate that a certain set of treatments might be useful (or not, depending on the patient). It is likely also a cluster of similar-looking diseases. Sounds a lot like the state of psychology, yeah?

Hopefully as we start understanding the brain, we can start diagnosing actual diseases with known causes, and not just a set of associated visible issues.

The DSM is hokey for sure. In fact, Thomas Insel, the director of the NIMH (one of the groups providing funding for this study) railed against it last year. The NIMH will not be funding studies based on DSM conditions. Rather:

> That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system. The best reason to develop RDoC is to seek better outcomes.

http://www.nimh.nih.gov/about/director/2013/transforming-dia...

I wonder if the results seen here are a result of this change in strategy?

There has been so much bullshit in psychiatry. My mother, who lived for her children, was essentially accused of child abuse by a psychiatrist during his explanation of my sister's diagnosis of schizophrenia to her. She apparently had been an over controlling and cold mother. None of her children would subscribe to that. However that accusation and the stress of caring for my sister over many years contributed, in my view, to my mother's untimely death to an autoimmune disease. I'm sure that psychiatrist probably never gave it any thought beyond that day. Psychiatry has a long way to go before I'll consider it has risen beyond quackery.

In general I agree with you - much of the mental health field is bullshit. However, there are some really good people who are trying to make it better. So, like much of medicine, the problem becomes trying to find one of the good ones...

How old are you?

Those attitudes - that mental illness are caused by the family - are old and not acceptable any more. See RD Laing for an example of a psychiatrist who used to push this incorrect theory. http://en.wikipedia.org/wiki/R._D._Laing

> Those attitudes - that mental illness are caused by the family - are old and not acceptable any more.

"Not acceptable"? Your post suggests that, because the "refrigerator mom" idea has been debunked, that mental health professionals can't think that way any more. But this isn't how psychiatry and psychology work. An absence of solid science (of explanations) means that, even though a way of thinking has been discarded at the top, those at the bottom are free to keep thinking the same way.

This is why, more than a year after Asperger Syndrome was abandoned, psychiatrists and psychologists continue to apply the diagnosis. This is why, decades after homosexuality was dropped from the DSM, psychiatrists and psychologists are free to offer therapies meant to correct this "defect" in some of their clients.

> See RD Laing for an example of a psychiatrist who used to push this incorrect theory.

Incorrect or not, it wasn't a theory, defined in science as an idea about a cause, an explanation, with supporting evidence and falsifiable by new evidence. There aren't any of those in psychology.

But mental illnesses definitely CAN be caused by the family. A mental illness is the result of genetics and environment interacting, same as any illness. You can have a genetic predisposition to depression, but something in your experience of the world has to trigger it.

It's like breaking a stick. The stick can be really thin and easy to break, or really thick and sturdy. But either way, outside pressure has to be applied to break it. The amount of pressure required varies.

It will take a generation or two for research like this to have any impact on practical diagnosis or treatment. The medical establishment is extremely conservative.

Consider the case of H. pylori and ulcers. This 2006 page from the CDC says, "Recently scientists have found that most ulcers are caused by an infection". (http://www.cdc.gov/ulcer/consumer.htm)

What is "recent" in medical research? Over two decades: http://www.cdc.gov/ulcer/history.htm

That is, the "recent" discovery of H. pyloi as the primary cause of ulcers was made in 1982, and general adoption of antibiotic treatment was still a work in progress in the late '90's and early 2000's.

On this basis, the current results--which will be difficult and expensive to replicate because the study is uniquely large and well-designed--will have at best a generational impact. Again, this is not entirely a bad thing: medical conservatism keeps doctors from doing a lot of harm, however frustrating it might be for those of us in the innovation business.

If you want to really cynical then it wasn't until the patent on Zantac expired that the H. pylori model made ground in the medical field.

Yeah, and the way these things are diagnosed is telling. (Basically, similar symptoms will tend to be classified as "borderline" or "schizophrenic" depending on the individual's demographics.)

yes, it's pretty ropey all in all - generally speaking people going to live with their families for a while has a higher success rate than anti-psychotic drugs, 60% vs 30%

in the 3rd world people can't afford drugs so tend to go for the family option

doctors in finland have adapted the 3rd world approach successfully and collected a lot of data along the way - incidence of schizophrenia is dropping in their region

http://www.mindfreedom.org/kb/mental-health-alternatives/fin...

I found this article a while ago that does a good job of detailing how psychiatry is absolutely not a science, and shouldn't be treated as such:

http://www.arachnoid.com/psychology/aspergers.php

This article does not seem to apply the same standards to itself that it purports to demand of psychology. Among other things, it freely makes false claims about the state of psychological research and then trots out a handful of examples to be assumed as exemplars.

It's little better than the Scientology "PSYCHIATRY IS DEATH" material.

Pot, meet kettle.

This article resonated with me very strongly, since I lived it. It seems to have struck a nerve for you too - maybe you're on the other side of the devout following?

Edit: I'm not claiming an emotional response to it, just that I can vouch for the validity of it in my case. Anecdotal evidence, but it's still a data point.

> This article resonated with me very strongly, since I lived it.

"X appeals to me emotionally because it conforms to and provides a pat explanation for my personal experience" does not imply "X is true".

In fact, disconnecting those two concepts is an essential step to beginning to approach the world scientifically.

You are incorrect. The article did not "strike a nerve" or otherwise provoke a strong emotional reaction in me. You may wish to stop and consider why you assumed that.

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