Why Are There No Biological Tests in Psychiatry?

[xchrom]

http://blogs.scientificamerican.com/streams-of-consciousness/2012/05/11/why-are-there-no-biological-tests-in-psychiatry/

When the third edition of psychiatry’s manual of mental illness, the DSM-III, was published 30 years ago, there was great optimism it would soon be the willing victim of its own success, achieving a kind of planned obsolescence. Surely, the combining of a reasonably reliable system of descriptive diagnosis with the revolutionary new tools of neuroscience would quickly yield a deep and broad understanding of psychopathology. And just as surely this would translate into standardized biological tests that would replace the cookbook listing of subjective symptoms and subjectively evaluated behaviors that comprised the DSM-III criteria sets

Sadly, progress has been much slower than anyone expected, with many exciting findings turning out to be no more than dead ends. The vast research funding has indeed provided a basic science revolution, but so far its discoveries have had no impact whatever on clinical diagnosis. Even the most promising candidates—biological tests for the accurate diagnosis of dementia—are several years away. And, for the rest of psychiatry, there is no immediate prospect that our rich basic science knowledge base and powerful investigative tools will contribute to clinical practice any time soon.

We have learned a great deal in the past 30 years, but perhaps the most important lesson is that the brain is ineluctably complex and reveals its secrets only slowly and in very small packages. There has been no low hanging fruit. The expectation that there would be simple gene or neurotransmitter or circuitry explanations for schizophrenia or bipolar or obsessive-compulsive disorder has turned out to be naïve and illusory. The problem of teasing out heterogeneous clinical presentations in psychiatry is compounded by the fact that they also have heterogeneous underlying mechanisms. There will not be one pathway to schizophrenia; there may be dozens, perhaps hundreds. Biological tests that appear to be associated with schizophrenia are never useful for making the diagnosis because they always show more variability within the category than between categories. And seemingly intriguing findings usually don’t replicate.

That progress in psychiatric diagnosis is slow should perhaps occasion no surprise. In every branch of medicine, the translational step between basic to clinical science has been difficult. For example, the discovery of genetic correlates for breast cancer has been much more of a slog than originally anticipated, with each advance explaining only a very small portion of the variance. And psychiatry faces the most awesome of translational leaps: the brain is ever so much more complicated than any other body organ, wired with complex redundancies that will defy simple and sweeping explanations of how it generates symptoms and behaviors. For the foreseeable future, except for dementia, we must reconcile ourselves to the staying power of purely clinical diagnosis in psychiatry.

[bananas]

1. It's like trying to find a software bug by analyzing the hardware. nt

[LiberalEsto]

2. Back in 1971 my mother was hospitalized with symptoms resembling schizophrenia.

Luckily she went to a regular hospital with a psychiatric ward.
After several days there, the doctors discovered that her symptoms were being caused by uremic poisoning due to kidney failure.
In other words, her kidneys were no longer filtering the wastes from her blood stream.
She was given dialysis and gradually recovered her senses.

This happened immediately following a semester of abnormal psychology in college, during which I did field work at a state psychiatric institution. With the help of my professor, I fought my father to have my mother placed in a private medical hospital with a psychiatric ward. And it's a damned good thing I did. Had she been sent to Greystone, (in NJ), I believe she would probably never have been correctly diagnosed, but doped to the gills on thorazine like the patients I worked with at Marlboro. In all likelihood she would have died from kidney failure soon after being admitted.

Because she got an accurate medical diagnosis, my mother lived for four more years.

I strongly believe that people showing signs of psychiatric illness should be given complete medical workups to rule out underlying disorders.

[cbayer]

3. Actually, there are pretty strict rules about medical workups set by the Joint

Commission on Hospital Accreditation. Hospitals must follow these rules and all psychiatric patients must have organic workups to rule out non-psychiatric causes of their symptoms.

The test your mother had would have been a routine part of any workup.

I am glad that her underlying illness was caught and treated.

[bananas]

4. Bush cash linked to death hospitals

Things have changed so much since 1971, haven't they?

http://www.guardian.co.uk/world/2000/dec/17/usa.uselections2000

Bush cash linked to death hospitals

Special report: the US elections
Special report: George W Bush's America

Ed Vulliamy in New York
The Observer, Saturday 16 December 2000 20.08 EST

America's President-elect, George W. Bush, held an investment in a company that leased a chain of psychiatric hospitals where patients died and the conditions were so appalling that many were shut down, The Observer reveals today.

The hospital chain - Charter Behavioral Health Systems - was exposed by a CBS television documentary last year after the deaths were reported. CBS had filmed widespread malpractices, acknowledged by government regulators. This led to a criminal investigation of Charter, which continues.

<snip>

[cbayer]

5. The US psychiatric system is, or should be, a national shame.

A large part of the problem is underfunding. Those private chains found ways to make money that were indeed appalling.

Psychiatric patients have no voice, no ribbons, no marches, no wristbands.

[Odin2005]

12. That reminds me of a House episode.

[intaglio]

6. The cheap and nasty answer

When there is a functional cause for a psychiatric disorder is discovered it ceases being a psychiatric disorder and becomes a neurological one.

[cbayer]

9. You beat me to it!

[bananas]

10. In post #2, the cause wasn't neurological, it was kidney failure.

And in post #4, the "cause" was having good health insurance.

[cbayer]

13. While the cause may have been kidney failure, the manifestations were neurological.

In other words, the end organ, the brain, is what produced the symptoms that appeared to be psychiatric.

[KT2000]

11. this is exactly why

testing for the effects of certain chemical exposures on the brain have not been done. Those who do conduct studies that show on brain scans the effects, are refused publication in mainstream US journals. It has already been determined by the "powers that be" that it is impossible to create an environment clean enough to conduct such a test so research is halted before it even begins.

People injured by chemical exposures then remain (unproven) psychiatric cases - malingerers, PTSD, personality disorder stemming from childhood, victimns of abuse etc.

[Warpy]

7. Psychiatry is what one goes into after a full medical education

so there's plenty of biology and chemistry involved.

The DSM is a fairly primitive tool to classify illness by blocks of symptoms in order to point one toward the best possible treatment out of the few we now have.

One of the places I worked consistently (I was a generalist who worked all specialties) was a neuropsychiatry unit, where insults to the brain had resulted in various cognitive and behavioral problems. Psychiatrists in training were clustered there.

Understanding brain structure and chemistry is still in its infancy, thanks in part to the persistence of Freud's theories but mostly because we simply didn't have the wherewithal to measure things like neurotransmitters.

[cbayer]

8. One observation here is that as underlying causes for illness that exhibit primarily as

psychiatric are found, those illnesses are moved out of the realm of psychiatry and into other fields.

This leaves psychiatry with all the illnesses that don't have markers or are poorly understood.

[HuckleB]

16. Can you give examples of this?

[Heddi]

18. I'm not cbayer, but I think that brain tumours would be an example

peopleexample people often exhibit bizarre signs like hallicunations, radical changes in behaviour (extreme anger, violence, sexual acting-out) that would initially cause some to think of a primarily-psychological basis for the behaviour, but is actually biological because of the tumor's effect on the brain.

I've seen patients brought in by ambulance for a psych eval because of just completely classic psych behaviours, the MD does a head CT and finds a mass the size of Nebraska in the frontal lobe...explains a lot.

same with pts with traumatic brain injury.

[HuckleB]

20. That's more of an issue of diagnosis, than an actual switch from one specialty to another.

[cbayer]

19. Porphyria is a good one.

Epilepsy is another.

For a very long time, both of these were thought to represent psychiatric disorders - madness of one sort or another.

Once the underlying causes were determined, they moved out of psychiatry and into hematology and neurology respectively.

[HuckleB]

21. You're talking something that occurred 50 plus years ago.

Thus, the argument offered seems to have little context.

[Odin2005]

14. The brain is really complicated.

They can't put you in an fMRI scanner and say "this shows you have Bipolar Disorder". We are closer to that now than we were 20 years ago, but we are still a ways away from diagnosing mental illness neurologically.

Heck, we don't even have a good neurological definition of Autism, yet. We know that an overgrowth of white matter and an abnormal cerebellum is involved, but there are no definite known indicators.

[kickysnana]

15. There are some scans that can detect some problems, sort of...

With insurance companies not paying, the government dumping patients onto the streets, no care in prisons where many end up and the total swamping of medicines as treatments. On top of that most Medical Doctors discriminate against those with mental illness diagnosis. You sometimes have quite a fight on your hands in the ER for them to do any tests when you are sick. In my opinion Psychiatry is probably now about 35 years behind other conditions.

[HuckleB]

17. Today's scans are crude research tools. They are nowhere near ready to assist in actual diagnosis.

[mopinko]

22. the least they could do is sleep studies.