Amongst my elderly relatives when I was a child, chemistry was associated with unpleasant smells, but it was also revered as a science. My enjoyment of chemistry at school was therefore met with some ambivalence in my family.
Considering the relationship between science and smells reveals something about a big kerfuffle happening right now in the US.
That big kerfuffle’s outcome will one day affect us here in the UK, and it already has an unmistakable smell of its own.
Suppose you discover that if you take a little of that powder and some of those crystals and grind them together, you can smell a smell remarkably similar to when Professor Frink farts. Well, that’s chemistry for you — but was it really the grinding of that stuff that did it, or was it the Prof?
It’s pretty easy to design an experiment to find out. In fact, you can design a randomized controlled trial using many professors. Of course, some of the professors will inevitably fart during the trial, but you can apply a statistical analysis to your results that will enable you to draw valid conclusions from them.
So that’s science.
Except…it’s not science.
If you really study chemistry, you find that it’s not at all about learning which things together with which other things make which kind of smell or whatever. It’s really all about why that kind of stuff happens.
Chemistry, like any science, aims to provide rational explanations for the way things work, to make sense of the world and the phenomena we can observe in it, so that we can understand what’s going on, make accurate predictions, and do useful things.
Science is not simply about collections of unconnected ‘facts’. It’s really about rational explanations. Scientific experiments are not about ‘proving’ unconnected ‘facts’. They are about clarifying and testing the rational explanations.
The missing word
Despite recent silly reports about the millionth word in the English language, there’s a useful word missing from English.
To illustrate, take cars, for example. People who design new kinds of car are called designers. People who drive cars (without doing anything creative) are called drivers. We have different words for the people who create the things and the people who use the things that were created. It’s not just cars that are like that in English, almost everything is like that.
But the word for a person who creates rational explanations for the way things work is ‘scientist’, and the word for a person who uses those rational explanations (without doing anything creative) is also ‘scientist’. Having to use the same word for people who do different kinds of thing makes it easy to get confused about what they do.
This is particularly important in the field of mental health, where unconnected ‘facts’ are not only tolerated, but are accepted as scientific in the apparent absence of rational explanations.
The American Psychiatric Association is preparing the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-V), with a planned publication date in 2012. The new edition is already controversial, partly because of the secrecy surrounding it.
The head of the previous (DSM-IV) task force, Allen Frances, recently published a warning about the approach that DSM-V is reportedly taking:
He mocked the DSM-V team’s ambition to create a paradigm shift in psychiatric diagnosis in which they will replace diagnostic categories with diagnostic dimensions. Here’s a key statement from his warning (my italics):
The simple truth is that descriptive psychiatric diagnosis does not need and cannot support a paradigm shift. There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders. The incredible recent advances in neuroscience, molecular biology, and brain imaging that have taught us so much about normal brain functioning are still not relevant to the clinical practicalities of everyday psychiatric diagnosis.
But in the politics of DSM-V, something has been forgotten.
There has already been a fundamental leap in our understanding of what causes some mental disorders. Those disorders that mostly affect emotions and behaviour, the disorders that are treatable with CBT, have well-understood causes.
On a case-by-case basis, CBT formulations regularly and reliably identify the origins of these illnesses, and confront them in the course of treatment. In the arguments around DSM-V, it seems all parties are agreed on one thing — that CBT’s rational explanations of mental illness are to be disregarded in favour of collections of unconnected ‘facts’.
How can this be? The answer to that may lie in the other reason that DSM-V is so controversial, the suspected involvement of ‘big pharma’, of drug companies who hope to profit from a new way of diagnosing psychiatric illness.
Trial and error medication
The common experience of patients, that psychiatric medication proceeds by trial and error, favours drug manufacturers. The logic of this is simple.
Suppose there’s a way to know in advance which drug will treat your condition. You start taking that drug, and your condition improves.
Now suppose instead that there’s no way to know in advance which drug to use, and you end up taking four other drugs that either don’t work or have intolerable side effects. Finally you end up with the right drug, and your condition improves.
In the second scenario, the pharmaceutical industry has made much more money from you, because you had to take all those other drugs first. To increase profits, that’s what it seems pharma should encourage to happen as much as possible.
The trouble with that today is that psychiatrists often have to make an embarrassing change of diagnosis in order to try a different drug. These changes of diagnosis are also part of the common experience of patients.
With a dimensional model of mental illness instead of clear-cut categories, it will be much easier for psychiatrists to move patients from one drug to another. No embarrassing change of diagnosis will be required, just a slight shift in the dimensions.
In the UK, the Improving Access to Psychological Therapies (IAPT) programmes in England and Wales, and other programmes to increase the availability of CBT in Scotland and Northern Ireland, will suffer as a result of another feature of DSM-V.
There have been widespread reports that DSM-V will include new types of mental illness. That is, conditions that were not regarded as mental illness at all in the past will be classified as illnesses in the future. Labels like ‘Internet addicted’, ‘pre-psychotic’, and many others could come to be regarded as conditions requiring treatment.
Allen Frances describes this as:
…a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments–a bonanza for the pharmaceutical industry…
However, it’s a disaster for the NHS, potentially creating a huge increase in demand for mental health treatments.
Refusing to accept rational explanation, and instead relying on collections of ‘facts’ (which can easily be manipulated by big pharma) may turn out to have very serious repercussions, quite apart from the terrible smell around all this…the smell of money.