DSM-5: Alzheimer's Disease

I do not know whether dr. Frances, two of whose recent texts on the DSM-5 I wrote about five days ago, reads me, since I do not know him, and never mailed with him, but in the latest of his series on the DSM-5 in Psychology Today, dated today:

DSM 5 Minor Neurocognitive Disorder

he does address a point I raised five days ago. Here it is, with both dr. Frances' text and then my remark:

There are no prospects for quick breakthroughs in psychiatric diagnosis in the near future except for Alzheimer's, where diagnostic tests may be available in several years.

As it happens, I was sold that a paper test - a questionnaire - for my mother, who had Alzheimer's, was a diagnostic instrument, or so the medics and shrinks told me, ca. 1994. But Frances probably means that the biological mechanism that leads to Alzheimer is close to being known.

Indeed he did. Here is his first paragraph:

Within the next 3-5 years. we will likely have biological tests to accurately diagnose the prodrome of Alzheimer's disease (AD). Much remains to be done in standardizing these tests, determining their appropriate set points and patterns of results, and negotiating the difficult transition from research to general clinical practice. And, given the lack of effective treatment, there are legitimate concerns about the advisability of testing for the individual patient and the enormous societal expense with little tangible benefit. Despite these necessary caveats, there is no doubt that biological testing for prodromal AD will be an important milestone in the clinical application of neuroscience. (*)

As it happens, I treat this here with the prefix "DSM-5:" and with a link to dr. Frances' article, but my main reason to write about it in Nederlog is that it is of concern to me:

Both my mother and her father died rather miserably and awfully in the clutches of Alzheimer's Disease, and it would be very nice if there was a good diagnosis and indeed also an effective treatment for it.

So this is hopeful news, though dr. Frances also has a DSM-5 related point: The editors of that manual decided to include something they call Minor Neurocognitive Disorder, and Frances is rightly worried:

Clearly the advancing science makes this proposal obviously premature and unnecessary. Any DSM 5 definition has necessarily to be based exclusively on extremely fallible clinical criteria that will have unacceptably high false positive rates - surely exceeding 50 percent. Why scare half the people taking the tests unnecessarily, especially when there is no effective treatment even for those who are true positives.

I quite agree, especially with "obviously premature and unnecessary". And there are two related points, one of medical morality and one of terminology.

First, medical morality. While dr. Frances rightly raises the question why one would want to include a test that, at least initially, will have many false positives, I do have a cynical answer: Because diagnosable diseases generally come with some sort of treatment plan, that is a source of income for medical people.

Overall, as medical science is today, that is not bad and indeed a sine qua non, since medical folks must make a living too, but as I have argued in my earlier texts on dr. Frances on the DSM-5, that is not bad only on the condition that the medical science involved is real science, and the diagnosis provided has a well-founded statistical probability that it is, at the very least, more likely to be true than false. If this is not the case, the diagnosis must certainly not be part of a diagnostic manual, for then on that issue the manual is bound to have it more often wrong than right, which simply is not ethical, and is medical malfeasance. (**)

Second, I have a terminological point, that illustrates the general wackiness in the terminology the editors of the DSM-5 use: What is the sense - the meaning, the point, the definition, the rationale - of a term like "Minor Neurocognitive Disorder"?

Are there perhaps cognitions that do not have a neural base? Possibly - what do I know of the DSM-5 worthies - from so exalted a realm as the immortal soul of dr. Regier? I don't have one, I think, and I am an atheist philosopher, but apart from that: In real science there are no "cognitions" that are not produced by a brain, so at best the "Neuro"-prefix is a pleonasm.

And what does "Minor" mean in a phrase like this? Is it a moral judgment? Is it a factual judgment? Is it perhaps - as one must suspect with the dialectics of the DSM-5 - both and neither, just as it is most handy for the psychiatrist making the judgment, with an honest and intelligent facial expression?

Finally, what is the rationale for antiseptic terms like "Disorder"? Is it because - as the editors of the DSM-5 and indeed other psychiatrists - have been very fond of suggesting "to save the feelings of the patients, who do not like to be told they are mad", which indeed is often served to the public as if this is beneficial, on the part of psychiatrists, whereas in fact it is hypocritical and dishonest: Whether you are locked up or by force injected with psychiatric drugs because you are said to be "disordered" or because you are said to be "a paranoid schizophrenic" (or whatever) does not matter to what is being done to you in fact - except that an antiseptic terminology makes it appear that you shouldn't complain and be thankful that you are not locked up because you are "mad" but because you are "disorderly", in some sense. To me, that sounds like the preferred terminology of Soviet-style psychiatry, and with the same danger or purpose: To loosen the boundaries between deviance and madness; to increase the possibilities for incarcerating dissidents on the pretext that they are "disorderly" and making people "disordered".

Is it perhaps that the editors of the DSM-5 want to classify lots of things that are not precisely ailments, diseases, or clear forms of insanity, but much rather moral or legal judgements disguised as "psychiatric evidence-based science"? Because that gives them very much more power over others; or because that will be very helpful to authoritarian states; or because it makes psychiatry-in-DSM-5 form applicable to far more than medical diseases?

My own guess: Probably all of these, but neither the editors of the DSM-5 nor the leadership of the American Psychiatric Association will deign to clarify: As ever, their main message to "the public" is that only they themselves are capable to judge rationally about their manual (not even dr. Frances is, the APA and the DSM-5 have told the public!) and that one should trust the goodness, the intellects and the honesty of the DSM-5 and the APA: "Trust us!"

Well... here is again a link to what I call the DSM-5's mascot, an erstwhile leader of the APA also, to serve as a counterweight to the illusion that US psychiatrists must mean well:

Behold the face of US psychiatry:

My own guess is that he would have loved the DSM-5. And his type of psychiatrist does deserve more renown, especially with the general public, and not because all psychiatrists are like Cameron - they aren't - but because psychiatry, in any shape or form, is and has been very apt to be abused, for many reasons also, in very many contexts, for very many ends.

 (*) I do not know much about Psychology Today, but it seems very much "popular science" to me, which means - to me - that it is not real science. This is not necessarily bad (the public should be informed about science, and that can only happen in some more or less popular form), but I do find what I have seen from Psychology Today apart from dr. Frances' series of essays, rather irritating: Lots of folks who address me as if I am a moron, and who spin tales that I know to be rather overstated, at the very least, and to make claims or promises that just have no sound factual basis.

Also - and this is the reason for my note - they have an irritating habit of linking terms that occur in articles they publish, including those of dr. Frances, to definitions of their own, in something they call "Psych Basics". Those I've read were pretty awful, and that's my reason to replace the linked definitions in "Psych Basics" of the underlined terms in the quotation by the items under these names in Wikipedia, that also need not excel in rationality and style, but surely are clearer and more useful than what I read in "Psych Basis".

(**) I formulated this intentionally in terms of "well-founded statistical probability" and "a diagnostic manual": There are quite a few senses of probability, and not all of these are correctly applied in medicine. Thus, subjective probabilities require no more than consistency, without any necessary reference to empirical facts, while statistical probabilties require an empirical population that has been properly sampled, which is the sense of "probability" on which medical diagnosis ought be based, if possible. And of course, apart from a diagnostic manual there should be more liberty for medical people to make diagnoses: What is part of a diagnostic manual should only be the well-tested probably correctly diagnosable illnesses, and not the fanciful ones.

But that last point is part of dr. Frances general argument against the DSM-5, in which he is quite right, both intellectually and morally.
 

P.S. Corrections, if any are necessary, have to be made later.
-- Feb 17, 2012: Corrected a few typos.

Also, as to "neurocognitive": Itis conceivable this is meant as an implicit causal hypothesis (like "cognitive problems due to some ailment of the brain rather than low blood pressure", say). If so, it may make sense. Apart from that, the sort of terminology, definitions and use of language in the DSM-5 are so  consistently horrible, unclear, and bogus, that I must infer that this is, for the most part, not well explained by intellectual incompetence, but is well explained by careful design: As Heidegger also knew very well and as the Postmodernism Generator illustrates so very well - now also available for $ 0.99 on your iphone, if you want to learn how: - with an intentionally obscure but also very pretentious style, one can hide a lot of bullshit and make it seem as if it might be good but difficult science or philosophy.
 

Short descriptions of the above: