Tuesday, 5 January 2016

'Is an Ominous New Era of Diagnosing Psychosis by Biotype on the Horizon?' Michael Cornwall @Mad_In_America

'Is an Ominous New Era of Diagnosing Psychosis by Biotype on the Horizon?' by Michael Cornwall on Mad in America

 "When former NIMH chief Dr. Thomas Insel speaks, people listen. Dr. Insel famously criticized the DSM a couple of years ago for its lack of reliability. He notably broke ranks with the APA by saying there were no bio-markers, blood tests, genetic tests or imaging tests that could verify or establish a DSM diagnosis of schizophrenia, bipolar or schizoaffective disorder.

However in a new article in Scientific American, Rethinking How We Diagnose Psychosis, Dr. Insel announces research that claims to have found bona-fide physiological markers that identify three specific "biotypes" of psychosis. This system could, purportedly, identify a person as possessing a specific biotype of psychosis, instead of a DSM-category diagnosis.

The new research, from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP), is based on a battery of tests given to 711 people diagnosed with schizophrenia, bi-polar or schizo-affective disorder. The tests were described as "a brain-based panel of cognitive tests, studies of eye movements, a test of cognitive control, and electro-encephalogram. In addition, each subject had a brain imaging test."

Dr. Insel reports that the tests results were run through a computer model "to look for what they called biotypes." Sure enough, the  researchers found what they had already decided they were looking for; the so-called biotypes. These three new biotypes are seen as suggestive of new categories of psychosis, even though each biotype shared overlapping elements with the three existing DSM categories.

"Is there any reason to think that these biotypes are more valid than a clinical diagnosis based on symptoms?" Insel asks, then answers:

"A few observations suggest that the B-SNIP investigators may be on to something. First, some of the biotype differences were also found in first-degree family members, for whom data was also collected, suggesting a genetic basis for the new categories. Second, biotypes differed in social functioning—with people in Biotype 1 showing more serious functional impairment relative to the other biotypes. Third, the brain imaging studies (not used in defining the biotypes) showed clear differences in regional gray matter, especially in frontal, cingulate, temporal, and parietal cortex."

Here Insel overlooks, first, the obvious and well-established problems with assuming that similarities among family members suggest or constitute heritability. Second, he repeats the conflation of "symptoms" (here, social functioning) with biology; a mistake upon which generations of discriminatory practices have been based, all of which conveniently ignore the much more verifiable and - potentially, at least - addressable environmental and psychosocial factors. Third, he commits the classic mistake of presenting correlation as causation, where there is no basis for assuming causality, and where - more importantly - there are myriad other factors (such as socially induced stress and trauma) that might easily explain the differences.

To his credit, Insel acknowledges that "none of these observations proves that the biotypes are more valid than clinical diagnosis" even as he asserts that they "together encourage a fresh approach to the diagnosis of psychotic disorders." This approach will not only continue, we can assume, to ignore the substantial evidence pointing to psychosis' roots in psychosocial stress and trauma in favor of an hypothesized (but never established) biomedical basis, but will in actuality double down on the theory by establishing an ever-stronger bulwark against research that looks at these psychosocial bases.

As someone who views the psychiatric disease paradigm of human emotional suffering as a failure in both theory and applied clinical practice, I'm very concerned that Dr. Insel's report of the supposed "discovery" of new "distinct" biotypes of psychosis that can be identified with quantifiable bio-markers will help to usher in a new era of adverse consequences for individual humans, and for humanity.

Biomarkers for psychiatric conditions have been the long-sought holy grail for every practicing psychiatrist I worked alongside for 30 years - even more so than the hoped-for genetic basis for psychosis. Because, as Dr. Insel explains in his intro to the article, its been very difficult for psychiatrists that they have never been able to diagnose with the certainty of their counterpart MD's in other specialties. So, it's a huge game-changer for Dr. Insel to confer on these new biotypes of psychosis the status of having been identified by a quantifiable bio-marker.

However, if you've ever had access to the medical charts of people in the mental health system you know that, over time, almost every person receives multiple major diagnoses - sometimes four or five different ones, each with "specific" prescriptions for medication. It's not uncommon to find that someone who has been in the system a long time has been prescribed over a dozen different medications. I believe that's going to change if the biotype/bio-marker becomes the new standard of diagnosing psychosis.

This new diagnostic system is even more potentially ominous, because people will no longer even be seen as individuals who have discrete, if multiple, psychiatric diseases; they will be seen as a unique type of person who suffers from a biological abnormality alongside others in their biotype cohort. In apparently authoritative style, a biotype of "psychotic" will be assigned to those who test positive for an hypothesized biomarker-identified phenotype. People experiencing extreme states will be categorized and labeled as a class of people that can easily be identified with a battery of tests that "establish" a biotype, because those screening tests purport to confirm a bio-marker that's as reliable - Finally! - as the blood work screening that establishes, for example, diabetes.

Dr. Insel celebrates, in his opening remarks for the article, the supposed advance of his NIMH research agenda that Robert Whitaker warned about in "The Taint of Eugenics in NIMH-Funded Research Today" when he writes that "...moving psychiatry into a new era of biologically based diagnosis has been a long sought goal - and a priority at the NIMH, where I served as director for 13 years. Now a study published online in the American Journal of Psychiatry raises fresh hope." He further writes that "it will be important to know whether genomic variation, functional brain measures, or other behavioral measures can refine or further validate these biotypes."

Thoughts of "bio-behavioral" measures and genomic variations have danced in the heads of researchers for decades, if not centuries, with no clinically useful results. Nonetheless, Insel's approach provides the basis - if not for establishing a genetic and/or biomedical basis for psychosis - then at least for a "new and improved" eugenically-tainted approach for the next decade, or longer.  I hope I'm wrong but we may someday wish for the bad old days of the DSM."

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