APS Fellow Lee Anna Clark is the lead author of a forthcoming Psychological Science in the Public Interest report on the scientific and practical challenges of classifying mental disorders. The report examines the International Classification of Diseases (for which Clark is a member of the Personality Disorders Working Group), the Diagnostic and Statistical Manual of Mental Disorders (which she was actively involved in revising 4 years ago), and the National Institute of Mental Health’s Research Domain Criteria initiative. Psychological Science in the Public Interest reports are available here.
The Observer spoke with Clark about the impetus for the report and her views about the state of the science in diagnostics.
A lot of the information in your new report is directly relevant to researchers and clinicians, but what do you hope that the average person, who is not necessarily involved in clinical issues on a daily basis, gets out of this report?
I think one of the main things that we kept coming back to is helping people to realize that “having a mental disorder” is very different from having the measles or even something like diabetes — and that it can actually be helpful to think about mental disorder psychopathology in this more complex way. While there definitely are treatments and ways to help people deal with mental disorders, there aren’t any magic bullets like there are for pneumonia or a “simple” infection or even “simple” directives to eat better, exercise, get more sleep, and stop smoking. We would hope from this that people would take away that nobody just wakes up one day and discovers they have a mental disorder, and nobody then goes to the doctor and takes care of it 10 days later. Psychological problems arise out of a long, unfolding process.
Treatment for mental disorders transitioned from a predominantly psychoanalytic approach to a more medicalized approach — is the field now realizing that mental disorders don’t fit within the medical model quite as well as people originally hoped?
Yes, I definitely think that’s part of it. It’s so tempting to think, “If we could only zap out this one gene, schizophrenia would be gone from the world.” But my prediction is that as we learn more, things will also be revealed that are even more complex than we can imagine. One of the things I tell my students when I’m teaching psychopathology is that between the time you cut yourself or skin your knee and a scab forms, there are something like 27 distinct biological steps in between the one and the other. And if there are 27 steps in something that we think of as an absolute everyday, normal, “simple” phenomenon, how many more steps are there going to be between genes and the development of psychological problems? It’s mind-boggling.
Was there anything you found particularly interesting or surprising in working on the report?
Working on this project made me realize — and I’d heard this many times before, I’d read it, I’d probably even written it — that there are other stakeholders in diagnostic systems and there are immediate needs that science can’t address. So I came to appreciate the necessity of putting forth knowingly imperfect systems for diagnosis and classification because life can’t wait for the science.
Sort of a “perfect is the enemy of the good” situation?
Yes, that’s a good way to put it. If we waited for the science, we’d be waiting a long time, people would be suffering a long time, and there are many, many things we can do with the current knowledge that we have. There’s no question that we know a ton more than we did 25 and definitely 50 years ago. The DSM, with all its flaws, really did lead to a huge amount of research that has pushed things forward — pushed things forward to the point that we saw what the limitations of the system were. That’s a good thing.
And what we know can get us a very long way toward helping people even if we don’t understand all the little “ins” and “outs.” This is not a great analogy, but you and I use computers absolutely every day without having a clue about how they work.