The dazzling guidelines

To the Editor

I am flattered that my brief comment (Rosenman, 2021) on the mood disorders guidelines (Malhi et al., 2020) gained such an interesting response from the authors (Malhi et al., 2021). However, the response calls for clarification.

I called the guidelines intellectually ‘dazzling’. That is not a compliment. The dazzle of the intellectual achievement blinds us to the substantial problems in it.

The problem is not just with categorical diagnoses. Trading dimensions for categories doesn’t solve the problem of a set of diagnostic beliefs and opinions appearing as a prescriptive and self-confirming taxonomy. The diagnostic criteria focus on a small number of phenomena and ignore many. We select and warp what we see to fit the taxonomy’s diagnostic rules.

My apparent support of the ACE model in place of Bipolar Disorder is the support of disentangling and discriminating phenomena. ACE only shines a light in that direction. Activity (A), Cognition (C) and Emotion (E) are still generalisations not phenomena. Fear and love are both emotion. Agitation and stimulus-seeking are both activity. The different phenomena have different implications. We still need to make relevant discriminations up to the limits of our time, our language and our experience. The generalising language of ACE does not do that.

The novel proposed treatment programmes may be as imaginative and innovative as their names and acronyms (even if WARP and CRP seem like trademarks that look out of place in college guidelines). However, you must understand that there can be no such thing as a specific ‘antidepressant’ or ‘antipsychotic’. Depression and psychosis are not particular species of illness any more than weeds are a particular species of plant. A diagnosis is a class of heterogeneous experiences that are drawn together by a complicated network of overlapping and criss-crossing similarities that Ludwig Wittgenstein called ‘family resemblance’. The class members need not share any essential morphology, genetics or psychology that could be the specific target of specific treatment. If the guidelines and the imaginative ‘treatment paradigms’ are aiming at specific diagnoses, they are aiming at chimeras that are non-targets for specific treatments.

While the guidelines acknowledge much of this, they make a pragmatic accommodation with existing diagnostic terms so that the guidelines are possible. However, that accommodation looks uncomfortably like collaboration with an occupying cultural hegemon.