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a1000shadesofhurt

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Tag Archives: DSM

You needn’t be wrong to be called delusional

07 Wednesday Jan 2015

Posted by a1000shadesofhurt in Uncategorized

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conspiracies, credibility, delusion, delusions, DSM, fixed beliefs, Martha Mitchell effect, mental health issues, paranoia, stigma

You needn’t be wrong to be called delusional

It’s not clear who forcibly sedated her in 1972. It’s not certain that she was admitted to a psychiatric ward in the following year. What’s definite though is that many people thought she was mad as she ranted about conspiracies in the White House during eccentric phone calls to the press. Questions about Martha Beall Mitchell’s sanity were encouraged by the Nixon administration, who consistently briefed against her and probably had her medicated against her will. But ultimately her claims were proven correct when the Watergate scandal broke.

Mitchell was the wife of the US attorney general and saw the planning and cover-up of the Watergate burglaries first-hand. In retrospect, her seemingly paranoid claims made sense and, in her honour, Harvard psychologist Brendan Maher named the Martha Mitchell effect after her to describe the situation where someone is incorrectly diagnosed as delusional but turns out to be right.

But, contrary to popular belief, the relationship between madness and truth is a complex one. They are made out to be strangers but often they are more like distant cousins.

This relationship has recently been acknowledged with the publication of the new version of the psychiatrists’ diagnostic manual (the DSM-5) where one of the most interesting but less noticed changes has been the redefinition of the delusion, a symptom that has long been considered the “basic characteristic of madness”.

Delusions, in the medical sense, are not simply a case of being mistaken, as the everyday use of the term suggests. They are profound and intensely held beliefs that seem barely swayed by evidence to the contrary – even to the point of believing in the bizarre. My heart has been replaced by steam. My thoughts are being stolen by satellites. The government communicates with me through birdsong.

But many delusions are not outlandishly eccentric, they are simply implausible. Consider the scenario where people believe that their neighbours are conspiring against them or that they are the subject of a film star’s secret affections. Occasionally, these beliefs turn out to be true, but this is not a reliable guide to whether someone is delusional or not. This was memorably illustrated by the psychiatrist Andrew Sims, who warned in his psychopathology textbook Symptoms in the Mind that spouses of people with delusions of infidelity may occasionally be driven to infidelity. This romantic betrayal does not suddenly cure their partner of their mental illness.

The general idea is that delusions represent a problem with how you believe – that is, a problem with forming and changing beliefs – not a problem with what you believe. In other words, simply believing something strange or unusual should not be considered a problem but having “stuck” beliefs that are completely impervious to reality suggests something is mentally awry.

On the ground, mental health professionals are often required to decide if someone’s thinking indicates a disturbance in their understanding of the world, and this is where the new DSM-5 definition of a delusion may usher in a quiet revolution in psychiatry. No longer are psychiatrists asked to decide whether the patient has “a false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary”. A wordy and unhelpful definition that has so many logical holes you could drive a herd of unicorns through it.

Instead, the new definition of delusions describes them as fixed beliefs that are unswayed by clear or reasonable contradictory evidence, which are held with great conviction and are likely to share the common themes of psychosis: paranoia, grandiosity, bodily changes and so on. The belief being false is no longer central and this step forward makes it less likely that uncomfortable claims can be dismissed as signs of madness.

And this is where the larger issue lies. As happened with Martha Mitchell, claims against authorities are often dismissed by suggesting that the person has mental health problems.

History is littered with such examples but sadly there are enough contemporary cases to illustrate the point. In a controversy currently rocking Germany, evidence of money-laundering at a big bank has become a huge scandal, not least because it was dismissed as delusional seven years ago when the accuser was diagnosed with mental illness.

Closer to home, when the NHS whistleblower Kay Sheldon reported failings in the Care Quality Commission, the first response was to suggest she had a mental health problem and to commission a psychiatric assessment.

I have no idea whether these people had mental health difficulties but it should have had little bearing on how seriously their concerns were taken. The fact that their claims could be dismissed by allusions to poor mental health is part of the unfortunate stigma that still surrounds the issue. But the stigma goes both ways, and assuming people do not have mental health difficulties because they are correct is the flip side of this.

In the years after Martha Mitchell had been dismissed as delusional, it emerged, contrary to her claims, that she was under the care of her own psychiatrists, drinking heavily and, at times, suicidal. Nixon, for his part, said Watergate would never have happened if it wasn’t for Martha. Both believed that mental illness would undermine her credibility. History, however, came down on the side of truth.

Are mental illnesses such as PMS and depression culturally determined?

20 Monday May 2013

Posted by a1000shadesofhurt in Uncategorized

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culture-bound syndromes, Depression, diagnosis, DSM, mental health issues, symptoms

Are mental illnesses such as PMS and depression culturally determined?

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders – DSM 5 – was published over the weekend. Produced by the American Psychiatric Association, it describes the symptoms of a vast range of mental illnesses and is intended as a guide to diagnosis.

Why should we in the UK care? Simple: the political dominance of the US means that as soon as a mental disorder is named in the DSM, that disorder becomes valid in the eyes of many.

But not everyone is a fan. The DSM committee has been accused of continually expanding the categories of mental illness, resulting in“diagnostic inflation” – with the result that increasing numbers of us are diagnosed with one condition or another.

The committee has also fallen foul of the US National Institute for Mental Health (NIMH), which dislikes the DSM’s symptom-based approach. The NIMH argues that laboratory tests for biomarkers are the only rational way to diagnose mental illness.

And two weeks ago the British Psychological Society released a statement claiming that there is no scientific validity to diagnostic labels such as schizophrenia and bipolar disorder.

Indeed, the DSM’s fondness for the categorisation of mental illness is a major reason for its unpopularity in many quarters. According to Gary Greenberg in the New Yorker, frustrated scientists believe its beloved categories “don’t correspond to biological reality”.

Is that a fair criticism? I would argue that the categorisation of mental illness based on symptoms can be useful. But – and it’s a big, fat, hairy but – we must accept that those diagnostic categories are cultural constructions, not global certainties.

Culture-bound syndromes are most often the preoccupation of anthropologists. Typically, the patient displays symptoms that are recognised as indicating a particular illness only by other members of that patient’s cultural group. The dhat syndrome observed in parts of India, characterised by fatigue, anxiety and guilt and usually experienced by men, is a well-documented example of a psychological culture-bound syndrome, as is the susto, or fright sickness, of Latin America.

In a recent editorial in the British Journal of General Practice, Professor Christopher Dowrick argues that depression could be a western culture-bound syndrome, rather than a universal disorder. In support of his case, Prof Dowrick notes the lack of consensus in psychiatry over what even constitutes depression: the endless shifting of diagnostic goalposts.

He points out that there is no discrete genetic variation known to cause depression. Rather, there is genetic overlap across a range of mental illness, including depressive disorder, autism and schizophrenia.

Prof Dowrick’s point is that as China and India become politically dominant, spreading different concepts of what constitutes mental illness, we will have to be more sceptical of our cherished diagnostic categories. “In western anglophone societies we have developed an ethic of happiness, in which aberrations … are assumed to indicate illness,” he writes.

Others have argued that pre-menstrual syndrome, too, is a Western culture-bound syndrome. In 1987, Thomas S Johnson claimed that the symptoms were an expression of “conflicting societal expectations” on women. In 2012, a meta-analysis of published research failed to find evidence that negative mood correlates to the pre-menstrual phase of the menstrual cycle. And earlier this year, a qualitative study found that a “cognitive reframing” of the symptoms could reduce self-reported pre-menstrual distress.

Could depression and PMS really be culture-bound syndromes rather than biological entities? For sure, no one is arguing than they are not genuine illnesses – to the patient, the symptoms are real and painful. I used to be convinced by the biomedical model of depression, but now I’m not so sure. Could depression, and other familiar mental conditions, be interpreted as a kind of local language – our culturally established way of expressing distress and asking for help?

A DSM-style categorisation of illness based on symptoms could still be useful, provided we bear in mind that our local diagnostic categories are no more universal than our local language. We may also need to accept that treatments for mental disorder are not universally applicable. Culture-bound syndromes need culture-bound treatments: interventions recognised as “medicine” by both patient and practitioner.

It’s a very complex subject – not least because there may be crossover between the cultural and the biological; between the BPS’s dismissal of diagnostic labels and the NIMH’s desire to find a biomarker for every illness.

“I think the distinction between ‘biological’ and ‘social’ causes can get tricky. Lots of human practices that are clearly culturally patterned – child-rearing practices, diet, and sleep patterns, for example – affect our biology,” Dr Rachel Cooper, author of Classifying Madness, tells me in response to an email. “You could have cases where a ‘core’ biological disturbance is expressed differently in different cultures. Some have suggested that this might be the case with western-style depression and Chinese neurasthenia.”

And in the end, as Dr Cooper concludes, “A biomarker can only tell you that a person is different – not whether that difference should be considered pathological.” Much of mental pathology could be a consequence of culture.

The Diagnostic and Statistical Manual of Mental Disorders has been updated but should we beware this manual’s diagnosis?

09 Thursday May 2013

Posted by a1000shadesofhurt in Uncategorized

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DSM, mental health issues

The Diagnostic and Statistical Manual of Mental Disorders has been updated but should we beware this manual’s diagnosis?

Next month, the latest edition of a book will be published in America that, according to its critics, will give you a starring role in your own private performance of One Flew Over the Cuckoo’s Nest – by turning aspects of your normal behaviour, such as checking Twitter a little too often, into a new mental disorder.

Many see its publication as part of a continuing attempt to create order out of the chaos of the human mind by updating a set of common criteria for mental disorders that encourages research as well as helping in the diagnosis and treatment of patients.

Yet the debate is so polarised that the American Psychiatric Association (APA) is publishing the $200 fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) into a maelstrom of controversy. Indeed, two of the DSM’s fiercest critics, Dr Allen Frances and Dr Robert Spitzer, are former chairmen of the task forces that composed previous editions.

Now, just two weeks before the new edition appears, the National Institute of Mental Health, the world’s largest mental health research institute, has announced that it is withdrawing support for the manual as “it lacks validity” due to the unscientific basis of its classifications.

The DSM classifies psychiatric disorders and provides a checklist of symptoms for each separate disorder. The first edition was published in 1952 following research by the US military during the Second World War; since then there have been three more revised editions, the last 20 years ago: the fifth is due out on 31 May. The DSM has grown substantially in size: from 130 pages and 106 mental disorders in 1952 to 492 pages and 265 disorders in 1980. And it is expected that the new DSM-5 will be even larger.

An alternative – and free – publication, International Statistical Classification of Diseases (ICD), issued by the World Health Organisation, provides an official international classification system of mental illness that the DSM sometimes borrows. The ICD is used in Europe for clinical treatment in preference to the DSM and without the lurid headlines. The DSM, though, is increasingly influential on our way of thinking about mental health.

For writer and broadcaster, Jon Ronson (pictured right), attitudes to the DSM “have changed”. Ronson’s bestselling book, The Psychopath Test, has helped to bring the DSM to the attention of a UK audience.

“When DSM first came out people were really excited. There was something alluring about it because people loved nothing more than mental health checklists. It was also a change from the pseudoscience that had gone before.”

Now people hate it for the same reason. “They feel that there is an ivory tower elite trying to turn normal human behaviour into disorders and they don’t want to be told what they are feeling isn’t normal.”

The former chairman of the work party for DSM-IV, Dr Allen Frances, was once one of this elite, and he is clear why he is not looking forward to the new edition of the DSM. He believes it threatens to unleash what he has called a “diagnosis hyperinflation” by “greatly expanding the number of people considered mentally ill, and reduces the ranks of the normal”.

“Grief becomes Major Depressive Disorder; worrying about being sick is Somatic Symptom Disorder; temper tantrums are Disruptive Mood Dysregulation Disorder; gluttony is Binge Eating Disorder; and soon almost everyone will have Attention Deficit Disorder.”

For Chris Lane, a case in point is the transformation of Social Anxiety Disorder from something that did not “formally exist” before the 1980s to what Psychology Today called “the disorder of the decade in the 1990s”. Lane is author of Shyness: How Normal Behaviour Became a Sickness, and to write the book he was given access to the DSM archive of unpublished material.

In 2010, more than 24.4 million prescriptions for generic formulations of Prozac were filled in the US alone, yet the two psychiatrists who had first identified Social Anxiety Disorder in the late 1960s, Isaac Marks and Michael Gelder, were adamant in calling it “rare and mostly innocuous”. They were “steamrolled over”.

Dr David Kupfer, chair of the DSM-5 taskforce, unsurprisingly, does not think DSM-5 is about redefining what is normal.

“DSM has been periodically reviewed and revised since it was first published in 1952. The previous version of DSM was completed nearly two decades ago; since that time, there has been a wealth of new research and knowledge about mental disorders that is not reflected in the current [DSM-IV] text.”

In DSM-5, the revisions to autism spectrum disorder and substance use disorders are particularly important, he believes.

However, he accepts that “criticism is an inherent part of any robust scientific discussion”.

“It is understandable that patients and their loved ones would feel impassioned about ensuring that people with mental disorders are diagnosed accurately and correctly. So at every step of development, we sought to make the process as open and inclusive as possible and did so to a level unprecedented for any area of medicine.”

As a result, more than 13,000 comments on the proposed diagnostic criteria were received and reviewed.

For professor Michael Owen this consultation made the process “so conservative” that “many possible changes were not incorporated”. Owen is a psychiatrist and researcher from Cardiff University’s School of Medicine, who has been involved in putting together DSM-5, and has been at the forefront of looking at the genetics behind mental illness.

The polarisation of the debate, he accepts, comes in part “from the fact that in recent years many, milder conditions such as mild depression, anxiety and stress” have come under the “remit of medicine” and without a better understanding of the mechanism of psychiatric diagnosis “the designation of something as a psychosis sometimes seems unacceptably arbitrary”.

“There are better arguments for demedicalising these than for severe disorders such as schizophrenia, bipolar disorder or autism.”

However, Owen feels strongly that the suspicions of some critics that Big Pharma is somehow “in cahoots” with the APA are wrong. “I saw no evidence of this in DSM-5.”

In fact, he says “we need them if we are to have new treatments. Unfortunately many of the major companies are leaving the neuroscience area because they see it as unprofitable.”

But Peter Tyrer, interim head of the Centre for Mental Health at Imperial College London, thinks there may be some truth to the criticisms of diagnosis inflation. Tyrer jokes that “DSM” really stands for “Diagnosis as a Source of Money, or Diagnosis for Simple Minds”, since all profits go to the APA and it can encourage a tick-box approach to diagnosis.

More seriously, he believes that the problem is that it is a “precocious adolescent” that dominates psychiatric classification.

The issue is that there is “no biological basis” for the classifications so “their status is pretty dodgy”, and this has led, Tyrer believes, “to allegations of over-diagnosis”, reinforced by drug companies pushing for new diagnoses that allow them to promote their products.

In the end, this could be the last edition of the DSM as we will no longer need checklists to define who is not normal.

Although professor T W Robbins, from the Behavioural and Clinical Neuroscience Institute at the University of Cambridge, believes that the DSM “will still be a useful clinical instrument when DSM-5 is launched”. Indeed without it, he says, there would be “chaos”.

“Much of the future will depend on advances in neuroscience, including cognitive neuroscience”.

“It is particularly important to identify ‘endophenotypes’, which are more accurate descriptions of deficits in such functions as the processing of reward and punishment, the ability to make rational and also empathic decisions, and the ability (in certain contexts) to inhibit inappropriate automatic and habitual behaviours.”

If this happens along with understanding how they go wrong in mental disorders, then the future debate may be less about defining normality, and more about how far should we go.

“It will enable us to detect disorders in the vulnerable, at-risk state and treat or intervene with drugs or cognitive therapy before the damage is done,” says Robbins, “as once things start going wrong they are much harder to treat”.

Normal Grief vs Depression In DSM5- Medicalizing Grief

09 Thursday Feb 2012

Posted by a1000shadesofhurt in Depression

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Bereavement, DSM, Grief, Major Depression

http://www.psychologytoday.com/blog/dsm5-in-distress/201003/normal-grief-vs-depression-in-dsm5

The recently posted draft of DSM5 makes a seemingly small suggestion that would profoundly impact how grief is handled by psychiatry.  It would allow the diagnosis of Major Depression even if the person is grieving immediately after the loss of a loved one. Many people now considered to be experiencing a variation of normal grief would instead get a mental disorder label. For example, take the case of a man whose spouse unexpectedly dies. For two weeks after the death, he feels sad, doesn’t want to go to work, loses his appetite, has trouble sleeping and concentrating. Currently, this is normal grief. The DSM 5 suggestion would have this be major depression.

Undoubtedly, this would be helpful for some people who would receive much needed treatment earlier than would otherwise be the case. But for many others, an inaccurate and unnecessary psychiatric diagnosis could have many harmful effects. Medicalizing normal grief stigmatizes and reduces the normalcy and dignity of the pain, short circuits the expected existential processing of the loss, reduces reliance on the many well established cultural rituals for consoling grief, and would subject many people to unnecessary and potentially harmful medication treatment.

Grief is an inescapable part of the mammalian experience and a necessary correlate of our ability to attach  so strongly to other people. Though grief is universal, there is no one right way to grieve. Different cultures prescribe a wide variety of different behavioral and emotional reactions and rituals. Psychiatry needs to tread lightly and have compelling reasons before encroaching with its own rituals  on such time honored and usually effective practices.

Within a given culture, normal individuals also vary enormously in the content, symptoms, duration, and impairment of their grief and in their ability to draw consolation and sustenance from others.  There is no bright line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help.

The numbers on each side of the normal/mental disorder divide are probably very lopsided-most people who grieve do not have a mental disorder. Ever since the dawn of man, humans have had frequent occasions to grieve. Almost all of us come to terms with the loss and the altered conditions of a new life without the benefits of psychiatry-and do just fine on our own. The change in DSM5 would attempt to identify the very small percentage of people who have a complicated grief that goes beyond the average expectable in severity, symptom pattern, and duration – those who would not remit as part of the natural evolution of their grief. But when you use a big shovel to capture a small needle in the haystack, what you mostly get is hay. Any change in the way DSM5 defines grief may gather a very large proportion of false positives who would do better avoiding psychiatric help.

The rationale given by DSM5 for its radical proposal is brief, cryptic, and fails to provide anything like a risk/benefit analysis of  potential effects. DSM5 states that there is no evidence that the depression triggered by the stress of losing a loved one is any different than  depression triggered by other severe stressors (such as job loss or divorce)- thus claiming that there is no justification to withhold the diagnosis of major depression after a loss. This  rationale places the burden of proof in the wrong direction.  DSM5 should make so consequential a change only after a careful and considered evaluation proves with compelling evidence that it will do more good than harm.

Such evidence is simply not available.  The research in this area is interesting but in very early development and we don’t know many essential things. We have no idea how any proposed criteria set would work in the general population.  What percentage of grieving individuals would get the diagnosis (especially once drug companies raise awareness of it)? Among the people who would be diagnosed, we don’t know what percentage truly need psychiatric help, what percentage would do better without it.

Pies and Ziskind (in a recent commentary in Psychiatric Times) have  gone far beyond the meager DSM5 rationale to present the strongest possible case for allowing the diagnosis of Major Depression in grief situations. They cite several lines of argument:

1) There is a clinical need- some individuals have severe, complicated grief that looks just like severe Major Depression and does not get better spontaneously. The longer that diagnosis and treatment are delayed, the greater their suffering, impairment, and risks (eg job loss, injured relationships, lowered treatment response, suicide).

2) The loss of a loved one is not essentially different from the many other serious stressors that abound in life.

3) It is impossible to predict the future misuse of the DSM5 system so we should make decisions based only on the best possible science.

4) The criteria for complicated grief could be tightened to reduce false positives.( They suggest two useful ways described below and I add two others).

5) Education can solve the problem of false positive diagnosis and the risk of providing medicine in milder cases when time, support, and/orpsychotherapy would be more indicated.

The  excellent proposal made by Pies/Ziskind to reduce false positives could be strengthened even further if two additional exclusions were added to the  two(#’s 1and 2 below) that they   suggested . The entire package differentiating grief  from depression would require:

1) An extended duration of one month.

2) A particularly severe presentation that  includes some combination of unreasonable guilt, worthlessness, hopelessness, self loathing, anhedonia, a focus on negative memories of the departed, alienation from others, and inability to be consoled.

3) To recognize the different cultural expressions, the diagnosis of depression would not be made if the person’s grief is within  cultural norms.

4) An exclusion could be added that would take into account the person’s own past experience of grief and its previous outcomes.  If the individual previously had severe grief symptoms, but recovered spontaneously (without going on to a major depression), this would suggest they are now grieving their own way and do not require diagnosis or treatment.

DSM5 has made many poorly thought through suggestions that can be fairly easily dismissed. Though I continue to disagree with the  Pies/Ziskind proposal, it is reasonable and deserves serious consideration. Here are the opposing points:

1) Re clinical need: In appropriate cases displaying  clinically significant impairment, distress, or risk, the diagnosis Depression Not Otherwise Specified covers their false negative problem.

2) I believe there is a difference between losing a loved one and most other life stressors. This  explains why grief is the universal target of communal healing rituals.  It would be unfortunate forpsychiatry to prematurely roam into problems usually better handled by family and other cultural institutions. Cultural biases would be very hard to surmount in making this diagnosis.

3) My disagreement with Pies and Ziskind is strongest on this point. All decisions for DSM5 should follow the injunction-“First Do No Harm.”Although it is impossible to predict precisely how any DSM5 change will eventually play out once the manual is in general use, that doesn’t reduce DSM’s responsibility for the problems that occur, even if they are unintended. All potential risks have to be thought thru and factored into a thorough risk/benefit analysis.  The argument that we should just go to where the science takes us ignores that the science is (as they point out) not definitive, is subject to different interpretations, and is not readily generalizable from research to real world settings. Once the genie is out of the bottle and DSM5 makes it easy to diagnose depression in grief situations, this could easily become an industry propelled fad diagnosis.

4) The tightened criteria would help reduce, but certainly not eliminate, the grave potential harm caused by the massive misidentification of false positives.
False positives and excessive treatment are not be a problem for skilled and cautious clinicians (like Pies and Zisook), but in the real world most of the prescriptions will be written by primary care physicians who have six minutes with each patient, don’t know the fine points of the criteria sets, and want the fastest solution.

The false positive problem is too unknown and potentially far too large to ignore. At a minimum, there would need to be field trials to determine prevalence, reliability, false positive, and false negative rates. I doubt that DSM5 has the time, money, and skill to pull this off.

5) It would be naïve and unwise to rest our hopes that any educational  program  would reduce over diagnosis and the overprescription of medication in grief situations. To the contrary, most of theeducation would go the other way. The drug companies devote enormous resources to “educating” physicians to be quick on the draw in prescribing medication.

I respect the arguments made by Pies and Ziskind  and believe they  work well when applied by experts like them. My worry is the misuse of even reasonable ideas in the real world  situations where most diagnosis and treatment is done. Loose diagnostic and treating habits could lead to the widespread medicalization of grief well beyond what Pies and Ziskind would themselves recommend. There are two ways of avoiding this. The first is to keep things as they are and not to diagnose Major Depressive Disorder in the first two months after the loss of a loved one.

The second is for DSM5 to allow for the diagnosis of complicated grief but with a  criteria threshold set high and including all four protections against false positives outlined above. As recommended by Pies and Ziskind, there should also be a  physician and public education campaign normalizing normal grief and  sharply delimiting the small group of grievers who need psychiatric
help.

Weighing the pluses and minuses, my call is to keep things as they are and not risk an “epidemic” of psychiatric grief.

The Mass Production of Mental Illness and What To Do About It

01 Wednesday Feb 2012

Posted by a1000shadesofhurt in Psychiatry

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'Anti-Psychiatry', 'AntiPsychiatry', cbt, chlorpromazine, diagnosis, drugs, DSM, ECT, Kraepelin, Laing, medication, Medicine, mental health issues, misdiagnosis, psychiatry, Rogers, Rosenhan, schizophrenia, Skinner, Szaza, treatment

The Mass Production of Mental Illness and What To Do About It

DOCTORING THE MIND: IS OUR CURRENT TREATMENT OF MENTAL ILLNESS REALLY ANY GOOD?
By Richard P. Bentall
NYU Press, 364 pages. $29.95

“Conventional psychiatry, which reached its zenith with the neo-Kraepelinian movement, has not only failed to deliver tangible benefits for patients (antipsychotics…were an accidental discovery) but has also failed to deliver a credible explanation of psychosis. It is not that there is a lack of biological evidence; rather, the evidence has been misinterpreted and shoehorned into a biomedical framework that fits it poorly. A radical new approach to understanding severe mental illness, which brings together the evidence on the social, psychological and biological causes of psychosis, is urgently required.”

In the 1960s, a movement called “antipsychiatry” (prompted in Britain by R. D. Laing and in the U.S. by Thomas Szazs) questioned the basic assumptions about mental illness and its treatment. Not only psychiatry, but methods popular earlier in the twentieth century, such as the prefrontal leucotomy, electroconvulsive therapy (ECT), and insulin coma therapy, lay thoroughly discredited. The anti-psychiatrists encouraged treating the patient as a whole person, putting his “madness” in the social and environmental context. Unfortunately, with the passage of the counterculture the medical establishment returned with a vengeance to explaining mental illness strictly as a manifestation of physical disorders of the brain and treating it with particular medications.

Dr. Richard P. Bentall, professor and practitioner of clinical psychology in Britain, who earlier wrote Madness Explained: Psychosis and Human Nature (2003), exposes the highly dubious nature of reigning presumptions about the causes and treatment of mental illness. He favors the “recovery-oriented, autonomy-promoting” model, particularly cognitive behavioral therapy, over the “paternalistic-medical” model, which favors reductionist diagnosis, genetic causation, and reliance on drugs to correct so-called “chemical imbalances.” Bentall explores why the biomedical approach has become dominant, instead of a social approach to madness, which was gaining traction in the 1960s. There is little evidence to show that psychiatric drugs are effective in the long run; by making spurious connections between damaged brains and drugs alleged to overcome such disfigurement, the medical profession ignores better treatment options.

In his important book The Rise and Fall of Modern Medicine (1999), James Le Fanu identifies twelve definitive moments in the history of medicine, one of which is the discovery of the drug chlorpromazine in the early 1950s. Over the long run, however, the medical profession has been manifestly unable to improve recovery outcomes for patients suffering from mental illness. A striking finding is that patients in developing countries, with much less health care expenditure per capita, recover better from schizophrenia than patients in developed countries. The accidental discovery of chlorpromazine by a French doctor must be viewed in the context of the state of psychiatric treatment, a shambles before the excitement caused by the new drugs. As Le Fanu concludes, “Why should a compound that blocks histamine in the tissues of the body also interfere with an entirely different chemical–dopamine–in the brain in a way that alleviates the symptoms of schizophrenia? What is schizophrenia? What is its cause? The map of mental illness, like that of Africa before the arrival of the Victorian explorers, remains a blank.” Medical discoveries have sharply fallen off since their post-World War II peak; both “The New Genetics” and “The Social Theory” (attributing disease to lifestyle choices) have failed to halt the rise of illness, particularly psychiatric illness.

Emil Kraepelin (1856-1926) is the key figure in the classification of psychiatric disorders, making a distinction between dementia praecox (senility of the young, later relabeled schizophrenia) and manic depression. The growth of mental asylums, particularly in the U.S., didn’t abate until the middle of the twentieth century. Also in parallel, extreme remedies including electroconvulsive therapy, prefrontal leucotomy, and insulin coma therapy became popular. Walter Freeman, the American evangelist for prefrontal leucotomy, used “a hammer to tap an ice-pick-like instrument placed above the eyeball and against the orbital bone behind,” after which “he would move…[the instrument] from side to side in order to produce the desired lesion.” Rosemary Kennedy, sister of President John F. Kennedy, was a famous victim of Freeman: “a woman who had perhaps suffered from mild intellectual impairment, but who could read and write…was left incontinent and able to utter only a few words.” In insulin coma therapy, patients’ “brains were starved of glucose,” and they would slip into a coma. Brain-cell death, and the desired catatonic state, resulted.

Contesting behavior modification programs, articulated by pioneers B. F. Skinner (author ofWalden Two) and Carl Rogers, varied in their approaches to control versus autonomy, but the impact of innovation remained limited in the asylums and clinics. David Rosenhan published a famous paper in Science in 1972, called “On being sane in insane places,” throwing doubt on the supposed empirical nature of psychiatric diagnoses. With seven other “pseudo-patients,” Rosenhan showed up at psychiatric clinics pretending to have symptoms of schizophrenia. Staff at the hospitals were unable to change their diagnostic presuppositions to match the pseudo-patients’ perfectly normal behavior once admitted: “A pseudo-patient waiting outside a cafeteria half an hour before it opened (there was nothing else to do) was described by one psychiatrist as having an ‘oral acquisitive syndrome.’ When observed making notes, another was said to exhibit ‘obsessive writing behavior.'” Interestingly, the patients picked up that the pseudo-patients were journalists or professors.

Meanwhile, unable to rise to the challenge posed by Thomas Szazs’s groundbreaking The Myth of Mental Illness (1960), psychiatrists doubled down on the idea that there is something “wrong with the brains of mentally ill patients.” Thus came about the “chemical-imbalance explanation for mental illness, an idea that was to prove more potent in the minds of ordinary people than anything dreamed up by the antipsychiatrists.” In other words, even as Freudian assumptions about the unconscious, the role of sexuality, and repressed fantasies were being discredited, the science of biological psychiatry emerged to put forth the idea that “too much dopamine at the [brain synapses]…causes schizophrenia,” and that “an imbalance in the neurotransmitter serotonin” causes depression. Note that these two ideas are at the basis of every psychiatric drug peddled since the 1960s, and if they can be thrown into doubt, so can the efficacy of all the drugs currently on the market. Certainly, the drug companies’ interests (as Marcia Angell, above all, has pointed out in her work) are well-served, but can we say the same for patients? Even the president of the American Psychiatric Association lamented in 2005: “As a profession, we have allowed the biopsychosocial model [of mental illness] to become the bio-bio-bio model.”

The new biological researchers styled themselves neo-Kraepelinians, and the American Psychiatric Association’s landmark Diagnostic and Statistical Manual-III (DSM), issued in 1980 and since then further revised, is a monument to Kraepelin in sharply distinguishing between the normal and the sick, in separating discrete categories of mental illnesses, and in focusing on the biological approach to mental illness. If each of these dubious propositions can be shown to be weak or even false, then the entire edifice of current psychiatric practice also collapses. Neuroscience, not any sort of talking therapy, was to be the panacea; “manipulating neurotransmitters, not…understanding and interpreting the patients’ thoughts and feelings,” was what young psychiatrists should learn. Has the DSM led to more accurate diagnoses than was the case before? Lauren Slater, in Opening Skinner’s Box: Great Psychological Experiments of the Twentieth Century (2004), describes replicating Rosenhan’s experiment by presenting herself as a patient at psychiatric emergency rooms.

Now to the dismantling of each of the three key propositions upon which present psychiatric practice rests. First, are psychiatric diagnoses meaningful? The concepts of both dementia praecox (schizophrenia) and manic depression, first proposed by Kraepelin, have undergone repeated transformations over the last century, with allied growth in various neuroses (anxiety disorders), subdivided into many classes. The DSM sought to achieve consistency in psychiatric diagnoses, but precision remains spurious. A significant obstacle to precision, according to Bentall, is comorbidity; often patients suffering one psychiatric illness seem to suffer from others as well, which keep shifting in intensity over time. As Bentall concludes damningly, “If the same drugs work for everyone, the diagnosis given to the patient has virtually no implications at all.”

Second, as to the boundary between the “sick” and the “normal,” many people have psychotic symptoms without requiring treatment. Schizophrenia is best perceived on a continuum, rather than as the dark side of a clear dividing line between normality and a lifetime of helplessness. In recent years, psychiatrists have desperately sought to preserve the structure of diagnostic precision by resorting to increasing “fractionation,” for example of the “bipolar spectrum into bipolar 3 disorder, bipolar 4 disorder, and so on.” Schizophrenia and bipolar disorder, instead of being thought of as ‘real conditions,” might be better seen as ‘scientific delusions.”

The third fundamental error of psychiatry follows from the “neo-Kraepelinian… assumption that psychiatric disorders are genetically determined diseases that are little influenced by the trials of life.” The most that can be argued is that “genes play some role at some point in increasing the risk of mental illness, but nothing else.” Bentall explains that “the only findings that have proved to be even marginally replicable concern genes that confer only a very small risk of psychosis and which are absent in the majority of patients” and that “if there were any genes with more direct and marked effects, they would have certainly been discovered by now.” It is important to consider that “not a single…[patient] has ever benefited from genetic research into mental illness.”

Yet current psychiatric practice prefers unchanging genetic influence over environmental factors–particular stresses and traumas in life–in aggravating mental illness. As Bentall argues, “Insecure attachment and victimization appear to contribute to paranoia, sudden trauma appears to cause hallucinations, and parental communication deviance has been implicated in thought disorder.” Yet the psychiatrist’s job these days is focused on getting the patient to agree to a discrete diagnosis, followed by quick agreement to take the prescribed medication. At the research level, psychiatric geneticists are busy trying to identify specific genes involved in schizophrenia, bipolar disorder, and other conditions–a fool’s errand, if ever there was one, since the venture is premised on ignoring environmental influences.

The neo-Kraepelinians, i.e., the majority of the psychiatric profession today, have been obsessed with reliance on CT scans, and more recently MRI’s, to locate the exact sites of brain disease. Yet even if dopamine neurones are involved in paranoia, it stands to reason that “the nervous system of an animal living the life of repeated victimization will become highly attuned to the detection of further threatening events.” So it is reasonable to think that “the dopamine system becomes sensitized as a consequence of adverse experiences that predate the onset of illness,” rather than being the cause.

The excessive profits of drug companies–“in 2002, the combined profits for the ten [largest] drug companies…[exceeded]…the profits of all the other 490 companies put together”–can be explained by our unreasonable expectations about what medical science can deliver. In The Role of Medicine: Dream, Mirage or Nemesis (1979), Thomas McKeown argues that most of the “health gains achieved during the nineteenth and early twentieth centuries were the consequence, not of advances in medical science, but of improvements in nutrition and sanitation.” This concept leads to the recent global movement embracing evidence based medicine, which, Bentall argues, has so far not affected the psychiatric profession. Big Pharma continues to exploit loopholes in the concept of the randomized controlled trial (RCT), to adduce greater effectiveness for drugs than warranted.

In the late 1980s, SSRI’s (serotonin re-uptake inhibitors), represented by Prozac, became immensely popular. The drug industry made extravagant claims for their effectiveness. Yet “subsequent metaanalyses have reported that nearly all of the therapeutic response to both the old and new antidepressants can be attributed to the placebo effect.” Drug company data, submitted to the FDA in support of licensing applications, is kept secret, but when occasionally it comes to light severe problems of duration, size, and sample become manifest. For example, data from “47 trials of the six most popular new antidepressants…[shows] that the most rigorous of the studies had examined the patients for a mere eight weeks without any attempt to find out what happened to them afterwards, and that drop-out rates were so high that only 4 out of the 47 were able to report what happened to more than 70 percent of the patients.” In short, psychotic drug trial data cannot be trusted.

Rather than adhere to the Hippocratic Oath of “first do no harm,” psychiatrists are recently pushing for the earliest possible intervention–lifetime prescription of psychotic drugs–based on the manifestation of pre-symptoms, rather than actual illness, and for the inclusion of the widest possible population in such prescreening. Contrary to this drive, studies have shown that “first-episode…patients benefit less from…treatment than patients who have been ill for some time.” Big Pharma and psychiatrists also claim that so-called second-generation drugs have fewer side effects, but many studies show that this is clearly not true. Of even more concern is the fact that long-term administration of psychotic drugs may worsen symptoms because of “the proliferation of the number of D2 receptors in the brain”–in other words, “the brain responds to having its dopamine receptors blocked by making more of them.”

If drugs have been oversold, what is to be done then? Cognitive behavior therapy (CBT), which seeks to alter negative thought patterns, is one approach. It may or may not be more effective than other forms of psychotherapy, but at least it shows more respect for the patient than condemning him to a lifetime of medication, and making him feel useless because of irremediable genetic dysfunction in the brain. Many patients can manage the symptoms of schizophrenia without having to be condemned or committed. The aim should be to help patients improve their quality of life, rather than relying on bright-line distinctions between normality and illness. In the “paternalistic-medical” model, patients’ preferences about treatment are ignored because their judgment is not trusted; in the “autonomy-promoting” model Bentall advocates, patients are actively involved in deciding the course of treatment. Bentall offers a neat schematic splitting the two models along the axes of principal advocates, beliefs about mental illness, attitude toward diagnosis, goals of treatment, attitude towards patients’ judgments, attitude towards treatment, attitude towards the therapeutic alliance, attitude towards risk and coercion, and attitude towards medical skills that sharply distinguishes the polarities between the two approaches.

At stake in this debate is the utilitarian (Benthamite) versus deontological (Kantian) ethic. Both moral philosophies emphasize individual rights, the Kantians in particular arguing that individuals should always be treated as ends in themselves, rather than as means to ends. Present psychiatric practice, heading as it is toward condemning large swaths of the population to a perpetual sentence of mental deviance, doesn’t even match the less rigorous scales of utilitarianism when it comes to individual autonomy. The present model is based on coercion, and coercion is wrong on several counts as an approach to mental illness.

Joanna Moncrieff, in The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment(2008), has pointed out that we should free ourselves of the delusion that there can be specific drugs for discrete mental illnesses. She demonstrates that “a majority of the published trials show that antidepressants are a bit better than placebo, but despite the many possible biases which make positive results more likely, many studies found that antidepressants were no better than placebo and some found that they were worse.” She also shows how “decades of research have failed to produce clear and independent evidence of a dopamine abnormality in people with psychosis or schizophrenia that cannot be attributed to some other cause” and that “there is little evidence to suggest that there is a characteristic abnormality in [the serotonin and noradrenalin]…systems that is associated with depression.” Instead, Moncrieff argues that “the early marketing campaigns for antidepressants had to establish the idea of depression as a common, medically treatable condition”–the more common, the better, from the drug companies’ point of view.

In addition to recognizing the limitations of drugs, more emphasis needs to be placed on the sociological roots of depression (as Bentall points out, the majority of mentally ill patients tend to be unemployed, and employment tends to assist in recovery). Psychiatry, since the early 1950s, has stalled; the revolutionary impetus of the 1960s is gone; the profession needs to reboot, and start treating people again as people, not as “plants.” The motivation behind the new drugs remains the same as it was for the radical remedies of electroconvulsive therapy, prefrontal leucotomy, and insulin coma therapy.

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