Infighting, boycotts,
resignations: Psychiatry faces another crisis of confidence
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By Sharon Kirkey, Postmedia News May 19, 2013
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In
the early 1970s, psychologist David Rosenhan set out to answer a simple
question: Can psychiatrists tell the sane from the insane?
Rosenhan
and seven other perfectly rational “pseudopatients” went to a dozen U.S.
hospitals complaining that they were hearing voices. All but one were diagnosed
with schizophrenia and sent to a psychiatric ward. Each had been warned by
Rosenhan that, to get out, they would have to convince the psychiatric staff
they weren’t insane. So, immediately after they were admitted, they stopped
mimicking symptoms of “abnormality” and behaved as they normally would.
Still,
they were kept in the hospital for periods ranging from seven to 52 days, each
finally discharged with a diagnosis of schizophrenia, “in remission.”
The
Rosenhan experiment sparked a crisis of confidence in psychiatric diagnosis — a
crisis that appears to be playing out again today.
This
time the catalyst is the newest and fifth edition of the official guidebook of
psychiatry: the Diagnostic and Statistical Manual of Mental Disorders, or
DSM-5. The encyclopedic tome has undergone its first major revision in nearly
two decades and makes its official debut May 18 at the annual meeting of its
publisher, the American Psychiatric Association.
The
rewrite has been rocked by boycotts and the resignations of some of the very
experts tapped to give advice — including the former head of the department of
psychiatry at the University of British Columbia, John Livesley, who says he
quit the DSM-5’s personality disorders work group over a “disregard for
evidence.”
Thomas
Insel, director of the U.S. National Institute of Mental Health — essentially
the country’s top psychiatrist — has announced that his agency is
“re-orienting” its research away from the DSM over the book’s “lack of
validity” while it pursues its own alternative diagnostic system, which Insel
promises will be more firmly anchored in brain science.
The
leaders of the DSM-5, such as Dr. David Kupfer, co-chair of the DSM-5 task
force, have fired back, saying the book reflects the strongest means available
today for cataloguing mental illness, and insisting that while genetic and
other biological tests would be the ultimate holy grail of diagnosis, there’s
no sign that such foolproof methods will be available anytime soon.
The
public clash is making psychiatry look like “nonsense,” says Allen Frances, the
man who led the task force that created the fourth edition of the DSM in 1994.
“It’s bad for patients. This will discourage people who desperately need help
from getting it.”
Frances
has been the DSM-5’s most dogged and unapologetic critic. He says the book
contains untested diagnoses on the “fuzzy boundary of normality” and that it
recklessly lowers the thresholds for existing ones.
“I’m
a strong believer in the value of psychiatric diagnosis and treatment when done
well,” Frances says. “But it’s silly and harmful to be
over-treating people who don’t need it, and tragic to be neglecting the needs
of those who do.”
Psychotherapist
Gary Greenberg is more blunt. “Even at its best … psychiatric diagnosis is
fiction sold to the public as fact,” Greenberg writes in his new book, The Book
of Woe: The DSM and the Unmaking of Psychiatry.
“There
is a huge disconnect between what psychiatry claims for itself, and what it can
actually do,” he says.
Canadian
psychiatrist Joel Paris says that “no one really knows what a mental disorder
is,” or how to clearly separate normal from abnormal. “It’s all very fuzzy.”
In
other words, 200 years after psychiatry was recognized as a medical discipline,
a stark question persists: Is psychiatry credible?
There
is no doubt about the validity of psychological suffering. Mental illness, in
its extreme, is undeniable. “With psychotic people, there’s very little
argument,” says Paris, a professor and past chair of the department of
psychiatry at McGill University in Montreal. Johns Hopkins clinical
psychologist and writer Kay Redfield Jamison has described the “profound
horror of depression,” while chronic, intense anxiety is described as so totally
absorbing a person’s consciousness, that every minute they feel as if they will
die.
But
our mental reactions to the smaller pieces of daily tragedy are more complex,
Paris says. When does the sadness from a break-up become depression? When does
normal human experience become somehow “sick”?
“You
can diagnose almost anybody with the DSM, and unfortunately this is happening,
with a lot of over-diagnosis going on clinically,” Paris says. “A lot of people
are being given stimulants because they don’t pay attention, and mood
stabilizers because they’re moody and antipsychotics for almost everything
these days.”
In
fact, there are no valid definitions for many of the conditions so neatly laid
out in the DSM, Paris and others argue, and no laboratory test exists that can
confirm a diagnosis in psychiatry. Despite growing research into the
convolutions and folds of the human brain, the science is revealing more about
normal brain functioning than any kind of “psychopathology,” or sickness,
Frances says.
Still,
psychiatry keeps creating new illness categories, new ways the brain and mind
can become “disordered.”
Major
changes to the DSM include the addition of “disruptive mood dysregulation
disorder,” or DMDD — defined as children who exhibit “persistent irritability”
and frequent behaviour outbursts, a freshly minted diagnosis that observers say
hasn’t been adequately studied yet and could make DMDD as entrenched in our
vernacular as ADHD, or attention deficit/hyperactivity disorder.
Also
new to the manual is hoarding (“persistent difficulty discarding or parting
with possessions”), excoriating (skin picking) disorder, binge eating disorder
(“frequent overeating at least once a week for three months”) and a loosening
of the criteria for attention deficit/hyperactivity disorder.
Gone
from the new manual is “bereavement exclusion” for a diagnosis of major
depressive disorder. Under the old manual, people who recently suffered a loss
could not be diagnosed with major depression unless their symptoms persisted
beyond two months. Now, a diagnosis of depression can be made a mere two weeks
after the loss of a loved one.
For
the first time in the manual’s history, the total number of diagnoses will not
grow, its leaders have said. But the stakes, they say, are high: Writing
in the Journal of the American Medical
Association, David Kupfer and DSM-5 task force co-chair Darrel
Regier state that approximately 30 to 50 per cent of patients who see a family
doctor have “prominent mental health symptoms or identifiable mental
disorders.”
In
Canada, we are told that one in five of us will suffer from a mental illness in
any given year. In the federal public service, nearly half of the long-term
disability claims in 2010 were related to mental illness.
While
the statistics may suggest that we’re in the grips of an epidemic of mental
illness, experts say there is no evidence that we are getting sicker as a
nation.
The
one-in-five estimate is based on epidemiological studies in which large numbers
of people are surveyed, usually by lay interviewers, not experts.
As
well, as the surveys have grown more detailed, a larger number of disorders are
being included, increasing the overall findings of apparent problems.
There
are no blood tests or X-rays for mental illness, and no such tests, except for
Alzheimer’s disease, are on the horizon. Doctors rely on what their patients
tell them, Greenberg says, “which, in turn, is dependent entirely on what you
ask, which, in turn, depends entirely on what you look for.”
The
psychiatric guidebook, the DSM, assigns a name and number to each disorder, and
provides a list of criteria that can be counted, leading to diagnosis.
For
example, if a person exhibits three out of seven symptoms for a “hypomanic
episode” — “a distinct period of persistently elevated, expansive or
irritable mood” — the person qualifies for that diagnosis. Having five out of
nine symptoms adds up to borderline personality disorder.
The
thresholds are essentially “best guesses” based on clinical experience and the
consensus of expert panels. Greenberg tells the story of how, when the
psychiatrist who first proposed the criteria for depression was asked why he
set the threshold at six out of 10 symptoms, he said, “It felt about right.”
“I’m
certainly not saying that they just pull this stuff out of the air for the sake
of it,” Greenberg says. “It does match problems that you see coming into the
clinic.” But there is a certain amount of arbitrariness to it, he says.
Take,
for example, anxiety disorders. Jerome Wakefield says humans are hardwired by
evolution to experience anxiety. “There are ways that it appears we’re
designed to experience anxiety that are now being labelled ‘disorder’ that are
quite normal for our species,” says Wakefield, co-author, with Allan Horwitz,
of All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into
Mental Disorders.
The
essential feature of social phobia is defined as a “marked and persistent fear
of social or performance situations in which embarrassment may occur” — the
very situations in which fear can be perfectly normal and natural, says
Wakefield, professor of social work at New York University.
Paris,
of McGill, says DSM is imperfect, but necessary. “What I tell my students is,
‘Look, read this, learn it, use it. Don’t believe it’s a bible. Don’t take it
too seriously. Don’t think it’s the be-all and end-all.’
Psychiatric
diagnoses are based entirely on signs and symptoms, he says. “In medicine, we
went beyond signs and symptoms 100 years ago. We had X-rays and blood tests,
all kinds of things which allowed us to directly observe what was going on in
various organs in the body. And we’re nowhere near that with the brain. We just
can’t do it.” It could take another 50 years before the field even gets close,
he says.
But
in an attempt to strengthen its legitimacy, psychiatry is becoming increasingly
enthralled with the promise of neuroscience – with linking psychiatric
disorders to broken brain mechanisms. Lost, some fear, is a focus on the
psychosocial factors that can help explain human distress.
The
brain is undoubtedly involved, says psychologist Frank Farley, past president
of the American Psychological Association. “But you can’t boil everything down
to a laboratory measure. People do not live in laboratories — that’s not where
the pain is, that’s not where the living is, that’s not where the relationships
are. We need to bring the social side of life into diagnosis.”
Greenberg
believes doctors are motivated “by a desire to relieve suffering. Their purpose
in cataloguing our troubles is surely not to turn us into Shrink McNuggets,” he
writes in The Book of Woe.
But
not all mental suffering is a medical disorder, he says, “and nobody knows how
to draw that line, but the DSM chugs along as if we did.”
Dr.
Suzane Renaud, president of the Canadian Psychiatric Association, rejects the
accusation that psychiatrists may somehow be over-diagnosing.
“Obviously
we want to attend to the people who come in and say, ‘I’m not functioning well;
I’m suffering.’ We want to treat the people who truly are sick.” But, she
emphasizes, psychiatrists also reassure patients when their reactions to life’s
stresses are entirely normal.
Frances
sees it differently. Psychiatry, he says, is a “noble and essential
profession.” But its diagnostic labels are too pliant and rubbery, “too
elastic,” he warns.
As
with Rosenhan’s experiments of 40 years ago, it’s still too easy “to make
patients out of people who are basically normal.”
———————————————————————————————-
Psychiatry
101: a history, a glossary and what they say about it now
Here’s
a short history of psychiatry:
Psychiatry
comes from the Greek words “mind healing” and is the branch of medicine that
focuses on the treatment and prevention of mental disorders.
1792
or 1793: French doctor Philippe Pinel is appointed director
of the Bicetre Insane Asylum in France. He believed mental illness was a
disease, not caused by demonic possession. His treatments included unchaining
patients and access to the outdoors.
1808:
First formal use of the term “psychiatry” attributed to German Prof. Johann
Christian Reill in a long essay that justified the creation of this new medical
specialty.
1840:
“Idiocy/insanity” recorded in the U.S. census, the first attempt to gather
information about mental illness in the United States.
1858:
The Mount Hope Asylum for the Insane is founded in Darmouth, N.S.
1883:
German Dr. Emil Kraepelin publishes the first edition of the Textbook of
Psychiatry, arguing that many mental illnesses had biological causes and
created a classification system for mental illness.
1899:
Sigmund Freud publishes the Interpretation of Dreams, establishing the
foundation of psychoanalyis and his theory that mental illness is shaped by the
conflicts of childhood.
1893:
Kraepelin defines “dementia praecox,” now known as schizophrenia.
1908:
University of Toronto opens a department of psychiatry in the medical school.
1934:
Insulin shock therapy is introduced, a precursor to electroconvulsive therapy
(ECT). Up to this point, the main treatments for mental illness were
institutionalization and psychotherapy.
1935:
Portuguese neurologist Egas Moniz performs the first lobotomy (frontal
leucotomy) believing certain behaviours can be stopped if the circuits in the
frontal lobes of the brain are disconnected.
1943:
McGill University opens psychiatry department, headed for the next 20 years by
Dr. Ewen Cameron.
1949:
Moniz wins the Nobel prize for medicine for inventing the lobotomy.
1950s:
The first antipsychotic drug, chlorpromazine, is successfully used in France.
1951:
The Canadian Psychiatric Association, a voluntary professional association, is
formed.
1952:
The first Diagnostic and Statistical Manual of Mental Disorders (DSM) is
published, containing 106 disorders.
Late
1950s: The beginning of the “deinstitutionalization”
movement to get people out of mental institutions and back into the community
so they can receive outpatient care.
1970:
Lithium is approved by the U.S. Food and Drug Administration for some
illnesses.
1974:
The American Psychiatric Association agrees to remove homosexuality from the
DSM.
1975:
The film adaption of the Ken Kesey novel, One Flew over the Cuckoo’s Nest,
shows horrific, albeit fictional, conditions and treatments inside a
psychiatric ward.
1980:
Third edition of the DSM is published; the number of disorders grows to 265.
1987:
Prozac is approved in the U.S. It is launched in Canada a year later.
1994: Fourth
edition of DSM is published, listing 365 disorders.
1994:
The federal government settles the last law lawsuits related to brainwashing
experiments conducted by Dr. Ewen Cameron at the Allan Memorial Institute in
Montreal and partially funded by the American CIA.
2013:
The fifth version of the DSM is released.
–
Compiled by Kirsten Smith, Postmedia News
Sources:
Canadian Encyclopedia; Encyclopedia Britannica, Psychiatry’s 200th birthday
(British Medical Journal); Historical Synopsis – Department of Psychiatry at
the University of Toronto; BBC; Wikipedia
Here’s
a glossary of psychiatric terms:
Psychiatrist: A
doctor who has completed a minimum of five years of additional accredited
training following four years of general medicine training. There are about
4,100 psychiatrists in Canada. Demand continues to exceed supply.
DSM:
Diagnostic and Statistical Manual of Mental Disorders. First published in 1952.
First edition contained 106 disorders. DSM-IV, published in 1994, lists 356.
Binge
eating disorder: Frequent overeating at least once weekly over the
last three months.
Bipolar
disorder: Extreme shifts in mood, from extreme highs or
“mania” (talking very fast, jumping from one idea to the other, racing
thoughts) to depression (feeling worried or empty; loss of interest in
activities once enjoyed).
Brief
psychotic disorder: Delusions, hallucinations, disorganized speech.
Episodes last at least one day but less than a month.
Borderline
personality disorder: A “pervasive pattern of instability of
interpersonal relationships, self-image” and “marked impulsivity.”
Disruptive
mood dysregulation disorder: Severe temper outbursts that
occur three or more times per week that are grossly out of proportion to the
situation.
Generalized
anxiety disorder: Excessive anxiety and worry occurring more days
than not for at least six months. People find it difficult to control the
worry. The anxiety and worry are associated with three or more of six symptoms,
including restlessness or feeling keyed up or on edge, irritability, and poor
sleep.
Manic
episode: Distinct period (at least one week) during which
there is an abnormally and persistently elevated, expansive or irritable mood.
Major
depressive disorder: Severely depressed mood and activity level that
persists two weeks or more.
Obsessive
compulsive disorder: Recurrent obsessions (persistent ideas, thoughts,
impulses) or compulsions (repetitive behaviours such as excessive hand-washing)
that consume more than one hour a day or cause significant distress or
impairment.
Panic
attack: Period of intense fear or discomfort that is
accompanied by at least four of 13 symptoms, including pounding heart,
sweating, trembling or shaking, and fear of losing control or dying.
Social
phobia: Fear of social or performance situations in which
embarrassment may occur.
–
Compiled by Sharon Kirkey, Postmedia News
(Sources:
DSM-IV; Centre for Addiction and Mental Health; Canadian Psychiatric
Association; American Psychiatric Association)
What
they’re saying about psychiatry:
From,
“Saving Normal: An Insider’s Revolt Against Out-of-control Psychiatric
Diagnosis, DSM-5, Big Pharma and the Medicalization of Ordinary Life,” by Allen
Frances, MD, chair of DSM-IV Task Force:
“Normal
needs to be saved from the powerful forces trying to convince us that we are
sick.”
“Society
has a seemingly insatiable capacity (even hunger) to accept and endorse newly
minted mental disorders that help to define and explain away its emerging
concerns.”
“The
best way to deal with the everyday problems of living is to solve them directly
or to wait them out, not to medicalize them with a psychiatric diagnosis or
treat them with a pill.”
The
“massive misuse of antipsychotics is crazy and shameful — a triumph of
marketing might over common sense and good medical practice.”
From,
The Book of Woe: The DSM and the Unmasking of Psychiatry, by Gary Greenberg:
“Their
(psychiatrists) purpose in cataloging our troubles is surely not to turn us
into Shrink McNuggets. But they are in the grips of forces bigger than they are,
bigger than any of us. It’s not their fault that medicine is a service
industry, that diseases are market opportunities and that a book of them is
worth its weight in gold.”
“Even
at its best…..psychiatric diagnosis is fiction sold to the public as fact.”
From,
All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into
Mental Disorders, by Allan Horwitz and Jerome C. Wakefield:
“Perhaps
the oddest thing about the DSM-IV definition of social phobia is that it
classifies as disordered those people who are afraid in exactly those
situations in which fear is most natural: social or performance situations in
which the person is exposed to unfamiliar people or to possible scrutiny by
others.’”
“When
are our fears normal and when do they reveal that something has ‘gone wrong’
with our minds? There is no precise answer to this question … No sharp lines
divide natural sadness from depressive disorder, attention deficit disorder
from boisterousness or bipolar disorder from ordinary mood swings.”
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