Monday, January 23, 2006

Shooting diagnostic fish in the psychiatric barrel: part one

Does psychiatry pathologize normal behavior, inventing diseases with the reckless abandon of Dr. Unheimlich? Is the DSM an atlas of cultural bias, without a shred of tissue-based evidence to support it? Yes, says Dr. Irwin Savodnik, in this provocative, satirical LA Times editorial. He blasts the APA and its diagnostic manual: 1994, the manual exploded to 886 pages and 365 conditions, representing a 340% increase in the number of diseases over 42 years.

Nowhere in the rest of medicine has such a proliferation of categories occurred. The reason for this difference between psychiatry and other medical specialties has more to do with ideology than with science...Where, though, is the diseased tissue in psychopathological conditions?

Unlike the rest of medicine, psychiatry diagnoses behavior that society doesn't like...
One of my supervisors was fond of such arguments. He would whip out his pocket DSM during rounds, recite criteria for cyclothymia or dysthymia, and ask, "How is this a disease?" It's easy to shoot diagnostic fish in the psychiatric barrel - in fact, one can make a career of it. It's not hard to see why.

Many psychiatrists agree that things have gotten out of hand. Here's Dr. Andreasen, an early author of DSM, in the New Scientist. She explains how DSM was conceived, and how it expanded. She's very critical of DSM now:
DSM is based on careful observation but it is just not complete - it was never meant to be the absolute truth. That's what people miss. We put in enormous caveats: use this book as part of a total clinical evaluation, use with great care, for use only by qualified doctors, and so on. But it represented a huge shift. It introduced diagnostic criteria. We wanted to make a statement about the importance of making psychiatry more objective.

One example is the description of schizophrenia: in DSM II, it is about five sentences. In DSM III, there are four or five pages of description followed by diagnostic criteria. We also managed to take out neurosis, which was important because we thought it was especially vague - and we put in a new approach to classification so we could incorporate medical and psychosocial elements of a clinical evaluation when it came to reaching a diagnosis.
Before the ink was dry on the first DSM, problems were apparent. Because the DSM-described behaviors have a social component and occur in a social context, they reflect biases in our culture. DSM has always been a work in progress (and it always will be). We must use extreme care when we use the term "pathological." Here's more from New Scientist:
In psychiatry, the cost of erroneous scientific theories can be incalculable. Get things wrong (or even only half right) and once adopted by the profession it can take years to weed them out. The result can be millions of shattered lives...

Some of the world's leading psychiatrists believe that this is just what has happened in their craft today...

Now into its fourth edition, DSM was meant to help doctors diagnose mental illnesses by categorising diseases according to a small number of telltale signs. What has happened, say Nancy Andreasen and many other psychiatrists who have helped to write DSM, is that it has become the main reference for diagnosis, something it was never intended to be. Now psychiatrists everywhere are reluctant to diagnose an illness unless its symptoms can be found in DSM...As the revisions to DSM multiplied, so did the criticisms: the manual's diagnostic categories were called prescriptive, arbitrary and driven by literal-mindedness. They did not reflect all opinions in psychiatry, said the critics, nor even a complete set of all psychiatric disorders worldwide.
This is serious criticism, and points toward some possible solutions. Clearly, we have tremendous work ahead of us.

But Dr. Savodnik seems to say: let's toss out the whole enterprise. Why does he send up Seasonal Affective Disorder? He doesn't cite any research or diagnostic criteria that trouble him. Satirized and oversimplified, his take on the disorder makes nice holiday copy, and illustrates his chief complaint: that APA is "selling mental illness," when there isn't any such thing.

...which brings me to part two. Next!


Blogger jw said...

I'll give my experience, which may show cultural error. From cultural error one can see the size and scope of the problem, without seeing how to fix the problem.

I'm male and once experienced a very violent female offender sexual assault. I had custody of two boys and they -tiny as they were- watched me lay on the floor in my own vomit & urine for two days.

Now, any attempt to bring that point (and any harm done by it) up with a psychiatrist or psychologist universally (6 in 6) results in a statement to the effect of "There are no female offender rapes of males so you were not hurt by one." (I might as well add that the breakdown is 8 in 9 for psych nurses.)

The diagnosis is therefore some form of personality disorder wherein I "must" want attention. I see cultural bigotry of the highest order ...

Bill Masters MD said that this would be true. He tried throughout his career to change some of the bigotry: He failed. (Now, of course, some accuse me of "name dropping" because I happen to have once spoke with Bill Masters! (Sorry, a pet peeve.))

So we have a situation wherein the truth is rejected in favour of a culturally acceptable falsehood. Harm is done to the patient to protect a false view of society. This happened to gays and others.

I spent a lot of time advocating for fathers with custody. In telling some of the stories I have been told "There was never discrimination against fathers with custody so you could not have had to work so hard to fix that problem. The problem did not exist in the first place." (The quote is accurate and from a psychiatrist. A psych nurse made a similar statement.)

Again, a supposed professional supporting a culturally convenient falsehood. Why? I've no idea, plenty of guesses, but nothing concrete.

I do know that the habit of supporting culturally conveniant lies over truth is rampant and causes real harm to real people. The experience of the few other men with assault histories similar to mine closely mirrors my own, just like Bill Masters said it would.

How then can I or any other reasonable person take the "craft" of psychiatry/psychology seriously? To me, I see a group of people who have the best interest of their own viewpoint as the first (and only?) guide for patient treatment.

Now, obviously, I have not seen every psychiatrist or psychologist (although I think that would make for a fascinating study, given my experience). That said, I have seen enough to say that there appears to be a real possibility that supporting cultural bigotry is --to the craft-- more important than treating patients.

I might note that the person who most helped me had a certificate from a mail-order university. Late in my complete story she ran from the room crying. THAT, that had an effect on me which lasted and helped. Now, when I get a bit down about the past, I think of her tears and feel better.

So, DSM aside, there are problems within the field which barr growth into a craft which offers real help to real people. Without making changes to the mental health "trade" so that reality comes first ... I draw a blank. I cannot see a way for psychiatry to grow as I cannot see a way to overcome the cultural errors which infest it.

2:33 AM  
Blogger Joel said...

jw: There are some chauvinistic doctors who dismiss patients' complaints because they just don't want to admit the possibility that the group they wish to protect would do such a thing or that the sufferings of those they thought were the enemy were real.

White male doctors have done it for years, often to female patients who come to them with complaints such as fibro-mylagia. Before I went dismissing that disease, for example, I would check and recheck the situation. Women have often been subjected to accusations of hypochondria. The same thing happened to you.

I have had the experience of relating what my mother did to me as a child. I get the lecture about how she was a victim of my father (though they argued passionately, I don't think he hit her). They don't want to listen as I describe how she slapped me around, humiliated me in front of others, tried to choke me, dug her fingernails into my wrist, and violated sexual boundaries. I have to completely forgive her and love her because "she was a victim".

Pardon me, but I went through more hell than she did during the years we lived together. And despite this, I don't call myself a victim but a survivor.

Patients and other therapists need to challenge any kind of thinking which promotes treatment along doctrinaire lines. After reading what I wrote, you might think that I ignore the feelings of women who have fallen prey to abusive men. On the contrary, I see them as comrades in the struggle against abuse. They know how I feel better than the hoi polloi. When I counsel anyone who wants to separate from a spouse on vague pretenses, I try to ascertain if there is real abuse or just the strange offense-taking of a mood swing (e.g. I am mad at my husband because he is too hairy. My wife should have bigger breasts.) I will never tell anyone that their hurt isn't real -- even if it sounds to me like they're grabbing at trivial stuff because of a med change or a mood shift. I've been there. The stuff is real.

9:28 AM  
Blogger BiPolar Guy said...

Good post!
Personally I don't think psychiatry can ever be an objective science considering all of the subjective participants (docs and clients).

Unlike the body, the mind has few boundaries, so boxing this enigmatic concept into neat categories will never work.

11:11 PM  

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