Monday, January 23, 2006

Shooting diagnostic fish in the psychiatric barrel: part two

More thoughts on this article. (Part one is here.) Dr. Savodnik writes:
"All medicine rests on the premise that disease is a manifestation of diseased tissue. Hepatitis comes down to an inflamed liver, while lung tissue infiltrated with pneumococcus causes pneumonia. Every medical student learns this principle. Where, though, is the diseased tissue in psychopathological conditions?

Unlike the rest of medicine, psychiatry diagnoses behavior that society doesn't like. Yesterday it was homosexuality. Tomorrow it will be homophobia. Someone who declares himself the messiah, who insists that fluorescent lights talk to him or declares that she's the Virgin Mary, is an example of such behavior. Such people are deemed — labeled, really — sick by psychiatrists, and often they are taken off to hospitals against their will. The "diagnosis" of such "pathological behavior" is based on social, political or aesthetic values.

This is confusing. Behavior cannot be pathological (or healthy, for that matter). It can simply comport with, or not comport with, our nonmedical expectations of how people should behave. Analogously, brains that produce weird or obnoxious behaviors are not diseased.
He's not just shooting the fish. He's attacking the barrel.

I’m no philosopher. I can’t offer a discourse on the meaning of illness or disease. But I wonder: why dismiss the mounting evidence (hormonal, neurochemical, and genetic) that's converging on a physiologic mechanism for so many mental disorders? (See here and here...and my current favorite bit of thought along these lines: here.) The work is far from done. (Will it ever be done?) But why dismiss what we've already discovered?

Here’s Dr. Peter Kramer (of Listening to Prozac fame):
Some of the brain research that we have seen in the past seven or eight years has really made it clear that depression is a disease--there are neuroanatomical changes that are associated with depression, either causing it or being caused by it. But we don't have the kind of consistent marker that allows us to say in the way we can say with polio, ‘You have the symptoms of the disease, but you don't have the disease,' because we don't have the biological marker...
For some, the argument ends there. No biological marker? Then no disease called "depression." Yet so many lines of research have offered up clues. We seem so close...

So, Dr. Maurice, since you asked: here (finally) is my response. Yes, I think that we psychiatrists tend to over-pathologize. Yes, psychiatry must take responsibility for this behavior, and be vigilant about exposing and preventing it. No, I don't think that mental illness is a myth. I don't think personal responsibility is a myth, either. One of our most important jobs is to help patients take responsibility for their behavior. (And one of our thorniest issues is: when does illness impair a person's capacity to take responsibility?)

Yes, I think that research actually tells us something about the pathological basis of certain behaviors (unless the research was done by this guy.) As I've said before: the debate most certainly does not end here.

(APA President Dr. Steven Sharfstein answers Dr. Savodnik here. I wonder how he would answer Dr. Andreasen...)

15 Comments:

Blogger Spiritual Emergency said...

You raise some good questions.

A few years ago I underwent what would be referred to as psychosis or an acute schizophrenic break. Because I didn't realize that's what such experiences are called in this culture, I didn't seek medical care. Instead, I went into the psychosis and fully engaged the imagery therein -- it made for a rather fascinating story that was not the least bit disordered at all, although it certainly was "fragmented" at the beginning.

More than a year passed before I had a "name" for that experience. Since then, I've discovered other names as well. In the meantime, I've been working for the past three years, I've not had any formal therapy, and I've not been on any form of psychiatric medicine. I've been told by more than a few people that I couldn't get well without neuroleptics, yet, I seem to have managed quite well without them.

I've spent the past few years actively researching what it was that happened to me and collecting a number of articles that have helped me interpret, integrate and move through that experience. I've organized them on my blog should you or anyone else choose to take a look at them.

2:41 AM  
Blogger Fallen Angels said...

Hmmm...I have asthma, as long as it is under control (it is) and I do not have a virus or infection that is causing it to flare up, then I don't have a disease? I'm diabetic also, no complications yet (ever? knock on wood). Also under good control. So the only sign of diabetes is if I do not watch my carb intake..THEN my sugar levels sky rocket...so again, no diseaes? Just because it can't be physically seen with the naked eye (or aid of a microscope), does not make it any less real. I do agree that maybe things are over pathologized (maybe that guy with sociopathic tendancies is just plain mean)...I do NOT agree that many psychiatric "issues" are not biologically based. Depression, schizophrenia and bipolar disorder to name three. I have had many bouts of depression. If it were not, in part, biologically based, then why would it respond to meds? Not placebo effect either, we tried 3 antidepressants before finding one that helped.

Sera

6:35 AM  
Blogger Joel said...

I'm just shaking my head at this guy and at the newspaper which printed him.

How much does the Church of Scientology pay him?

9:06 AM  
Blogger Joel said...

Hmmm. Just checked. Savodnik hates the Church of Scientology.

What bothers me is this: some months ago, another blogger attacked me and other bipolars by suggesting that our mood swings were "normal, so just get off it." I found the statement dismissing and entirely clueless when it came to feeling this disease from the inside.

I remember when I was unmedicated. If I told people how I was feeling, I'd get these Looks. A few would tell me that they never got the feelings. Others would tell me to "chill" or make a similar oppressive comment. I often heard that I was whining for attention (which I was because it hurt) and then told that it was all just because I was a loser who didn't have the right attitude.

When I read Savodnik's words, I feel that the philosopher-shrink has loaded up a million rounds and handed them out to the cruel. One small misleading article in the Times, one giant setback for sufferers of mood disorders.

9:13 AM  
Anonymous Anonymous said...

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3:09 PM  
Blogger Spiritual Emergency said...

Fallen Angels: I do NOT agree that many psychiatric "issues" are not biologically based.

I would agree. But just as there are different forms of diabetes which require different forms of treatment, I think too that there are different forms of mental illness, each of which may present differently in different individuals.

For example, the root cause of "schizophrenia" has been attributed to genetics, neurology, nutritional deficiencies, stress, environment, culture, and more. I would suggest that all or some of those may play a role to varying degrees in a psychotic episode but those degrees will vary.

If it were possible to accurately measure the impact of each factor we might discover that one individual was 13% genetic; 28% neurological; 11% stress; 9% environment, etc. Another individual could have an entirely different make-up.

Unfortunately, the ability to make such a finite diagnosis is not available and may never be. Instead, we know that some people get better with this drug, or some people get better with that drug, or some people benefit more from lifestyle changes and talk-therapy. I think where discussion breaks down is when we adopt an either/or attitude, such as it's always nue to neurology or it's always due to environment. The "face" of any degree of mental illness is a very individual face.

7:13 PM  
Blogger Fallen Angels said...

Spiritual Emergency...your points would be why I said "in part, biologically based".

7:58 PM  
Anonymous mchebert said...

When I was in college, I had a friend that drove me crazy any time we had a debate. We could be arguing about capital punishment, for instance, and he would end up arguing, "you can't define murder. What is a crime? What right does society have to punish?" He was using and old philosophical trick. When you have no argument, make the other guy define things. Ultimately, you end up splitting grains of sand into atoms, and then splitting atoms, and then you have nothing. Defining things is very, very slippery.

And yet, the world is obviously real. It is miserable defining depression, but we all know what it feels like, we have all felt it. Just because one can tear apart the specifics of the DSM-IV doesn't mean it is not getting at something very real.

Psychiatry lags far behind medicine. This is because traditional medicine has existed since ancient times, but arguably psychiatry has only existed as a discipline for 100 years. One would expect such a young science to be less precise than say, cardiology.

Angina was known as a clinical entity centuries before its cause was understood. But just because William Osler could not point to a specific disease process to explain angina did not mean it did not exist. In fact, thousands of doctors throughout the centuries describing angina with increasing precision opened the door for a physiologic explanation for angina.

Psychiatry is in the description phase. We should expect DSM criteria to get more and more elaborate as we sift through the facts. As the underlying pathology is understood, these descriptions will serve as the framework for the pathological explanations, when they come.

8:17 PM  
Blogger Joel said...

SE and FA: The way I see it is that the body is just one of the environments in which we sufferers exist.

9:07 PM  
Blogger Lisa said...

Wow, that comment from the doctor above, seeking a personal audience with Shrinkette, is the scariest comment in this thread. Enough to make a blogger's blood run cold!

Now on to the meat of this post. It seems to me that a lot of stuff that's presently in the DSM -- and in the history of psychiatry -- has not exactly been science, and by science I mean presenting falsifiable claims. Let's say someone gets a diagnosis of cancer. Well, that diagnosis is a falsifiable claim -- we have ways of going and checking if that statement is true or not. For many psychiatric disorders, this is not the case. How would you falsify a diagnosis, of, say, Narcissistic Personality Disorder?

Like Shrinkette I think we will narrow in on many biological processes gone awry that cause mental illness. In the meantime, the fact that we don't have those -- and the diagnostic tools to go with them -- absolutely affects patients. Without clear and falsifiable diagnoses, treatment becomes an experiment the patient performs upon themselves -- trying (with their doctors' permission, of course) different drugs at different combinations, throwing things at the wall to see if they stick. How can such a patient tell if the lift they feel is placebo or not? This is not a question that sufferers of, say, pneumonia have about their treatment; it's much clearer when something is actually working.

Think about that for a minute. People with psychiatric illnesses, when they finally seek treatment, go home with something which neither they nor their doctor knows whether it will work or not, and many will not know for weeks whether it does, and even then it might not be exactly clear whether it's working.

Yikes!

If the making of psychiatric diagnoses leaves the realm of art and judgement and moves further along the spectrum towards being a science -- prodded by advances of our understanding of the brain --it will be a great thing for everybody, patients and doctors included.

9:34 PM  
Blogger jw said...

Aside from my belief/experience that psychiatry puts culturally convenient falsehoods ahead of truth ... Aside from that, I see a lack of willingness to use a true definition of science as set out by Feynman.

For example, if I get more than 50 hours sleep each week, I have no psychiatric symptoms (other than annoyance at bigotry as set out before). Now, it seems to me that psychiatry is not at all willing to answer the question "Which is the cause?"

Do I become psychotic at 35 hours per week because of a mental illness? OR Does a lack of sleep, due to cause unknown, cause psychiatric symptoms?

It does appear that the answer within psychiatry is a matter of answering the question "Which medicine do I have to throw at this problem?" That is, in my mind, not science.

3:03 AM  
Blogger David said...

It would be very strange if there were no forms of mental illness that are not entirely mental..that is, that have no biological basis.

By analogy: it's possible for your computer to have software problems even if the hardware is working perfectly.

And it's probably possible to acquire sets of ideas that will drive you crazy, even if you have no underlying biological problems.

The flow of causality may, of course, work in the other direction...your bad ideas make you depressed, and the depression creates hormonal changes that can be detected.

6:01 PM  
Anonymous Anonymous said...

Your link to the VEN article is fascinating, in that I have a number of relatives and friends who are particularly intuitive/empathetic.
Would love to know if women have more VEN cells.

This discussion of depression is also of enormous interest, having gone through my father's year-long refractory depression long-distance, which, in retrospect, was largely "managed" medically by my mother and myself.

Hospitalizations--short term, of course--meds increased, meds changed, thyroid added. CBT added to existing therapy. As you are already anticipating--finally, the call to zap him. Magic! And why not six months earlier? Or three months earlier?
But never any type of objective assessment of anything. Left on current meds at current doses because???? Why the thyroid ???

Folks, it's a long, long way from looking like this care/treament has much to do with science. MAJOR "art".
No blame here, just the view from the trenches.
Next time, we'll do the exercise/ fish oil more intensely...

10:03 AM  
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5:39 PM  
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8:36 PM  

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