Marxism, Anarchy, Psychiatry as art and/or science
woniahcmos
Reading-GreenbergPsychiatry.docAll quotes taken from:
http://www.wired.com/magazine/2010/12/ff_dsmv/
http://www.newyorker.com/online/blogs/elements/2013/05/the-scientific-backlash-against-the-dsm.html
http://www.newyorker.com/online/blogs/elements/2013/04/the-dsm-and-the-nature-of-disease.html
The DSM (Diagnostic and Statistical Manual of Mental Disorders) is a publication of the American Psychiatric Association. It is in it's fifth edition. It is by far the most influential diagnostic tool in American psychotherapy.
A number of very notable psychologists and psychiatrists, notably Thomas Insel (Director, National Institute of Mental Health), Steven Hyman (Former Director, N.I.M.H.), Al Frances (Lead editor, DSM IV), Robert Spitzer (Lead editor, DSM III) have come out as extremely critical of the committee that put together the DSM V. Their criticisms are diverse and unique to each person, but there are a number of common threads: that the diagnosis in the DSM are hopelessly unscientific, that they probably benefit insurance companies and pharmaceutical companies more than patients and doctors, and most of all, that the DSM can actually impede science rather than help it. For instance, many scientists are searching very hard for a some sort of biological (viral, neurological, hormonal, etc.) cause for borderline personality disorder. Insel and Greenberg would assert that the problem with this is that borderline doesn't exactly...well, exist, strictly speaking. More on that later.
No-one has chronicled this "revolt" within psychiatry more than Dr. Gary Greenburg, publisher of many books and articles. In one of his latest pieces for the New Yorker, Greenberg interviews comments at length about Thomas Insel's latest comments:
When Thomas Insel, the director of the National Institute of Mental Health, came out swinging with his critiques of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, a couple of weeks ago, longtime critics of psychiatry were shocked and gratified. Insel announced that that the D.S.M.’s diagnostic categories lacked validity, that they were not “based on any objective measures,” and that, “unlike our definitions of ischemic heart disease, lymphoma or AIDS,” which are grounded in biology, they were nothing more than constructs put together by committees of experts. America’s psychiatrist-in-chief seemed to be reiterating what many had been saying all along: that psychiatry was a pseudoscience, unworthy of inclusion in the medical kingdom...
...But Insel was not saying anything he hadn’t been saying for years. In fact, he wasn’t even the first N.I.M.H. director to say such a thing. Steven Hyman, his predecessor at the post, first began expressing concerns about the D.S.M. more than a decade ago, noting that its categories had been invented primarily to provide a common language for psychiatrists...Diagnostic labels, according to Hyman, had never been intended as more than useful constructs, placeholders that would provide agreement until psychiatry could develop objective measures—presumably when the understanding of the brain caught up with the understanding of the heart or the understanding of viral transmission.
Greenberg is rather cynical about our ability to understand depression and anxiety at this point from a neurological level; the neuro-psychiatric revolution has been rather slow in happening. For now, science is barking up the wrong tree:
From the time the D.S.M.-III first took the descriptive approach, in 1980, bureaucracies like Insel’s and Hyman’s, which fund most of the mental-health research in the country, began acting as if diagnoses like schizophrenia and bipolar disorder described conditions as real as AIDS or lymphoma, encouraging, if not forcing, researchers to tie their studies to D.S.M. diagnoses. At the Food and Drug Administration, new drug applications tied to D.S.M. diagnoses were placed on a faster (or less slow) track than drugs only tied to symptoms; it was much easier to get approval for a drug targeted to a major depressive disorder than a drug targeted to, say, sadness. In school systems, a D.S.M. diagnosis was an indication that a child had a medical condition that required special services. In courtrooms, expert testimony about a defendant’s mental disorder could affect the disposition of the case. The D.S.M. had been taken, as one of its staunchest defenders put it, “too seriously.” An entire mental-health system had followed the manual down a rabbit hole and into a world that doesn’t really exist. Or, as Hyman put it—and as Insel had long agreed—the D.S.M. had locked psychiatrists in an “epistemic prison."...
...The reification of the D.S.M. might not have been more than a philosophical problem, were it not for the fact that, at least in Hyman and Insel’s view, it was beginning to hamstring research. And, indeed, the D.S.M. has frustrated scientists, who note that the most common symptoms of mental disorder—sadness and worry, for instance, or delusions and hallucinations—appear as criteria for many different diagnoses...Looking for the neurochemistry of mental disorders that don’t necessarily exist has turned out to be as futile as using a map of the moon to get around Manhattan.
Taking the D.S.M. seriously is not helping psychiatry at all. The pharmaceutical industry seems to be giving up on psychiatric drugs, and people like Hyman attribute the empty pipeline directly to their disenchantment with the D.S.M’s failure to correspond to neurochemical reality. Late in 2011, Insel seemed to be in a state of despair about his profession, which he attributed in part to the D.S.M. “Whatever we’ve been doing for five decades, it ain’t working,” he told me. “When I look at the numbers—the number of suicides, the number of disabilities, the mortality data—it’s abysmal, and it’s not getting any better. Maybe we just need to rethink this whole approach."
Let's break this down into two basic ideas:
The Gary Greenberg project:
(1) Lighter thesis (what definitely Allen Frances, Thomas Insel, and probably psychiatrists, especially outside the U.S., would probably agree with):
Diagnosis are weaker, in terms of hard science, than many patients think that they are. It is destructive for patients to hear, "you have depression," as a statement of scientific fact, at least not the same way that being HIV positive is a fact. For a patient who has HIV, 20 doctors will agree on this, unless there was a lab error. For a patient who is sad and anxious, a number of different diagnosis might be rendered, and this is as it always has been. Psychiatry is a young science, and patients should never take a diagnosis on as a full-blown identity. They often do, of course, and psychiatrists who know better should speak out more about this. A VERY serious part of this problem is that many patients with common diagnoses never, or only very briefly, talk to a psychiatrist. Approximately 80% of diagnoses of depression and anxiety disorders come from a primary care physician or an ER doctor, not from a psychiatrist.
This last point is worth pausing on, in order to understand why this is considered a problem: Let's say that young person tries to hurt themselves or someone else, and takes a trip to the hospital; an ER doctor sees them for 10 minutes, says that they clearly are depressed, gives them an anti-depressant. The patient proceeds to take on, for the rest of their life, the identity of having an incurable disorder that they pour all their negative emotions into. No psychiatrist would ever encourage them to do this, but that's the thing: they've never seen one. They interpret the weight and finality of the DSM in their own way.
This problem is widespread and destructive.
The Heavier Thesis: What Greenberg thinks, and others are more guarded about; this 'extreme' position may have many doctors behind it, but it is certainly not the consensus:
(2) The diagnosis aren't weak; they're ephemeral; they refer to nothing at all. Gary Greenberg gives the example of a neurological disorder that was commonly diagnosed in the mid 1800's: runaway slave depressive disorder. Some runaway slaves showed persistent signs of depression, an unwillingness to accept their status as slaves upon being re-captured. Southern neurologists and doctors paid a great deal to study the disorder. It had ever single attribute of a modern personality disorder, says Greenberg: a distinct set of physical symptoms that manifested under predictable circumstances in a certain group of people. But now, of course, we would say that the slaves were depressed for good reason. "But there are so many rational reasons for despair and grief," Greenberg writes. Who is to say that most of us aren't sad for rational reasons as well? There is a simple logical fallacy that underlies all modern psychiatry: that something that has a material manifestation (ie, depression or anxiety, which can be described in terms of chemistry and brainwaves) must have a material cause. If I deeply religious in my youth and lose my faith when I'm 25, and then go through a period of deep depression and anxiety, a psychiatrist could diagnosis me as clinically anxious and depressed, but this misunderstands the nature of my condition: the cause of his depression is philosophical, and not material. Every human experience (love, beauty, hatred, depression) can be described in terms of brainwaves and body chemistry, but this does not mean that the cause of Jack and Jill falling in love is most accurately described as, "a mutual firing of endorphins." That's like saying that the cause of a fight was a fist hitting a jaw. It is approximately as stupid (Greenberg, Frances, and Insel would all agree on this point) to sit down with someone who is depressed and say, "the cause of your depression is a lack of serotonin." The lack of serotonin is the manifestation of their depression, not necessarily the cause.
It is very hard to overstate their thesis: Greenberg, Insel, and Frances (and to a lesser extend Hyman and Spitzer) are saying that clinical depression or anxiety are not medical diagnoses at all, to the best of our knowledge. We've spent 50 years throwing checklists and drugs at them, and still there is not even a whiff of consensus on the difference between someone who is depressed out of grief, depressed because of bad genes, or depressed because they're going through a phase.
My own opinion: Many people I know who have tried them have been helped by anti-depressants and anti-anxiety meds, and many others have been hurt by taking their diagnosis of depression too seriously. I have also witnessed more than once now the horrid farce of a couple in breakup both parties diagnosing the other as having narcissistic personality disorder, borderlines personality disorder, etc.; it's ugly, ridiculous, and bringing psychiatrists in on the conversation doesn't always help, because they disagree with each other as well. And yet, it is hard for me to completely accept the Greenberg/Frances/Insel polemic; the implications for our mental health system are just too..well, depressing. Most doctors, psychiatrists, and patients have a somewhat subtle view of these things.
And here's something that we do know: some people display symptoms of anxiety and depression and are helped by medication, and this is actually quite similar to many medical conditions, such as RSD or Chronic Pain Syndrome. RSD clearly is a medical condition; we simply diagnose it using symptoms and effectiveness of treatment, rather than testing for a particular cause. Chronic Pain Syndrome, quite common, is obviously real because they pain is real, but we do not what exactly causes it, nor do we understand why some people get better and others don't.
And yet the more that I read of Insel and Greenberg, I am astounded by the depth of their criticism; they paint a picture of a profession that is essentially a massive joke, an exercise in groupthink that probably hurts people more than it helps them. To quote Allen Frances (lead editor, DSM IV), supposedly one of the most respected psychiatrists in the world, "There is no definition of a mental disorder. It's bullshit." Really, Allen? Yikes.
The greatest counterargument to their work is not that most psychiatrists disagree with them (most could be wrong; that's the nature of groupthink), but that so many patients seem to be genuinely helped by mainstream psychiatry, warts and all. Anyone who is planning on going into the profession ought to take their thesis seriously. The articles cited at the top of this reading are a good place to start, as are Dr. Greenberg's books, Manufacturing Depression and The Book of Woe.
The best single book perhaps ever written about depression, as a diagnosis and as an experience, is The Noonday Demon by Andrew Solomon. Interestingly, everyone on all sides of this debate respects this book. It's a poetic, rigorous analysis of the author's own experiences with clinical depression crossed with his research on it's history; the author relies on medication and therapy to function, but he is also deeply cynical of the DSM as an absolute tool for the same reason the Greenberg is. If there is a middle ground, this book represents it quite well.
