Psychiatric Diagnoses: Fact or Fiction?

Below is a guest post from Tim Desmond. I do not necessarily agree with all of the the contents of the post below, but I thought the topic was thought-provoking and controversial, so I have agreed to publish it. Feel free to add comments as you see fit; I will likely add my two cents in the next couple days...

I would like to contribute to the discussion on this blog by summarizing the work of Richard Bentall, psychologist and award-winning author, on psychiatric diagnosis and the DSM-IV. While we may be able to agree that long-term use of neuroleptics should not be the treatment of choice for schizophrenia, or that bipolar disorder is being over-diagnosed in children, I would invite us to question whether 'schizophrenia' or 'bipolar disorder' are valid diagnoses at all. Over the course of his career Richard Bentall has critiqued the medical model of modern psychiatric diagnosis and proposed instead a more personalized symptom-based approach.

The basic question is this: Do people suffer from a finite number of discrete psychiatric disorders/diseases or do people experience varying degrees of human suffering in their own idiosyncratic ways (which include spectrums of sadness, fear, dissociation, etc)? The modern mental health establishment clearly subscribes to the former as evidenced by the structure of the DSM and the theory of 'chemical imbalance.' This belief is so pervasive that even people who claim to disagree with the medical model of diagnosis often think within its terms. For example, the idea that one can be 'misdiagnosed' presupposes that a correct diagnosis could exist. Similarly, saying that schizophrenia is partially caused by psychological factors assumes that 'schizophrenia' is a valid way to group people.

The theory that psychological distress is caused by a finite number of psychiatric diseases can be attributed to Emil Kraepelin, who first published his Compendium of Psychiatry in 1883. Kraepelin believed that the psychiatric patients he treated suffered from diseases analogous to any treated by a practitioner of internal medicine. (Note the common comparison today between psychiatric diagnoses and diabetes forwarded by the pharmaceutical industry.) He said a specific disease process should generate identical symptoms, have identical pathological anatomy and identical etiology (or cause). According to Kraepelin, all that was needed was for these diseases to be discovered in order for diagnosis and treatment in psychiatry to catch up with the rest of medicine. Since it was far beyond the knowledge of his time (or ours for that matter) to find common pathological anatomies or etiologies, he chose to group symptoms. He believed that if he grouped symptoms 'correctly' the people grouped together would be sharing the same underlying disease. They would therefore have the same anatomical problems, the same etiology and respond more or less identically to treatment. He hoped that this kind of systematizing would lead to great advances in the efficacy of treatment.

While Kraepelin's categories have changed over time and grown from 3 to over 200, the basic idea persists to this day – that there are a finite number of discrete psychiatric disorders/diseases people can have and if we were to somehow group symptoms 'correctly' we would have isolated real disorders/diseases.

The problem with this idea is that it is not at all based in evidence. It began as Kraepelin's assumption and he was unable to provide any research in his lifetime to support it. However, it has been an idea so compelling to psychiatrists that they have tried in vain to support it for over one hundred years. In fact, there is a large body of research that directly contradicts this theory.

For example, you would expect that if one doctor diagnosed you with Strep Throat, you would be able to go to any other doctor and get the same diagnosis – and you'd be right. The reason for this is that Strep Throat is a real disease associated with an infection of streptococcal bacteria. You either have it or you don't and there are reliable ways to test if you do.

However, if you are experiencing severe psychological distress and one psychiatrist diagnoses you with "bipolar disorder" there is only a 50-60% chance that the next one you see would give you the same diagnosis. Why is this? Both psychiatrists would have been highly trained in diagnosis, and they would be using the same criteria to make their judgment. So if one says you have PTSD, another says bipolar and a third says brief psychotic disorder, which is the "correct diagnosis?" What do you really have?

Bentall argues the problem is that Kraepelin's main assumption – that there are a finite number of discrete psychiatric disorders – is just not true. You don't have any of those disorders because they are not real. Instead he argues that any psychiatric patient is experiencing a high level of emotional distress that is expressing itself through a range of symptoms and these symptoms can be better understood as extreme expressions of normal human responses to distress.

Bentall advocates for abandoning psychiatric diagnoses altogether. He claims that psychiatry's stubborn attempt to treat mental distress as a medical problem is what has led to its inability to improve treatment outcomes over time. Citing a large body of research, Bentall shows that symptoms from depressed mood to hallucinations can be accounted for psychologically and that doing so is not only more in line with science but more humanizing to patients. Therefore he favors what he calls a 'complaint-oriented' approach in which each patient would be assessed according to his or her unique symptomology. The focus becomes the symptoms themselves and we avoid trying to groups them into arbitrary non-existent disorders. Symptoms can be understood and treated, while disorders cannot because they are not real.

To learn more about Bentall's work, read his 'Madness Explained' which won the British Psychological Society's Book Award.

Author Note: Tim Desmond offers phone counseling and training for therapists through his website at www.coherencecounseling.com

Furious Seasons is On Fire

Furious Seasons suffers from a chronic case of excellence, but standing out even more than usual were a quartet of posts today that should be read by all:

• DSM-V Authors Tied to Pharma (hardly surprising, but interesting)
• Beatdowns in Texas Mental Hospitals. In the land of TMAP, disgusting behavior is apparently quite widespread.
• Is Bipolar Disorder Overdiagnosed? Nah, of course not.
  
• Seroquel for Depression -- Start the Countdown. Another chapter in the Seroquel for Everything saga about to be put into print. Lock up the women and children, since they'll be the first to be 'Quelled.
  

Shyness: Pathological or Normal Experience

SmikeKlineBeecham/GlaxoSmithKline, the psychiatric elites who devised the Diagnostic and Statistical Manual of Mental Disorders, and social phobia. An interesting combination. I read a fascinating op-ed in the New York Times by Christopher Lane , an English professor at Northwestern University that discussed the growth of social phobia, especially among kids. Here are some highlights...

"How much credence should we give the diagnosis? Shyness is so common among American children that 42 percent exhibit it. And, according to one major study, the trait increases with age. By the time they reach college, up to 51 percent of men and 43 percent of women describe themselves as shy or introverted. Among graduate students, half of men and 48 percent of women do. Psychiatrists say that at least one in eight of these people needs medical attention.

"But do they? Many parents recognize that shyness varies greatly by situation, and research suggests it can be a benign condition. Just two weeks ago, a study sponsored by Britain’s Economic and Social Research Council reported that levels of the stress hormone cortisol are consistently lower in shy children than in their more extroverted peers. The discovery upends the common wisdom among psychiatrists that shyness causes youngsters extreme stress. Julie Turner-Cobb, the researcher at the University of Bath who led this study, told me the amounts of cortisol suggest that shyness in children “might not be such a bad thing.” [Not sure that this finding in itself is strongly suggestive of anything important, but it's interesting.]

Lane goes on to write about his perception that the diagnostic criteria are too loose for social phobia. Then, enter Paxil.

Then, having alerted the masses to their worrisome avoidance of public restrooms, the psychiatrists needed a remedy. Right on cue, GlaxoSmithKline, the maker of Paxil, declared in the late 1990s that its antidepressant could also treat social anxiety and, presumably, self-consciousness in restaurants. Nudged along by a public-awareness campaign (“Imagine Being Allergic to People”) that cost the drug maker more than $92 million in one year alone ($3 million more than Pfizer spent that year promoting Viagra), social anxiety quickly became the third most diagnosed mental illness in the nation, behind only depression and alcoholism. Studies put the total number of children affected at 15 percent — higher than the one in eight who psychiatrists had suggested were shy enough to need medical help.

This diagnosis was frequently irresponsible, and it also had human costs. After being prescribed Paxil or Zoloft for their shyness and public-speaking anxiety, a disturbingly large number of children, studies found, began to contemplate suicide and to suffer a host of other chronic side effects. This class of antidepressants, known as S.S.R.I.’s, had never been tested on children. Belatedly, the Food and Drug Administration agreed to require a “black box” warning on the drug label, cautioning doctors and parents that the drugs may be linked to suicide risk in young people.

You might think the specter of children on suicide watch from taking remedies for shyness would end any impulse to overprescribe them. Yet the tendency to use potent drugs to treat run-of-the-mill behaviors persists, and several psychiatrists have already started to challenge the F.D.A. warning on the dubious argument that fewer prescriptions are the reason we’re seeing a spike in suicides among teenagers. [Note that I tackled this recently.]

It goes on to close with...

With so much else to worry about, psychiatry would be wise to give up its fixation on a childhood trait as ordinary as shyness.

To view the diagnostic criteria for social phobia, please go here. Here is a key symptom:

"The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia."

The diagnosis depends to a large extent what the doctor considers as "interferes significantly" or as "marked distress." When Paxil was being pushed, I'd be willing to bet that the reps were given scripts that helped to expand the boundaries of social anxiety disorder. When words like "significantly" or "marked" are used, one has to wonder what they mean? Who shapes physicians' judgment on these matters? To a notable extent, physician perceptions are influenced by commercials, er, continuing medical education and cheerleaders, er, drug reps.

A great piece from the New Republic in 1999 relevant to the expansion of social phobia can be found here. The points raised in the article ring true today. Let me be clear: I've seen real social phobia -- it exists and it is painful. But does it really affect 13% of Americans? I think not. I'm quite glad that Dr. Lane is stepping into the fray. I'm not sure I agree with him wholeheartedly, (I'll have to read his upcoming book first), but I know that I'm glad someone is willing to bring these issues to the fore. At the very least, this is a subject worthy of debate and discussion, not blind acceptance of the current orthodoxy that social phobia (like everything else) is underdiagnosed and undertreated.

DSM System is WHA?

The DSM system of diagnosing mental disorders is dehumanizing. Not my words (though I think it's largely true), but the words of Nancy Andreasen, a rather big-name psychiatry researcher at the University of Iowa. Here's a quote [emphases added]...

The DSM has had a dehumanizing impact on the practice of psychiatry. History taking—the central evaluation tool in psychiatry—has frequently been reduced to the use of DSM checklists. DSM discourages clinicians from getting to know the patient as an individual person because of its dryly empirical approach. Third, validity has been sacrificed to achieve reliability. DSM diagnoses have given researchers a common nomenclature—but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity.

Ouch. Training in psychiatry programs as well as (sigh) some psychology programs has often been reduced to memorizing symptoms and asking yes-no questions from a checklist. See what diagnosis a person has by asking a bunch of structured questions then whip out a prescription pad. Talk with the patients about their problems, develop a relationship? Nah, we never learned about that in our graduate/medical training.

Hat tip: AHRP.