Saturday, May 4, 2013

How Scientific Is Psychiatry?

By now, just about everyone has recognized that psychoanalysis is not a science. Most of us console ourselves with the thought that psychiatry, the kind that involves diagnosing illnesses and prescribing medication to treat them is hard science.

Of course, psychiatry also has its discontents. Among them is the fact that it too often mistakes everyday suffering for disease. Extending diagnostic categories to the point where they pathologize  normal human emotion serves no purpose... for anyone but psychiatrists, that is.

If your anxiety or depression is trying to tell you something, it’s better to take heed than to silence the messenger.

Yet, psychiatry continues to invade the culture. Through its Bible, the Diagnostic and Statistical Manual psychiatry has colonized human experience and set its own standards for human conduct.

Therapist Gary Greenberg described the book’s importance in Wired Magazine in 2010:

The book is the basis of psychiatrists’ authority to pronounce upon our mental health, to command health care dollars from insurance companies for treatment and from government agencies for research. It is as important to psychiatrists as the Constitution is to the US government or the Bible is to Christians. Outside the profession, too, the DSM rules, serving as the authoritative text for psychologists, social workers, and other mental health workers; it is invoked by lawyers in arguing over the culpability of criminal defendants and by parents seeking school services for their children.

Now, as a new edition of the DSM is about to appear, many prominent members of the profession are expressing their doubts. [FYI, Greenberg’s new book on the subject, The Book of Woe has just appeared.]

Greenberg explained the issues in Wired:

The authority of any doctor depends on their ability to name a patient’s suffering. For patients to accept a diagnosis, they must believe that doctors know—in the same way that physicists know about gravity or biologists about mitosis—that their disease exists and that they have it. But this kind of certainty has eluded psychiatry, and every fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can’t rigorously differentiate illness from everyday suffering. This is why, as one psychiatrist wrote after the APA voted homosexuality out of the DSM, “there is a terrible sense of shame among psychiatrists, always wanting to show that our diagnoses are as good as the scientific ones used in real medicine.”

As it happens, the DSM has very little to do with science. Thomas Insel, director of the National Institute of Mental Health explained the difference in a recent post:

The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Significantly, Insel declared the NIMH will be replacing the categories in the DSM for new diagnostic criteria based on neuroscience.

Greenberg offered his own critique of the method used by the DSM. He quotes the view of Allen Frances, the lead writer of the last edition of the DSM:

Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have “major depression,” no matter your circumstances or your own perception of your troubles. “No one should be proud that we have a descriptive system,” Frances tells me. “The fact that we do only reveals our limitations.” Instead of curing the profession’s own malady, descriptive psychiatry has just covered it up.

As the DSM encroaches on everyone’s lives it has created both, as a thriving industry and a monstrosity. Whether out of zeal or blindness many writers of the DSM have failed to notice that it leads to over-diagnosis and over-medication. Here is what happens when the DSM introduces a new disease:

This new disease reminded Frances of one of his keenest regrets about the DSM-IV: its role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. 

Greenberg continued:

To harness the power of medicine in service of kids with hallucinations, or compulsive overeaters, or 8-year-olds who throw frequent tantrums, is to command attention and resources for suffering that is undeniable. But it is also to increase psychiatry’s intrusion into everyday life, even as it gives us tidy names for our eternally messy problems.

Senior psychiatrists understand the problem and have been explaining that the DSM is merely “provisional.”

Greenberg offered a fine rebuttal:

As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are psychiatrists ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

Sigmund Freud discovered that when you present strange ideas as scientific fact you can gain authority, power and prestige. Few people give it all up for the truth.


Anonymous said...

it seems to me that many problems stem from real situations: if a family member dies in front of someone it is not strange that that person is temporarily depressed

Anonymous said...

It was said that a person can have all the symptoms of an illness and still not have the illness. This makes Psychiatry a guessing game not an exact science.

Dennis said...

Could that not be said about Medicine or a lot of endeavors? It is about educated guesses that may or may not help. Psychiatry more so because it deals with mental illness and abnormal behavior. Both of which do not lend themselves to a "scientific" definition that is utile in many cases and downright wrong in others.
We each have our own DNA and are not an exact match for any other human being. This is why a medicine might help one person and be toxic to another. It is why we get this sheet of paper that lists all of the various side effects which if one reads it can make one wonder which is worse, the disease or the cure.

Lastango said...

Thanks for this excellent post! There is much food for thought here, with larger implications for other professions. (For one thing, it reminds me of how some of the most vocal opponents of a simplified tax code are accountants.)

The thing that bothers me the most about the DSM is the naked rent-seeking. Diagnostic categories fabricated for the purpose of tapping research grants and insurance money impact real lives. For a profession that prides itself on its deep grounding in ethics, and that preaches to the rest of us from a lofty pulpit, it's a jarring disconnect to have one foot in something very grubby.

Sam L. said...

Echoing Lastango--ya can't get paid for something if it isn't in the book.

So let's get more stuff in the book, and get paid for more, more, MORE! (Docs cut off legs and out innards for the $$$, sayeth BHO.)

Larry Sheldon said...
This comment has been removed by the author.
Larry Sheldon said...

People who know me have heard me complain about this:

"The authority of any doctor depends on their ability to name a patient’s suffering. For patients to accept a diagnosis, they must believe that doctors know—in the same way that physicists know about gravity or biologists about mitosis—that their disease exists and that they have it."

The two cases that leap instantly to mind both involve my suffering a whole lot more than I wanted to--of even that I thought I could bear anymore.

The most resent example involve pretty severe pains in one shoulder or the other, from which I could find no relief, either through changes of position or as a result of any of the chemicals I was willing to ingest. This was the apex of something that I have since decided started 20 or more years ago but various doctors, physical therapists, fad diagnoses, and drugs had done, at best, temporary and partial reliefs.

I was talked into seeing a chiropractor. (People my age remember when chiropractors were arrested for pretending to be doctors and the distrust runs deep. To this day I think much of what they teach is quackery or worse)

In due time the chiropractor announced that I had (have?) "brachial neuralgia" which is Latin, I believe, for "arm nerve hurts".

As good fortune would have it, he also had some "adjustment" tricks in his back that relieved (eliminated?) the symptoms. I don't know (or much care) if he "cured me". At my age and with the wear, tear, and abuse my body has experienced, I'd be a little surprised.

But I do know that the debilitating pain is gone for at least a while, as are the "carpal tunnel" pains and an annoying thing that I don't know how to describe--"twitch" is the short form of my attempts. The latter has annoyed me for years and disrupted my ability to relax and to sleep. All of these symptoms in my mind are consistent with a "pinched nerve" in the shoulder region of my spine.

I still see him every week or so (or else the twitch returns), but I still get my flu shots and I think diphtheria, smallpox and polio are good for small children.

The other case I mentioned quite a few years ago--I had been on a trip out in the desert for several days and had worn military-style calf-high boots much longer that I should have and got back to town with both feet (as the firemen might say) "fully involved" with what I guessed (from the smell) was a fungal infection.

As soon as I could, I got in to see a dermatologist, who in due time, after some poking and probing and "hmmmmm"ing announced triumphantly that I had "tinea pedis". Which is, I think, Latin for "feet itch".

Anonymous said...

I want to know what Tom Cruise what he thinks of all this. Tom Cruise is the final word for me on all matters related to mental health. Like he said,all of this can be handled with vigorous exercise, regardless of the level of mental anguish. If you'll just open your own personal copy of Dianetics, we can go to page...


Dennis said...

Again thanks for the laugh. I'm sure L. Ron Hubbard covered all of this in exquisite detail???????

Sam L. said...

Dennis, I think yo0u have to jine up and pay the big bucks for L.Ron to learn you how to 'fix' yourself.

Anonymous said...

Now more than ever, patients in need of psychiatric care are given a fair chance. As modern medicine evolves and as more people are educated about mental disorders and addictions, the stigmas attached to psychiatry are starting to dissipate and the quality of treatments available are improving.
psychiatry Salem MA

Unknown said...

Psychiatry often defined as the science of pathological behaviour and mental life.

Psychiatrist and Therapists in NYC