How American Psychiatry Can Save Itself: Part 1
How American Psychiatry Can Save Itself: Part 1
[Note: For Part 2 of Dr Pies' article, click here.] Charles Dickens might well say of American psychiatry, “These are the best of times and the worst of times.” Certainly, our profession can point to some important accomplishments. In the past 30 years, the burgeoning fields of neuropsychiatry and behavioral neurology have begun to bridge the Cartesian rift between mind and body. Using new types of brain imaging, neuroscientists can now peer into the molecular and chemical mechanisms that underlie such basic human emotions as anger and grief.
Devastating illnesses, such as schizophrenia and bipolar disorder, are slowly disclosing the subtle ways in which they affect the brain’s structure and function.1 And, in the past 3 decades, psychiatry has made notable progress in developing effective forms of both psychotherapy and “somatic” treatment. For example, the 1980s and 1990s saw the growing use of cognitive-behavioral therapies (CBTs) for anxiety and depression and the development of clozapine—arguably the most effective medication for schizophrenia. Technical refinements in the use of electroconvulsive therapy (ECT) led to reduced cognitive adverse effects while efficacy in the treatment of severe depression was maintained.2
And yet, this rather glossy synopsis omits many reasons why psychiatry as a profession finds itself in deep trouble. (Googling the phrase “psychiatry is in trouble” brings up over 2100 hits.) A spate of recent books by psychiatrists and other mental health professionals offers a range of “diagnoses” for psychiatry’s present malaise: for example, claims that psychiatry lacks a unified model of so-called mental illness (a term that is itself a sign of philosophical confusion in the field); that psychiatry has no “objective” criteria or biological markers for any of its principal diagnoses; that psychiatry has “medicalized” perfectly normal human reactions to stress and loss; and finally, that psychiatry has botched its diagnosis and classification system—witness the present debacle over the still-developing DSM-5.
Perhaps most damning is the charge that psychiatry has abandoned its most fundamental and sacred obligation: to see the suffering patient as a whole person and not merely as a cerebral container in which a bunch of chemicals are sloshing around. (Etymologically, our term “patient” is related to the Latin pati, “to suffer.”) Recently, several high-profile articles claiming that psychotherapy has nearly vanished from psychiatric practice3 seem to have convinced the public that psychiatry’s demise is all but certain—and sometimes this conviction is voiced in the spirit of “Good-bye and good riddance!”
Each of these critiques contains at least a grain of truth—and some contain a few drams. Yet, in my view, each of these claims regarding what is wrong with psychiatry either oversimplifies the problem or ignores more fundamental issues. Here I consider each critique in some detail. In part 2 (which will appear in a future issue) I address what I believe are more central problems for American psychiatry and some ways of redressing them.
Lack of a unified model of “mental illness”
It is true that psychiatry lacks a unified model of so-called mental illness. For critics such as psychiatrists Niall McLaren4 and Dusan Kecmanovic,5 this “conceptual cacophony” is a serious, even a fatal, flaw. To be sure, any modern textbook of psychiatry is likely to explain conditions such as schizophrenia and major depressive disorder by invoking biological, psychological, social, and even spiritual factors, with greater weight usually given to the biological realm, for the most serious disorders.
Yet there is nothing inherently “unscientific” in such pluralistic models; on the contrary, the testing and verification of these potentially complementary causal hypotheses are very much a scientific endeavor. Furthermore, many of the most important advances in the history of psychiatric treatment have occurred in the absence of any single, unifying “model” of mental illness—for example, the discovery that lithium is effective in stabilizing the mood swings of bipolar disorder, or the development of CBT for mood disorders. (The “fathers” of CBT—psychiatrist Aaron Beck and psychologist Albert Ellis—had to push back hard against the prevailing psychoanalytic model of mental illness.)
Lack of “objective” criteria for diagnoses
The claim that modern-day psychiatry lacks “objective” criteria or biological markers for any of its principal diagnoses is only partly correct. Much depends on what we understand by the term “objective.”a
Scientists steeped in the philosophical tradition known as logical positivism insist that “objective” data are those obtained by direct observation and measurement—for example, by viewing bacteria under a microscope. But this model is hard to apply to many medical specialties, and the positivist notion of “objectivity” has been largely discounted by many modern-day philosophers of science.
The neurologist who takes a careful history of the patient’s head pain and makes a diagnosis of “migraine headache” sees nothing at all under a microscope: the relevant “data” consist almost entirely of the patient’s narrative, in the presence of a normal neurological examination. This is entirely commensurate with the psychiatrist’s method of arriving at a diagnosis after a careful history and mental status examination, after ensuring that the patient has no medical or neurological disease that explains the symptoms. In so far as their observations are systematic and replicable by other qualified practitioners, the neurologist and the psychiatrist are carrying out “objective” investigations.
Furthermore, there are no “lab tests” or imaging studies that allow the neurologist to “confirm” a diagnosis of migraine. Like epilepsy and many chronic pain syndromes, the diagnosis is clinically based.
Finally, while it is true that no psychiatric disorder has an office-ready, biological marker or “blood test” associated with it, it is incorrect to conclude that no progress has been made in this regard. Several biological markers of psychiatric illness have been repeatedly supported by careful studies over several decades; for example, abnormal smooth pursuit eye movements in schizophrenia6 and derangements of hypothalamic-pituitary-adrenal function in certain types of severe (“melancholic”) major depression.7 Unfortunately, for a variety of practical and theoretical reasons, these tests have not found a useful place in everyday psychiatric practice.
“Medicalizing” normal human behavior
One of the most widely bruited claims in recent years is that psychiatry has “medicalized” or “pathologized” various types of “normal” human behavior. This claim is sometimes voiced most forcefully by psychiatrists themselves, as several widely publicized critiques by Allen Frances, MD, make clear.8 (Dr Frances, of course, was Chair of the task force that developed DSM-IV.)
The “medicalizing” claim has been made in relation to a variety of psychiatric conditions, including ADHD, incipient psychotic states, and major depression. For example, in their book The Loss of Sadness, professors Jerome Wakefield and Allan Horwitz argued that recent “decontextualized” DSM criteria for major depression have created a false epidemic of depression in this country. (In fact, however, several epidemiological studies in the US and Canada have shown that the incidence of major depression has remained largely the same over the past 50 years when the same basic criteria are carefully applied.9)
The problem with the notion that psychiatry is “medicalizing” normality is that it rests on certain assumptions about the terms “disease,” “disorder,” and “normality”: for example, that there are relatively clear demarcations or veridical tests that define these terms. Seen from this perspective, any attempt at broadening the criteria for a particular disorder runs the risk of creating “false positives” or even “false epidemics.” Yet in truth, terms such as “disease,” “illness,” “dysfunction,” and “disorder” have been in flux throughout the history of clinical medicine. The philosopher Ludwig Wittgenstein10 cautioned us against so-called essential definitions—those specifying the necessary and sufficient conditions that define a term—and argued that words derive their meaning from the diverse ways in which they are used.Therefore, the term “disease” will acquire a variety of legitimate meanings, depending on whether the word is used by an epidemiologist, a psychiatrist, or your next-door neighbor.
Furthermore, since there are no universally agreed on biological criteria for psychiatric disorders, the notion of a “false positive” becomes extremely difficult to explain, in a psychiatric context. Indeed, the term “false positive” was appropriated from fields such as microbiology, where, for example, we can point to the organism Treponema pallidum as the causal agent of syphilis. It is easy to define a “false positive” in such cases—no bug, no disease. It becomes much harder when dealing with the diagnosis of, say, major depression. Much depends on what degree of suffering and incapacity we wish to impute to the realm of the “normal”—and this is only in part a matter of “objective” science. It is, in greater measure, an existential decision, involving very general ideas about health, disease, and how we wish to live our lives.
Botched system of diagnosis and classification
On the claim that the APA has badly mishandled the entire DSM-5 process, much has been written, sometimes based on quite valid concerns. Dr Allen Frances as well as others have complained, for example, that the DSM-5 work groups are planning to reify new, untested diagnoses; that most members of the work groups lack “real-world” clinical experience and have been isolated from much-needed input from everyday clinicians; and that lower thresholds for several diagnoses will lead to excessive prescription of psychotropics. (Dr Frances11 has also called for an independent scientific review of the entire DSM-5 project, and on that issue, we are in agreement.)
But while each of these criticisms of DSM-5 is worthy of debate, they all miss the central problems with the most recent DSMs, which run much deeper than Dr Frances’s concerns. Fundamentally, the entire DSM approach to understanding and classifying psychiatric illness—while useful for researchers—is routinely disparaged or ignored by many work-a-day clinicians, who use the DSM codes principally to satisfy insurers and third-party payers. As Dr James Phillips12 advised psychiatrists, “Give up your expectations that the [DSM] should tell you what is essential in your assessment and treatment of your patient. Think of it rather as a crude guideline that, we hope, will land you in the right diagnostic ballpark—and not much more.”
To be sure, the DSM criteria sets help researchers by creating what is termed “good inter-rater reliability”; that is, the specific categorical diagnoses can be readily agreed on by multiple researchers. The DSMs have also helped establish “thresholds” of pathology (eg, by stipulating interference with social or vocational function). But, in my experience, most clinicians have neither the time nor the inclination to follow the stringent inclusion and exclusion rules demanded by the DSM—nor do many clinicians believe that these criteria sets tell us much about the nature and “deep structure” of the patient’s problem. The “person” has been lost, as Dr Phillips12 has put it.
Indeed, DSM-IV and impending DSM-5 share a fundamental and perhaps fatal paradox: by lacking either a sound biological basis or a rich description of the patient’s subjectivity, they create “the worst of both worlds” for clinicians. On the one hand, without biological markers for the major disorders, the DSM diagnoses remain only loosely moored to modern medical science. On the other hand, the DSM does not provide the deep understanding of the patient’s “inner world” that existential, psychodynamic, and phenomenological approaches foster. The solution to this paradox will not come easily, but I will try to sketch some radical ways in which our diagnostic system needs to change.
Acknowledgment—I would like to thank both Joseph Pierre, MD, and James Knoll IV, MD,a for their helpful comments on this essay.
aJames Knoll IV, MD, has pointed out to me (personal communication, January 2, 2012) that several judicial decisions reflect the misleading view that psychiatry is “totally subjective.” For example, Dr Knoll notes that in Sheehan v Metropolitan Life Ins. Co., 368 F.Supp.2d 228 (2005), which involved the recovery of unpaid disability benefits, a high federal district court held: “Unlike cardiologists or orthopedists, who can formulate medical opinions based upon objective findings derived from objective clinical tests, the psychiatrist typically treats his patient’s subjective symptoms.”
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