Melvin Gray, MD

It is imperative for a psychiatric classification system to integrate theories of matter, consciousness, emotion, personality, social interaction, and behavior into as much of a unified system of diagnosis as possible. For a diagnostic classification system to be meaningful, it should include at least the following components: physiological expression of the central and autonomic nervous systems, cognitive appraisal (evaluation), subjective experience, and behavioral activities.

Current psychiatric classification, for the most part, excludes the emotional dimension, yet emotions are innately stored as neural programs within the brain. They are expressed in universally and socially understood ways and have common qualities that help determine the adaptiveness or non-adaptiveness of a particular action, in a particular situation. Emotions affect the whole person from the level of the neuron to a worldview. They can even be considered as an altered or special state of consciousness. Emotions can often exist independent of other states but usually interact and influence coexisting states or processes, either in consciousness or non-consciousness.

If this is so, then no behavioral, perceptual, cognitive, or neuronal condition can be absolutely free of emotion-and therein lies the problem of current psychiatric diagnosis and treatment. Since our current system is mainly empirically based and materialistic, it reflects only a partial and perhaps naive understanding of the human person. Knowledge gained from other sources, such as intuition, creativity, spirituality, and subtleties of feeling and emotion, may be lost in this type of approach. The loss of these qualities of mind has led to an undesirable alienation of psychiatry from a humanistic approach to treating the mentally ill.

A case presentation may help our understanding:

Mary is a slim, 32-year-old woman who speaks rapidly, gets upset easily, and is inclined to cry at the least provocation. In her work for an automobile agency, she expresses doubt about her secretarial capabilities. During the past 4 months, she and her boyfriend, Paul, began what was her first sexual relationship. Recently, they talked about “love,” and this made Mary realize that Paul is not her ideal partner. Questions about their compatibility began to crop up in her mind: he is not handsome enough, they lack common interests, their cultural and educational backgrounds are different, he could be more considerate of her, etc. After thinking over these concerns for about a week, Mary decided to terminate the relationship, even though she “liked” Paul.

After the breakup, Mary was sad, but within several weeks she began feeling better, even though she was not dating. Her daily life became one of going to work, returning home, and remaining alone. After another month of this routine, she developed a reluctance to leave her high-rise apartment for any reason other than shopping and work. One day while entering the elevator, Mary became extremely anxious. She described how her heart pounded and her chest tightened, as sweat rolled down her back and she became dizzy. Before the elevator reached the street level, her tension became so great that she impulsively exited the building. Once outside, she slowly calmed down and eventually returned to a normal state. This sequence of events occurred repeatedly, ultimately resulting in Mary’s inability to go to work, and even a reluctance to leave her apartment.

The symptoms I have described were indications for pharmacological and psychotherapeutic intervention. At the patient’s request, I submitted statements to the insurance company, listing the dates, costs, and time spent for each treatment, as well as the appropriate diagnostic and procedural codes. (Was this an infringement on my patient’s privacy?) Problems with the insurance payment began immediately. First, with respect to the prescription, the insurer wanted justification for use of a brand-name drug. Why didn’t I prescribe a generic instead? Then my billing statement was rejected: they initially wanted my Social Security number, but that was not good enough. After much arguing, this “provider” was required to submit his PIN number and medical license number. When all was said and done, it took over 6 months before payment was received.

Corporate medicine, lawyers, the pharmaceutical industry, and insurance companies are using psychiatry as a tool. They use the current diagnostic system to encourage and enhance the use of medicines by psychiatrists. Lawyers and patients can also use the diagnostic system in the pursuit of lawsuits. Moreover, the current diagnostic system does not consider the specific individuality of patients and deters creative thinking. What the Academy of Psychiatry created, the government and the industrial complex have used for their own advantage-at the expense of psychiatrists and their patients.

Mary’s case illustrates the minimum components necessary for a “comprehensive diagnosis.” Beginning with a stressful situation that upset her equilibrium, Mary appraised the circumstances with Paul, both positively and negatively, and made a decision that led to their breakup. She later developed an irrational fear that resulted in stimulation of her autonomic and voluntary nervous systems. This, in turn, motivated an impulsive action to escape from what she interpreted as a dangerous situation.

But does this “rational explanation” really explain Mary’s behavior-or is there something more? In his 1934 poem 

, T. S. Eliot suggests an answer, in the very questions he raises:


                                     Where is the wisdom we have lost in
                                                      knowledge?
                                     Where is the knowledge we have lost in
                                                       information?

Logical and scientific explanations of causation are limited and open to falsification; there is something to be known beyond what science or deductive logic can offer us. We need psychiatrists who are experts in dealing with the human condition; who understand the depth of human feelings; and who share the joys, agonies, and distresses of their patients. We do not need psychiatrists who fit people into categories and slots and treat them as if they are robots, according to the dictates of a recipe book called 


 • Chalmers D. Facing up to the problem of consciousness. 

A Feeling of What Happens: Body and Emotion in the Making of 

New York: Harcourt Brace; 1999.
 • Dennett DC. 

Sweet Dreams: Philosophical Obstacles to a Science of Consciousness. 

Cambridge, MA: MIT Press; 2006.
 • Dunbar F. 

 4th ed. New York: Columbia University Press; 1954.
 • Eliot TS. Preface. In: 

Thoughts for Meditation: A Way to Recover From Within.

 London: Faber and Faber; 1951:12. 
 • McDermott JJ, ed. Introduction and Preface. In: 

The Writings of William James: A Comprehensive Edition. 

Chicago: University of Chicago Press; 1977:9-134.


  

Articles

We do not need psychiatrists who fit people into categories and slots and treat them as if they are robots, according to the dictates of a recipe book called “The Diagnostic and Statistical Manual.”

The Limitations of Our Diagnostic Classification: Beyond DSM’s Checklists

The usual procedure for a funeral or memorial service in today’s world begins with the attendees arriving at a set time, followed by the mourners’ lining up in the chapel or other setting and cordially greeting one another.

In the Jewish tradition in which I was raised, the rabbi speaks to the mourners, either on the day of the services or the evening before, and gathers biographical information regarding the deceased. In many cases, the rabbi didn’t know the deceased or if he did, it was on a superficial basis. At the service, the rabbi delivers a sermon, summarizing the individual’s life as told to him, usually including some Biblical references such as the twenty-third psalm and a few prayers. Then a relative or a close friend may make some statements. Following that, the funeral director instructs the group on how to proceed to the cemetery and where the 

” refers to the week-long mourning period in Judaism, for first-degree relatives of the deceased.) 

The service is conducted before a closed casket; or, in the case of a cremation, some pictures are displayed, and in these circumstances, there is no burial. (Orthodox Judaism does not permit cremation, but the practice is permitted by many Reform rabbis.)

On arriving at the cemetery, the mourners gather under a tent and the pall-bearers wheel the casket toward the pre-prepared open grave, which has an installed concrete base. The casket is then placed on a gurney-like structure over the grave. The rabbi says a prayer or prayers, places a black ribbon on the clothing of each of the mourners, cuts the ribbon, and the casket is then lowered by cemetery employees. After the casket is in the concrete casement, some of the mourners shovel dirt on the casket (usually 3 scoops each). When all the people who want to shovel have finished, everyone leaves and some go to the 

 home where, after washing their hands, they find a rather elaborate feast waiting.

The mourners sit around the dining area and talk. As is often the case in other religious traditions, the usual post-burial conversations include political events, how the stock market is doing, the latest sport stories, general news of the day, and perhaps some personal vignettes about themselves or their children’s activities. There is very little talk regarding the deceased, and all seem to be in fairly joyous mood and in good spirits.  But on occasion, someone in the crowd may shed a tear, and express praise for how beautifully the rabbi (or minister) spoke during the service.

In today’s world, we are witnessing a de-emphasis and depersonalization of how the bereaved experience the death of a loved one. In fact, the occasion of death is frequently referred to as a “celebration,” despite the pain and suffering that can occur. Death is not an occasion for a celebration. Death is a time for mourning by family and friends. Death is a loss-not only to the deceased, who lost everything, but to all those who care about the deceased.

Some mourning rituals nowadays involve a feast that frequently includes alcoholic beverages-more a party than a sad occasion! This forces the mourning process to become an internalized, psychologically private affair-a solitary experience, rather than a shared occasion. Mourning hides behind a closed door and lacks the closeness and intimacy that should be shared. Under these conditions, the mourners avoid facing the unpleasant facts of putrefaction and decay, which the body inevitably undergoes. Instead, death is viewed as a “beautiful” experience. The realities of the body’s decay are obscured by embalming, flowers, fancy caskets, and a superficially joyous mood.

Today, one no longer expresses grief in public. Men and women behave “rationally” and exercise “self-control” during mourning, as proof of their will power and maturity. If grief is expressed openly for a “prolonged” time (more than about 60 days), it is interpreted as a refusal to accept reality-and, by some, as “pathological.”

I reject this attitude. I think it is wrong and psychologically damaging to the mourner. In contrast, I believe the Jewish religious tradition is psychologically healthy. It involves an initial mourning period of 7 days (

), during which a prayer known as the “mourner’s kaddish” is recited by the bereaved. 

is followed by a period of mourning known as shloshim, which extends for 30 days from the burial. For those grieving the death of a parent, an additional year of mourning is required. I believe these extended periods of mourning have much to offer, and show that we are souls and spirits more than mere flesh. In this mourning process, religious belief and tradition is in harmony with scientific knowledge regarding the need for adequate time to grieve.


  
Finally, speaking of science, I believe we came from stardust, and that with death, we return to dust-only to be “re-circulated.” Could it be that, in this sense, there is a kind of afterlife, as so many religious traditions have held?

 Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160/?report=abstract

For more details on Jewish mourning practices, see:


http://www.jewishmag.com/52mag/mourning/mourning.htm

Melvin Gray, MD

Articles

The Limitations of Our Diagnostic Classification: Beyond DSM’s Checklists

Grief, Mourning-and the Denial of Death