Many psychiatrists limit the application of their skills to individuals whose discomfort matches the phenomenological criteria of DSM-IV-TR. Can psychiatry transcend the concept of "objective cure" and include "subjective perfection" as a goal? Is there a logical reason why the concept of "treatment pills" cannot coexist with that of "lifestyle pills" on the psychiatric prescription pad? Dr. Giannini reflects on whether there can be both "cosmetic" as well as "reconstructive" psychiatry and if a disease is needed in order to be treated.
"Is that all there is?" may not be a question limited to recovering psychiatric patients. It is one that can be asked by any person, including those who do not meet diagnostic standards. Many psychiatrists tend to limit the application of their skills to those whose discomfort matches the phenomenological criteria of DSM-IV-TR.
It is the mission of this profession to render assistance to any who seek relief from emotional illness. This noble mission, however, does not currently apply to people who seek only subjective perfection. These are people who, while not experiencing a psychiatric disorder, wish to minimize the emotional discomforts of everyday life, reducing any minute impairment in their work life, love life or play life. It is therefore valid to ask: Can psychiatry transcend the concept of "objective cure" and include "subjective perfection" as a goal? Is there a logical reason why the concept of "treatment pills" cannot coexist with that of "lifestyle pills" on the psychiatric prescription pad? Cannot there be both "cosmetic" as well as "reconstructive" psychiatry? Does one need a disease in order to be treated?
By utilizing DSMs and other official disease catalogues, the psychiatric profession achieves mastery of its domain. It defines disease and then limits treatment to those who have disease: the patients. But the D-word can be applied and withdrawn at will. Homosexuality can be a disease or not, depending on the votes. Premenstrual syndrome can be accorded or denied disease status or relabeled "L2D2." Nicotine use can mutate from non-disease status to a dependency to an addiction. The scarlet D can or cannot be bestowed. But if it is not bestowed, one cannot be defined as "patient." Without the proper definition, no treatment is available.
All diagnostic categories, even the "V" codes (for other conditions that may be a focus of clinical attention) require a disease or problem state. The sick can be cured and made well; there is no room for the well who have no disease or problem, but merely wish to pursue their subjective definition of perfection. This definition may be particular to the individual, and it may even be peculiar. However, if it requires the psychiatrist to do no harm, then individuals should be able to expect professional guidance in pursuing their self-defined ideal state of being.
This pursuit, however, is blocked by a wasteland of introjected ideology and professional inertia. The operational medical protocol encompasses diagnosis, prognosis and treatment. As such, it may be a quantum jump to practice in the absence of diagnosis and prognosis and then proceed immediately to treatment. What HMO will authorize treatment for a wish that is neither Axis I disease nor a V code problem? Indeed, how does a psychiatrist justify prescriptions for people who have unfulfilled ambitions, not diseases? How does the psychiatrist fill in the "diagnosis" line on mail-in prescription forms? For the strictly disease-oriented psychiatrist, it may be difficult to prescribe a medication without a PDR-recognized indication or "minority school of thought" for support.
Well people seeking subjective perfection are discouraged by physicians wielding the persuasive powers of diagnostic definition--no diagnosis or label, no prescription, no pills. Acceptance of the label redefines the "well" as the "unwell."
By such transformative redefinition, the well are not seeking cosmetic change; rather, the sick are asking for cure. Now defined as "patients" who are ill, they can receive prescription medication. Well people are now diagnosed as "dependent," "addictive" or the all-encompassing "personality disorder not otherwise specified." Ideology is served. Choices can now be made on the basis of social coercion, not individual choice (Foot, 2002). Who, indeed, is to be master?
Cosmetic psychiatry may raise fears of a brave new world with a "pill for every ill." Yet, Huxley (1958) in his review of the drug-oriented society, Brave New World Revisited, worried not about the use, but the overuse, of psychoactive drugs. It was the need for equipoise that drew his concern. Western philosophy does not allow emotions to be erased; the physical, intellectual and spiritual worlds exist to be "experienced." It is also a post-Enlightenment axiom that the full range of human emotion is the birthright of all. This birthright, however, is not always accepted. Physicians routinely mask the "experiences" of pain, insomnia, nausea and motion sickness. In addition, physical cosmetic pharmaceutical agents such as tretinoin (Retin-A), minoxidil (Rogaine) and α-hydroxy acid are used daily by well patients wishing only to blur the effects of aging by cosmetic physical pharmacology.
It is the use and not the abuse of psychotropic medication that forms the framework of cosmetic psychiatry. Cosmetic use is conceptualized as an adaptive, nonabusive approach to life. This is in contrast to the nonadaptive, abusing retreat of addiction. Cosmetic psychiatry can enhance but not distort memory and perception, increase performance but not create introversion, and establish conditions for an overall sense of enjoyment and fulfillment.
Many nonaddictive, relatively safe medications are available for the well person seeking subjective perfection. In some cases it is the side effect that provides the desired enhancement.
Propranolol (Inderal), an antihypertensive, has short-lived anxiolytic effects and can be cosmetically prescribed for people who do not meet criteria for an anxiety disorder but must, nevertheless, occasionally function in emotionally charged situations (Kohnen and Oswald, 1988). Overscheduled students could likewise benefit from the short-lived energy boosts and diminished sleep requirements associated with the early phase of bupropion (Wellbutrin) usage (PDR Drug Guide for Mental Health Professionals, 2002). Moderate weight reduction can be achieved with sertraline (Zoloft) in euthymic patients without amphetamine-like effects (PDR Drug Guide for Mental Health Professionals, 2002). End-of-workday ennui can respond to the γ-aminobutyric acid (GABA)-ergic effects of kava kava (Piper methysticum) without the intoxication of an evening nightcap (Singh, 1992). (The U.S. Food and Drug Administration advised consumers of the potential risk of severe liver injury associated with the use of kava-containing dietary supplements in 2002--Ed.)
A feeling of overall well-being, not quite realized in daily pursuit of the mundane, can sometimes be produced with St. John's wort (Hypericum perforatum) without addiction in people without depression (Hoffman and Kuhl, 1979). Bupropion can increase libido, while fluoxetine (Prozac) can decrease this drive depending on the requirements of the well person's lifestyle. Overstressed workers can "come down" with valerian (Valeriana officinalis), experiencing enhanced mood and diminished anxiety (Kohnen and Oswald, 1988).
Well people can use these substances with or without the guidance of psychiatrists. If this guidance is withheld, the users of these medications may be exposed to the dangers of side effects and misuse. It has been reported that self-prescribing individuals without guidance are less likely to follow directions and report greater toxic effects (Beckman et al., 2000; Chan et al., 1995). Our knowledge of psychopharmacology can be properly employed to achieve the greatest possible benefit. It is our responsibility to use that knowledge when harm is not done and well-being is enhanced (Glazer et al., 2001).
It may be further argued that acceptance of the concept of cosmetic psychiatry can also encourage recreational drug use. This argument, however, ignores the current availability of cosmetic psychotropics. Valerian and kava kava can be purchased in commercially bottled teas or tea bags. These botanicals, as well as St. John's wort, can also be purchased without prescription in capsule form at the neighborhood pharmacy or mall-based health food store. The public is ready for these agents. One need not embrace the libertarian agenda to accept that, in a free society, adults are capable of making informed decisions regarding their emotional status (Bentham, 1996). Psychiatry can respond to the legitimate needs and expectations of the public or be shunted aside. We can appropriately administer these medications to well people or allow such use to proceed without our guidance (Giannini and Giannini, 2000).
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