Friday, November 14, 2014

Science and Pseudoscience in Psychiatric Training: What Psychiatrists Don't Learn and What Psychiatrists Should Learn

Phrenology was a pseudoscience of the 19th century, based on the notion that skull morphology could reveal psychological attributes. The hodgepodge of models of mind today may be no better.
Though psychiatric residency training is a year longer than internal medicine residency training in the United States, psychiatrists in training are expected to master a smaller proportion of the knowledge and skills than their internal medicine colleagues are. Worse still, the fraction of diagnoses that psychiatrists are expected to manage compared to internists include pseudomedical disorders, the status of which is suspect even within the profession [1]. Given that psychiatrists are charged with the task of caring for the most vulnerable members of society, the basic level of training should equip psychiatrists to fulfill this task. The knowledge base of neurological, medical and genetic disorders with neuropsychiatric presentations, the insights of psychological and social sciences, evidence-based practice, and the philosophy and ethics of psychiatry must become part of the training of every psychiatrist. Many would claim this is already the case, but what is currently emphasized is tantamount to pseudoscience. 

The Medical Basis of Psychiatry
The remedicalization of American Psychiatry was ushered in by the publication of DSM-III in 1980 [2]. The triumph of DSM-III was to firmly establish the central role of psychiatric diagnosis in the practice of psychiatry. As the DSM-5 debacle has shown, psychiatric diagnoses are not the product of nature but common consensus, a consensus that has been criticized for eroding the range of human behavior seen as normal [3]. This emphasis on the DSM has marginalized the contribution of descriptive psychopathology [4], de-emphasized the construction of the medical and neurological differential for the psychiatric patient [5], and led to the uncritical acceptance of psychiatric diagnoses whose validity and reliability are questionable [6].

Descriptive Psychopathology
In focusing on teaching psychiatric diagnosis à la DSM, psychiatrists are no longer familiar with the rich descriptions of morbid mental life described by Kraepelin [7], Jaspers [8], Bleuler [9], and Schneider [10], who attempted to feel their way into their patients’ experiences and catalog the heterogeneity of human suffering. In contrast, the DSM teaches psychiatrists there are prescriptive ways to suffer or become mentally ill throughout the globe [11]. When the psychiatrist meets a patient who has the audacity to have not read the DSM and not present a constellation of symptoms described therein, the psychiatrist is at a loss, and the patient finds herself ‘not otherwise specified’.

Differential Diagnosis
Rather than teaching practices that amount to pseudo-diagnostics, psychiatrists should learn more about the infectious, autoimmune, toxic, nutritional, metabolic, vascular, degenerative, and drug-related causes of disturbed moods, thoughts, behavior and perception that lead to psychiatric consultation. The recent discovery of the N-methyl-D-aspartate receptor autoimmune limbic encephalitis has led to a renewed interest from psychiatrists into other medical causes of neuropsychiatric disturbance [12]. Yet most psychiatrists learn little about when to order EEGs, neuroimaging, viral, autoimmune, and paraneoplastic panels, heavy metal screens and other investigations that can help diagnose their patients’ maladies, and how to distinguish between these and primary psychiatric disorders. We must be advocates for patients with neuropsychiatric disturbance whatever the etiology and this begins with diagnosis.

One of the most burgeoning fields of psychiatric research is genetics and psychiatrists in training are expected to learn something of this research [13]. The research so far has no clinical relevance to the practice of psychiatry. On the other hand, there are number of well recognized syndromes that are associated with intellectual impairment, emotional, behavioral and perceptual disturbances that lead to psychiatric consultation. The majority of these syndromes presents in childhood or adolescence. Occasionally however, these genetic syndromes can present in adult life. Most psychiatrists are familiar with genetic diseases like Huntington’s disease and Wilson’s disease that lead to psychiatric care, but are totally unfamiliar with the inborn errors of metabolism, chromosomal microdeletions, or mitochondrial diseases that can present with neuropsychiatric disturbance. Conditions such as orthnithine transcarbamylase deficiency [14], velo-cardio facial syndrome [15], or mitochondrial encephalopathy [16] are long forgotten from medical school if they were ever learned about at all. Many of these genetic syndromes are rare and it would be a waste of time for psychiatrists to learn the ever-growing list, but knowing when to suspect a certain type of genetic syndrome or when to consult a geneticist should be part of the training of psychiatrists.

By the 1980s, psychiatrists became so enthralled with the new drugs that many were no longer identifying as psychiatrists, but as psychopharmacologists. Yet with these new powerful tools at their disposal came the realization of serious adverse effects. Such is the risk associated with these powerful psychotropic drugs that Peter Gøetzsche, a co-founder of the Cochrane Collaboration, recently argued that they should be withdrawn from the market as physicians cannot be trusted to prescribe them [17]. Now that psychopharmacology has eclipsed psychotherapy as the mainstay of psychiatric treatment, it seems unacceptable that the study of toxicology in general and a full survey of the potential risks of psychotropic agents in particular is not part of psychiatric training. A recent study found only 2% of surveyed training programs had psychiatry residents elect formal training in toxicology and only 41% featured any toxicology in their didactic curriculum [18]. Little to no training is provided on withdrawing psychiatric drugs. It is unclear how many psychiatrists are familiar with the literature on supersensitivity psychosis [19], antidepressant related tardive dysphoria [20], or antidepressant-associated chronic irritable dysphoria [21].

Though psychiatrists routinely prescribe atypical antipsychotics, which cause metabolic syndrome, few psychiatrists are comfortable with treating hypertension, diabetes and dyslipidemia [22], and many of our patients are unable to access primary care. It is a shameful state of affairs that psychiatrists are not being trained to treat the very illnesses they cause in their patients and undermines the very basis of psychiatry as a medical specialty.

The Psychological Basis of Psychiatry
Although psychiatry’s love affair with biology long ago made a cuckold of psychodynamics, dynamic theory and therapy still form the crux of psychological approaches to our psychic woes that American psychiatrists learn. Many psychodynamic concepts are useful. It it is hard to argue with the core principles: our past experiences shape our present experience, our subjective consciousness is unique and should be respected, we are less aware of our motivations for actions than we like to think, our past relationships play out in the clinical arena, and our minds have carefully developed methods to help us ignore or avoid that which we do not wish to acknowledge [23].

That aside, psychodynamic theory is not scientific, can lead to blaming patients for the atrocities they suffer (for example the domestic violence victim is a ‘masochistic personality’ who needs to suffer [24]), often blames patients for not getting better (failure to recover is a ‘resistance’, the possibility that the therapy is simply ineffective rarely entertained), and can lead to fatuous interpretations which cannot be rejected by the patient who does not agree with the therapist (rejection of the interpretation is again, but a ‘resistance’, to the truth and the therapy). Some formulations are so ridiculous as to serve only perfunctory mental masturbation on the part of the therapist [25].

As a result of the psychodynamic hegemony over theoretical thinking in psychiatry, most psychiatrists have little awareness of the psychological theories that do have more robust support from research and help us understand our patient’s suffering. For example, cognitive psychology offers valuable explanatory frameworks that can be helpful in understanding depression [26], PTSD [27], and the formation of delusions and hallucinations [28]. The role of self-esteem and self-efficacy [29], theories of why different life events seem to trigger difficulties in different people [30], the development of social cognition in childhood [31], the role of attachment [32], and theories of personality [33-35] are given cursory attention if covered at all. Even though the same elements that comprise symbolic healing across cultures and therapies has been demonstrated [36], psychiatrists are still learning the basics of psychodynamic psychotherapy, cognitive behavior therapy, and supportive psychotherapy separately, instead of learning how to maximize the effects of contextual healing [37]. 

The Social Basis of Psychiatry
Despite the rich social science contributions to psychiatry that are extremely relevant to clinical practice, most psychiatrists, especially in the United States, are completely unaware of the classic studies in our field. Social scientists conceived of psychiatric disorders as social constructs [38] long before the geneticists realized these categories to be cultural rather than ‘natural kinds’ [39]. Social scientists highlight the role of social class [40], ethnicity [41], discrimination [42], life events [43], expressed emotion [44], the built environment [45], urbanicity [46], and social capital [47] on mental health. Goffman’s insights into the toxic effect of the total institution on psychiatric inmates [48], or the stigma of ‘spoiled identity’ [49] have passed a generation of psychiatrists by, despite being highly applicable to patient care. The damaging and unintended consequences of psychiatric labeling [50], the concept of mental illness in cross-cultural perspective [51], and the lack of validity of psychiatric diagnoses were highlighted by social scientists [52], and yet these studies are not must-reads for psychiatrists in training. Social science research explored why the prognosis of schizophrenia is better in developing countries [53], and the effects of political economy on mental health [54], and yet most psychiatrists are completely oblivious to the evidence for the causal role of macrosocial factors in major mental illness.

Instead ‘social psychiatry’ curricula consider ethnic and sexual minority groups, homelessness, insurance programs, and the structure of mental health programs. Even then, the causal role that minority status may play in collective and individual suffering is minimized. Many psychiatrists still believe that 1% of the population has schizophrenia, without respect to gender, ethnicity, or geography, despite widespread differences in the incidence of psychosis, even within the same city [55]. As Kleinman observed, the rest of medicine began to embrace the social sciences at the same time that psychiatry was turning her back on it [37]. Lay opinion holds that psychiatric illnesses are significantly influenced if not entirely caused by social factors [56]. Psychiatrists risk being out of touch with the public if they do not have a full appreciation of the effects of social factors on the etiology and course of mental illness.  

The Clinical Epidemiological Basis of Psychiatry
Evidence based care is supposed to drive up standards, ensure uniformity, establish best practice, guide clinicians and protect patients. This should be celebrated. Instead, evidence-based mental health is openly disparaged [57], and when psychiatrists don’t get the results they want, they ignore them, suppress them, or denounce them. The suggestion that antipsychotics could worsen the course of psychosis [19] was such an important one that you would think it would deserve considerable study, yet it has been largely forgotten. The finding that antipsychotics cause significant cerebral volume loss, rather than immediately being published [58], was analyzed again and again, until the reality of this finding could no longer be denied [59]. When randomized controlled trials, the gold-standard investigation, showed that SSRIs were associated with suicidal ideation [60], the results were denounced invoking correlational studies showing a inverse relationship between adolescent suicides with SSRI prescriptions [61], despite these studies being methodologically inferior. These attitudes have repercussions on the training of psychiatrists.

All of this is damning enough without calling into question the veracity of the evidence base which influences patient care. The deceptive influence of the pharmaceutical industry, the ghostwriting of journal articles, and selective publication bias, are well known to the public. Yet these concerns sit at the periphery of psychiatric training instead of the core.

The Philosophical and Ethical Basis of Psychiatry

The concept and nature of mental disorder
Most psychiatry residency training programs claim to teach a ‘biopsychosocial’ approach to psychiatric illness, though this approach has been deconstructed and derided as meaningless [62], anarchic [63], and a myth [64]. Although most psychiatrists also claim to use a biopsychosocial approach, a number of studies show that psychiatrists have different explanatory frameworks for different patients [65-67]. Assumptions about the nature of mental disorder go unexamined. These assumptions filter into the psychiatrist’s approach to the patient. Given that values, meanings and assumptions about the concept and nature of mental disorder, whether acknowledged or not, are at the very heart of psychiatric practice, they should also be at the heart of psychiatric training.

The mind-brain problem
The central debate of the philosophy of mind is the mind-brain problem. Although psychiatrists may wish to remove themselves from the fray, and pretend it has little to do with psychiatric training or practice, it confronts us at every turn [68]. Psychiatrists often make contradictory statements about the relationship of mind and brain without a second thought. Whether one invokes substance dualism, property dualism, materialism, explanatory dualism, functionalism, or eliminativism, far from being irrelevant, shapes our approach to patient care and how we frame research questions. Training psychiatrists in the philosophy of mind is neither practical nor useful, but psychiatrists should have an awareness of the different approaches they reflexively use and the implications on their work.

The Ethics of Psychiatry
Psychiatric ethics tends to focus on individual interactions between clinicians and patients, and psychiatrists consider issues of boundary violations, capacity, consent and coercion as part of their training. Given that the ethical basis of psychiatry as a profession is so often challenged, psychiatrists should learn not just psychiatric ethics, but the ethics of psychiatry. The ethics of psychiatry concerns itself with rights: the right to autonomy and self-determination, the right to happiness, the right to (refuse) treatment, and even the right to commit suicide. The ethics of psychiatry can thus be considered from the perspectives of utilitarianism, liberalism, libertarianism, Rawlsian ethics, and communitarianism [69]. Again, I am not suggesting psychiatrists be quasi-ethicists or philosophers, only that these aspects so implicit and entwined in psychiatric work be subject to critical examination that must begin with the training of psychiatrists.

The suggestions outlined above are not my own but have been developed from listening to what the public, patients and their families, and psychiatric survivors say they want. Those who don’t call for the outright dissolution of the specialty want psychiatrists to be able to know when a serious medical or neurological illness is responsible for their problems, to not have normal human suffering medicalized, and to avoid applying those pejorative labels that have no scientific basis. They want psychiatrists who not only can start medications but also safely withdraw them, be judicious with their use, be familiar with the inherent risks and respond appropriately to them; who can think psychologically about their problems; who understand what healing looks like; who can see as clearly as they can how powerful social forces and life events can affect mental health; whose practice is based on the evidence as it is and not how they wish it to be; who examine the assumptions and values that underlie their practice; and whose practice is ethically defensible. Current psychiatric training does not adequately meet these needs, and if not remedied, will lead to the continuing criticism and marginalization of psychiatry in medicine.

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Monday, January 6, 2014

Medicalizing Misery and the Loss of Social Suffering

Happy Pills
The real money always lay not in convincing sick people they were ill, but well people they were sick

Throughout the 1990s, the UK Royal College of Psychiatrists and Royal College of General Practitioners, enabled generously by the pharmaceutical industry, campaigned to educate clinicians and the public about depression and its treatment. The Defeat Depression campaign was pithily encapsulated in the slogan: “Depression. Treat it. Defeat it.”  Today depression is so overdiagnosed, that a recent study found that over 60% of those diagnosed did not meet the diagnostic criteria for a major depressive episode, rising to over 90% of those over the age of 65. A recent article in the BMJ claims that the DSM-5, by expanding the definition of depressive illness to include reactions to bereavement, will further erode the concept of normal sadness, leading to more people incorrectly diagnosed and treated for depression. If not depressive illness, what are we experiencing? The answer: social suffering.

The changing face of depression

From 1992 to 1996, the Royal Colleges of General Practitioners and Psychiatrists led the Defeat Depression campaign, to raise public awareness of depression as a medical illness, and to educate professionals to diagnose and treat it. A UK survey of public attitudes at the time found that 85% believed counseling to be effective but were against antidepressants, and almost 80% believed antidepressants were addictive. By 2003, traces of metabolites of the antidepressant Prozac would be found in the water supply. By 2012, 50 million antidepressant prescriptions were issued in England alone, with 1 in 6 people in some areas using antidepressants. This is despite the number of people suffering from depressive illness at any one time staying roughly stable at about 6%. How did this sea-change occur? So successful was the public education campaign and other sources of information, that many people have now come to believe that depression is caused by a chemical imbalance in the brain that is corrected by antidepressants. As the sociologist Nikolas Rose notes, we have come to recode our moods in terms of neurotransmitters, and identity in what he calls ‘the neurochemical self’. In addition, primary care doctors who bear the brunt of the endemic minor misery were heavily pushed into screening for depression, and reimbursed on quality measures including documenting depression scores of self-report rating scales like the PHQ-9. The result was an increase in new antidepressant prescriptions throughout the 1990s. This was coupled with the lack of availability of psychological treatments, with waiting lists in some areas as long as two years.

Although the detection of hitherto unnoticed individuals who suffered extreme mental anguish explain some of the rise in depression diagnoses and antidepressant prescriptions, in the early 2000s something strange happened. In the UK at least, the number of new prescriptions for antidepressants weren’t increasing, but the overall number of prescriptions were. That is to say, it wasn’t that more and more people were being prescribed antidepressants, it was that those who were on them continued. Depressive illness, once thought of as a temporary aberration, sometimes chronic and lifelong, was becoming more chronic. It is likely that antidepressants themselves may have played some role in this. There is some suggestion that some individuals on long-term antidepressant use will become depressed as a result of the chemical changes occurring in their brain, the so-called tardive dysphoria syndrome. Part of this is likely psychological too – in the narrative of chemical imbalances, taking antidepressants is just like insulin for diabetes. If you stop taking your antidepressant won’t your chemical imbalance come back? Further, by locating the source of distress inside a broken brain or twisted molecules we have disempowered individuals to take charge of their lives. The reality is, as I discussed previously, the notion that depression or any mental illness is caused by chemical balances is an oversimplification at best and a myth at worst. That is not to say there is no biological basis to depressive states, but this despair cannot be meaningfully reduced to aberrant brain chemistry.

The currency of depression

Today the word depression provides a currency of validation. When we see a doctor feeling deflated, tired, sleepless, joyless, or sad, a diagnosis of depression is like a badge of honor for the wounded warrior, it confers recognition that we have suffered so. There is something reassuring to hear an ‘expert’ tell us they know what is wrong and they know how to help. When you feel like you are drowning, a prescription for a pill, is like a lifeline that keeps you afloat. And even though you know the reasons you feel so terrible, which you are constantly reminded of, it becomes convenient to believe that something as simple as a chemical imbalance is at the root of it all. Even if you realize that the remedy may be in deeper psychological work, having more money, a better relationship, a better economy, better behaved children, a sense of self-worth, or even taking better care of yourself, those things are unavailable or not forthcoming. We make do with what’s on offer. And what’s on offer is antidepressants.

Incidentally, whilst states of despair and misery have existed throughout time and space, depression only has currency in the West in recent times. In China whilst the same syndrome of major depressive disorder is recognizable, it has no cultural cachet. Instead the diagnosis of neurasthenia is made. In Zimbabwe, anxious and depressive ruminations are captured by the term ‘kifungisisi’ (which is included in the DSM-5) which means 'thinking too much'. In Somalia, there is no linguistic concept of depression. The closest thing is ‘Qu’lub’ which translates as ‘the feelings a camel has when its friend dies’. In Latvia, the term “nervi” or damaged nerves captured the endemic suffering following the fall of the Soviet Union. Depression is as much a cultural concept as it is a biological one.

Whither Social Suffering?

In the anthropological literature, there is a concept that describes the misery that individuals experience in contexts where they are powerless, where things have no prospect of improvement, and the feelings are entirely understandable. The concept is that of social suffering. In the medical and psychiatric literature, little attention has been paid to this concept, yet it afflicts the majority in large parts of the world who are indeed the inhabitants of unstable and uncertain sociopolitical landscapes. Although this term is often applied to those in developing countries, it seems apt to describe many patients in the developed world as afflicted by social suffering too.

It is not surprising that psychiatrists have neglected social suffering. There isn’t a pill for it. We may empathically bear witness to the suffering of others, but that only goes so far. It is not surprising either that these individuals are incorrectly diagnosed as depressed, and that this misdiagnosis increases in those over 65 and live in a world that has no use and sees no value in those who no longer work. It’s much easier for everyone to transform this endemic misery into depressive illness, because if it’s depressive illness then it may benefit from medical or psychological remedy. Those in primary care feel an enormous pressure to ‘do something’ and prescribing a pill is easy enough. It temporarily satisfies both patient and clinician that something has been done. The reality is by seeing the individual as a problem, we conveniently ignore the wider social, economic, and political forces that oppress, and yes, depress. These are problems that need resolution through public policy, and not through pills or psychotherapy.

Blame the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders is certainly beleaguered with problems, but the emphasis on the description of major depression as being responsible for overdiagnosis is just not true. The DSM is irrelevant to clinical practice, especially in primary care, because nobody uses it. People who felt depressed following bereavement were diagnosed and treated for depression long before the DSM-5 and will continue to do so. Sadly, the DSM-5 does not include a term that would aptly describe much of what we see, without labeling it a mental illness. That term is demoralization. Many of the patients I see are demoralized by their situation – in the face of a relationship they cannot escape from, a diagnosis of terminal illness, dashed career hopes. This is not an illness, but it deserves recognition.

As discussed above, most people diagnosed with depression don’t meet the criteria for DSM major depressive disorder. This isn’t because doctors can’t tell the difference between normal sadness and depressive despair. It’s because, when you have 10 minutes to see someone, and they tell you they’re depressed, and they want your help, and you feel pressure to ‘do something’ you are going to tell them they’re depressed and you’re going to give them what they want. And in the UK at least, there was a whole campaign that told you that’s exactly what you were supposed to do.

The medicalization of endemic misery and its medical treatment is our own doing. It takes time and resources away from the management of those with more serious physical and mental maladies, and is profitable for neither clinicians nor patients. The one actor that has profited, and handsomely at that, is the pharmaceutical company. The real money always lay not in convincing sick people they were ill, but well people they were sick. And so we continue to mask social suffering in the guise of depression.

Monday, May 13, 2013

Does DSM-5 Matter? Yes, but not to Psychiatrists.

It is an open secret that most psychiatrists do not use the DSM.

Read the news and you may be forgiven for thinking there is some violent fervor about the release of DSM-5. Its arrival is apparently “long awaited” and “hotly anticipated.” Petitions denounce it. Organizations note their “concern”. Lobby groups have called it unsafe, unfit for purpose. Campaigns for the abolition of psychiatric diagnoses appear. Survivor groups issue premature pronouncements of psychiatry’s death. I’ve been wondering: who exactly has been awaiting its arrival? It’s not researchers: The National Institute of Mental Health has made it clear that the psychiatric research agenda has moved on from categorical diagnoses. It’s not clinicians: most psychiatrists do not even use the DSM to make diagnoses. It’s not insurance companies: even in the US, most payers do not accept the DSM for billing purposes. It’s certainly not patients: a new system of classification will not improve patient care or revolutionize treatment. So then, what’s all the fuss about? Does the release of DSM-5 even matter? The answer is yes, but not as a psychiatric document. What makes the DSM so pernicious is that it is a cultural document whose influence transcends not only psychiatric practice but also the Western civilization from which it originates. Each revision of the DSM rescripts and reimagines how we make sense of our experiences, reinterprets what thoughts, feelings and behaviors are socially sanctioned, and ultimately what it means to be human.

Psychiatrists Don’t Use the DSM

One of the fiercest criticisms of DSM-5 is that it will expand the borders of mental disorder and thus psychiatrists will wrongly diagnose and treat people as mentally ill. Allen Frances, former chair of the DSM-IV task force, most ardently voices this criticism. He comes across as a silly old man nursing a narcissistic injury (he was excluded from DSM-5), throwing his toys out of his pram. He makes the assumption that psychiatrists use the DSM to make diagnoses. It is an open secret most psychiatrists in fact do not! If most psychiatrists used the DSM constructs we would not see an epidemic of bipolar diagnoses in children as young as two. In fact, most of the patients who come to me with the label of bipolar disorder, do not meet the criteria for the DSM-IV bipolar disorder construct. Schizoaffective disorder, which is supposedly a rare diagnosis, is possibly the most common diagnosis I see in the charts of inpatients which is deeply suspicious. More systematic studies show diagnoses patients garner have little to do with the DSM. For example, one study in the Veteran’s Administration system suggest 25% of schizophrenia diagnoses did not meet DSM criteria, and psychiatrists often made up diagnoses so Veterans could get benefits. In the private systems, fraudulent diagnoses are given as diagnosis determines remuneration.

Most psychiatric diagnoses are not made by psychiatrists but in primary care. Most primary care physicians do not know the diagnostic criteria for most of the common mental disorders as described in the DSM, but that does not stop these labels being used. Even for some common mental disorders most psychiatrists do not know the diagnostic criteria off by heart, and even if they do, take no heed. Take posttraumatic stress disorder as an example. This is a common mental health diagnosis. The diagnostic criteria for the construct are many and complex. I would hedge that over 90% of psychiatrists do not know the diagnostic criteria verbatim. Even if they did, one criterion is than an individual responded to a traumatic event with “fear, helplessness, or horror.” I do not know of any psychiatrists who ask their patients whether they responded in one of these three legitimated ways of responded to severe adversity, and if they did, their patients would probably be puzzled. Having no immediate reaction, or feeling anger or shame instead of “fear, helplessness or horror” to rape will not preclude a psychiatrist making a PTSD diagnosis, but if you stayed faithful to the DSM-IV, PTSD cannot be diagnosed. For depression, the bereavement exclusion is going and there has been concern people will now be diagnosed with depression following bereavement. It is already happening and has been happening for years.

That is not to say that diagnostic assessments are never useful, but this goes beyond the DSM. Diagnosis is important when it comes to identifying whether the morbid mental state is secondary to a medical condition. For example, I have treated patients who present with ‘depressive psychosis’ but this is due to myxedema coma, or those who are behaving bizarrely but have a metabolic encephalopathy. It is also important to identify whether the individual has fried their brains with drugs such as methamphetamine, ‘bathsalts’, or ‘spice’ which can lead to florid perceptual distortions and erratic behavior.

DSM diagnoses no longer guide treatment

Perhaps diagnosis informed treatment once upon a time, but this does not seem to be the case today. This is at least partly true. Individuals have experiences of mental life that cause distress and lead them to behave in ways others feel are bizarre or un-understandable. As a result they may see a psychiatrist. The psychiatrist can engage in the semiotic act of making a diagnosis. In order to do that, he engages in a precursor semiotic act, which involves recoding individual experience and observable mental phenomena or behaviors into ‘symptoms’ and ‘signs’ respectively. If he stops there, he can, and often does ‘treat’ the patient. If those ‘symptoms’ and ‘signs’ are regarded as psychosis, he will end up on a neuroleptic. If the patient is seen as ‘depressed’, he may end up on a serotonin reuptake inhibitor. If he appears ‘anxious’, perhaps a benzodiazepine will be prescribed. If ‘mood swings’ are observed, lithium or an anticonvulsant will be the order of the day. Many patients have experiences that are recoded into a bewildering combination of depression, elation, irritability, psychosis, anxiety, and may end up on an ‘antidepressant’, anticonvulsant, neuroleptic, and benzodiazepine, and if there is no response, this experience will be interpreted as ‘treatment-resistance’ and another medication will be added! I would like to say that this is a caricature of American Psychiatry, but this appears to be the rule rather than the exception. This is not how I practice, and am fortunate to have thoughtful trainers, but outside the academic ivory tower and in the community rampant polypharmacy is the rule. This happens in spite of diagnostic constructs in the DSM, not because of them. Sometimes response to cocktails is even used to support a diagnosis in a backward logic. In this way the DSM is largely irrelevant to the practice of psychiatry. Systems of psychiatric classification are relevant in the consultation room more from their influences on cultural consciousness and experience of the self, than from use in guiding diagnosis and treatment.

Redefining Personhood

Throughout history there have always been individuals who have been regarded as mad, or as Philippe Pinel called it, suffering from ‘mental alienation.’ For Pinel, to be mad meant one’s “character, as an individual of the species is always perverted; sometimes annihilated”. Without reason, man is no different “from the beasts that perish”. It is not madness that causes one to relinquish personhood, but to be identified as such. Psychiatrists, as the moral arbiters of mental life are thus also the high priests of personhood. Psychiatric diagnoses today extend far beyond ‘mental alienation’ and include a wide array of behaviors and experiences regarded as deviant. The removal of homosexuality from the psychiatric cannon is the best example of how personhood was restored to individuals previously regarded as pathological and deranged. For DSM-5, ‘gender identity disorder’ is being replaced with ‘gender dysphoria’. This is similar to homosexuality being replaced with ego-dystonic homosexuality before being expunged altogether. So whilst transgender individuals will no longer be regarded as mentally ill, it is a mental illness if you feel shit about it. A step to reclaiming personhood perhaps, but the transperson’s response to an intolerant society is still seen as pathological.

Far away from the locked psychiatric unit and the consultation room, the DSM exists in classrooms, libraries, the internet, the popular imagination. Each diagnosis at once hijacks personhood and redefines it. With the disappearance of Asperger’s syndrome, a cohort of socially awkward computer geeks have been disenfranchised and forced to rejoin ‘neurotypicals’ or be redefined autistic. The DSM provides the script of how we should respond to trauma; the narrative of resilience replaced with vulnerability. It is a veritable ‘how-to’ for those wanting to be anorexic or bulimic and join ‘pro-ana’ communities. It conveniently rewrites the ways we can be seen as ill, seek professional help, gain compensation, or even moral exculpation for our behavior. From Portland to Port Moresby, the DSM unites us with a global template for being mentally ill. In doing so, the DSM not only seeks to describe the landscape of psychopathology, it actively shapes it. Whilst removing the bereavement exclusion for diagnosing major depression may not change the psychiatrist’s attitude, it does refashion the cultural expectations of what constitutes acceptable misery. What is pernicious about the DSM is not how it shapes psychiatric practice directly – it doesn’t. Instead, it at once erodes personhood from those seen as ‘mad’, and for everyone else creates a cultural expectation that we are all sick and in need of treatment.

Wednesday, February 6, 2013

Prescribing Masturbation: An Idea Whose Time Has Come (Again)

Should vibrators be available on prescription and covered by healthcare plans?

Masturbation is the most ubiquitous expression of good sexual health. Despite this, not a moment of my medical training was devoted to the topic. Whilst masturbation is no longer explicitly considered a disease entity or the cause of disease, the idea that masturbation is pathological or immoral persists. For example, childhood masturbation continues to be called ‘gratification disorder’ by pediatricians, whilst the endurance of the term masturbation itself which literally means defilement by hand harks back to a 19th century notion that the act was ‘Forbidden by God, [and] despised by men.’ Nevertheless medicine has enjoyed a complex relationship with masturbation regarding it both as a cause of disease and as a cure. Whilst the evidence for the therapeutic uses of masturbation is not robust, I can’t help but feel that since medicine has done so much to malign masturbation, we now have a moral obligation to promote it. The time has come once more for us to prescribe masturbation.

The Medicalization of Masturbation

Whilst medical men had remarked upon masturbation on occasion since the time of Hippocrates, the belief that masturbation was not only a vice but also a disease did not take hold until the 18th century. With the publication of Onania in 1759 the stage was set for masturbation to establish itself as a pathological process that posed a looming threat to humanity. The belief in the deleterious effects of masturbation on human health was not unanimous; however, such was the popularity of this text that there appeared to be sweeping consensus of the dangers of masturbation. By the 19th century, masturbation had become associated with consumption, scrofula, feeble mindedness, insanity, a diminution of vision, and syphilis. If in the 18th century, masturbation would be seen as both a moral vice and a cause of maladies physical and spiritual, in the 19th century the Swiss physician Samuel Tissot expunged all discussion of the moral and spiritual and secured the place of masturbation as the cause of many maladies, with a “scientific” basis. In addition to the usual complaints experienced by men, Tissot proclaimed that female masturbators could also experience hysteria, jaundice, ulceration and prolapse of the uterus, and clitoral rashes. His ‘scientific’ theory was that masturbation led to disease through unnatural loss of ‘la liqueur séminale’ and secondly through the mental activity required which effectively damaged the brain. Quite how the former ‘scientific’ theory explained the ill effects of masturbation in women is unclear.

Antimasturbation fervor was at its greatest in America. Treatments including cold baths, tying of the hands, even applying carbolic acid to the penises of young boys were all enthusiastically used in the treatment of this ‘disgusting and revolting’ act. The Michigan-based physician Alonso Garwood documented a case of an orphan boy from a poorhouse who he raised as his own with a particularly severe compulsion to masturbation, and noted in the Northwestern Medical and Surgical Journal:

After using every moral means in my power, I tried cold bathing, restricting his diet to plain unstimulating food, whipping him as hard as I dared to without injuring the child, blistered his penis till it was all over raw, and as a dernier resort tied his hands. All these efforts were entirely abortive; whilst his penis was raw, he indulged as much as ever, and did not seem to regard the soreness. And when his hands were tied, he would bring on a seminal discharge by friction against his clothes, between his thighs, or between his abdomen and bed clothes, and at last he obtained such command over the abdominal, perineal and glutial muscles, in connection with the force of imagination, that he could produce a discharge sitting on a chair in my presence when there was no motion perceptible.

The desire of self gratification appeared to be constantly in his mind, and I am convinced that he would forgo any and everything else, even death itself, before he would quit the practice. Giving up all hopes of effecting a cure, and his presence becoming so disgusting and repulsive, I laid the case before the superintendents of the county and the board of supervisors, accompanied with the request, that they would destroy the indentures, and receive him again as a pauper, which they did accordingly.

Incidentally, although clitoridectomies were occasionally performed to curtail excessive female sexuality, the available medical literature almost entirely refers to males. It is almost as if the notion that women could obtain sexual pleasure without penetration was too offensive to male sensibilities.

Female masturbation did not go unremarked, however. Even in Onania, the author remarked "to imagine that Women are naturally more modest than Men, is a Mistake" and noted that “Female masturbators suffer from imbecility, fluor albus [leucorrhoea], hysteric fits, barrenness and a "total Ineptitude to the Act of Generation itself." The psychiatrist Richard von Krafft-Ebing in his Psychopathia Sexualis cites the case of two sisters who masturbated from childhood, regarding them as ‘most revolting’ and notes that hot iron treatment to the clitoris failed to temper their enthusiasm for the practice. He further notes a case of a woman who started masturbating in childhood, noting with horror that she ‘continued to practice masturbation when married, and even during pregnancy. She was pregnant twelve times.’ Krafft-Ebing believed that ‘since woman has less sexual need than man, a predominating sexual desire in her arouses a suspicion of its pathological significance.’ The Swiss psychiatrist Eugen Bleuler is noted to have smelt the hand of one of his schizophrenic female patients, for evidence of masturbation, presumably believing a causal connection.

Epidemiology of Masturbation

Given the prevalence of masturbation, and the rarity of many of the conditions it was ascribed to, it is not surprising that the view that masturbation caused so many ills did not go unchallenged. The Scottish surgeon John Hunter was among those to point out that one would expect a tendency for impotence to be more common if it were truly caused by masturbation. More recent epidemiological surveys shed light on the frequency of masturbation in various populations.

In a British Study of 11 161 participants, 73% of men and 36.8% of women reported masturbating in the 4 weeks prior to telephone interview. In striking contrast, whilst men who reported masturbation were less likely to report vaginal sex during the same period, women were more likely to report vaginal intercourse. Conversely, both men and women reporting same-sex sexual partners were more likely to report masturbation. Similarly in a study of Australian Adolescents aged 15-18, 58.5% of boys reported ever having masturbated, compared with 38.3% of girls. Further, a US cross-sectional survey of adolescents aged 14-17 found that whilst prior masturbation increased with age in females, recent masturbation did not. This contrasted with males where 67.6% of the 17 year olds reported recent masturbation, compared with 42.9% of 14 year olds. The gender disparity of masturbation epidemiology is not new. The Kinsey studies, which were the first to systematically outline sexual behavior in men and women, found that whilst 92% of men reported masturbation to the point of orgasm at some point in the life course, only 58% of women did. This prevalence figure for women was still more than was expected during the sexually conservative 1950s, and this finding was one among many that meant the publication of sexual behavior in women was much more controversial and condemned than the previous publication delineating sexual behavior in the human male. According to data pooled from the online dating website Ok Cupid!, from a sample of 78200 users, 21% Jewish women claimed to have never masturbated, compared with 9% of Jewish men. In contrast, 7.5% of women identifying as agnostic claimed to have never masturbated, along with 5% of agnostic men. Further, 18% of Muslim women, and 17% of Hindu women reported having never masturbated, far higher than male counterparts of the same religion. In sum, there exists a significant gender disparity in masturbation, and this is across cultural bounds.

Masturbation on Prescription?

Since the time of Hippocrates the treatment of hysteria in women has involved massage of the genitalia by the physician or midwife. Despite this therapy, it appears that women themselves were never encouraged to bring themselves to orgasm by stimulating their own genitalia. In fact, this was something that was explicitly discouraged on the grounds that it was deleterious to health as discussed above. Quite why the hands of the physician or husband should be therapeutic, but the woman’s own hands should be viewed as toxic to her own genitalia is inexplicable. Inexplicable but for the implication that women were incapable of arousing themselves without men. The social historian Rachel P. Maines talks of the androcentric model of sexuality, which she notes has been the predominant model in the history of sexuality. The androcentric model of sexuality recognizes preparation of orgasm, penetration, and male orgasm as the constituents of sexual activity. Female orgasm, though expected, is incidental and irrelevant. Safe for a few reports by medical men, female masturbation is but a footnote in the history of masturbation, and female masturbators are caricatured as morbid, pathological and deranged.

By the end of the 19th century, the first medical vibrator was devised, which effectively reduced the effort and manpower needed to manually stimulate the genitalia of ‘hysterical’ women. It seems likely that not only was female sexual pleasure not a goal of electromechanical stimulation, it was not even conceived of as a side-effect. If orgasm was the result of penetration in the prevailing worldview, it was not going to be achieved in this way. Little did the inventors know that not only could vibrators facilitate orgasm, they would often be far superior to penetration.

Vibrators as medical devices?

Today, vibrator use is exceedingly common. In one cross-sectional study of women who have sex with women, over three-quarters reported vibrator use, and over a quarter within the past three months. In another cross-sectional study of over 1000 participants, this time males, 44.8% reported vibrator use, either in solo or partnered sexual activities, 10% having done so in the past month. Vibrators are often recommended in the treatment of both male and female sexual dysfunction. There has been a proliferation of devices available on the market. There is a dearth of data available on which vibrators may be best for whom. Clinical research has been particularly captivated by the move to comparative effectiveness, which aims to test out different interventions against one another, on multiple outcomes in order to answer questions such as which performs better in different groups, or for different conditions. Could this sort of methodology be applied to vibrators? The answer is a resounding yes, but at what cost? A multitude of questions are generated. Should vibrators be registered and regulated as medical devices? Who will pay for the head to head comparisons of different vibrators? Should vibrators be available on prescription and covered by healthcare plans? Perhaps most concerning, do we want to risk remedicalizing masturbation and the vibrator? The answer then is not that vibrators should once again be medical devices and tested as such, but that we need more comparative data in the form of Consumer Reports and other such methodologies than can better help inform women’s choices. There appears to be a relative dearth of impartial information out there on this topic and it is not surprising. Even today, the notion of women’s sexual pleasure, especially without men appears to offend our sensibilities. Recently the Mayor of Boston’s office rejected Trojan’s request for a permit to give away free vibrators in Boston’s City Hall Plaza. Whilst we may have advanced in our attitudes towards masturbation, taboo and stigma persist.

Prescribing Masturbation: the moral imperative

There is a paucity of research investigating the efficacy of masturbation as a therapeutic treatment or as a public health intervention. Although it had been suggested that promoting masturbation may reduce HIV and STI transmission, particularly in endemic regions, the evidence supporting this is weak. On the other hand, masturbation is an important expression of good sexual health, a way for individuals to acquaint themselves with their bodies, and to relieve stress. Given how much the medical establishment has done to demonize masturbation, and denounce it as the cause of all disease and degeneration, the time has now come for us to promote masturbation. As most men masturbate, seeking to redress to the gender inequalities in masturbation would be a logical starting point. Clinicians should first seek permission to discuss the topic with women, whilst remaining culturally sensitive. They can then address any misconceptions or barriers that exist in women who do not masturbate, suggesting it as a possible activity to add to the repertoire of good sexual health. At the same time, clinicians should be mindful to explore attitudes, beliefs and concerns about masturbation without extolling the virtues beyond the evidence base. Sexual health screenings and well woman checks could provide opportune moments to discuss this, and education and counseling about masturbation can be incorporated into comprehensive preventive care and thus covered by health insurance plans.

Incorporating education about masturbation into healthcare will be challenging because taboos surrounding the discussion of masturbation persist. Arguments will be made that broaching this topic in a clinical consultation constitutes an unnecessary and unwanted intrusion of the personal sphere, and would be uncomfortable for patients and clinicians alike. Such criticisms are untenable. Given how ardent practitioners of the past were to denounce masturbation as the harbinger of disease and debility, without a shred of supporting evidence, it seems perfectly reasonable that clinicians of today might respectfully enquire whether their patients would like to talk about masturbation as part of a wider discussion of sexual wellbeing. The real challenges are not around archaic notions of sin or taboo. Rather, the challenge to redress gender inequalities in masturbation is the entrenched androcentric view that women either cannot or should not be capable of sexual satisfaction without penetration. Masturbation then, is not just a tool for sexual wellbeing, but an expression of autonomy and liberation and a challenge to the persisting attitudes that, like female orgasms, women are not only incidental but irrelevant.