Monday, December 1, 2014

When Homosexuality Came Out (of the DSM)

the removal of homosexuality from the DSM was not the result of scientific advancement but political will

41 years ago this month, homosexuality ceased to be a mental illness. Amid growing opposition from gay activists, and dissent within its own ranks, the American Psychiatric Association was begrudgingly forced to expunge homosexuality from the DSM-II. Paradigmatic of the social nature of psychiatric diagnosis, the purging of homosexuality from the psychiatric nomenclature highlights the instability of the psychiatric sign: once signifying disease and perversion, homosexuality came to be recognized by the establishment as a normal variant of human sexuality. The ‘coming out’ of homosexuality from the DSM-II allows us to reflect on the following: (1) change in the concept of mental disorder is slow; (2) diagnosis-making is a social act; (3) the construct of illness and disorder, ‘mental’ or otherwise is a social one; (4) the construct of illness has social consequences; and (5) shifts in the concept and nature of disorder reflect wider social, political and economic forces more than scientific advancement.

The slow demise of homosexuality as disease

Although the removal of homosexuality from the DSM is often heralded as a radical and rapid sea-change in how sexual orientation was viewed, the reality is more sobering. Homosexuality was not actually removed from the diagnostic nomenclature of the revised DSM-II. Instead, it was shifted into parentheses of the new diagnosis of "sexual orientation disturbance". The change in diagnosis was supposed to create as little disruption to psychiatric practice as possible, and the position statement about this change notes that ‘hardly anyone can disagree’ that ‘Modern methods of treatment enable a significant proportion of homosexuals who wish to change their sexual orientation to do so.’  While noting that homosexuality does not fulfill criteria for a psychiatric disorder, the same position statement goes on to note “no doubt, homosexual activists will claim that psychiatry has at last recognized that homosexuality is as “normal” as heterosexuality. They will be wrong.” The same year, 1973, a number of publications discuss diagnostic and treatment aspects of homosexuality, including aversive conditioning, use of electric shocks, and even lobotomy. Further, the diagnosis of ‘sexual orientation disturbance’, later to become ‘ego-dystonic sexual orientation’ was only applicable to same-sex attraction. The implicit assumption is that it is not possible for those with opposite-sex attraction to feel negatively about this. Whether true or not, the assumption goes unchallenged.

It was not until 1987 that homosexuality completely disappeared from the DSM, but the concept of ego-dystonic sexual orientation persists in the World Health Organization’s International Classification of Diseases. More recently we have seen a similar shift with transgendered individuals. It is interesting to note as homosexuality came out of the DSM, transsexualism was making its debut. This transformed into gender identity disorder, and most recently, to gender dysphoria in DSM-5.

Diagnosis making as a social act

The ritual of making a diagnosis is a performance that occurs within the social space. Making a diagnosis, as Arthur Kleinman has pointed out, is a semiotic act. It involves transforming experiences into ‘symptoms’ and ‘signs’ that signify disease or disorder. These diagnoses confer social meaning not just for those labeled so, but also come to signify what it means to be without disease or disorder. Taking the example of homosexuality, its appearance as a social and medical concept at the end of the 19th century, also coincided with the invention of heterosexuality. Psychiatry was thus instrumental in creating and polarizing sexual identities in a way that persists today despite the demedicalization of sexual orientation. Diagnoses thus convey not only information about the treatability and prognosis of particular states, they also create identities, confer recognition, or conversely erode personhood, and our ability to construct meaningful narratives beyond the medico-psychological discourse. Schizophrenia is not just a diagnosis, but signifies a particular identity that shifts with cultural convenience – once capturing the attractive delicate white woman who has been trampled by society, to the imposing, aggressive black man who poses a threat to social order.

The social construction of ‘mental illness’

Whilst the concept of the sodomite dates back to biblical times, the concept of the homosexual did not emerge until the late 19th century. At once, sexual behaviors were transformed into a diagnosis and a sexual identity. That this transformation occurred when it did, is no accident, but accompanied the tacit acceptance that sex was not simply procreative but pleasurable, the increasing prominence of the physician-as-expert, and the need for physicians to ‘prescribe a healthy sexuality.’ Similarly, the demise of homosexuality as disorder came at a time when pleasure could be celebrated over duty, with the rise of anti-authoritarianism, and psychiatry’s grand venture into solving the social ills of our time. Whether homosexuality or psychosis have some biological basis, does not detract from the role of psychiatrists as agents of social control. For example, in 1972, just a year before the DSM expunged homosexuality, John Feighner and colleagues proposed diagnostic criteria for various mental disorders to be used in research. Among the ’14 psychiatric illnesses’ was homosexuality defined so:

A.    This diagnosis is made when there are persistent homosexual experiences beyond 18 (equivalent of Kinsey 3 to 6)
B.    Patients who fulfill the criteria for transsexualism are excluded.
C.   Patients who perform homosexual activity only when incarcerated for a period of at least one year without access to members of the opposite sex are excluded.

Here we see a psychiatric definition of homosexuality that is operational and wholly arbitrary, with the long-term incarcerated given a free ticket to buggery, unencumbered by psychiatric labeling. All medical diagnoses, psychiatric or otherwise are socially constructed, but psychiatric illnesses also confer identities – wanted or unwanted – that other medical illnesses seldom do.

The social consequences of illness

Illnesses can be stigmatizing, and although such diseases including leprosy, TB, cancer, and AIDS have carried stigma for sufferers at some point in history, they rarely alter the experience of the self in the way that psychiatric diagnoses do. The pathologization of homosexuality convinced some individuals that they were sick, and that in itself may have made them (feel) sick! The removal of homosexuality from the psychiatric canon has undoubtedly facilitated the rights of those who identify as lesbian, gay, or bisexual. Adoption rights, same-sex marriage, the repeal of Don’t Ask Don’t Tell, would never have occurred if homosexuality continued to be seen as the developmental end-point of deep psychopathology. In the same way, diagnoses of mental illness, confer individuals with a sense of otherness, that they are somehow different than other people, perhaps less important, less deserving, or of less worth. With a diagnosis of schizophrenia, if internalized, comes the erosion of personhood, lowered self-esteem, shattered dreams, and a sense of disenchantment. The psychiatrist Richard Warner has even suggested that those who reject the diagnosis of severe mental illness may have better outcomes as they retain the right to construct their own narrative of personhood and define what really matters for them. Despite public education campaigns (or perhaps because of them), the stigma of mental illness is as enduring as it was 50 years ago.

The rise of illness: scientific advancement or commercial cash cow?

As discussed above, the removal of homosexuality from the DSM was the result of sociopolitical forces, and not a reflection of scientific advancement. Even within psychiatry, the mass proliferation of psychiatric diagnoses is viewed as something commercial. Up until the 1970s psychiatric diagnoses were not necessary to treat individuals with a wide range of problems, and psychiatrists had little competition from other mental health professionals. With the growth of clinical psychology and other mental health professions who could provide psychotherapy more cheaply, psychiatrists needed to maintain their moral authority over the mental life that had come under their purview. What psychiatrists, as physicians, could do that others could not was make diagnoses. Thus the medical profession created new diagnoses for the range of mental life that psychiatrists were already seeing in their offices; and these became the signifiers that these patients had a medical illness that required treatment. The growth of psychopharmacology allowed the boundaries for these new diagnoses to expand, creating new markets, not only for the pharmaceutical industry but also for the mental health field. There was no problem too small to warrant pharmaceutical relief.

But what of the social and political forces that facilitated the growth of mental illness? At the same time that homosexuality was losing its status as mental disorder, the US was in the midst of a deepening economic crisis. By 1980, the year of publication of DSM-III, a new Republican government headed by Ronald Regan entered the White House. Rather than draw attention to the psychiatric casualties that would amass under neoliberal policies, it became convenient to locate mental illness within the self – in brain, cell, and molecule – rather than as a product of community, society, and state. It is for this reason that psychiatrist Joanna Moncrieff has suggested that a “marriage of convenience” exists between biopsychiatry and the politics of neoliberalism. A biological model that was gaining ascendance was fortified by the political expedience of supporting a paradigm of psychic discontent that obfuscated the wider social, economic and political forces at play. In the same way the removal of homosexuality from the DSM was not the result of scientific advancement but political will, the solidifying of disease status of minor psychiatric diagnoses and their biological basis are more the result of these same forces than scientific triumphalism.

Further Reading
1.    Disturbance: Proposed Change in DSM-II, 6th Printing Page 44 Position Statement. (accessed 12/24/13)
2.    Freund K, Langevin R, Cibiri S, Zajac Y. Heterosexual Aversion in homosexual males. Br J Psychiatry 1973; 122:163-169
3.    McConaghy N, Barr RF. Classical, avoidance and backward conditioning treatments of homosexuality. Br J Psychiatry 1973; 122:151-162
4.    Rhodes RJ. Homosexual aversion therapy. Electric shock technique. J Kans Med Soc 1973; 74:103-105
5.    Freeman W. Sexual behavior and fertility after frontal lobotomy. Biol Psychiatry 1973; 6:97-104
6.    MacDonal AP Jr., Huggins J, Young S, Swanson RA. Attitudes towards homosexuality: preservation of sex morality or the double standard? J Consult Clin Psychol 1973; 40:161
7.    Lesse S. The current confusion over homosexuality. American Journal of psychotherapy 1973; 27:151-154
8.    Stoller RJ, Marmor J, Bieber I, Gold R, Socarides CW, Green R, Spitzer RL. A Symposium: should homosexuality be in the APA nomenclature. Am J Psychiatry 1973; 130:1207-1216
9.    Maletzky BM, George FS. The treatment of homosexuality by ‘assisted’ covert sensitization. Behav Res Therapy 1973; 11:655-657
10.American Psychiatric Association. Homosexuality and Sexual Orientation
11.Feighner JP, Robins E, Guze SB, Woodruff RA, Winokur G, Munoz R. Diagnostic Criteria for Psychiatric Research. Arch Gen Psychiatry 1972; 26:57-62
12.Ch.3 The Fall and Rise of Homosexuality. pp55-99 In: Kutchins H, Kirk SA. Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York: The Free Press, 1997
13.Katz JN. Ch.7 the invention of heterosexuality. Pp83-98 In: Privilege: a reader.
14.Tanner BA. Shock intensity and fear of shock in the modification of homosexual behavior in males by avoidance learning. Behav Res Therapy 1973; 11:213-218
15.Skene RA. Construct shift in the treatment of a case of homosexuality. Br J Med Psychol 1973; 46:287-292
16.   Moncrieff J. Neoliberalism and biopsychiatry: a marriage of convenience. In: Cohen C, Timimi S. (Eds.) Liberatory Psychiatry. p235-257 Cambridge: Cambridge University Press, 2008

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.

1.    Axelson DA, Birmaher B, Findling RL, Fristad MA, Kowatch RA, Youngstrom EA, Arnold EL, Goldstein BI, Goldstein TR, Chang KD, Delbello MP, Ryan ND, Diler RS. Concerns regarding the including of temper dysregulation disorder with dysphoria in the Diagnonstic and Statisical Manual of Mental Disorders, Fifth Edition. J Clin Psychiatr 2011; 79: 1257-62
2.    Wilson M. DSM-III and the transformation of American Psychiatry: a history. Am J Psychiatry 1993; 399-410
3.    Michels R, Frances A. Should psychiatry be expanding its boundaries? Can J Psychiatry 2013; 58:566-9
4.    Andreasen NC. DSM and the death of phenomenology in America: An example of unintended consequences. Schizophr Bull 2007; 33:108-112
5.    Taylor MA, Vaidya NA. Psychopathology in neuropsychiatry: DSM and beyond. J Neuropsychiatry Clin Neurosci 2005; 17:246-9
6.    Frances A. The new crisis of confidence in psychiatric diagnosis. Ann Intern Med 2013; 159:221-2
7.    Kraepelin E. Manic-Depressive Insanity and Paranoia. Edinburgh: Livingstone, 1921
8.    Jaspers J. General Psychopathology. Chicago: University of Chicago Press, 1953
9.    Bleuler E. Dementia Praecox: Or, the Group of Schizophrenias. New York: International Universities Press, 1950
10.Schneider K. Clinical Psychopathology. New York: Grune & Stratton, 1959
11.Summerfield D. “Global mental health” is an oxymoron and medical imperialism. BMJ 2013; 346:f3509
12.Kayser MS, Kohler CG, Dalmau J. Psychiatrist manifestations of paraneoplastic disorders. Am J Psychiatry 2010; 167:1039-50
13.Hoop JG, Savia G, Roberts LW, Zisook S, Dunn LB. The current state of genetics training in psychiatry residency: views of 235 U.S. educators and trainees. Acad Psychiatry 2010; 34:109-14
14.Solas HA 3rd, Ence TC, Mendez TR, Cruz AT. At the intersection of toxicology, psychiatry, and genetics: a diagnosis of ornithine transcarbamylase deficiency. Am J Emerg Med 2013; doi: 10.1016/j.ajem.2013.05.010
15.Williams HJ, Monks S, Murphy KC, Kirov G, O’Donovan MC, Owen MJ. Schizophrenia two-hit hypothesis in velo-cardio facial syndrome. Am J Med Genet B Neuropsychiatr Genet 2013; 162B: 177-82
16.Jou SH, Chiu NY, Liu CS. Mitochondrial dysfunction and psychiatric disorders. Chang Gung Med J 2009; 32:270-9
17.Gøtzsche PC. Deadly Medicines and Organized Crime: How Big Pharma Has Corrupted Healthcare. Oxford: Radcliffe Medical Press, 2013
18.Ingels M, Marks D, Clark RF. A survey of medical toxicology training in psychiatry residency programs. Acad Psychiatry 2003; 27:50-3
19.Chouinard G, Jones BD. Neuroleptic-induced supersensitivty psychosis: clinical and pharmacological characteristics. Am J Psychiatry 1980; 137:16-21
20.El-Mallakh RS, Gao Y, Briscoe BT, Roberts RJ. Antidepressant-induced tardive dysphoria. Psychother Psychosom 2011; 80:57-9
21.El-Mallakh RS, Ghaemi SN, Sagduyu K, Thase ME, Wisniewski SR, Nierenberg AA, Zhang HW, Pardo TA, Sachs G; STEP-BP Investigators. Antidepressant-associated chronic irritable dysphoria (ACID) in STEP-BD patients. J Affect Disorder 2008; 111:372-7
22.De Hert M, Schreuers V, Van Winkel R. Metabolic syndrome in people with schizophrenia: a review. World Psychiatry 2009; 8:15-22
23.Gabbard GO. Psychodynamic Psychiatry in Clinical Practice. Washington, D.C.: American Psychiatric Press, 2000
24.Kutchins H, Kirk SA. DSM-III-R: the conflict over new psychiatric diagnoses. Health Soc Work 1989; 14:91-101
25.Berk M, Parker G. The elephant on the couch: side-effects of psychotherapy. Aust N Z J Psychiatry 2009; 43: 787-94
26.Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry 2008; 165:969-77
27.Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther 2000; 38:319-45
28.Garety PA, Kuipers E, Fowler D, Freeman D, Bebbington PE. A cognitive model of the positive symptoms of psychosis. Psychol Med 2001; 31:189-95
29.Eccles JS, Wigfield A. Motivational beliefs, values, and goals. Annu Rev Psychol 2002; 53: 109-32
30.Frith CD, Frith U. Mechanisms of social cognition. Annu Rev Psychol 2012; 63:287-313
31.Bifulco A, Brown GW. Cognitive coping responses to crises and onset of depression. Soc Psychiatry Psychiatr Epidemiology 1996; 31:163-72
32.Rutter M. Developmental psychopathology: a paradigm shift or just a relabeling? Dev Psychopathol 2013; 25:1201-13
33.McCrae RR, John OP. An introduction to the five-factor model and its applications. J Pers 1992; 60:175-215
34.Mischel W. Toward an integrative science of the person. Annu Rev Psychol 2004; 55:1-22
35.McAdams DP. What do we know when we know a person? J Personality 1995; 63:365-396
36.Frank JD, Frank J. Persuasion and Healing: a Comparative Study of Psychotherapy. Batimore: Johns Hopkins Press, 1991
37.Kleinman A. Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press, 1988
38. Cooksey EC, Brown P. Spinning on its axes: DSM and the social construction of psychiatric diagnosis. Int J Health Serv 1998; 28:525-54
39.Craddock N, Owen MJ. The beginning of the end for the Kraepelinian dichotomy. Br J Psychiatry 2005; 186:364-6
40.Hollingshead AB, Redlich FC. Social Class and Mental Illness: A community study. New York: John Wiley, 1958
41.Morgan C, Charalambides M, Hutchinson G, Murray RM. Migration, ethnicity and psychosis: toward a sociodevelopmental model. Schizophr Bull 2010; 366:655-64
42.Wamala S, Boström G, Nyqvist K. Perceived discrimination and psychological distress in Sweden. Br J Psychiatry 2007; 190:75-76
43.Brown GW, Monck EM, Carstairs GM, Wing JK. Influence of family life on the course of schizophrenic illness. Br J Prev Soc Med 1962; 16:55-68
44.Brown GW, Harris TO. The social origins of depression: a study of psychiatric disorder in women. New York: Free Press, 1978
45.Halpern D. Mental Health and The Built Environment: More Than Bricks and Mortar? Abingdon: Taylor and Francis, 1995
46.Faris REL, Dunham HW. Mental Disorders in urban areas: an ecological study of schizophrenia and other psychoses. Chicago: University of Chicago Press, 1939
47.De Silva MJ, McKenzie K, Harpham T, Huttly SRA. Social capital and mental illness: a systematic review. J Epidemiol Community Health 2005; 59:619-627
48.Goffman E. Asylums: essays on the social situation of mental patients and other inmates. Garden City, NY: Anchor Books, 1961
49.Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs NJ: Prentice Hall, 1963
50.Scheff TJ. Being Mentally Ill: a sociological theory. New York: Aldine Pub. Co., 1984
51.Murphy JE. Psychiatric labeling in cross-cultural perspective. Science 1976; 191:1019-28
52.Rosenhan DL. On being sane in insane places. Science 1973; 179:250-8
53.Sartorius N, Jablensky A, Shapiro R. Two-year follow-up of the patients included in the WHO International Pilot Study of Schizophrenia. Psychol Med 1977; 7:529-41
54.Warner R. Recovery from Schizophrenia: Schizophrenia and Political Economy. New York: Brunner-Routledge, 2004
55.Veling W, Susser E, van Os J, Mackenbach JP, Selten JP, Hoek HW. Ethnic density of neighborhoods and incidence of psychotic disorders among immigrants. Am J Psychiatry 2008; 165:66-73
56.Link BG, Phelan JC, Bresnahan M, Stueve A, Pescosolido BA. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. Am J Public Health 1999; 89:1328-33
57.Sobo S. Does evidence-based medicine discourage richer assessment of psychopathology and treatment? Psychiatric Times 2012 (accessed 01/19/2014)
58.Ho BC, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Arch Gen Psychiatry 2011; 68:128-37.
59.Gustafson J. How schizophrenia affects the brain. 2013 (accessed 01/19/2014)
60.Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA 2004; 292:338-43
61.Gibbons RD, Hur K, Bhaumik DK, Mann JJ. The relationship between antidepressant prescription rates and rate of early adolescent suicide. Am J Psychiatry 2006; 163:1898-904
62.McHugh PR, Slavney PR. The Perspectives of Psychiatry. Baltimore: Johns Hopkins University Press, 1998
63.Ghaemi SN. The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Practice. Baltimore: Johns Hopkins University Press, 2010
64.McLaren N. A critical review of the biopsychosocial model. Aust N Z J Psychiatry 1998; 32:86-92
65.Ghaemi SN. The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Mental Illness. Baltimore: Johns Hopkins University Press, 2003
66.Miresco MJ, Kirmayer LJ. The persistence of mind-brain dualism in psychiatric reasoning about clinical scenarios. Am J Psychiatry 2006; 163:913-8
67.Harland R, Antonova E, Owen GS, Broome M, Landau S, Deeley Q, Murray R. A study of psychiatrists’ concepts of mental illness. Psychol Med 2009; 39:967-76
68.Kendler KS. A psychiatric dialogue about the mind-body problem. Am J Psychiatry 2001; 158:989-1000
69.Roberts MJ, Reich MR. Ethical analysis in public health. Lancet 2002; 359:1055-9

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.