Saturday, December 20, 2014

Psychiatry and the Problem With the Medical Model - Part 1

In The Myth of Mental Illness Thomas Szasz argued that mental illness was but a metaphor for problems in living. He still identified as a psychiatrist and was a member of the American Psychiatric Association until his death.

 Psychiatry is a branch of medicine. As such, psychiatrists apply the medical model to problems of emotion, thought, behavior, human relations, and living. This narrow gaze of the biomedical on problems that seem to transcend disease and disorder, brain and biology, has brought the field under severe criticism both from external commentators and from within its own ranks. Thomas Szasz, the libertarian psychiatrist, went as far as to argue that mental illness was in fact a “myth”.1 In contrast, the narrative of the history of medicine is one of technical triumphalism, with the historian Roy Porter titling his treatise on the topic The Greatest Benefit to Mankind.2

Many critics of psychiatry engage in “splitting”. They see psychiatry as an “all bad” object, mired by pseudoscience, pathologizing all of mental life, peddling quack treatments, often under coercion or control. So-called “real medicine” is idealized as the product of scientific advancement, with diagnoses and treatment precise, its diseases and treatments not influenced by sociopolitical, or economic fancy, and its practitioners portrayed as healers rather than agents of social control. Psychiatry aspires to be like the rest of medicine. Given that the problems that beleaguer psychiatry in particular, are true of medicine in general, it is a mistake to criticize psychiatry alone, and not locate it within a medical-industrial complex in need of dire reform.

Illness, Disease, and Slippery Syndromes

Many critics of psychiatry object to the use of the term ‘mental illness’. These critics argue either that because the mind is a metaphor, it cannot be diseased (and thus conflate disease with illness), or wrongly believe the term implies such problems are biomedical in origin and warrant medical intervention.1 Illness is the subjective experience of being unwell, does not imply the existence of underlying disease, and labeling problems as illness never has led the majority of people to seek medical consultation. Medical sociologists have noted there exists an ‘illness iceberg’ whereby the majority of people in the community who identify as experiencing illness do not seek medical attention, and if they were the system would be completely overwhelmed.3 Instead, most people tend to consult a ‘lay referral system’, seeking explanation and remedy of their problems from friends, family, and informal experts within their community, before seeking medical attention.4 Even with the creeping medicalization of everyday life and professionalization of helping, it is still the case that the majority of those who may identify as ill, ‘mental’ or otherwise, do not seek medical attention. Thus it is incorrect to state that ‘illness’ implies medicalization when it is a subjective experience that may or may not correspond with disease. Many of the individuals I see endure immense suffering and understandably see themselves as sick. I think it would be incredibly invalidating of me to say they are not ‘ill’ though they do not have disease.

The actual definition of disease is one of contention. I refer to the term disease to describe a clinical syndrome for which there is a well-described underlying pathology or pathogen. In this definition, schizophrenia, bipolar disorder, or major depression are not diseases. Alzheimer’s, vascular dementia, and frontal lobe syndrome due to traumatic brain injury do fall under this definition of disease. In other areas of medicine, it is clear that physicians cannot reach a consensus outside of infectious disease, which problems should be classified as ‘disease’.5 Epilepsy for example, in my definition could not be considered a disease. There also appear to be differences in definitions of disease between general practitioners, non-medical academics, medical academics and high school students.6

Psychiatry has rightly been criticized for the ever-expanding definition of mental illness, with the boundaries between mental health and mental illness (arbitrary as they are) becoming increasingly blurred. However this is true of medicine as well, where asthma is now diagnosed in children with minor wheezing and breathlessness, and diabetes expanded with a lower threshold of glucose level needed for the diagnosis. There is now even ‘pre-diabetes’, a harbinger state of full-blown disease recognized as a condition.

With the increasing transparency of the body we are recognizing disease in those who are not ill. CT scans will routinely pick up lung nodules of unknown significance or early cancers in people who have no symptoms at all. These individuals are not ‘ill’ (they do not subjectively feel unwell) but through the medical gaze they do have disease, disease for which the significance may be entirely unknown and treatment cause more harm than good.


‘The medical establishment has become a threat to health.’ So begins Ivan Illich, social scientist and priest, in his book Medical Nemesis: The Expropriation of Health.7 He noted that with the professionalization of medicine, doctors had come to transform problems that were previously seen as social, moral or spiritual in nature into medical ones. In the process, physicians had created a new disease killing many: iatrogenesis. As such, medicine was doing more harm than good with the ill-conceived notion of treating problems that physicians had no business treating.

Psychiatry has particularly come under attack for transforming grief, shyness, hyperactivity, worry, and social suffering into mental disorders requiring professional intervention and quite rightly so. Given that extreme states of despair lie on a nebulous continuum with emotional states we all experience on a daily basis, it is no surprise that the mental health industry in particular has been particularly successful in increasing the range of human misery falling under its province. But it is a mistake to think that psychiatry alone is guilty of making us sick.

The menopause, once part of the normal reproductive trajectory of a woman’s life has been transformed into a sickness needing medical intervention.8 These interventions have now been shown to increase the risk of blood clots, strokes, and breast cancer. The urge to moves one’s legs about is now an increasingly diagnosed as restless leg syndrome9, and treated with drugs that can cause confusion, psychosis, dependency, or compulsive gambling. Pfizer has been successful in redefining the quality of an erection, leading many men to seek Viagra as a lifestyle pill, with the risk of blindness, deafness, and priapism.10 The American Medical Association last year voted to classify obesity as a disease, despite the evidence showing doing so is harmful by de-emphasizing the role of behavior and lifestyle in weight control. It is not by coincidence the emergence of obesity as a ‘disease’ occurred just as two new drugs for obesity appeared on the market.11 The pharmaceutical industry’s co-option of medicine neither begins nor ends with psychiatry.

Although obstetrics, a field once known as “man-midwifery” was denounced by the rest of the medical profession, today pregnancy is so entrenched in the medical model and so profitable, that the American College of Obstetrics and Gynecology continues to promote obstetric involvement in normal labor, despite the evidence that home births or midwife-led deliveries are better for uncomplicated pregnancies.12 In the same way, the American Psychiatric Association will never renounce any practice that would affect the earning of its members, regardless of the evidence base for those practices, no other professional organization in medicine or beyond would do so. Professional organizations by their very nature are self-serving. You do not bite the hand that feeds you. The profit motive has corrupted medicine and transformed it into a multi-billion dollar business – psychiatry is not the exception but the rule.

The Myth of ‘Objectivity’ in Medicine

Psychiatry by its very nature deals with subjectivity. Patients present with experiences; experiences that I can never know, nor ever see.13 The field has come under criticism for lacking objectivity, and not having blood tests or imaging or other confirmatory markers for the existence of illness or disorder. In a misguided attempt to look more scientific and objective, psychiatry has turned to the ridiculous task of looking for blood tests or biomarkers for depression and other such mental states. Quite apart from just how absurd it would be to ‘diagnose’ someone with depression or psychosis from a blood test or brain scan, the reliance on so-called objective indicators of disease is a hermeneutical nightmare. The technologization of medicine has led to spiraling healthcare costs, the devaluing of relationships and narratives, and the deskilling of doctors.14

Take the example of hypertension. This is a risk factor rather than a disease, but it is ‘objectively’ measured and thus the point at which blood pressure is considered hypertension in need of treatment should be uniform based on the scientific evidence. Yet if you live in the US and had uncomplicated hypertension, you would be treated when your blood pressure is above 150/90mmHg.15 In the UK, you would be treated if your blood pressure is above 160/100mmHg.16 What constitutes hypertension in need of treatment cannot then be based on science alone. It is constrained by interpretation, an act which itself is constrained by the surrounding social, political, and economic space.

Turning to cancer, which most people would consider a diagnosis made through objective means, the story is even more frightening. One test that has been used in the US until recently to screen for prostate cancer is the prostatic specific antigen (PSA). Screening identifies cancers in people who are not ill, do not need or benefit from diagnosis and are ultimately harmed by treatment. Overdiagnosis of prostate cancer is as high as 50% in those diagnosed with prostate cancer. In one of the largest studies of its kind involved 182000 men, 1410 men had to bee screened and 48 unnecessarily treated in order to prevent one death.17 Complications of treatment of prostate cancer routinely include impotence, urinary incontinence, and radiation proctitis. The largest study of its kind to review the effects of mammography for breast cancer found that over a 30 year period 1.3 million women were unnecessarily diagnosed and treated for breast cancer, with 70 000 women in 2008 alone unnecessarily diagnosed with breast cancer.18 Mammography routinely identifies disease in those who would never become ill (have symptoms), or where the cancer would never pose a threat to life. The use of objective tests in medicine is rife with their own problems because they need interpretation. Where there is interpretation, there is error.

Diagnostic tests in the majority of cases were never meant to ‘make’ a diagnosis but to support a diagnosis, which is made from carefully listening to the history of the illness and through physical examination. As medical practice has become more litigious and we have become more reliant on tests to make diagnoses, doctors spend less time listening to their patients, and no longer trust their clinical skills. I went into psychiatry because of the focus on subjectivity, narrative, meaning and relationships. Because these are no longer valued in medicine, they are also less valued in psychiatry.

Coercion and Control

One of the biggest criticisms of psychiatry is that ‘treatment’ often involves coercion and that psychiatrists are agents of social control. I don’t believe any meaningful treatment can occur within a coercive setting, and find it troubling how often force is used, and how comfortable psychiatrists seem to feel with its use. As a lowly intern, I found myself accused of “insubordination” for refusing to write an order for compelling intramuscular neuroleptics for a patient. Involuntary ‘treatment’ and drugging occurs far too often and is often avoidable. For almost 60 years, we have known that the organization of psychiatric units which foster an “us” and “them” mentality between patients and staff leads to inappropriate use of force and can be re-organized for the better.19 Non-hospital residential alternatives to hospitalization such as Soteria House have also successfully shown than in the majority of cases, violent behavior can be managed without recourse to coercive practices.20 Unfortunately, there do not appear to be models of care that have successfully avoided coercive practices in those who are actively dangerous to themselves or others altogether.

Some critics of coercion in psychiatry seem to ignore the reality that coercive practices occur in all of medicine, and in many occasions more often. In the institutions where I have worked, mechanical and chemical restraint of patients overwhelmingly occurs in the emergency room or medical wards, with no psychiatric involvement. Although there have been some recent studies exploring use of restraints in the medical (as opposed to psychiatric) setting, including identifying racial biases21, the use of coercion in these settings comes under far less scrutiny or study than in psychiatric settings, despite these patients not being involuntarily detained.

Similarly, physicians in all fields are agents of social control. In addition to caring for patients, physicians have the sometimes conflicting task of protecting the public. This includes determining safety to drive, fitness to care for children, and control of infectious diseases. Those who refuse treatment for TB can be detained against their will and forced to have treatment against their will or face legal repercussions.21 In the recent Ebola panic, Kaci Hicox was inappropriately quarantined in a misguided attempt to protect the public from a disease she did not have.23 In the case of the HPV vaccine for schoolgirls, Rick Perry as governor of Texas tried to force all school girls to have the vaccine, which appears to have been motivated from kickbacks he received from Merck, the makers of the vaccine.24

In the United States the overwhelming majority of psychiatrists are not involved in civil commitment or forcibly drugging their patients. For many, this facet of psychiatric practice is extremely uncomfortable. However, it is misguided to pretend that coercion does not occur in the rest of medicine, when it routinely does with less accountability than in psychiatry. We need to critically examine the use of control and coercion in all areas of medicine so that it is truly a rare occurrence and always of last resort.

The mental health industry has a lot to answer for. The psychologization of everyday life has eroded the range of human experience seen as normal, disempowered people to manage their own life challenges, professionalized helping relationships and undermined the already decaying support structures through which people found meaning and connection, stigmatized people through psychiatric labeling, led to iatrogenic misery from harmful treatments and traumatized already vulnerable individuals through excessively coercive practices. It is not because psychiatry is distinct from the rest of medicine that it has done so much damage. Rather it is precisely because it is a part of medicine and aspires to the medical model, a model that outside all but the most acute problems has been an abject failure, that it has done so. If our approach to problems of emotion, thought, behavior, human relations, and living is to be radically altered, we must take a closer look at what is wrong with medicine as a whole. 

1.      Szasz T. The myth of mental illness. American Psychologist 1960; 15:113-118
2.      Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. London: Fontana Press, 1999
3.      Hannay DR. The ‘iceberg’ of illness and ‘trivial’ consultations. Journal of the Royal College of General Practitioners 1980; 30:551-554
4.      Friedson E. Client control and medical practice. American Journal of Sociology 1960 65:374-382
5.      Smith R. In search of “non-disease”. British Medical Journal 2002; 324:883-885
6.      EJM Cambpell, Scadding JG, Roberts RS. The concept of disease. British Medical Journal 1979; 2:757-762
7.      Ilich I. Medical Nemesis: The Expropriation of Heath.  London: Caldar & Boyars, 1975
8.      Moynihan R, Cassels A. Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients. New York: Nation Books, 2006
9.      Woloshin S, Schwartz LM. Giving Legs to Restless Legs: A Case Study of How the Media Helps Make People Sick. PLoS Medicine 2006; 3: e170. doi:10.1371/journal.pmed.0030170
10.  Lexchin J. Bigger and Better: How Pfizer Redefined Erectile Dysfunction. PLoS Medicine 3: e132. doi:10.1371/journal.pmed.0030132
11.  Pollack A. A.M.A. recognizes obesity as a disease. New York Times, June 19th 2013, B1
12.  Bennhold K, Saint Louis C. British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies New York Times, December 4th 2014, A6
13.  Laing RD. The Politics of Experience. Harmondsworth: Penguin Books, 1967
14.  Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. Cambridge: Basis Books, 1988
15.  National Institute for Health and Clinical Excellence.  Hypertension: Clinical Management of Hypertension in Adults. London: NICE, 2011
16.  James PA, Oparil S, Carter BL et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Reprot from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 2014; 311:507-520
17.  Schröder FH, Hugosson J, Roobol MJ et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine 2009; 360:1320-1328
18.  Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. New England Journal of Medicine 2012; 367:1998-2005
19.  Cameron JL, Laing RD, McGhie A. Patient and nurse; effects of environmental changes in the care of chronic schizophrenics. Lancet 1955; 269:1384-1386
20.  Mosher LR, Menn AZ, Vallone R, Fort D. Treatment at Soteria House: A manual for the practice of interpersonal phenomenology. 1992, unpublished monograph.
21.  Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. The Journal of Emergency Medicine 2003; 24:119-124
22.  Centers for Disease Control and Prevention. Module 9: patient adherence to tuberculosis treatment reading material. (accessed 12/20/14)
23.  Hartcollis A, Fitzsimmons EG. Tested negative for Ebola, nurse criticizes her quarantine. New York Times, October 26th 2014, A1
24.  Colgrove J, Abiola S, Mello MM. HPV vaccination mandates – lawmaking amid political and scientific controversy. New England Journal of Medicine 2010; 363:785-791

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.

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