Bryan Caplan  

Psychiatry's Disorders

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Wired has a nice piece on the psychiatric in-fighting behind the new Diagnostic and Statistical Manual of Mental Disorders.  Highlights:

1. The arbitrariness of psychiatric diagnoses:
The authority of any doctor depends on their ability to name a patient's suffering. For patients to accept a diagnosis, they must believe that doctors know--in the same way that physicists know about gravity or biologists about mitosis--that their disease exists and that they have it. But this kind of certainty has eluded psychiatry, and every fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can't rigorously differentiate illness from everyday suffering. This is why, as one psychiatrist wrote after the APA voted homosexuality out of the DSM, "there is a terrible sense of shame among psychiatrists, always wanting to show that our diagnoses are as good as the scientific ones used in real medicine."
And so:
Since 1980, when the DSM-III was published, psychiatrists have tried to solve this problem by using what is called descriptive diagnosis: a checklist approach, whereby illnesses are defined wholly by the symptoms patients present. The main virtue of descriptive psychiatry is that it doesn't rely on unprovable notions about the nature and causes of mental illness, as the Freudian theories behind all those "neuroses" had done. Two doctors who observe a patient carefully and consult the DSM's criteria lists usually won't disagree on the diagnosis--something that was embarrassingly common before 1980. But descriptive psychiatry also has a major problem: Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have "major depression," no matter your circumstances or your own perception of your troubles.
2. Rent-seeking run amok.  Al Frances, lead editor of the last edition of the DSM, shares one of his "keenest regrets" about the book:
[I]ts role, as he perceives it, in the epidemic of bipolar diagnoses in children over the past decade. Shortly after the book came out, doctors began to declare children bipolar even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease. Within a dozen years, bipolar diagnoses among children had increased 40-fold. Many of these kids were put on antipsychotic drugs, whose effects on the developing brain are poorly understood but which are known to cause obesity and diabetes. In 2007, a series of investigative reports revealed that an influential advocate for diagnosing bipolar disorder in kids, the Harvard psychiatrist Joseph Biederman, failed to disclose money he'd received from Johnson & Johnson, makers of the bipolar drug Risperdal, or risperidone. (The New York Times reported that Biederman told the company his proposed trial of Risperdal in young children "will support the safety and effectiveness of risperidone in this age group.") Frances believes this bipolar "fad" would not have occurred had the DSM-IV committee not rejected a move to limit the diagnosis to adults.
More to the point:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he'd been seeing for a couple of months so that she could bill the insurance company. "I hadn't really formulated it," he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

"Did it change the way you treated her?" I asked, noting that he'd worked with her for quite a while without naming what she had.

"No."

"So what would you say was the value of the diagnosis?"

"I got paid."

3. Incoherent philosophy of mind.  The article is weakest on psychiatry's most fundamental failing, but far from silent:
The fact that diseases can be invented (or, as with homosexuality, uninvented) and their criteria tweaked in response to social conditions is exactly what worries critics like Frances about some of the disorders proposed for the DSM-5--not only attenuated psychotic symptoms syndrome but also binge eating disorder, temper dysregulation disorder, and other "sub-threshold" diagnoses. To harness the power of medicine in service of kids with hallucinations, or compulsive overeaters, or 8-year-olds who throw frequent tantrums, is to command attention and resources for suffering that is undeniable. But it is also to increase psychiatry's intrusion into everyday life, even as it gives us tidy names for our eternally messy problems.
HT: Living legend Thomas Szasz



COMMENTS (11 to date)
Ken B writes:

Szasz made a huge impression on me in the late 80s, and one remark I remember in particular. Paraphrasing: Whenever psychiatry gets involved with law it is to keep people who have committed a crime out of jail or to put people who have committed no crime into jail.

Steve writes:

More accurately, Wired "had" a piece. It came out a year ago.

Name Nomad writes:

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Glen S. McGhee writes:

I have to admit that Szasz also made an impact on me many years ago, but here again, historical context is missing.


And then there is the writing of Ken Gergen, also very important for understanding the social basis of psychology.

Reichians, Freudians, Jungians, Sullivanians, Rogerians, Gestaltists, and numerous other practitioners account for the diversity described here.

But at a more abstract level, refer to the work of Kurt Danizger, Constructing the subject: Historical origins of psychological research (http://catdir.loc.gov/catdir/samples/cam031/89022160.pdf)

I came across Danziger preparing my own chapter on the social history of cognitive dissonance, that is, the sociological analysis of a psychological theory. More broadly understood, science (and medicine: see Paul Starr) can itself be understood in terms of social networks, technology, etc., as in Stephan Fuchs, Against Essentialism. Fuchs follows Ludwig Fleck (1930s) who influenced Thomas Kuhn and Mary Douglas.

The richness of the cultural context leads directly to the discovery of connections with psychological testing, eugenics, college admissions, and the birth of modern statistics. It is important to know about these things if we want to more fully appreciate the present.

Bill Hocter writes:

"Even assuming a person is diagnosed properly, they will never be cured; often enough their symptoms won't even be helped much if at all! Once we have the brain better mapped out or understood and can assess a person's mental state with some sort of device, real progress can begin."

Actually, in spite of the many problems accurately detailed in the article, most of my patients seem to get better. I do agree that "cure" may not be the most appropriate term since most conditions bear substantial risk of recurrence at some point after remission. Sometimes they even fail to reach full remission, but may still improve. We do need to get better tools for diagnosis and treatment. We need to somehow do this without forgetting that patients need to feel understood as people, not just as diagnoses.

One might question whether it is appropriate for me to take credit for my patients' improvement. I think it is at least to some extent. Most treatments seem to do better than wait list (no treatment) populations in studies on various conditions. Recent studies showing that some antidepressants do no better than placebo likely indicate a need for diagnostic tightening-earlier studies that used hospitalized subjects did not seem to suffer from this problem.

I think diagnostic tightening (as well as more conservative use of medication)is likely to occur given the side effects of medication and improvements in various types of psychotherapies. Remember that part of the reason that medications were more greatly emphasized in the '90s was that it takes longer to learn about side effects than treatment effects, even with the FDA. Early on it was hoped that the apparently ultra low risk medicaitons would open the opportunity for "cosmetic" psychopharmocology. Those hopes lie in ruins.

For what it's worth, I think my field has much in common with macroeconomics. Certainly at the political level, economists like to take credit when things are going well (e.g., "The Great Moderation") and have received blame when things go poorly. I can still remember my father, as a Federal Reserve Economoist during the 1970s, being bummed out by the public criticism of economists at the time. In particular I remember a New York Times cartoon showing the Council of Economic Advisors portrayed as caged monkeys with the cage displaying the caption: "Do not feed-ever".

In regard to DSM-5, I suspect (and hope) the APA will continue to delay publication until it can put out a manual that is less controversial and more diagnostically restrictive.


CC writes:

I always thought these objections to psychiatry were silly. So what if they argue about definitions, the corresponding "check lists", and the definitions change over time?

Astronomers argued over the definition of a "planet" (and even created a check list). And then they changed the definition! Pluto was a planet one day and not the next. So what?

And biologists argue about the definition of a species. Now are you going to tell me that physics and biology aren't science?

Chris T writes:

Modern day psychiatric medicine can be summed up with 'throwing sledge hammers at a wall and seeing what sticks'. Unfortunately, as Name Nomad noted, there really isn't a better approach until we have a good working theory of the mind.

Jill writes:

I am very happy see your article. People need to know that in my opinion psychiatry is a fraud.

If anyone wants more proof of what Brian has written they can contact my organization. We have a DVD all about how the DSM is created. There are medical and mental health professionals in this dvd stating that their Psychiatrists) illnesses are made up.

I work for an organization that was co founded by Dr. Szasz.

There are alternatives to psychiatric "treatment" - all one has to do is look.

Evan writes:
I always thought these objections to psychiatry were silly. So what if they argue about definitions, the corresponding "check lists", and the definitions change over time?

Astronomers argued over the definition of a "planet" (and even created a check list). And then they changed the definition! Pluto was a planet one day and not the next. So what?


The main difference is that no one has been imprisoned over the definition of a planet, not in recent memory anyway. Psychiatry is playing for higher stakes, so it should be held to higher standards.

The main problem I see with psychiatry is that it seems to hold this view that people's preferences consist of two different classes, "real" preferences which are caused by some sort of Ghost in the Machine and "fake" preferences caused by the circuitry of the brain. Mental illness, according to this view, occurs when the "fake" preferences of your biological substrate usurp the "real" preferences of the Ghost in the Machine.

According to this view it is okay to imprison "mentally ill" people and give them involuntary treatment because their preferences aren't real. It's their brain that holds those preferences, not them (!) It seems to me that most psychiatrists hold this view, even ones who claim to be materialists through and through.

The key to getting a better and more humane model of psychiatry is to realize that all your preferences are "real." It might still be that you want to suppress some of those preferences because they cause you to hurt others, or interfere with you achieving some other preferences of yours. And psychiatrists can help you with that. But dismissing someone's preferences as an illness is obviously silly in light of what we've learned about the inseparability of the mind and the brain.

Ray writes:
The main difference is that no one has been imprisoned over the definition of a planet, not in recent memory anyway. Psychiatry is playing for higher stakes, so it should be held to higher standards.

This is a szaszean point that was true when he wrote it 60 years ago but is not anymore.

No one has been imprisoned recently over the definitions that are under revision. The standard for imprisonment is imminent risk to self or others, regardless of the diagnosis.

Ray writes:

Bryan Caplan leaves out a very important paragraph from the article that does not support his conclusions:

His implication is that the rest of medicine, in all its scientific rigor, doesn’t work that way. But in fact, medicine makes adjustments all the time. As obesity has become more of a social problem, for instance, doctors have created a new disease called metabolic syndrome, and they’re still arguing over the checklist of its definition: the blood pressure required for diagnosis, for example, and whether waist circumference should be a criterion. As Darrel Regier points out, diabetes is defined by a blood-glucose threshold, one that has changed over time. Whether physical or mental, a disease is really a statistical construct, a group of symptoms that afflicts a group of people similarly. We may think our doctors are like Gregory House, relentlessly stalking the biochemical culprits of our suffering, but in real medicine they are more like Darrel Regier, trying to discern the patterns in our distress and quantify them.

Bryan, care to comment?

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