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The Trickcyclists

The way that we think and talk about psychiatric illness has implications for all of us – not only mental health professionals and their patients, but anyone with affected friends and family members, policy-makers struggling to know what services to provide and pharmaceutical companies considering future profits. So it’s unsurprising that a proposed new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), widely described as the “psychiatrists’ bible”, is causing much furore – but slightly more surprising that much of the dissent comes from within psychiatry.

Oh yeah. That document is medicine’s Protocols of the Elders of Zion. It is toxic and refuses to die.

Since the publication of the third edition in 1980, the DSM has employed a checklist approach to assigning diagnoses. By ticking off the symptoms listed under each disorder, a mental health professional can reach a diagnosis that is likely to be in agreement with the judgment of any other mental health professional.

Huh? I mean that is spectacular. Let me tell a story here. In the late ’90s I had chronic back pain. I saw several doctors and physios and it was sorted but not by the first person I saw, not even by the third. A diiference in clinical technique is enormously valuable. Now don’t get me wrong here. I am not saying the earlier attempts to sort me were incompetent. What I’m saying is what works with one patient doesn’t necessarily work with another. Certainly not with maladies as essentially mysterious as bad backs or disorders of the noggin. Not least because the guy I finally saw I had faith in. Not my previous GP who when taking my history asked what I did and when I told him he said, “Oh, I wish I’d done physics – I only did medicine to please my mother”. I was speechless.

The main focus has been the broadening of psychiatric diagnoses, making an increasing range of behaviours targets of psychiatric concern. (As evidence this is already happened to an alarming degree: last year about one in four US citizens took a psychiatric drug.)

That means on an average 767 in the US 75 folks are on jollop for insanity! Let us hope none of them are near the yoke or throttle!

For example, it has been proposed that grief should be dropped as an exclusion criterion for the diagnosis of depression, raising the risk that normal grief reactions will be considered evidence of illness.

Now that is mad! For some reason I’m thinking of Marilyn Monroe. In an interview she once said she’d spent hundreds of hours in therapy and thousands of dollars on it and she wondered why the journalist was asking why she was depressed? Grief is part of life. Expecting someone to be chipper when the missus has cleared out the joint account and run over your dog on the way to elope with the milkman is bizarre. I mean it would be very odd not to feel a bit unhappy about that turn of events. Indeed verging on psychopathic.

In the case of severe mental illness, the discovery that a large proportion of the population (about 10%) sometimes experience “subclinical” hallucinations and bizarre beliefs has led to the inclusion of an attenuated psychosis syndrome.

“Bizarre beliefs”? OK call me in on that! I tend to think the best possible next POTUS is former Governor Johnson. Fewer than 10% of Americans share this view. What really disturbs me is how redolent that is of the Soviet Union and diagnosing dissidents as mad. For many, many years the US psychiatric establishment refused to believe their Russian counterparts could do something so at variance with medical ethics. This is bizarre and I would think almost willfully so. The entire history of medicine is steeped in profound quackery.

Behind these concerns about the expanding scope of psychiatry lies a deeper problem. The proposed revision has been constructed on the basis of clinical consensus – psychiatric folklore institutionalised by committee – rather than scientific research.

That reminds me of a nursing student I lived with. We were watching Dracula and it had scenes of the Victorian Bedlam Mental Hospital. He quipped, “So no change in psychiatric nursing then!” I mean would you approve a cancer drug on the basis of “consensus” and not research? You might as well prescribe tar-water! Or here’s another medical consensus. Up to and including the Battle of Waterloo the standard treatment for a gun-shot wound was bleeding. Any modern combat medic would regard that as the very last thing to do. Try saying that 200 years ago though and the consensus of grizzled heads would laugh you out of town.

Defenders of the DSM and similar systems argue that some kind of categorical method of diagnosing patients is required to allow communication between clinicians.

The easy lie rather than the difficult truth? Here’s a story for you. V=IR. You probably know that as Ohm’s law. That’s how they teach it in schools anyway. Now the full version is rather more terrifying than that – that presupposes a linear, isotropic and homogenous medium amongst other things! Or here’s another. Kepler’s laws of planetary motion are fine physics but it ain’t the full nine-yards. For that there is the disturbing function and even then that’s approximate. It is nails but if you really must know here’s a publication that ought to do it for you. It was written by my solar system dynamics lecturer, Carl Murray. Now he’s not a brain surgeon. He’s merely a rocket scientist. Really! He did work for NASA.

Oddly enough that probably will make you go mad as a trout. Relativity or Quantum Mechanics have nothing on it.

28 Comments

  1. CIngram says:

    I think ‘attenuated psychosis’ is a good answer to the question ‘What is it like to be human?’
    My rabbit asked me exactly that question the other day and I didn’t know what to say. If he brings the subject up again, I’ll have the answer ready (or should I just go to the pub?).

  2. RAB says:

    If your rabbit is called Harvey Clngram, I think you’ll find he’s down the pub keeping you a seat already. ;-)

  3. CIngram says:

    RAB

    Actually his name’s Whisky, so he’s probably got to wolf-whistling the barmaid by this time of the evening.

  4. RAB says:

    Pseudo Science, don’t you just love it?

    Started off with Freud who was basically a fraud, and basically based all his theories on a handful of neurotic sex starved women in Vienna. Anyone seen my Id? I know I left it round here somewhere? He also believed Cocaine to be a universal panacea, yet still the twat is revered.

    The there was his pupil and pal (till they fell out over a woman I believe, tee hee!) Jung, who thought the I Ching was a diagnostical tool!

    Then on to Wilhelm Reich who was going to sort the sex starvation out by basically advocating wholesale fucking in the streets, and his little box of joy, the Orgone Accumilator, Sheesh!

    And finally R D laing, who didn’t believe anyone was bonkers at all.

    Now we have a plague of Roz and Dave’s (they started as just one breeding pair in the late 60s) who call themselves councellors cos they arn’t bright enough to understand the long words the previous gents used, so they just make it up as they go along instead. Why oh fuckin why do we pay any mind to any the dozy fuckers?

    As I said on another thread, not one child in China (and there are a fuck of a lot of them) has ADHD. Why? because the Chinese don’t believe it exists, and i think they are right. Let’s tell the whole fuckin lot of rent seeking pseudo scientists (and that goes for most of the practicioners of the dismal science too) to fuck right off out of our lives. We’ all be healthier and happier.

  5. kevin smith says:

    When “The Homosexuals” (as they were then known) got
    organised and acquired some political power, they were
    able to have “Homosexuality” deleted from the DSM,
    thus proving that the DSM can be politically influenced.
    (Not to be interpreted as anti-gay, just a statement of fact)

    Before the abolition, slaves who tried to escape were labelled
    as mentally ill.

    Psychiatry is, in part, concerned with deviation from social norms,
    so the DSM is inevitably influenced by religion, specifically US christianity,
    of a more or less fundamental nature.

    As any observer of the USA knows
    (watching their cute TV programmes does not count as observation)
    there are powerful political forces working to impose a fundamentalist
    christianity as THE social norm.
    So some possible future DSM entries would be:

    Failure to accept Jesus Christ as the only true saviour;
    Refusing to say your prayers (to the one true god);
    Making babies in defiance of the eugenics commission;
    Wanting an abortion because you got pregnant by being raped by a cop;
    Refusing to stand quietly in the queue to the gas chamber;
    Belief that man and chimps share a common ancestor;
    etc.

    On the last example, evolution, I have an interesting hypothetical situation:
    Some backward US county makes it an offence to publish anything ‘evlutonry’;
    US requests extradition of ‘our’ (UK) Desmond Morris and Richard Dawkins
    to answer for their ‘crimes’. (Assuming that answering is permitted)
    Does the UK government resist the extradition?

    With best wishes to the ‘Land of the Free’

    (Thanks for the sounding board Nick, Reuters.com rejected this comment)

  6. Jay Thomas says:

    I think ADHD, like many psychiatric conditions is simply a label given to people on one end of the bell curve distribution of psychological traits. There really are extremely distractible scatterbrained and impulsive people in whom these traits are pronounced enough to fuck up their life in fundamental ways. Disease or not those are still the facts and it also seems pretty clear to me that such ‘symptoms’ have a strong genetic basis. If pharmaceutical interventions exist that can make the lives of such people more productive and satisfying then that is a fact to be applauded.

  7. kevin smith says:

    You having a go at me?

  8. kevin smith says:

    My best tale of medical buffoonery:
    Medics learned their anatomy on supine cadavers.
    The X-Ray machine was invented, and the patient was photographed standing up.
    Medics noted abdominal organs hanging lower than expected, and invented
    “Droopy organ syndrome”, then invented operations to fix it!
    The horror!

  9. RAB says:

    Jay, I think labelling should be confined to supermarket shelves, so we know what we’re buying. Human beings are not tins of beans, we are way more complex than that.

    I also think that much psychoanalytical labelling, Sociopath, Bipolar etc etc is just making excuses for fundamental bad behaviour, and a way of shifting blame away from personal responsibility to “society” at large. The people in control of their lives get all the blame and the evil scrotes running amuck get a free pass.

    I’m told by my parents, that I was hyperactive as a child, but they hadn’t invented the term yet, so those around me had to cope with me being a whirling Dervish from the moment I opened my eyes in the morning till I fell exhausted into bed of a night. And they did.

    Today I would have been diagnosed as ADHD, and chemically coshed, when all that was the matter with me, if “matter” it was, was that I was a very energetic kid, always doing things at full speed, with a rather large IQ and a very good memory (unrecognised at the time by my teachers) so I got bored and disruptive, wanting to move on to new things when my fellows were still struggling with the last. Once one clever teacher recognised this and treated me accordingly, my disruptive tendencies disappeared (well almost).

    Kevin. No he was not having a go at you. Don’t be so Paranoid… Ooops! ;-)

  10. kevin smith says:

    Now why did he say that?
    And why did he say it *like* that?!!

  11. Ian B says:

    I’m somewhat known for writing long comments taking issue with blog posts. Not this time. “I couldn’t ágree more” is a bit of a tired cliche, but Nick, I really “couldn’t agree more”. Excellent post.

  12. NickM says:

    Ian,
    Thanks. That’s the second time you’ve said similar in a week. Now your mission, should you choose to accept it, is…

    Kevin,
    I think this blog is unique in it’s thrust to weight ratio – like an F-15. Well, commentator to reader ratio. We are a sounding board. I wouldn’t bother myself if it wasn’t for the comments. I think your scenario is far-fetched mind. The USA is a very religious (by Western standards) nation but I don’t think it is a particularly religious state and there is a difference. I think it’s a difference a lot of Republicans don’t understand. Certainly not the likes of Santorum. Anyway, we have over 27,000 comments now and I really like that.

  13. Rod says:

    The shrinks would be funny if it wasn’t for the fact that they routinely lie. And I don’t just mean their unfalsifiable hypotheses and diagnoses. They deliberately misrepresent and misquote their patients in exactly the same way that a common perjurer lies about matters of ordinary fact.

    I’m talking about psychiatry as it’s practiced in state funded hospitals and out-patient clinics. This goes for the social workers and nurses as well.

    I’ve known hundreds of coercively psychiatrized people and read the so called medical histories of several dozen. I have not read a history that does not contain significant amounts of egregious concoction and falsification.

    A psychiatrist is a failed physician. A real scientist might occasionally entertain an unfalsifiable hypothesis. Maybe leave it on the intellectual back burner for a while. But he wouldn’t practice it on people especially when he has to lie about matters of fact to support what he does.

  14. Ian B says:

    The problem is, 26000 of them are me saying “I couldn’t agree more Nick”.

  15. Lynne says:

    RAB, in my experience ALL trick cyclists are diagnostical tools. Pills, potions and any psychocrap du jour you care to name, simply do not work. Psychiatry seems nothing more than a limitless, rent seekers charter. There’s always another bullshit new therapy or several to hand. This bunch of Cinderellas haven’t a clue.

  16. NickM says:

    Aw, shucks Ian! I must be more controversial and put-up my dreadful kitten-porn post…

    A whole new meaning to shaved pussies on the web ;-)

  17. Ian B says:

    At the risk of being serious for a second, this bit’s quite revealing-

    Defenders of the DSM and similar systems argue that some kind of categorical method of diagnosing patients is required to allow communication between clinicians.

    That seems to me to be very Popperian. Popper recognised that everyone is subjective, but tried to fix that by a criterion of, can’t remember the proper term, “communicatability” or something similar. That is, if you can communicate your results to some wider group, that overcomes the problem of individual subjectivity. It seems to me to be the basis of the flawed peer review system, that is Peer Review is an articulation of a Popperian paradigm.

    But Psychiatry shows us what is wrong with this idea. Kuhn would recognise that the DSM is paradigmatic. You can only communicate your science with people who share the same paradigm. So, if the paradigm is wrong, everyone is wrong, no matter how big the group is and no matter how well they can communicate their results to one another. Consensus can’t bridge the gap from the subjective to the objective. We might even tentatively suggest that the whole current fascination with “The Consensus” is a consequence of Critical Rationalism.

    I’ve become quite militantly anti-Popperian of late, I think. ISTM that if you believe in CR, you can believe that science can attain objectivity, and thus dismiss all criticism. That’s a rather dangerous certainty to be afflicted by.

  18. NickM says:

    Ian,
    And that is precisely why I have had some epic fights on the likes of Samizdata over Popper vs Kuhn. I think the word you are looking for is “commensurable”.

  19. You had a go at Laing, but wasn’t he effectively saying that much so-called mental illness was not illness per se, just differences from some norm. In the USSR that was politically derived while in the USSA it seems to stem from a strange chimaera of religious intolerance and corporatism.

  20. Ian B says:

    Well, they’re a funny bunch over there Nick, you know.

  21. CIngram says:

    Lynne,

    To say that they don’t work is rather too sweeping. It’s true that the chemistry (and for that matter the biology) of the brain are little understood compared with the body, but there are many pharmaceutical treatments which certainly do work, in the sense that they bring about a change in the patient’s mental state that can be predicted and identified. Although in some cases the desired target state is defined by the doctor in the interests of ‘society’, most treatments are for anxiety or depression, and it is the patient who wants to feel physically calmer or to face the world with a measure of confidence. These goals can generally be achieved chemically. It may not be an ideal solution for a number of reasons, but it works, and the patient is grateful for it.

    Normality should, ideally, be something for each of us to define for ourselves, but when you are feeling like shit for months on end and can’t see an end to it, you have a real problem, and your idea of a solution is to feel like the people you see around you. That can often be achieved, and it surely means that the treatment is working.

    Lying on a couch I’m not so sure about. Like in teaching, there seems to be a huge amount of theory but it’s not anchored in reality. But people are hugely influenced by what others tell them, and if the therapist can establish himself as an authority in the eyes of the patient, it’s possible that telling the patient to feel better will have a perceptible effect. I suspect therapy works best on people who don’t really have much of a problem in the first place.

  22. RAB says:

    I actually have a soft spot for Laing ian(not that one) b, but he just went to the other extreme from the rest. His ideas resulted in the massive increase in “care in the community” cases, when I’m afraid that there really are some folk who’s reality doesn’t even close to that of the rest of us, and are an actual physical danger to the general public, and themselves.

    The real bad guys these days though are the various brands of Councellors, “Experts” and lightly trained social workers. Hence we got Satanic abuse witchunts etc.

  23. Lynne says:

    I’m sure there are good psychiatrists and bad ones. Shame the former seem to be in very short supply. The ones I’ve come across tend to treat a patient of my acquaintance by working through the psychopharm alphabet and hope they hit upon a solution. No luck so far. Lots of psychiatric waffle though. Meanwhile the patient tries to get on with life the best way possible while trying to avoid medical zombification that shrinks mental horizons and smothers like cling film. They never seem to be short of a new drug to try. I’m thinking: unpaid guinea pig.

  24. Tim Newman says:

    One of the ongoing debates in Norway at the moment, which Samizdata mentioned a month or so back, is over the recent “diagnosis” of Anders Breivik as criminally insane. Now Breivik obviously holds some weird opinions and is seriously fucked up in terms of the degree to which he is prepared to put his theories into practice, but there is nothing I’ve read in that lump of text he wrote about the Knights Templar which strikes me as the words somebody who is insane and doesn’t know what he’s doing. Quite the opposite, in fact. He doesn’t refer to men from space controlling a radio in his head, he refers to lefty politics, white supremacy, and an invasion of muslims into Europe. Pretty nasty stuff, but again, hardly the sign of somebody off his rocker.

    His “diagnosis” is looking more and more like a political decision to avoid any acknowledgement of the issues he believes he was addressing, and to deny any further output legitimacy as it can be written off as the ravings of a nutter. How convenient. I think a lot of Norwegians are pretty unimpressed with this, not least because – as Breivik himself has acknowledged – it means he cannot be sent to prison, only committed to a mental hospital – and then only for as long as he is considered insane. He might only serve a few years before he demonstrates to the satisfaction of some psychiatrist that he is not insane and is by law required to be set free. Given that he is not insane, doing so should not be difficult.

  25. Tim Newman said:

    “Given that he is not insane, doing so should not be difficult.”

    Actually, given that he isn’t insane it might be very difficult, because locking a sane person up in a mental institution isn’t likely to do a lot for your mental health. At best there might be no change, therefore no improvement.

  26. wh00ps says:

    Oh goody. A lot MORE things i can get the internet to diagnose me with.
    The last personality disorder test i took i was three disorders short of the full set!
    i LIKE COLLECTING THINGS :-P

  27. Hexe Froschbein says:

    Here is a song to go with your blogpost: http://www.youtube.com/watch?v=O-KWb6JuYp0

  28. DeNihilist says:

    now here’s some real weird shit, maybe not for a physicist…

    http://judithcurry.com/2012/02/15/ergodicity/

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