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.