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DSM critique in the New England Journal of Medicine is not what it seems 05/21/2012

Posted by ALT in DSM-5, Mental Health Research.
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1 comment so far

I heard the rumors of a fight, and I came a-running. 

Fisticuffs, you say? I’m in!

This morning, I read [here] that the following inflammatory remarks were published in this week’s New England Journal of Medicine:

 … [Only when psychiatrists address] psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations … by the causal processes and generative mechanisms known to provoke them … will psychiatry come of age as a medical discipline and a field guide [the DSM – Diagnostic and Statistical Manual] cease to be its master work.

- Paul McHugh, MD and Phillp Slavney, MD in the NEJM [emphasis added]

Damn, that’s cold.  And did I mention it was published in the New England Journal of Medicine (!), which is “one of the world’s most prestigious medical journals… cited in scientific literature more frequently than any other biomedical journal”?  All kinds of doctors, clinicians, and practitioners read this thing!

A big deal.

Sounds like the authors are saying mental illness is fundamentally NOT like diabetes, that psychiatry as a discipline will continue to suffer from its immaturity and crippling inferiority complex (“we wanna be scientists, too!”) as long as diagnosis doesn’t rest on a firmly established foundation of physical pathology, and that the DSM is a poor substitute for that kind of a foundation.

Them’s fighting words.  Words that might make the NEJM readership think twice before handing out diagnoses and their accompanying pharmacological interventions like the proverbial candy.

Don’t believe every rumor you hear

Having matured a bit from my high school days of running directly to join the ring of kids chanting “fight, fight, fight!”, I decided to get a little context.  Who are these guys -– researchers? psychiatrists? some other kind of doctors? — and what does the rest of their NEJM editorial say?

“These guys” are two psychiatrists, professors at the Johns Hopkins School of Medicine.  Paul McHugh, the lead author, is a rather famous one.  He’s attended Harvard, designed a famous cognitive test often used as a dementia/Alzheimer’s diagnostic tool (a mere 11 questions!), served on the Presidential Council of Bioethics under GW and on a lay panel put together by the Catholic Church to look into the abuse of young boys by priests – none of these things being very high recommendations in my book.  The two, together, have written a popular paperback for the general public entitled The Perspectives of Psychiatry which takes the biopsychiatric/disease-based approach to mental health.

And their editorial?  It starts off very nicely with a critique of the DSM-delineated “field guide” method of diagnosis – the main problem being that clinicians no longer think too long or hard about causation.  This promotes a “rote-driven” method of treating folks, and as the authors so rightly state “identifying a disorder by its symptoms does not translate into understanding it.”  Or treating it effectively, if long-term studies of schizophrenia outcomes are any indication.

But things go sour real fast as we get to the “what’s to be done about it” part.  We simply must establish causation for psychiatric disorders, and – guess what?—the authors have already done that! 

The causes of psychiatric disorders derive from four interrelated but separable families: brain diseases, personality dimensions, motivated behaviors, and life encounters.

-McHugh et al.

Good, good.

They have also helpfully sorted out some common psychiatric disorders into the four families, or “causal perspectives”:

It’s written in a table so it MUST be true!

Right there, in the NEJM (remember – prestigious medical journal read by everybody), we’ve got schizophrenia neatly categorized as “brain disease.” 

Oh, dear.

I diagnose thee… Flipfloppers!

Contrast the NEJM editorial with the polite phrasing the authors used in the aforementioned co-authored The Perspectives of Psychiatry, chapter 6:

The continuing failure to identify a particular cerebral pathology or pathophysiology in these disorders [manic depression and schizophrenia] undermines attempts to proclaim them as diseases with complete confidence.  They remain mysteries in the sense that a confirmation of their essential nature is lacking…

- authors Paul McHugh, MD and Phillp Slavney, MD in The Perspectives of Psychiatry [emphasis added]

And yet they feel comfortable, only a few years after these words were published, with proclaiming schizophrenia as a “brain disease,” without providing any citations for new, groundbreaking research whatsoever.  Clearly this “DSM critique” is not what it seems.

Middle way protestors all the way

As it turns out, these guys are total middle way DSM protestors – the only thing they’d like to fight is the bad public image of the DSM, not the institution of psychiatric diagnoses masquerading as science, and all of the poor treatment that goes along with such posturing (symptom suppression via pharmaceuticals, coercive treatment, et al.).

According to McHugh and Slavney, “no replacement of the criterion-driven diagnoses of the DSM would be acceptable; clinicians are too accustomed to them.”  Rather, the only solution is for everyone [clinicians, researchers, families, patients] to embrace their causation groupings – and for that to be coded and billable, too, one can only presume.

In no other field would you continue to reach for an admittedly blunt, ineffective tool simply because it’s “what people are used to.”  Surely there are some other possiblities?

I believe that there is another way – instead of fitting people and their “symptoms” into predetermined boxes, we could communicate with each unique individual, offering our support and encouragement (help) when it’s wanted, and offering our respectful non-interventionism and acknowledgement of the humanity of the suffering individual when our “help” is neither helpful nor desired.

I believe there is life after the DSM – and I’d like, as a society and a community, to live it!

Dystopian Dreams of a World Without the DSM 05/15/2012

Posted by ALT in DSM-5, Patient Rights and Advocacy, Philosophy/Spirituality.
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A world without psychiatry’s “Bible,” the DSM [Diagnostic and Statistical Manual].  I can see it now…

In this world, much like our own, there is still suffering.  There is still poverty, crime, crushing sadness, despair.  There is still violence.  Regrettably, there may even still be some people who choose to take their own lives, preferring death over the pain of the moment.

But things are a helluva lot better in this world.  Not perfect, mind you.  Nevertheless a far more hospitable place for humans to be (in distress or not).

Not a utopia

I don’t promise you a utopia, because I have learned that utopian thought is always a trap.  It inevitably leads to State supervision of, well, everything.  We’ve got to maintain that perfect agreement about what constitutes the perfect order, right?   At any cost.  Moreover, utopian thought requires the mechanization (and consequently dehumanization) of the culture, the community, the human beings involved therein.

A feature of nearly all utopias has been addiction to elaborate social machinery like schooling and to what we can call marvelous machinery. Excessive human affection between parents, children, husbands, wives, et al., is suppressed to allow enthusiasm for machine magic to stand out in bold relief…

All machines are merely extensions of the human nervous system, artifices which improve on natural apparatus, each a utopianization of some physical function. Equally important, the use of machinery causes its natural flesh and blood counterpart to atrophy, hence the lifeless quality of the utopias. Machines dehumanize, wherever they are used and however sensible their use appears. Yet the powerful, pervasive influence of utopian reform thinking on the design of modern states has brought utopian mechanization of all human functions into the councils of statecraft.”

- John Taylor Gatto in “The Lure of Utopia

So I give you, instead, some dystopian dreams of a world without the DSM.

In this world…

Psychiatrists, as a profession, en masse, have admitted: WE WERE WRONG.

We shouldn’t have done it,” they will humbly concede.  “We shouldn’t have insisted it was a fact that the ‘disorders’ we outlined in the DSM were objective, scientific, distinct pathologies (just like diabetes!) when we had virtually no proof of that.  We shouldn’t have told our patients that they had ‘faulty genes’ or ‘faulty brains,’ that they were doomed to suffer chronically, for the rest of their lives, from the effects of chemical imbalances of neurotransmitters in their heads when we literally had no way of measuring balances of neurotransmitters [in the brain] in the first place, no way to establish a baseline for what is ‘normal’ and what is not.

And we certainly shouldn’t have partnered with drug companies, we shouldn’t have accepted their bribes, their promises of prestige and honor, allowing them such tremendous influence over the development of the diagnostic criteria.  We shouldn’t have turned a blind eye to the terrible, terrible harm the pharmaceuticals they were so enthusiastically peddling were doing to our patients, to our communities.  We should’ve looked further than the drug company-sponsored ‘research,’ we should’ve listened to what our patients were telling us, the facts that were staring us in the face, if only we were willing to take off the blinders so kindly provided us in our years of PhD training in pharma-sponsored schools and research hospitals.

Folks, we were wrong, and we’re deeply sorry for the harm we’ve caused.  We’d like you to send back your DSMs (don’t worry, we’ll cover the postage), so that we can dispose of them in a safe and secure manner.”

(Dumping them down the drain, so to speak, simply won’t do.)

Interring them in an underground tomb, however…

Now, as my significant other likes to say, there are three kinds of apology:

Type One: “I’m sorry you didn’t like it, but I fully intend to do it again.”
Type Two: “I’m sorry it happened, but it wasn’t really my fault.”
Type Three: “I’m sorry I did it, I take full responsibility for my actions, and I will make sure not to do that again.”

This will be a full-on, Type 3 apology, and it’s going to force all psychiatrists to ask of themselves some very serious questions about their profession, their practice, their beliefs about humankind.  The self-proclaimed “soul healers” are going to do some critical thinking and some soul searching (like this).  With humility and a greater sense of empathy, many (but probably not all) will emerge on the other side, repentant, contrite.

We move forward, having abandoned the purely “biopsychiatric” approach to mental illness, with a renewed commitment to seeing mental distress and madness for what they are (instead of trying to fit them to a biopsychiatric model that was flawed from the start, given its roots in pharmaceutical marketing campaigns, NOT actual observation of the process).

We move forward.

Our cultural narrative about mental distress has fundamentally changed.

Once this monumental apology has been issued, the books sent back, the labels redacted, “bipolar disorder,” “schizophrenia,” and “dysphoric mood disorder” won’t exist anymore as such.  [oh wait, I guess Dysphoric Mood Disorder doesn’t quite exist yet… well, give it time, give it time.]

But there will still be people convinced of the coming apocalypse, walking circles around the city at night with visions of destruction surrounding them.  There will still be children throwing terrible tantrums day in and day out.  There will be racing thoughts, deep depressions, panic attacks; there will also be euphoria, epiphanic realizations of the oneness of humanity, creation, deep outpourings of love and spiritual healing.

Yes, there will still be “extreme states of consciousness” – some of which will be quite distressing to the people who experience them.

But our cultural narrative explaining the presence of such extreme states will have changed dramatically.  When they are no longer catalogued “symptoms” of a fearsome “disease” that some people get and some people don’t, but just one part of a vast spectrum of human experiences possible to all humankind, it will no longer be feasible to adopt an us and them mentality.

“Mental illness” as the “bad genes” of “unfit stock” manifested? Not anymore.  We weed out our old eugenical ideas about “the mentally ill,”  roots and all (and that includes the idea that there exists a class of people called “the mentally ill” and another class called “the normal” and that the one is fundamentally different from and dangerous to the other).

Goodbye, weed. Move over and make room for the flowers!

We understand that “it” (extreme states of consciousness and diasgreements with consensual reality) could happen to any one of us – and that if it does happen, each and every human deserves to be treated with compassion, respect, lovingkindness… like this.

In practical terms, we don’t give folks forced “intramuscular medication” (time-released injections), we don’t electroshock people against their will, we don’t chain them, humiliate them, perform experiments on them, stigmatize them, silence them, lie to them “for their own good,” condemn them to a slow, drug-induced death, brand them again and again as a “danger to society,” something fundamentally different, other.  We don’t do any of these things because we refuse to violate anyone’s humanity  — and we recognize that when we do this to someone else, we open the door to having it done unto us.

People are able to define, for themselves, their subjective experiences of reality.

Without a so-called “scientific” definition of mental illness spelled out in the DSM, readymade for the force-feeding, people will be left with a blank page on which to write out their own truths.  Truths about our society, our world, and what is “acceptable” in these contexts.  Truths about what it means to be well, right-minded, living right.

Those who reject the DSM are already doing this:

In the culture of the Icarus Project some years ago we developed a rough prototype of a document we call a Wellness Map (or affectionately a “Mad Map”.) It’s a very practical document to be written in good health and shared with friends and loved ones and it starts with the simple (yet not always easy to answer) question:

How are you when you’re well? What does wellness look like to you?

This question is followed by: What are the signs that you’re not so well?

and eventually: What are the steps that you and your community need to take to get you back to wellness?

-Sascha Altman DuBrul, in his essay “Mad Pride and Spiritual Community: Thoughts on The Spiritual Gift of Madness

Maps of wildly diverse terrains, pages and pages of difference!  What’s right for me may not be right for you – and that’s a beautiful thing.   As you can see, this is no utopia.  We don’t have to agree about what “perfect order” is [and then single-mindedly enforce that order everywhere]; we don’t even have to strive for perfection at all!  We just have to be honest, creatively living our lives each day, mapping out our mental, emotional, and spiritual geographies, all the while respecting our fellow humans as they do the same.  And most importantly…

We offer our compassionate, “un-professional” support to our fellow human beings in distress (and out of it!).

This is crucial.  We humans weren’t made to be lonely – not in joy or grief, and certainly not in madness.  We long to share our experiences, to bond, to connect, to feel the lovingkindness of someone else’s attention, care.

So in distress and out of it, we can follow as an example the standard of care provided by luminaries like Loren Mosher and John Perry .  In distress and out of it, let’s be with each other, without judgment (diagnosis) or manipulation (“for your own good interventionism”), without “professional opinions” (self-fulfilling prophecies of chronicity and doom) or prescriptions (forced care).

Let’s make maps together; let’s be fellow geographers of the human condition.  Allow for grief in response to the deep sadness that is inevitably a part of life.  Allow for terrible fear, at times, and unbelievable joy.  Allow for madness as a transformative process, when it occurs; the birthing of a new consciousness.  Allow a safe passage, in loving company, through difficult times.  Allow our fellow human beings to emerge, on the far side of their extreme states of consciousness, “weller than well.”

We move forward.  We don’t look back.

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