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This is the first of an occasionally-appearing series on topics having to do with psychiatry.  Ever since Freud first wrote about young women sickened by their repressed sexual thoughts, America has been fascinated by the world of psychiatry.  And given that salacious introduction to the world of mental illness, who wouldn't be fascinated?  I too have been fascinated by the field of psychiatry, and I hope this series of articles will explain some of that fascination to readers in ways that are both enjoyable and enlightening.

Let's begin by defining some frequently-used terms.  Psychology is the study of mental processes and animal behavior.  Psychiatry is the study of mental illnesses, or disorders of thinking, and their treatment.  A psychologist is one who studies or practices psychology, while a psychiatrist is a practitioner of psychiatry.  Under current US law, both psychologists and psychiatrists are eligible to be licensed to treat patients with mental disorders, but only psychiatrists are allowed to prescribe medications.  Mental disorders are distinct from physical disorders of the brain, such as strokes, brain trauma, brain tumors, headaches, and the like.  These physical ailments are addressed and treated by the field of neurology, not psychiatry.  Freud, one of the founders of psychiatry, started his professional life as a neurologist.

If one wants to understand and treat an illness, it is important to know how the illness differs from the healthy state.  This is not always easy, because the healthy state can be highly variable, and often the manifestations of the illness can be subtle or mimic the healthy state.  Take high blood pressure, for example.  High blood pressure is a common illness in western industrialized nations, and making a diagnosis of high blood pressure depends on knowing what is a normal blood pressure and what is abnormal.  Unfortunately for doctors, normal blood pressure is known to vary widely from person to person: two individuals, both healthy, are likely to have very different blood pressures.  Worse yet, normal blood pressure in any one individual changes constantly on a minute-by-minute basis.  It changes with activity, position, breathing cycle, and even with mental state.  

Through years of observations done across groups of people and within individuals, doctors have determined that normal blood pressure exists in a range.  And doctors have defined that normal range explicitly and concretely, using pressure measurements made with the familiar sphygmometer.  Within that range, individuals are determined to have a normal blood pressure; fall outside of that range, and the doctors will diagnose a blood pressure problem.  In this way, doctors are able to make a diagnosis despite the great variability of blood pressure.

This discussion of making a diagnosis of blood pressure is relevant to the field of psychiatry in a couple of ways.  Firstly, like blood pressure, our human mental states varies greatly both across individuals and within any one individual.  And secondly, unlike heart doctors, the field of psychiatry has never defined what is a normal mental state.  The ability to distinguish healthy from disease states is important if doctors are to make accurate and reliable diagnoses, and if treatments are to be made based on rational and scientific principles or given out willy-nilly.

The psychiatrists use a textbook, called The Diagnostic and Statistical Manual of Mental Disorders (or DSM for short) that lists all the psychiatric illnesses within the field of psychiatry.  Psychiatrists felt it was important that they define all the disorders they treat so that doctors would have one standard by which they diagnose an illness.  Using the DSM, all psychiatrists use the same criteria to make a diagnosis of schizophrenia, or depression, or panic disorder, and the terms schizophrenia, depression, and panic disorder mean the same thing to all psychiatrists.  This increases the scientific validity of the diagnosis and its reliability and repeatability – so that all psychiatrists will arrive at the same diagnosis when examining the same patient.

The DSM now runs to 900+ pages, and contains descriptions of thousands of disorders.  It includes the familiar (Depression and Schizophrenia), and the obscure (Frotteurism and Pica).  Each disorder is described in terms of its characteristic features, its demographics, its course over time, and a list of diagnostic criteria.  The diagnostic criteria are then used by doctors to determine if a patient has the disorder or not.  Here for example are the diagnostic criteria for the disorder hypochondriasis:

Diagnostic Criteria for 300.7 Hypochondriasis
A.  Preooccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B.  The preoccupation persists despite appropriate medical evaluation and reassurance.
C.  The belief in Criterion A is not of delusion intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D.  The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E.  The duration of the disturbance is at least six months.
F.  The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.
The DSM is sometime referred to as “the Bible” of psychiatry.  But what it does not include is any description of a normal, healthy, or non-diseased state.  In the world of psychiatry, your mental health is only defined by the absence of illness.

Notice the contrast with disorders of blood pressure.  Walk into your Family Practitioner's office, and they will be able to tell you, with a very high degree of accuracy, if your blood pressure is normal or abnormal.  And if your blood pressure is normal, this gets written down in your medical records as “blood pressure within normal limits”.  Walk into your psychiatrists office, and you will never, ever get diagnosed as normal or healthy.

If you were to sit down and look through thousands of patient records made by psychiatrists (and I have quite literally done this so I know that of which I speak), you will find that every single patient has a diagnosis of one psychiatric disease or another.  Psychiatrists never make a diagnosis of healthy or normal: that diagnosis never appears in the patient's psychiatric record.  In a very real way, any person who is examined by a psychiatrist will be diagnosed as sick.  Indeed, the more severe critics say you become sick simply by the act to consulting a psychiatrist.

The causes for this lack of a normal or healthy state in the world of psychiatry are multiple.  Certainly, the fact that the DSM does not contain any description or definition of the normal mental state is part of the problem.  The DSM provides psychiatrists with criteria by which a diagnosis of schizophrenia or depression can be made, but no criteria to distinguish a normal healthy state.  And for the psychiatrist, there is no profit to be made from a diagnosis of normal or healthy.  If the psychiatrist records a “normal” diagnosis for a patient, the insurance company will not reimburse the doctor for further visits with that patient - even though the cardiologists get reimbursed for a diagnosis of “normal” blood pressure and for further repeated checks of the blood pressure.  And as with other businesses, the psychiatrist knows the importance of keeping the customer satisfied: if the patient complains of feeling depressed or anxious, 99 time out of 100 the doctor will prescribe a medication.  The patients mostly want and expect this, and a prescription justifies repeat visits to assess the impact of the medication and to write re-fills.  And the doctor will want to apply a diagnosis to substantiate the need for the  prescription.

The problem with having no normal is that it mean everyone is sick.  And indeed, careful studies have shown an increasing incidence of mental illness here in the US and around the world, to the point where the psychiatrists themselves are beginning to sound alarms.  The number of Americans who are so disabled by their mental illness that they qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) increased nearly two and a half times between 1987 and 2007 from one in 184 Americans to one in 76 Americans.  During the same period of time, there was a  thirty-five-fold increase in the number of children receiving such aid.  Between 2001 and 2003, the National Institute of Mental Health sponsored a survey of to measure the lifetime occurrence of mental illness across the US.  The survey was done using face-to-face interviews in a large sample of randomly selected households in rural, suburban, and urban areas.  Including all study subjects up to age 75, the survey found the 50.8% of Americans will have an anxiety disorder, a mood disorder, a conduct disorder, or a substance use disorder during their lifetimes (Kessler RC.  JAMA.  2005; 62(6):593-602 – here: http://archpsyc.jamanetwork.com/...).  Half of these illnesses were found to have their onset before age 14; 75% had their onset before age 24.  Recently, the Centers for Disease Control reported that 25% of all Americans have a psychiatric illness at any given moment (Reeves WC.  MMWR.  2011; 60:1-32).  The fact that half of Americans may have some sort of psychiatric illness during their lifetimes and that one quarter of the US population has a psychiatric diagnosis at any given moment indicates to some cynics that these are not illnesses at all, but rather are the normal state!

Psychiatrists themselves have begun to question this proliferation of psychiatric illnesses.  Recently a row broke out in the editorial pages of the British Medical Journal over the CDC report.  One editorial writer cited this statistic as evidence that the psychiatric community has “overmedicalised normality”.  Writes Allen Francis, Professor Emeritus of Psychiatry at Duke University and chairperson of the task force that wrote the fourth edition of the Diagnostic and Statistical Manual (DSM-IV): “The overdiagnosis of mental disorders has recently gotten out of hand with faddish false epidemics..... ”, and that “normality is an endangered species”.  The phenomenon of over-diagnosis is now appearing in scholarly article written in the medical literature (Is Bipolar Disorder Overdiagnosed?  Zimmerman M.  J Clin Psychiatry.  2008; e1-e6).

The problem with diagnosing too many people with mental illness is that it cost money and wastes resources that could be put to better use elsewhere, it exposes people to needless and potentially damaging medications and treatments, a psychiatric diagnosis can carry a stigma with long-lasting implications for future medical care and insurance coverage, and it trivializes very real and painful illnesses.  Because at a time when more and more Americans are getting diagnosed with psychiatric disorders, there is a growing group of troubled chronically ill people who can not get any access to doctors or the psychiatric treatments they desperately need.

There is a famous experiment in the world of psychiatry.  Back in the 1970s, a psychologist named David Rosenhan and seven of his friends, none of whom had ever a psychiatric problem, presented themselves to hospital-based psychiatrists and claimed that they were hearing voices that said the words “hollow”, “empty” or “thud”.  This and their pseudonyms were the only lies they allowed themselves.  Other than that they were to be  completely truthful about themselves to their doctors.  If they were admitted to the hospital, the group had agreed they would then stop complaining about voices in their head, act normally, and tell the hospital staff they felt well.  All eight were admitted to the psychiatric ward (some experimenter were willing to do this twice, so in all, there were 12 “faked” admissions), diagnosed as suffering from a psychiatric illness (seven were diagnosed as schizophrenic, and one diagnosed as manic-depressive), and put on powerful anti-psychotic medications.  The length of the hospitalizations ranged from 7 to 52 days.  The ruse was never detected by the hospital doctors and staff; all eight were discharged with a diagnosis of “schizophrenia in remission”.  The doctors in these hospitals could not distinguish “normal” from “ill”.  Rosenhan published his experiment in the peer-reviewed journal Science, and it raised quite a controversy among the psychiatrists of the day (you can read a text version of the study here: http://psychrights.org/...)

Of course, that was back in the 1970's, and psychiatric care has changed a good deal since then.  These days, no one gets admitted to the psych ward unless they can pay for it themselves or are threatening to kill someone.  But the problem of figuring out where normal ends and psychiatric disease begins remains.  

Psychiatric illness is very real and for its sufferers, very painful.  And more and more, those with the most severe illnesses are blocked from seeing doctors and getting badly needed treatments.  Sadly, the majority of psychiatrists prefer to see the mildly and marginally ill: they have insurance or can pay for their treatments, there are more treatment options available such as supportive and “talking” therapies, and those with milder illnesses are more likely to respond to treatment and this is more gratifying for the doctor.  The chronically and severely mentally ill are most often made poor by their illness and can't pay for doctors and treatments, and as a group tend to not respond as well to treatments even if they stick with them.  All this is very frustrating to doctors, so the severely ill get less attention.  

This situation is made worse by the pharmaceutical companies, who increase their profits by selling more meds.  So the pharmaceutical companies promote psychiatric illnesses as a way to boost sales of meds.  The pharmaceutical companies also lobby doctors and psychiatric organizations to give out more meds and loosen the criteria by which a diagnosis is made.  Of course, the need for medication is only properly justified by applying a diagnosis to an individual.  For the pharmaceutical companies, every diagnosis is a potential profit.

All these problems are exacerbated by the failure of psychiatry to clearly define normal from illness.  Erik Ericson tells us the Freud claimed that mental health meant “the ability to love and to work”.  One hundred years later, no better description of psychiatric health has been formulated.  The field of psychiatry has matured tremendously since the days when Freud was using hypnosis to treat hysterical young women.  No doubt as psychiatry continues to grow there will be new discoveries about the workings of our brains, in both sickness and in health.  And if psychiatry is to be more than simply a money-maker for doctors with very wealthy patients and the pharmaceutical industry, knowledge of both what is normal and abnormal must be advanced further.

Originally posted to Hugh Jim Bissell on Fri Jun 22, 2012 at 07:49 AM PDT.

Also republished by Mental Health Awareness.

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Comment Preferences

  •  Tip Jar (9+ / 0-)

    "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

    by Hugh Jim Bissell on Fri Jun 22, 2012 at 07:49:54 AM PDT

  •  No mention of Abraham Maslow? (1+ / 0-)
    Recommended by:
    Catte Nappe

    Okay, Abraham Maslow was a psychologist, not a psychiatrist. But he was one of the first to take up the pressing question of "what is a normal, healthy human mind like?" Like you, he was distressed that studies of the mind up until that point had made little attempt to figure out what normal was. He is best know for developing the concept of the Hierarchy of Needs, and for helping develop the concept of self-actualization.

    •  Maslow did fine work on healthy psychology (0+ / 0-)

      Maslow did fine work studying the psychology of healthy successful people.

      But he did nothing to advance the power and accuracy of psychiatric diagnosis.

      "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

      by Hugh Jim Bissell on Fri Jun 22, 2012 at 08:40:49 AM PDT

      [ Parent ]

      •  He didn't? (0+ / 0-)

        I thought you had said that the problem with psychiatric diagnosis was that we did not really know what a healthy mind looked like. Maslow helped us understand the healthy human mind. How can you then say he did nothing, without refuting your own hypothesis? Unless your claim is "He is a psychologist, not a psychiatrist, so he did not advance psychiatry."

        I mean, it sort of sounds like your thesis is really that psychiatry is bunk science and you don't want to hear anything to the contrary. Maslow wasn't the only one who studied the healthy mind. We know much, much more about the mind, both healthy and unhealthy, than your diary gives us credit for.

        In fact, our problem is NOT that we are unaware of what a healthy mind is like, it is that we simply have not found effective treatments that will turn an unhealthy or disordered mind into a healthy one.

        •  The issue is psychatric diagnosis (0+ / 0-)

          While Maslow studied "healthy" psychology, his work did not contribute the the psychiatrists' understanding of mental health and illness.  Had the world of psychiatry bothered to include a description or diagnostic criteria for "normal" or "healthy", we might see some of Maslow thinking in such a description, but sadly, the world of psychiatry has never attempted to formally describe "normal" or "healthy".

          I have no criticism of Maslow or his studies (well, see below), but rather my criticism is for the failure of the psychiatrists to work towards understanding what is "normal"

          My one criticism of Maslow is that he based his work of humanistic psychology on the writings of Albert Einstein, Lao Tzu, Ruth Benedict, and Max Wertheimer.  These were not ordinary Joes, but extra-ordinary individuals who were highly accomplished, hugely talented, and well-regarded people.  Such extra-ordinary people are perhaps poor models of "normal" people.

          "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

          by Hugh Jim Bissell on Fri Jun 22, 2012 at 10:36:39 AM PDT

          [ Parent ]

  •  Who can determine what normal is? (1+ / 0-)
    Recommended by:
    luckylizard

    Especially now-a days.

    I know 'odd' when I see it, but...

    "Time is for careful people, not passionate ones."

    "Life without emotions is like an engine without fuel."

    by roseeriter on Fri Jun 22, 2012 at 08:22:54 AM PDT

    •  The ones who determine what sickness is (1+ / 0-)
      Recommended by:
      luckylizard

      Most people know "odd" when they see it.  That is not so controversial.

      However, it is important for those who claim to distinguish sickness from health to know thoroughly what "health" or "normal" is.  If those doctors do not know thoroughly what "health" or "normal" is, they run the risk of identifying everything as illness.

      And that is precisely a danger for modern psychiatry.

      "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

      by Hugh Jim Bissell on Fri Jun 22, 2012 at 08:38:05 AM PDT

      [ Parent ]

  •  Thank You ... (0+ / 0-)

    for this essay on mental health. Very informative.

    JON

    "Upward, not Northward" - Flatland, by EA Abbott

    by linkage on Fri Jun 22, 2012 at 08:47:22 AM PDT

  •  I'd be ecstatic if gender dysphoria... (1+ / 0-)
    Recommended by:
    elmo

    ...we're removed from being a medical illness.

    Probably won't happen in my lifetime.

    •  Prepare to be happy (0+ / 0-)

      Thr current version of the DSM (SM IV-TR) does not recognize a "gender dysphoria" disorder.

      The DSM IV-TR recognizes a Gender Identity Disorder for both children, and adolescents and adults, and a Gender Identity Disorder, Not Otherwise Specified.  Also recognized: Hypoactive Sexual Desire Disorder, Sexual Adversion Disorder, Female Sexual Arousal Disorder, Male Erectile Disorder, and both Male and Female Orgasmic Disorders.

      But "gender dysphoria" is not a disorder recognized currently by psychiatrists.  If someone tells you that such an illness exists, they are pulling your leg.

       

      "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

      by Hugh Jim Bissell on Fri Jun 22, 2012 at 09:21:25 AM PDT

      [ Parent ]

      •  How is Gender Identity Disorder different, (1+ / 0-)
        Recommended by:
        elmo

        or even better than, Gender Dysphoria? It still suggests that identifying with an opposite gender is a mental illness.

        North Carolina: Where you can marry your cousin. Just not your gay cousin.

        by second gen on Fri Jun 22, 2012 at 09:41:14 AM PDT

        [ Parent ]

        •  Again, "gender dysphoria" is not a recognized (0+ / 0-)

          Again, to the psychiatrists, "gender dysphoria" is not a recognized illness.  So the quick answer to your question of how gender identity disorder differs from gender dysphoria is that psychiatrists recognize one as an actual illness.

          Your question highlights the difficulty to psychiatry of avoiding defining a normal state: everything becomes an illness.  This makes it easier for groups with a religious or political persuasion to invent an illness to substantiate their claims: "see gay people are sick, they have gender dysphoria".

          Do psychiatrists think that people who identify with the opposite gender have an illness?  Not officially as a group, tho' individual doctors may think differently.  To psychiatrists, one only qualifies for Gender Identity Disorder if one meets all four of the diagnostic criteria (cross-gender identification being one of the four).

          "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

          by Hugh Jim Bissell on Fri Jun 22, 2012 at 10:18:51 AM PDT

          [ Parent ]

  •  There is evidence that what we call (0+ / 0-)

    Attention Deficit Hyperactivity Disorder (ADHD) was once the normal state of our ancestors in the hunter-gatherer days, and that farming introduced a new normal. For example, descendants of some Native American groups of traditional hunters show a 100% rate of ADHD.

    I am considered disabled with ADHD, but I consider it a net benefit because of the hyperfocus, and the increased creativity and compassion that come with it. See Hallowell and Ratey, Driven to Distraction, for a sympathetic description. (The authors are psychiatrists who both have ADHD.)

    The only form of disability I "suffer" from is the inability to sit still for total guff such as Republican propaganda and bureaucratic bafflegab.

    It is my view that almost all adventure heroes in literature, from Odysseus to the modern detective, and many of their writers, have ADHD. You need someone who is willing to help when nobody else will, and able to solve seemingly intractable problems, often overcoming life-and-death threats. Many artists and musicians, also. It has been observed that people with ADHD are drawn to risky and exciting occupations, including the military, police work, journalism, and investment banking.

    I am fortunate. I do not need medication to manage my ADHD, largely because I simply avoided any form of employment where it would be a disaster. Well, after that one time, which is when I found out I had it.

    Many with ADHD benefit from stimulant therapy. Others have tried a variety of other drugs. Detective writer Dashiell Hammett is somewhat typical of those who try to use alcohol to balance their minds, only to fall over with a crash into alcoholism. Sherlock Holmes gives a very accurate portrayal of the use of cocaine to manage ADHD. He only uses it when he does not have a case to focus his mind on. These and other such uses of a wide variety of drugs are called, in the literature, "inappropriate self-medication".

    Jesus also shows symptoms of ADHD, in his concern for the poor, his lack of concern for material things, and his disdain for conventional religiosity, among other teachings.

    Busting the Dog Whistle code.

    by Mokurai on Fri Jun 22, 2012 at 09:34:36 AM PDT

  •  Republished to Mental Health Awareness nt (0+ / 0-)

    North Carolina: Where you can marry your cousin. Just not your gay cousin.

    by second gen on Fri Jun 22, 2012 at 09:42:11 AM PDT

  •  Your definition of psychology is not quite (0+ / 0-)

    accurate. Psychology is the scientific study of mental processes (emotional and cognitive) and behavior(human and lower animal). Only a portion of Psychologists are in practice, others are professors and scientists, including neuroscientists.

    Also, you are not quite correct concerning the distinctness of mental and physical disorders:

    Mental disorders are distinct from physical disorders of the brain, such as strokes, brain trauma, brain tumors, headaches, and the like.  These physical ailments are addressed and treated by the field of neurology, not psychiatry.
    Psychiatrists do treat these "physical disorders" as they are also trainied in neurology, as in "neuropsychiatry." And so do Psychologists as neuropsychologists.

    The line between mental and physical disorders of the brain is very fuzzy as particularly in case of bipolar diisorsder among others including schizophrenia.

    "There is nothing - absolutely nothing - half so much worth doing as simply messing about in boats ..." - Kenneth Grahame -

    by RonK on Fri Jun 22, 2012 at 11:27:06 AM PDT

    •  I accept your definition of psychology (0+ / 0-)

      Your definition of psychology is fine and I am happy to accept it.

      As you point out the dichotomy between physical and mental disorders of the brain is somewhat arbitrary.  Clearly, we recognize emotional aspects of physical disorders such as stroke, and understand there are physical components of mental disorders such as schizophrenia.

      You are entirely wrong that psychiatrists treat neurological disorder such brain tumors, infections and strokes.  Psychiatrists do not have the training, expertise, and experience in dealing with such conditions.  No responsible psychiatrist who values their patient's well-being and their professional reputation would take on such illness.  

      Some psychiatrists (and some neurologists) will get training in both fields, and become qualified to assess and treat both psychiatric and neurological conditions (called "double-boarded" in doctor-speak).  

      Psychiatrists may be asked to assess and make treatment recommendations of psychiatric aspects of neurological disorders (i.e. a patient who suffers a stroke and then develops depression).  But in such cases, the psychiatrist is not making treatment recommendations with respect to the neurological condition.

      Neuropsychiatry (also called Behavioral Neurology) is a specialized area within the domain of neurology.  Doctors who claim expertise in neuropsychiatry typically undergo a period of training, in addition to their extensive training in neurology.

      "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

      by Hugh Jim Bissell on Fri Jun 22, 2012 at 04:26:25 PM PDT

      [ Parent ]

  •  Mental illness is a useless term. (0+ / 0-)

    Psychiatrists, in a genuine attempt to relieve suffering, try to categorize symptoms into sets they can then call syndromes or diseases. Defining a disease is the first stop towards creating a treatment. But the mind is not subject to those kinds of empirical solutions. Asking "What is sanity?" is the same as asking "What's the best Beatles song? Mental health is relative and subjective and exists on a continuum. There are no easy answers let alone definitive ones.

    When a true genius appears in the world, you may know him by this sign, that the dunces are all in confederacy against him. --Jonathan Swift

    by Barnaby Grudge on Fri Jun 22, 2012 at 11:54:32 PM PDT

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