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 HypochondriasisThe 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.
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.
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.