Social Policy in Ontario

Where is its mind? What the battle over the ‘bible’ says about psychiatry

Posted on July 10, 2011 in Health Policy Context

Source: Globe & Mail — Authors: Ian Brown

TheGlobeandMail.com – life/health/new-health/conditions/addiction/mental-health
Published Saturday, Jul. 09, 2011. Last updated Sunday, Jul. 10, 2011.    Ian Brown

It’s possible, looking back on Robert Spitzer’s life as one of the most influential psychiatrists of the 20th century, to conclude that he had a genius for turning grudges into career moves.

As a teen in the 1940s, he tried Reichian therapy to calm his feelings about girls, and liked it. But as a grad student, after Wilhelm Reich’s orgone accumulator didn’t work as well as Dr. Spitzer hoped, he wrote a critical paper that contributed to Reich’s prosecution by the U.S. Food and Drug Administration.

He then became a psychoanalyst. And when talk therapy didn’t cure his patients fast enough, he created the modernDiagnostic and Statistical Manual of Mental Disorders, the bulky tome that revolutionized psychiatry and drove the last nail into Sigmund Freud’s coffin.

But revenge has a way of biting back. A new group of psychiatrists is now under fire as they try to prepare the latest edition of the DSM, the Sears Catalogue of mental illness, used by more than 28,000 psychiatrists to diagnose their patients’ afflictions.

The controversy over the proposed DSM-5 is forcing psychiatry to analyze its own issues – its fervid embrace of drugs; its enthusiastic use of genetics and brain imaging to expand existing diagnostic categories, perhaps prematurely; and the limits of its ability to understand the human mind.

This may, in turn, open the door again, at least a little, to talk therapy and Dr. Spitzer’s old enemy, the unconscious. For the failing notion that mental illness can be crisply categorized and fixed with drugs – an idea Dr. Spitzer helped to invent, and that then dominated mental health for 30 years – it seems the time, as the shrinks like to say, is up.

Nettling the narcissists

Every new version of the DSM has been controversial, but the groundbreaking fifth edition of the “dictionary of disorder,” now scheduled for release in 2013, is showing symptoms of being the most contentious ever. The rough draft published on the American Psychiatric Association’sDSM website has generated so much heat (50 million hits and more than 3,000 signed comments so far) that its release has been pushed back by a year.

The proposed new edition has created so many new categories of diagnosis, and widened the definitions of so many others, that the respected editor of the last edition, Allen Frances, has accused the new editors of reckless irresponsibility.

Meanwhile, entire disorders were to be excluded from the new edition – such as narcissistic disorder (“a grandiose sense of self-importance … requires excessive admiration”) – but the move aroused such indignation (imagine how the narcissists felt!) that the editors have had to re-include them.

The raft of proposed new disorders in DSM-5 has other people complaining in the opposite direction. Premenstrual dysphoric syndrome, a freshly minted slot (“marked lability of mood interspersed with frequent tearfulness … subjective feeling of being overwhelmed or out of control,” to name two of five symptoms necessary to qualify), has produced persistent irritability and anger (symptom 4) on the DSM website.

“Some groups,” the DSM’s editors note, “have felt that a disorder that focuses on the perimen- strual phase of the menstrual cycle may ‘pathologize’ normal reproductive functioning in women.”

The real surprise is that something as mundane as a diagnostic manual gets any attention at all. First published by the American Psychiatric Association in 1952, DSM-I and DSM-II were spiral-bound and 150 pages long. DSM-II listed 182 disorders, and sold for $3.50, mostly to intake departments at mental institutions.

But in 1974, Dr. Spitzer was given the task of renewing the manual. He’d previously spearheaded the APA’s bitterly divisive 1973 decision to delist homosexuality as sexual deviancy in the DSM.

Having rejected Freudian therapy, and dissatisfied with teaching as a professional goal – according to some of his collaborators, he wasn’t very good at reading people – Dr. Spitzer turned to rewriting the DSM.

By then, psychiatry itself was in crisis: Doctors seeing the same patients agreed on a diagnosis only 20 per cent of the time. With Freud’s notion of unconscious conflict as the seed of mental illness under heavy attack, Dr. Spitzer set out to create a more concrete diagnostic system, relying entirely on symptoms doctors could see with their own eyes.

Dr. Spitzer and 15 hand-picked, data-oriented researchers then carved human mental affliction into 265 disorders – frequently with no more compelling scientific evidence to back them up than their own judgment.

Attention-deficit disorder, anorexia and post-traumatic stress disorder were all named by Dr. Spitzer. He also – and this was just as radical – created checklists of symptoms for each disorder. Specific mental illnesses were now categorized and “measurable.”

The result, DSM-III, was finally published in 1980. Dr. Frances, who had worked for Dr. Spitzer before taking on the editorship of DSM-IV (1994), describes DSM-IIIas “a revolutionary document.” It was also a revolutionary success as a business venture.

The current DSM-IV-TR (“text revised”) is more than 900 pages long, lists 365 disorders and is on course to sell a million copies at $83 a bang. It’s published in more than a dozen languages.

U.S. insurance companies now require a DSM-based diagnosis before they will reimburse prescription drugs on health plans, and courts use it to define insanity.

The manual’s flashy exactitude, however exaggerated, dovetailed profitably with the interests of drug companies, which were further revolutionizing psychiatry with psychoactive drugs, starting with the tranquillizer Thorazine in 1954 and by no means peaking with Prozac in 1987. It all helped popularize the theory that mental illness is caused by chemical imbalances in the brain.

Never mind that the effectiveness of the drugs is uncertain (placebos often work just as well) or that the theory is widely disputed. By now, the alignment of pharmaceutical expertise with ever-more diagnostic categories, glued together by the medical-insurance industry, has completely changed the shape of North American mental health.

Fewer than 10 per cent of U.S. psychiatrists offer psychotherapy as a service any more. But 10 per cent of North American boys now take drugs for attention-deficit hyperactivity disorder, and in the past decade diagnoses of childhood bipolar disorder have risen at least fortyfold. According to a survey by the National Institutes of Health, 46 per cent of American adults fit the DSMcriteria for at least one mental illness.

“By the age of 32, half the people will have qualified for an anxiety disorder, 40 per cent for a depressive disorder,” Dr. Frances says, by way of criticizing the new edition’s ever-morphing, expanding definitions of mental illness.

“We’re getting to the point where it becomes impossible to get through life without having a bunch of diagnoses.”

An Rx for excess, with kids on antipsychotics

Diagnosis means treatment, which means drugs. It was the writer and TV hypochondriac Oscar Levant who once quipped that the Pharmaceutical Society had voted him Pill of the Year, but he would have lots of competition today. Ten per cent of Americans over the age of 6 now take antidepressants.

But the bestselling drugs in the United States these days, in dollar terms, are antipsychotics – a serious class of psychoactive medication now being given to more than half a million children.

At 5 per cent of all prescriptions ($14-billion worth), they outsell even cholesterol-lowering pills and antidepressants.

“Originally they were used for schizophrenia,” Dr. Frances says. “Then it was going to be for bipolar disorder too. And now they’re being used widely in nursing homes for agitation amongst the elderly, even though they may shorten life expectancy. And for kids who act up. And for people in general who become irritable.”

Antipsychotics are often prescribed off-label – that is, for ailments other than the one they were designed to cure. For example, they are widely prescribed for non-specific autism.

In the mid-1990s, autism was diagnosed at a rate of 1 in 500 North American children; by 2004, thanks in part to much broader DSM diagnostic criteria, the number was 1 in 90. (In well-behaved South Korea, it is 1 in 38 children.) Hence the complaint of Dr. Frances, who admits that even his own DSM-IV was responsible for over-diagnosis: “Because of the power of drug-company marketing and the Internet and consumer-advocacy groups, there have been a number of false epidemics, of fads in psychiatric diagnosis that have resulted in tremendous diagnostic inflation and much higher rates of mental disorder than ever before.

“And many more people getting medication, which in many cases is not useful and may be harmful.”

The DSM, in other words, has helped foster seriously questionable medical practices. The relationship between the pharmaceutical industry and over-diagnosis and off-label prescribing, which the DSM facilitates, is impossible to ignore.

Harvard Medical School recently spanked one of its high-profile doctors, Joseph Biederman, the subject of a congressional investigation.

As uncovered by Pulitzer Prize-nominated blogger Alison Bass and others, Johnson & Johnson, which makes the anti-psychotic Risperdal, gave Massachusetts General Hospital $700,000 toward a Biedermen-led research centre.

The centre, in turn, did studies promoting the use of Risperdal for childhood bipolar disorder, technically an off-label use, which Johnson & Johnson is by law not allowed to promote.

The side effects of drugs such as Risperdal, meanwhile, include tardive dyskinesia, a serious movement disorder, and neuroleptic malignant syndrome, which can cause paralysis and gross motor seizures.

And the Risperdal conflict is just the tip of the iceberg. More than half the 140 experts who are officially revisingDSM-5 have disclosed significant financial interests in drug companies.

Dr. Frances notes that health-insurance companies typically favour DSM-driven medications over talk therapy because the former is cheaper in the short run.

But in the longer term, he says, disorders such as depression are more cheaply and just as effectively treated with talk therapy, given the potential consequences of so many people taking so many serious drugs.

Freud’s system, the resolution of unconscious conflicts that cause mild anxieties and neuroses, might live to cure another day.

Improving the models, or just widening the net?

However, Dr. Frances’s nemesis, Darrel Regier, vice-chair of the new DSM-5 task force, doesn’t credit much of the criticism of the new manual. He insists there is plenty of new neurocognitive evidence (which his team has been reviewing for 10 years) to justify the broadening of diagnostic categories in DSM-5.

He also insists that overprescribing drugs is a marketing and clinical issue, not a diagnostic one, and that Dr. Frances is taking the new, more decentralized DSM too personally.

It’s a bewildering and complicated standoff. Take the way the new DSM turns obsessive-compulsive disorder into its own category.

In Dr. Frances’s DSM-IV, OCD was an anxiety disorder. Katherine Phillips, a professor of psychiatry at Brown University and leader of the DSM-5 work group on OCD, points to new neural imaging evidence that OCD is characterized by hyperactivity in the brain, what Dr. Phillips calls a “reverberating circuit” in the thalamus and the frontal cortex.

But so is body dysmorphic disorder – “preoccupation with a defect in appearance,” according to the DSM (the 60ish main character in Martin Amis’s recent novel, The Pregnant Widow, hopes he has it, by way of explaining the horror he experiences every time he looks in the mirror). And so is trichotillomania (hair-pulling disorder). As a result, both are now classed as obsessive-compulsive disorders, though they weren’t before.

That’s easy enough for a sophisticated researcher to understand. But what will happen in a busy, front-line family practice? The common drug treatment for OCD is Paxil or Zoloft. Will hair-pullers and body-haters now get those antidepressants as well?

The obsessive thoroughness of DSM-5’s editors results in casting a wider diagnostic net.

Hoarding disorder, another new candidate for inclusion as a free-standing affliction in DSM-5, entails “persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions.”

Hoarding can certainly be a serious and debilitating disorder. But those symptoms also describe anyone with a basement.

Or there’s minor neurocognitive disorder, “evidence of minor cognitive decline from a previous level of” – oh hell, what’s that word I’m looking for? – “performance.”

Even as the DSM tries to be more inclusive and “dimensional,” it runs the risk of sucking millions of merely unhappy and eccentric souls into the ranks of the mentally disturbed, at vast cost.

“I think there’s always a concern about mental disorders and the boundary between normality and psychopathology,” DSM-5’s Dr. Regier admits. “Just the stigma associated with mental disorders means that people get concerned.”

But that won’t stop him. “I think psychiatry is a field that’s in ferment. There’s an enormous amount of research that’s taking place at the molecular level” that suggests schizophrenia and bipolar disorder, at one end of the spectrum, and anxiety and depression, at the other, “are nowhere near as rigid as we thought,” he says.

“We’re trying to break out of the reification of these categories, and trying to describe the next generation of syndromes.”

To make God laugh, tell him your diagnoses

He and his colleagues will fail, of course. Science always does. At the renowned Centre for Addiction and Mental Health in Toronto, Vivian Rakoff has been practising and observing psychiatry for the majority of his 84 years, and its well-intentioned shortcomings have been on steady display.

“We can never live outside our time,” he says, chatting between patients. “You go with the knowledge you have. And you cannot castigate yourself for not knowing more than you do.

“The DSM is an ongoing process in which people try to refine diagnostic categories and implicitly define treatment modalities. The way it’s constructed is a bunch of guys on committees get together around each category of illness and try to hammer out the most objective picture they can obtain at that moment in history. And I think they do a responsible job of compiling all the info that is around.”

But it will never be complete, which is what none of us can admit.

If you want to remind yourself how inaccurate the DSM-5will turn out to be in the long run, find a 19th-century medical textbook, and laugh over how incomplete medical knowledge was a century ago.

Remember that in ancient Rome, the mentally defective (who we might call severe autistics today) were raised in the dark, until the surgeon Soranus proved that it didn’t help them (he was also the father of gynecology).

Remember that as recently as a decade ago, many doctors thought autism – now treated with anti-psychotics – was caused by uncaring mothers.

“The attempts to define things clearly in the DSM do sometimes strike me like the tailors on the island of Laputa in Gulliver’s Travels,” Dr. Rakoff concludes, referring to Jonathan Swift’s 1726 satire of an earlier outburst of irrational faith in science.

“You may remember that they don’t measure their customers with tape measures. They use theodolytes, which are surveying instruments of triangulation – to make suits. It’s science, applied wrongly. It’s pseudo-exactitude. And there is a measure of pseudo-exactitude in DSM-5. But it is a gallant attempt.”

Ian Brown is a feature writer for The Globe and Mail.

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