| Saturday,
February 27, 2010 I had noted this in my breakfast log, but
it seems Monty beat me to it:
Subj: Why Psychiatry Needs Therapy +
Cognitive-Behavioral Therapy + Comfortably Numb
http://online.wsj.com/article/SB1000142
4052748704188104575083700227601116.html
Interesting history about the struggle within the
American Psychiatric Association between the psychoanalysts and the
psychometricians. The DSM-III and its successors apparently embody a
both-and political resolution of that struggle.
>>Where is psychiatry headed? What the discipline
badly needs is close attention to patients and their individual
symptoms, in order to carve out the real diseases from the vast pool of
symptoms that DSM keeps reshuffling into different "disorders." This
kind of careful attention to what patients actually have is called
"psychopathology," and its absence distinguishes American psychiatry
from the European tradition. With DSM-V, American psychiatry is headed
in exactly the opposite direction: defining ever-widening circles of the
population as mentally ill with vague and undifferentiated diagnoses and
treating them with powerful drugs.<<
I wonder why Dr. Shorter did not mention
Cognitive-Behavioral Therapy, which stands in contrast to both the
psychoanalytic and the psychopharmaceutical enthusiasms?
See, for example,
http://www.nacbt.org/whatiscbt.htm
and particularly
http://nacbt.org/evidenced-based-therapy.htm
For another perspective on how mushy diagnoses and
psychopharmaceutical enthusiasm distract attention and divert resources
from the treatment of serious disease, try
http://charlesbarberwriting.com/
http://www.c-spanvideo.org/program/199864-1
Rod Montgomery==monty@starfief.com
The DSM did not exist when I was in graduate school in
psychology, and I have never studied it, so my views are not based on
experience or primary observations. Clearly my conclusions based on other
reviews and quotations from the DSM have not been sufficiently favorable to
goad me to becoming more familiar with it. When the first DSM came out it
seemed to me far too eager to label odd but not really abnormal behavior as
a "disorder" warranting treatment. In particular there were a list of
"disorders" attached to what seemed to me fairly common teen age funk. I
never thought talking back to Mother was something to be treated with a
pill.
DSM has, in my judgment, far too often been influenced by
the pharmaceutical industry, and used to justify payments from insurance; it
is, in my judgment, one of the many reasons for the high costs of health
care, since "mental health" coverage is now generally required in state
mandated healthcare insurance policies as one of the "minimum" requirements.
As to the conflicts between the Freudian analyst based theories of mental
disorder and the behavior-based medical theories that generally prescribed
chemical treatment, that was just beginning when I left psychology graduate
school. Of course my emphasis in psychology was in engineering and human
factors on the one hand, and mathematical and statistical analysis using
tests and measurements on the other, so I am hardly an expert on abnormal
psychology.
I did note that many years ago my friend Poul Anderson
became so depressed that he asked me to take him on a two week sail through
Channel Islands and down to Catalina (I owned a 20 foot midget ocean racing
sailboat in those days; Alan Susia built it for me in Seattle). The sailing
trip was a success in that he wasn't depressed while we were on the voyage,
but it wasn't a cure either: but not long after he was pretty permanently
'cured' by lithium treatments. It was a bit of a revelation to me, because
in my graduate studies in psychology there was no simple treatment of
depression. (Miltown existed, and was controversial; lithium was a treatment
for mania, but seemed to help some cases of depression.) Serious
depression was a candidate for shock treatment, particularly if there were a
pattern of manic then depressive episodes, and any danger of suicide.
Depression could be sorted into various categories, including
manic-depressive psychosis (with or without flight of ideas, etc.) and
involutional melancholia. The latter was what we now tend to call acute
depression, and often ended in suicide.
A few years after I left psychology graduate school the
various chemical treatments for depression became more widely used, and
while they certainly caused a lot of problems with side effects, they were
also highly effective. Poul was effectively 'cured' by lithium, and while he
had some episodes of depression for another 30 years, they weren't life
threatening. Poul died in 2001 of prostate cancer. He had told me thirty
years before that "that's what gets us all in the end." Whether that was
prophetic or he was making a clever pun I am not sure. Anyway, my
point is that acute depression and involutional melancholia were pretty well
considered incurable in the pre-chemical days of psychiatry, and the
Freudian treatment had no specifics. My textbook of psychiatry from the
1950's essentially says take steps to prevent suicide, and try anything that
seems to work. Occupational therapy is good, including getting the patient
interested in a hobby. Opiates sometimes help, but often do no good.
In those times some psychiatrists thought convulsive therapy
a good idea; Freudians and non-medical (psychologist) therapists generally
opposed it. Hydraulic treatments (pack and bath) were found to be seen "as
methods of coercion rather than cure." The most important thing was to
prevent suicide. The only sure way to do that was institutionalization.
I ramble. In any event,
the article is worth your time. And perhaps the DSM has done more good
than harm; certainly the development of chemical treatments for depression
seems to have done some good; those who blame the anti-depressants for
patient suicides seem to forget that prior to the discovery of chemical
treatments, suicide was a very common end to many forms of depression.
Incidentally, my own experience has been that fish oils
including salmon oils can have a positive effect on mild depression. So does
St. John's Wort. I get both of those from Trader Joe's.
The following extract is given to show some of the flavor of
the article. Think of it as a pull quote to get your attention:
Major depression became the big new diagnosis
in the 1980s and after, replacing "neurotic depression" and "melancholia,"
even though it combined melancholic illness and non-melancholic illness.
This would be like incorporating tuberculosis and mumps into the same
diagnosis, simply because they are both infectious diseases. As well,
"bipolar disorder" began its relentless on-march, supposedly separate from
plain old depression.
New drugs appeared to match the new diseases.
In the late 1980s, the Prozac-type agents began to hit the market, the "SSRIs,"
or selective serotonin reuptake inhibitors, such as Zoloft, Paxil, Celexa
and Lexapro. They were supposedly effective by increasing the amount of
serotonin available to the brain.
The SSRIs are effective for certain
indications, such as obsessive-compulsive disorder and for some patients
with anxiety. But many people believe they're not often effective for
serious depression, even though they fit wonderfully with the
heterogeneous concept of "major depression." So, hand in hand, these
antidepressants and major depression marched off together into the sunset.
These were drugs that don't work for diseases that don't exist, as it
were.
The latest draft of the DSM fixes none of the
problems with the previous DSM series, and even creates some new ones.
I don't claim ever to have been much of a clinical theorist. I've always
been more a psychometrician, and I have never been fond of any of the
Freudian-based personality theories. (Note that L. Ron Hubbard's
Dianetics was a synthesis of the Jungian offshoot from Freud and
Korzybski's General Semantics, both quite respectable disciplines in 1950)
because I have never seen any physical analogs of the various hypothetical
structures they mandate. I do wonder if the DSM has done more harm than
good.
Another pull quote:
A new problem is the extension of
"schizophrenia" to a larger population, with "psychosis risk syndrome."
Even if you aren't floridly psychotic with hallucinations and delusions,
eccentric behavior can nonetheless awaken the suspicion that you might
someday become psychotic. Let's say you have "disorganized speech." This
would apply to about half of my students. Pour on the Seroquel for
"psychosis risk syndrome"!
DSM-V accelerates the trend of making
variants on the spectrum of everyday behavior into diseases: turning grief
into depression, apprehension into anxiety, and boyishness into
hyperactivity.
If there were specific treatments for these
various niches, you could argue this is good diagnostics. But, as with
other forms of anxiety-depression, the SSRIs are thought good for
everything. Yet to market a given indication, such as social-anxiety
disorder, it's necessary to spend hundreds of millions of dollars on
registration trials to convince the FDA that your agent works for this
disease that previously nobody had ever heard of.
I am very glad that the DSM did not exist when I was growing up. I would
almost certainly have been diagnosed with a disorder that could only be
cured by drugs. As it happens, I was "cured" by being forced to learn a
modicum of self-discipline.
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