Sunday, April 21, 2013

4.21.13 - Discussions on the issues of Diagnosis in Psychiatry

Discussions on the issues of Diagnosis in Psychiatry

Links and References


What's Normal? What's Not?

By Allen Frances, MD | April 1, 2013
Twitter: @AllenFrancesMD

The liveliest debate in psychiatry today is where to draw the line between mental disorder and mental health. So much rides on the decision—who gets treated and how, who pays for it, whether a criminal is deemed mad or bad, whether someone gets damages in tort cases, who qualifies for disability payments and eligibility for extra school services, whether someone can adopt a child—and there's a whole lot more.
But here is the big problem. No bright line marks the boundary between illness and health. At the extremes, it is easy to diagnose mental illness accurately and to distinguish it from normality. At the fuzzy border, it is impossible.
This is true now and will remain true into the distant future—until we finally have biological tests in psychiatry. In a few years, there will be lab tests for Alzheimer's, but the pipeline for the other disorders is dry.
The problem with precisely defining “normal” has been recognized almost since the beginning of psychiatry as a separate profession in the 19th century. Peter Kinderman, the British psychologist who has become one of the leaders in opposition to DSM-5, has unearthed two wonderful quotes from 150 years ago that state the issue much more eloquently than anything that has been written since.
The first comes from an editorial in the London Times, from Saturday, July 22, 1854:
“Nothing can be more slightly defined than the line of demarcation between sanity and insanity. Physicians and lawyers have vexed themselves with attempts at definitions in a case where definition is impossible. There has never yet been given to the world anything in the shape of a formula upon this subject, which may not be torn to shreds in five minutes by any ordinary logician. Make the definition too narrow, it becomes meaningless; make it too wide, the whole human race are involved in the drag-net. In strictness, we are all mad as often as we give way to passion, to prejudice, to vice, to vanity; but if all the passionate, prejudiced, vicious, and vain people in this world are to be locked up as lunatics, who is to keep the keys to the asylum?”
The second equally telling quote is from the 1888 novella, “Billy Budd” by Herman Melville:
“Who in the rainbow can draw the line where the violet tint ends and the orange tint begins? Distinctly we see the difference of the colors, but where exactly does the one first blendingly enter into the other? So with sanity and insanity. In pronounced cases there is no question about them. But in some supposed cases, in various degrees supposedly less pronounced, to draw the exact line of demarcation few will undertake tho' for a fee some professional experts will. There is nothing namable but that some men will undertake to do it for pay.”
Victorian writing has a subtlety and grace of expression rarely found in our more utilitarian modern modes of speech. But the puzzle of defining the boundary between normal and illness is just as problematic today as it was then.
Decisions on where to draw the line must necessarily rest not on any abstract definition that clearly separates the two, but rather on practical consequences. Will including a new disorder in DSM, or changing the threshold for an existing one, result in more harm or more good?
This is a brass standard, but will have to do in the absence of a gold one. Clearly, we currently have an imbalance. Loose definitions, and even looser application of them under the pressure of pharma marketing, have expanded psychiatry beyond its competence and have made normal an endangered species.
It is time for a correction back to a reasonable Goldilocks balance. To get there, we need a tighter diagnostic system and an end to pharma marketing.
Let's close with one final great quote, this time from Isaac Newton: “I can calculate the motions of the heavens, but not the madness of men.” We can't do a very precise job of this either, but we can certainly do a lot better than we are now.


Psychiatry and the Myth of “Medicalization”

By Ronald W. Pies, MD | April 18, 2013

DSM-5, ethicsWhatever happened to common sense? You know what I mean—these psychiatrists medicalize every ordinary feeling and behavior, every normal stress and strain of living. Why, the way they want to call ordinary shyness “Social Anxiety Disorder,” or ordinary grief “Major Depressive Disorder”—it’s ridiculous! These so-called diagnoses are just false positives—not cases of disease or disorder. These self-appointed experts keep invading the territory of normal human experience like conquistadors! Then they prescribe all kinds of harmful medications for nonexistent diseases. And now, they are expanding their diagnostic system, to the point where nobody is normal anymore!
Are any of these claims even controversial these days? Even for some readers ofPsychiatric Times, I suspect not. After all, we have heard this line of argument from respected academics; many patients, or consumers; some of psychiatry’s own luminaries; and many sincere and conscientious clinicians. Recently, one particularly renowned critic pointed to the “diagnostic imperialism” of DSM.1 Indeed, before the final text of DSM-5 has even appeared, several books criticizing the manual have been published or are soon to be published.
But does this narrative of psychiatry’s medicalization of normality really represent common senseor is it mostly common nonsense? In my view, the medicalization narrative contains some kernels of truth, and many defenders of the term proceed from honorable and well-intentioned motives; for example, the wish to reduce unnecessary use of psychotropic medication—and who could be opposed to that? But on the whole, I believe the medicalization narrative is philosophically naive and clinically unhelpful. On close examination, the term “medicalization” proves to be largely a rhetorical device, aimed at ginning up popular opposition to psychiatric diagnosis. It not only stigmatizes the field of psychiatry and those who practice in it, but it also undermines our ability to provide the best care to our patients, by spuriously normalizing their suffering and incapacity.2
I am not claiming that careless diagnosis and over-diagnosis never occur in psychiatry. Alas, as in all of medicine, sometimes they do—particularly when insufficient time is allowed for the initial evaluation of the patient, and when no validated scales or screening instruments are used.3 (Under-diagnosis also occurs, as in the failure to recognize MDD in some settings—but that’s another story.4) Neither am I voicing a full-throated defense of the DSM-5 manual. Indeed, while I respect the good-faith efforts of the framers of DSM-5, I have serious concerns regarding some of their decisions, such as lowering the threshold for the diagnosis of somatoform disorders (now called Somatic Symptom Disorders).1
What I do want to claim is that when a psychiatric diagnosis is accurately and carefully made, according to generally accepted (eg, DSM or ICD) criteria, it should not be normalized or declared non-disordered because its manifestation is understandable or explained by the psychosocial context in which it occurs—or because it is deemed proportionate to some hypothetical evolved mechanism.5
The normality fallacy
For the proposition “psychiatry is medicalizing normality” to be true, we would need (a) adequate definitions of the terms “medicalizing” and “normality” and (b) convincing evidence that psychiatry is actually doing what the proposition asserts. Yet both required elements of truth turn out to be complex and problematic. For one thing, psychiatry’s critics almost never bother to define the terms “medicalizing” and “normality.” (Does medicalization refer to application of the medical model, or to the use of medication? And what is the medical model, exactly? Is normality a purely statistical term? Is it used in relation to a particular cultural subgroup, to the human species as a whole, or to the particular patient’s usual state of affairs?)
Moreover, those who argue that psychiatry medicalizes normality while simultaneously asserting that there is no clear demarcation between normality and abnormality effectively refute their own argument.6 For if there are no absolute, categorical boundaries separating normal from abnormal, then the claim “psychiatry is medicalizing normality” cannot logically be sustained: the argument is devoured by its own premise. That is: if normality has no precise boundary in the realm of disease—including psychiatric disease—then there can be no verifiable medicalization of normality. Neither can there be a veridical demonstration of psychiatry’s alleged diagnostic imperialism or its supposed creation of diagnostic false positives. Such claims are no more verifiable than a landowner’s complaint that someone has impermissibly planted a tree on his property, when there are no clearly established property lines. But let’s be clear: this doesn’t mean that we can’t make reasoned, empirically grounded judgments as to what conditions merit medical evaluation or treatment.
Psychiatry’s ethical aim is the relief of suffering and incapacity
So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease (dis-ease).5 To assert this is not to medicalize normality, but to affirm what physicians have recognized as an ethical imperative, for millennia: the need to relieve the misery of the patient. Indeed, as Prof H. C. Erik Midelfort, Professor of History at the University of Virginia and author of A History of Madness in Sixteenth-Century Germany,comments:
. . . for ancient and early modern physicians, there was no clear, bright line between disease and health. They did not, generally, decide that someone was suffering an understandable and proportionate sadness and was not therefore “ill.” They generally decided that if one were suffering, for whatever reason and whether proportionate or disproportionate, they would do what they could to help . . . [and their remedies] did not depend upon a strict decision that so-and-so was fundamentally “ill” while someone else was merely sad for good, sufficient, and proportionate reasons. (E. Midelfort, personal communications, October 2008 and March 2012.)
Indeed, as historian and Psychiatric Times blogger Prof Greg Eghigian7 has commented:
Midelfort get[s] at something important that many commentators on the history of psychiatry often either ignore or consider unimportant: the fact that the overwhelming majority of patients treated by psychiatrists, “mad-doctors,” mental healers, etc, over the centuries have presented symptoms clearly crossing the “threshold of chronicity or severity.” And indeed, this is one of the reasons why I have problems with the way in which self-identifying critics of psychiatry invoke the term “medicalization”—they more often than not neglect theextraordinary and painful nature of the maladies . . . [patients] were/are facing.7
Prof Eghigian leads us toward a critical insight: the obsessive debate about what is or is not normal is largely a distraction from 2 practical issues facing all physicians:
• What is the threshold for considering a condition a disease or disorder?
• How can we best help the patient?
As a practical matter, internists do not consider an upset stomach as crossing the threshold of disease, nor do psychiatrists of any wisdom consider a mildly fidgety, bored, and inattentive child to have a disease or disorder called “ADHD.” But in both instances, these threshold decisions are based primarily on the absence of pronounced or enduring suffering and incapacity—not on an obsessive fixation on what is normal. (If common upset stomach suddenly became vanishingly rare, it still would not qualify as disease.)
Physicians, fundamentally, are not philosophers or evolutionary biologists. We do not, as a matter of daily routine, entertain metaphysical and semantic questions, such as “What is truly normal for the human species?” Rather, physicians have a general concept of what constitutes health, and a general concept of enduring and significant departures from health. We find ourselves faced with a waiting room full of distressed and often incapacitated human beings who, in ordinary circumstances, are voluntarily seeking our help. We do our best to respond to them not as specimens of abnormality, but as suffering individuals—and as fellow human beings.


Muddled Thinking and Psychiatric “Diagnoses”

by PHIL on FEBRUARY 23, 2013
Until just a few years ago, the spurious nature of mental illness received little or no attention either in professional circles or in the general media. There were a few of us “cranks” who poked away at the issue, but peer condemnation was usually swift and outspoken.  On one occasion I was called an “anti-science Nazi” for daring to suggest that the condition known as ADHD might have more to do with ineffective parental discipline than with brain chemistry.  We were voices in the wilderness.
Happily the landscape has changed, and today speaking out against standard psychiatry from either a theoretical or practical position is a great deal more acceptable.  A number of factors have contributed to this development.  Firstly, and I think most importantly, the APA simply went too far, too quickly.  It has always been my contention that their ultimate goal has been to embrace every conceivable human problem within their taxonomic framework.  And it has to be conceded that in this they have been very successful.  But as the proposals for DSM-5 began to emerge, there was a groundswell of resistance from various sources.  The second factor contributing to the change has been the writing of individuals who have worked tirelessly to expose the philosophical flaws and the practical abuses in modern psychiatry.  These individuals include Robert Whitaker, Christopher Lane, Daniel Carlat, all the members of the Critical Psychiatry Network, Irving Kirsch, Marcia Angell, Gary Greenberg, Steven Ray Flora, Suzy Chapman, and many others.
So today we are in the midst of a great debate on the validity and usefulness of psychiatric “diagnoses” and the appropriateness of chemical fixes for ordinary human problems.
But unfortunately, and perhaps inevitably, the debate is often derailed by vagueness and muddled thinking.  The purpose of this post is to try to clarify, or at least identify, some of the issues.
Let’s start with the question:  Is schizophrenia a mental illness?  On the face of it this looks like a fairly straightforward question, and one might imagine that people who work in the field would be able to provide an answer.  In fact, one would imagine that such a fundamental question would have been resolved decades ago.  But in fact it’s not that simple.
To illustrate the problem, let’s consider another question, this one from the field of chemistry. Is sodium hydroxide an acid or a base (alkali)?  The answer is:  It’s a base.  The reason is that an acid by definition has a pH value less than 7; a base has a pH value higher than 7; and sodium hydroxide has a pH value of 14.  The reasons that this question can be so readily resolved are:  firstly, all the terms in the question have been precisely defined; secondly, a scale exists which enables one to assess the acidity or alkalinity of any substance; and thirdly, and I suppose most importantly, chemists and other scientists have devoted an enormous amount of time and energy to the refinement of their definitions generally, and to the matter of measurement.
From this context it is easy to see the problems with the earlier question.  Before such a question can be even addressed, we need to know what we are talking about; in other words, we need definitions.
So what have we got?  The APA defines the various mental illnesses by providing a list of criteria and specifying how many have to be met to make the “diagnosis.”
Superficially, this looks like the pH scale for acidity/alkalinity mentioned above.  Under 7 – acid; over 7 – alkali.  For schizophrenia, two or more items – yes; less than 2 items – no.  (It’s a little more complicated than this, but for our present purposes this is close enough.)  But the similarity is illusory, because the pH scale reflects, and is built around, the hydrogen ion concentration which is the essence of acidity.  In other words the scale was constructed to measure what acidity and alkalinity really are.  No such claim can be made about the items on the schizophrenia scale.
The pH definition is an essential definition: it elucidates or reveals the true nature of the matter.  “Behind” the scale there is a wealth of scientific understanding.  The schizophrenia scale reveals nothing of the essence of the matter.  There is nothing substantial behind the scale.  The scale plus the cutoff number is the definition of schizophrenia.
This is important, because the APA (and psychiatrists generally) claim that their system is scientific.  But in fact their definitions don’t meet even minimal requirements of general science.
But even if we put that matter aside, there are other problems with the schizophrenia scale.  The text reads:
“A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
(1)  delusions
(2)  hallucinations
(3)  disorganized speech (e.g., frequent derailment or incoherence)
(4)  grossly disorganized or catatonic behavior
(5)  negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.”
Firstly, the requirement of two or more items is arbitrary and unscientific.  Why not three? Or four?  The answer to this question is not based on anything in nature (as the number 7 is on the pH scale), but simply reflects an APAdecision.  Deciding is not the same as discovering.  The APA say they need two items – so it’s two items.  There is no other reason.  In theory the APA could “cure” approximately half of the victims of this “illness” by requiring four items instead of two!  This would be the equivalent of Earth scientists solving global warming by decreeing that normal ocean temperatures are two degrees higher than they are.
Secondly, there are 10 ways to extract two items from five (1 & 2; 1 & 3; 1 & 4;1 & 5; 2 & 3; 2 & 4; 2 & 5; 3 & 4; 3 & 5; 4 & 5), and there is no valid reason for supposing that these various permutations are really the same condition.  A person, for instance, who scores positive on items 3 and 5 might have very little in common with a person who scores positive on items 1 and 2.  But according to the APA, both individuals have the same illness.  There is no evidence to support this position.  Once again, it’s because the APA says so.
Thirdly, for an item to be scored positive it has to have been present for a significant portion of time during a 1-month period.  Here again, we have extreme arbitrariness.  Why one month?  Why not two?  Is there some essential underling reality about this condition that requires a one month time frame?  No.  It’s because the APA says so.
Fourthly, what’s a “significant” portion of time?  An hour?  A day?  A week?  Or do they mean this to be a proportion – an hour a day, say?  Or a day a week?  The manual gives no help.
Fifthly, even if these items were delineated more precisely, how in the world could you hope to get accurate data on what clients were doing months or even weeks ago?  If you were to ask me, for instance, how many hours a day have I spent writing, or talking on the phone, or arguing with my beloved spouse in the past two months, I couldn’t begin to give you anything better than a vague guess.  (Except, of course, the last item – that would be zero!)  It’s a well-established fact that we don’t recollect past events as accurately as we suppose.  So if a client or a client’s spouse tells a psychiatrist that the individual has been voicing delusional material for about half an hour a day for the past two months, how much credence can be placed in this?
Sixthly, the items themselves are vague.  What, for instance, is a delusion?  Here the APA does provide some help.  In their glossary of technical terms they define a delusion as follows:
“A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.”
Here we have lots of problems.  The only way that another person’s belief can be determined is through his overt behavior (including speech); but even then the inference is always tenuous.  An additional difficulty arises from the term “external reality.”  At present, I, for instance, believe that there is “…incontrovertible and obvious proof or evidence…” that: human activity is significantly raising the planet’s temperature; and that humans descended from lower species through natural selection; and that over six millions Jews and other persecuted minorities were murdered by German Nazis.  Other people (lots of them) believe that each of these statements is false.  So am I delusional or are they?  Who chooses?  If the psychiatrist is a creationist, would we evolutionists be considered delusional?  If a client says that the government is spying on him, do we know that this is false? At the present time a number of groups are protesting the use of drones over US air space on the grounds that they will infringe citizens’ privacy.  Should all these individuals be considered delusional?  And so on.  The point here is that deciding if an individual’s statements (beliefs) are false is in most areas a subjective, unscientific judgment.
With regards to delusions, it is also worth noting that the APA specifically excludes “articles of religious faith.”  This is not based on any kind of science, but rather to avoid conflict with religious groups.  If someone were to start a religion the central tenet of which were that the government is spying and compiling detailed files on all citizens, then delusional people who obsess about this issue would be instantly “cured,” provided they joined this church!
Similar criticisms can be leveled at the other items in A above (2 through 5).
So where have we gotten to?  We’re trying to make sense of the question:  Is schizophrenia a mental illness?  We’ve examined the APA’s definition of schizophrenia and find that it is descriptive rather than elucidative, which is a very serious problem because we can describe something in great detail and yet have not the slightest idea what it is.  (The rainbow is a good example.) But even if we go along with the descriptive definition, we find that it is impossible to apply with any degree of precision, and that it is riddled with arbitrariness and inconsistency.
So not only can we not say what schizophrenia is, we cannot even reliably identify which individuals belong in this category and which don’t.  And to make matters worse, the criterion items quoted above are only Part A of the APA’s definition of schizophrenia.  This is followed by B, C, D, E, and F, each of which suffers from reliability difficulties similar to those in Part A.
Part E is worth quoting:
“E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.”
What this says is that if the “symptoms” stem from substance abuse or a general medical condition, a diagnosis of schizophrenia cannot be assigned.  This is particularly interesting, in that it is very widely stated in the psychiatric profession that schizophrenia (whatever that means) is a brain disease, i.e. that it is caused by neurological damage or malfunction.  But neurological damage/malfunction is a general medical condition and therefore by the APA’s own definition cannot be the cause of schizophrenia.  A problem arises here in that the term general medical condition is not defined anywhere in the DSM (or at least I’ve never been able to find a definition), but the term is used frequently in the manual in the sense of a physical pathology within the organism.  In anxiety disorder due to a general medical condition, for instance, the manual lists “neurological conditions” as one of the possible culprits.  So, to my mind at least, it is clear that the APA are specifically excluding from their definition of schizophrenia any kind of aberrant behavior that results from neurological impairment.
Back to the question:  Is schizophrenia a mental illness?
As we’ve seen, the term “schizophrenia” is beset with difficulties, but the term “mental illness” is infinitely more troublesome.  Let’s see if we can define it.  Turning to the DSM, we find, to many people’s surprise, that the term “mental illness” is not used.  Instead they use the words “mental disorder.”
This is a complicated issue with lots of history, much of which I’ve discussed elsewhere.
The first DSM (1952) used the term reaction (depressive reaction, schizophrenic reaction, etc.) to reflect the fact that the various conditions were reactions of the individual to internal and external factors.  DSM II (1968) referred to mental disorders, largely I suspect because there was not at that time a consensus among psychiatrists that all, or even any, of the conditions listed were in fact bona fide illnesses.  And the term mental disorder has stuck.  In fact, in studying the DSM one might understandably draw the conclusion that there are no mental illnesses!
But, of course, this is not how matters are perceived in the field.  In practice the terms mental disorder and mental illness are synonymous.
So for a definition of mental illness we must turn to the APA’s definition of a mental disorder.  This is given on page xxxi of DSM-IV-TR:
“… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.”
It should be noted in passing that, once again, we have words like “significantly,” “important,” etc… which have to be interpreted subjectively, and inevitably introduce an element of vagueness into the definition.
So, is schizophrenia a mental illness?  Firstly, let us note that although the terms mental disorder and mental illness are used synonymously, there is nothing in the APA’s definition quoted above to suggest that we are dealing with an illnessin any conventional sense of the term.  The definition uses the phrase “clinically significant behavioral or psychological syndrome or pattern…” which sounds more like habit than illness.
But even if we let that go, and even if we ignore the problems in the definition of schizophrenia, it is clear that any significantly dysfunctional behavior will fall within the definition of a mental disorder.  To clarify this, I invite the reader to try thinking of a significantly dysfunctional habit that would not fall within this definition.  I certainly can’t think of any.  Playing car radios too loud is a mental disorder because if pursued long enough it will lead to deafness, which is a disability.  Even long-distance running is a mental disorder, because it is associated with a significantly increased risk of suffering pain!
So our question resolves into this:  Does the behavior of the vaguely defined, non-homogeneous group of individuals, embraced by the DSM’s definition of schizophrenia entail (for the individual concerned): present distress; orimpairment in one or more important areas of functioning: or  significantly increase risk of suffering death, pain, disability or an important loss of freedom?  In other words, do the vaguely defined problems of a vaguely defined group fall within the vaguely defined category which actually embraces all significant human problems?
The point is – and I apologize that it’s taken me so long to get here – that the question is nonsensical.  It’s a bit like asking:  Do witches have an evil aura which is detectable by trained witch-hunters?
In this article schizophrenia was used as an example.  Similar considerations apply to all the “diagnoses” in the APA’s manual.  The DSM system is logically and intellectually bereft.  It is pseudo-science; a house of cards constructed to expand psychiatric turf and to legitimize the administration of psychotropic drugs for virtually any human problem.
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