Sunday, November 04, 2007

Psychiatry Sure Has Its Critics

Not too long I wrote an article for a newsletter aimed at psychiatrists interested in a dialogue with philosophers. In this article I acknowledged that those of us trained as philosophers might seem rather cold and heartless to clinical psychiatrists when we start to talk about case studies. We often think in hypotheticals or we talk about mental diagnoses or illnesses in rather abstract terms and belie our lack of day to day interaction with those suffering from crippling illnesses.

I am not sure I want to justify what we do, but what I did say was that we aren't the only ones doing this. In fact, these days psychiatry has plenty of critics--perhaps those critics should take aim at the pharmaceutical industry. One of the regular features of the new criticism of psychiatry is the claim that mental illnesses diagnoses are fuzzy, are too inclusive of normal people, and that the DSM is an unfortunate compendium of mental illness diagnoses that the pharmaceutical companies exploit to sell new illnesses such as social anxiety disorder. I pointed this out to my colleagues in psychiatry in order to point to how philosophers might be helpful to psychiatrists these days when so many critics--ranging from scientologists to well-respected psychopharmacologists--are trying to delegitimize--once again--the profession of psychiatry. Philosophers might be able to clarify what it means to define a disorder, how classification works, why the DSM is not as evil as the critics want us to believe it is, and more importantly, how clinical psychiatrists differ from Big Pharma marketers.

Many of the psychiatrists responding to my article tended to dismiss my concerns as overblown or of little value to their "real" work. Perhaps they are right. But, when I found this article today over at the Wall Street Journal, I couldn't help but think that I was right. Unless someone steps in to explain why mental illness classification is not simply driven by Big Pharma, is not wholly arbitrary, or is not pseudo-scientific, we are likely to see many regular Americans totally turned off to the profession (even though they happily demand the drugs they see in TV ads).

Consider this book excerpt from Christopher Lane, an English Professor and author of Shyness: How Normal Behavior Became a Sickness.

One reason for the skyrocketing diagnoses is that doctors and psychiatrists require a very low burden of proof. They say social anxiety runs the gamut from stage fright to paralyzing fears of criticism and embarrassment. (The most common nightmare scenarios are eating alone in restaurants, with fear of hand-trembling a close second, and avoidance of public restrooms third.) Some doctors also include, as symptoms of the disorder, fears of sounding foolish and of being stumped when asked questions in social settings—fears that doubtless afflict almost everyone on the planet. Considering these elastic guidelines, we can grasp quite easily why the "illness" is so widely diagnosed, but it's harder to say why so many take the diagnosis seriously, much less accept its judgment of mental debility. The transformation of shyness into a disease occurred behind the closed doors of carefully vetted committee meetings. Over the course of six years, a small group of self-selecting American psychiatrists built a sweeping new consensus: shyness and a host of comparable traits were anxiety and personality disorders. And they stemmed not from psychological conflicts or social tensions, but rather from a chemical imbalance or faulty neurotransmitters in the brain.

Beginning in 1980, with much fanfare and confidence in its revised diagnoses, the American Psychiatric Association added "social phobia," "avoidant personality disorder," and several similar conditions to the third edition of its massively expanded Diagnostic and Statistical Manual of Mental Disorders. In this five-hundred-page volume, the bible of psychiatrists the world over, the introverted individual morphed into the mildly psychotic person whose symptoms included being aloof, being dull, and simply "being alone."

The fact that psychiatrists often playfully call this reference manual their bible doesn't offset the reality that they follow its pronouncements chapter and verse. The influence of the DSM also extends far beyond psychiatry, to a vast network of healthcare agencies, social services, medical insurers, courts, prisons, and universities. It took the psychiatrists in question just a few years to update their manual and turn routine emotions into medical conditions, but their discussions—detailed here for the first time—rarely dwelled on the lasting consequences of their momentous decisions. Those expecting deep ruminations on what it means to call half the country mentally ill (the chief conclusion of the latest national survey), may be surprised to learn that the psychiatrists' fundamental concerns included how best to keep the Freudians out of the room, how to reward the work of allies, and who should get credit for plucking a term out of a dictionary. Tackling a vast array of human experience, the DSM drains it of complexity and boils it down to blunt assertions that daily determine the fate of millions of lives, in this country as in many others.

The fourth edition appeared in 1994 with four hundred more pages and dozens of new disorders. It sold over a million copies, in part because insurance companies require a DSM diagnosis before they will authorize reimbursement, while defense attorneys cite it as gospel when trying to explain or mitigate the charges against their clients. Until the 1990s, moreover, the DSM competed with a rival diagnostic system: the International Classification of Diseases (ICD), published by the World Health Organization in Geneva, is more favorably disposed to psychoanalysis and less reliant on ambiguous narrative. Since the publication of DSM-IV, however, the European system has lost some of its cachet. The DSM has by contrast assumed global authority, an outcome greatly increasing the importance of its once-local arguments about social anxiety and related disorders. Indeed, with managed care and the pharmaceutical industry, this reference manual has begun to transform how the world thinks about mental health. As one psychoanalyst recently lamented to me, "We used to have a word for sufferers of adhd. We called them boys."

Not all of what Lane says is wrong. But what is unfortunate is how easily these criticisms of mental illness diagnosis, mental illness classification, and Big Pharma venality tend to get conflated with what clinical psychiatrists do. No matter how hard psychiatry tries to make itself legitimate--such as jettisoning Freudian psychoanalysis and embracing neuroscience--critics always turn up to depict the psychiatrist as one who finds abnormality everywhere. Meanwhile clinicians are seeing people who are really suffering from disorders that they scramble to label, such as social anxiety disorder. These folks didn't just go knocking on doors to tell shy people they were abnormal. Rather, they spent hours with patients who were miserable, suffering, and found their life crippled. This story gets left out of the critics' sweeping condemnations.

I am somewhat sympathetic to Lane's project, and would like to read the rest of his book. However, when I talk critically about contemporary psychopharmacological usage, I see it as a new moral dilemma over the permissibility of enhancement. If shy people want to take Paxil, should they be denied it? I worry less that the psychiatrists are pushing this on patients. I would worry far more about the drug company marketers.

What do you think?