Article: Why Psychiatry Needs Therapy

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Why Psychiatry Needs Therapy

A manual's draft reflects how diagnoses have grown foggier, drugs more

ineffective

By EDWARD SHORTER

To flip through the latest draft of the American Psychiatric Association's

Diagnostic and Statistical Manual, in the works for seven years now, is to see

the discipline's floundering writ large. Psychiatry seems to have lost its way

in a forest of poorly verified diagnoses and ineffectual medications. Patients

who seek psychiatric help today for mood disorders stand a good chance of being

diagnosed with a disease that doesn't exist and treated with a medication little

more effective than a placebo.

[DSM1] Mick Coulas

Psychopharmacology, or the treatment of the mind and brain with drugs, has come

to dominate the field. The positive side is that many illnesses respond readily

to medication. The negative side is that the pharmaceutical industry seeks the

largest possible market for a given drug, and advertises huge diseases, such as

major depression and schizophrenia, the scientific status of which makes

insiders uneasy.

In the 1950s and '60s, when psychiatry was still under the influence of the

European scientific tradition, reasonably accurate diagnoses still sat at center

stage. If you felt blue, uneasy and generally jumpy, " nerves " was a common

diagnosis. For the psychotherapeutically oriented psychiatrists of the day,

" psychoneurosis " was the equivalent of nerves. There was no point in breaking

these terms down: clinicians and patients alike understood " a case of nerves, "

or a " nervous breakdown. "

Our psychopathological lingo today offers little improvement on these sturdy

terms. A patient with the same symptoms today might be told he has " social

anxiety disorder " or " seasonal affective disorder. " The increased specificity is

spurious. There is little risk of misdiagnosis, because the new disorders all

respond to the same drugs, so in terms of treatment, the differentiation is

meaningless and of benefit mainly to pharmaceutical companies that market drugs

for these niches.

For those more seriously ill, contemplating suicide or pacing restlessly and

saying " It's all my fault, " melancholia was the diagnosis of choice. The term

has been around for donkey's years.

All the serious disorders of mood were once lumped together technically as

" manic-depressive illness " —and again, there was little point in differentiating,

because medications such as lithium that worked for mania were also sometimes

effective in forestalling renewed episodes of serious depression.

Psychopharmacology—the treatment of disorders of the mind and brain with

drugs—was experiencing its first big push, and a host of effective new agents

was marketed. The first blockbuster drug in psychiatry appeared in 1955 as

Wallace Lab's Miltown, a " tranquilizer " of the dicarbamate class. The first of

the " tricyclic antidepressants " (because of their chemical structure) was

launched in the U.S. in 1959, called imipramine generically and Tofranil by

brand name. It remains today the single most effective antidepressant on the

market for the immediate treatment of serious depression.

In the 1960s an entirely different class of drugs appeared, the benzodiazepines,

indicated for anxiety rather than depression. (But one keeps in mind that these

indications are more marketing devices than scientific categories, because most

depression entails anxiety and vice versa.) In the benzodiazepine class, Librium

was launched for anxiety in 1960, Valium in 1963. Despite an undeserved

reputation for addictiveness, the benzos remain today one of the most useful

drug classes in the history of psychiatry. They are effective across the entire

range of nervous illnesses. In one World Health Organization study in the early

1990s, a sample of family physicians world-wide prescribed benzos for 28% of

their depressed patients, 31% of their anxious patients; the figures are

virtually identical. In the 1950s and '60s physicians had available drugs that

truly worked for diseases that actually existed.

And then the golden era came to an end. The 1978 article of British psychiatrist

Malcolm Lader on the benzos as " the opium of the masses " would be a good

landmark. The patents expired for the drugs of the 1950s and '60s, and the solid

diagnoses were all erased from the classification in 1980 with the appearance of

the third edition of the DSM series, called " DSM-III. " It was largely the

brainchild of Columbia University psychiatrist Spitzer, an energetic and

charismatic individual who had been schooled in psychometrics. But his energy

and charisma nearly led psychiatry off a cliff.

The New Abnormal

A selection of new ailments in the planned manual.

Hoarding

[DSMside1] Associated Press

This is defined as " persistent difficulty discarding or parting with personal

possessions, even those of apparently useless or limited value, due to strong

urges to save items. "

Mixed Anxiety-Depression

[DSMside2] Flickr RM/Getty Images

" The patient has the symptoms of major depression…accompanied by anxious

distress. " The combination of depression and anxiety has been recognized

clinically for years; only now does it make it into the handbook.

Binge Eating

[DSMside3] Associated Press

This means eating " an amount of food that is definitely larger than most people

would eat in a similar period of time under similar circumstances, " in addition

to having " a sense of lack of control over eating. "

Minor Neurocognitive Disorder

[DSMside4] Tango Stock RM/Getty Images

" Evidence of minor cognitive decline from a previous level of performance, " a

commonplace occurrence for anybody over 50.

Temper Dysregulation Disorder With Dysphoria

[DSMside5] Image Source/Getty Images

A new definition for all children with outbursts of temper. It is seen as a way

to avoid using the term " bipolar. "

Mr. Spitzer was discouraged with psychoanalysis, and wanted to come up with a

new illness classification that would ditch all the old Freudian concepts such

as " depressive neurosis " with their implication of " unconscious psychic

conflicts. " Mr. Spitzer and company wanted diagnoses based on observable

symptoms rather than on speculation about the unconscious mind. So he, and

members of the Task Force that the American Psychiatric Association designated,

set out to devise a new list of diagnoses that correspond to natural disease

entities.

Yet Mr. Spitzer ran smack against the politics of the American Psychiatric

Association, still heavily influenced by the psychoanalysts. Mr. Spitzer

proposed such diagnoses as " major depression " and " dysthymia, " diagnoses that

were themselves highly heterogeneous, lumping together a number of different

kinds of depression. But the terms turned out to be politically acceptable.

So in DSM-III there was a lot of horse-trading. The biologically oriented young

Turks got a depression diagnosis—major depression—that was divorced from what

they considered the psychoanalytic mumbo-jumbo. And the waning but still

substantial number of analysts got a diagnosis—dysthymia—that sounded like their

beloved " neurotic depression, " that had been the mainstay of psychoanalytic

practice. Psychiatry ended up with two brand-new depression diagnoses with

criteria so broad that huge numbers of people could qualify for them.

There was one more bow to psychoanalysis: DSM-III continued to make depression

separate from anxiety (because the analysts thought anxiety the motor that drove

everything). And in homage to several influential figures in European

psychiatry, DSM-III brought in " bipolar disorder, " a condition alternating

between depression and mania thought separate from " major depression. "

A word of explanation: The evidence is very strong that the depression of " major

depression " and the depression of " bipolar disorder " are the same disease.

Experienced clinicians know that in chronic depressive illness many patients

will have an episode of mania or hypomania; it is implausible that such an event

would change the patient's diagnosis completely from " major depression " to

" bipolar disorder, " given that they are classified as quite different illnesses.

These rather technical issues in the classification of disease had enormous

ramifications in the real world. Bipolar disorder became divorced from unipolar

disorder. And anxiety—the original indication for the benzos—became soft-pedaled

because the benzos were thought, incorrectly, to be highly addictive, and

anxiety became associated with addiction.

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.

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.

DSM-V is not all bad news. It turns the jumble of developmental syndromes for

children into a single group of " autism spectrum disorders, " which makes sense

because previously, with Asperger's as a separate disease, it was like trying to

draw lines in a bucket of water. But the basic problems of the previous DSM

series are left untouched.

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.

— Shorter is professor of the history of medicine and psychiatry in the

Faculty of Medicine of the University of Toronto. His latest book, written with

Max Fink, " Endocrine Psychiatry: Solving the Riddle of Melancholia, " is

forthcoming from Oxford University Press.

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