View 611 February 22 - 28, 2010 (original) (raw)
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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.htmlInteresting 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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