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May 04 2013

Criticizing Psychiatry Without Throwing the Baby Out with the Bathwater

So, I read this article in The Atlantic called “The Real Problems with Psychiatry” and…I’m torn. The article is an interview with this guy Gary Greenberg, a therapist who has previously written a book called Manufacturing Depression: The Secret History of a Modern Disease and has now followed that up with The Book of Woe: The Making of the DSM-5 and the Unmaking of Psychiatry.

Now, to be clear, I haven’t read either of these books. I might, just to see the full depth of his arguments. But I decided to read the interview anyway and assume that he accurately represented his own claims in it.

Parts of the interview, I think, are really on point. Greenberg discusses the history of the DSM (the manual used to diagnose mental disorders) as a way for psychiatry as a discipline to establish credibility alongside other types of medicine. He criticizes the DSM on the grounds that the mental diagnoses that we currently have may not necessary be the best way to conceptualize mental illness, and he thinks that once we gain a better understanding of the brain we will find that they have little to do with the physical reality of mental illness:

Research on the brain is still in its infancy. Do you think we will ever know enough about the brain to prove that certain psychiatric diagnoses have a direct biological cause?

I’d be willing to bet everything that whenever it happens, whatever we find out about the brain and mental suffering is not going to map, at all, onto the DSM categories. Let’s say we can elucidate the entire structure of a given kind of mental suffering. We’re not going to be able to say, “here’s Major Depressive Disorder, and here’s what it looks like in the brain.” If there’s any success, it will involve a whole remapping of the terrain of mental disorders. And psychiatry may very likely take very small findings and trump them up into something they aren’t. But the most honest outcome would be to go back to the old days and just look at symptoms. They might get good at elucidating the circuitry of fear or anxiety or these kinds of things.

I don’t know if he’s right. But I suspect that he might be.

He also makes a great point about the fact that we often assume that anyone who acts against social norms, for instance by committing a terrible crime, must necessarily be mentally ill:

It’s our characteristic way of chalking up what we think is “evil” to what we think of as mental disease. Our gut reaction is always “that was really sick. Those guys in Boston — they were really sick.” But how do we know? Unless you decide in advance that anybody who does anything heinous is sick. This society is very wary of using the term “evil.” But I firmly believe there is such a thing as evil. It’s circular — thinking that anybody who commits suicide is depressed; anybody who goes into a school with a loaded gun and shoots people must have a mental illness.

Greenberg also discusses how mental diagnoses have historically been used to perpetuate injustice, such as the infamous “disorder” of “drapetomania,” which was thought to cause slaves to try to escape their masters, and the fact that homosexuality was once considered a mental illness (and other types of sexual/gender variance still are).

He also talks a lot about how the DSM and its categories are tied in with all sorts of things: scientific research and mental healthcare coverage, for instance:

To get an indication from the FDA, a drug company has to tie its drug to a DSM disorder. You can’t just develop a drug for anxiety. You have to develop the drug for Generalized Anxiety Disorder or Major Depressive Disorder. You can’t just ask for special services for a student who is awkward. You have to get special services for a student with autism. In court, mental illnesses come from the DSM. If you want insurance to pay for your therapy, you have to be diagnosed with a mental illness.

The point about needing a DSM diagnosis in order to receive insurance coverage is really important and cannot be overstated (in fact, I wish he’d given it more than a sentence, but again, he did write books). As someone who plans to eventually practice therapy without necessarily having to formerly diagnose all of my clients, this matters to me a lot, because it may mean that I might have to choose between diagnosing and working only with clients who can afford therapy without insurance coverage (which, at at least $100 per weekly session, would really not be many).

But sometimes Greenberg makes a good point while also making a terrible point:

One of the overlooked ways is that diagnoses can change people’s lives for the better. Asperger’s Syndrome is probably the most successful psychiatric disorder ever in this respect. It created a community. It gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed. It can also have bad effects. A depression diagnosis gives people an identity formed around having a disease that we know doesn’t exist, and how that can divert resources from where they might be needed.

First of all, we don’t “know” that depression “doesn’t exist.” We know–or, more accurately, some of us suspect–that the diagnosis we call “major depression” might not map on very accurately to what’s actually going on in the brains of people who are diagnosed with it. What we call “major depression” is a large cluster of possible symptoms, and since you only have to have some of them in order to be diagnosed, two people with the exact same diagnosis could have almost completely different symptomology. Further, because depression can vary like a spectrum in its severity, the cut-off point for what’s clinical depression and what’s not can be rather arbitrary. It’s not like with other types of illnesses, where either you have a tumor or you don’t, either you have a pathogen in your bloodstream or you don’t.

Second, Greenberg doesn’t seem to extend his analysis of the effects of the Asperger’s diagnosis onto other disorders. There is absolutely a community of people who have (had) depression, eating disorders, anxiety, and so on. Those communities are absolutely valuable. My life would be demonstrably worse without these communities. They haven’t “diverted resources” from anything other than me wallowing in self-pity because I feel like I’m the only person going through these things–which is how I used to feel.

Right after that:

What are the dangers of over-diagnosing a population? Are false positives worse than false negatives?

I believe that false positives, people who are diagnosed because there’s a diagnosis for them and they show up in a doctor’s office, is a much bigger problem. It changes people’s identities, it encourages the use of drugs whose side effects and long-term effects are unknown, and main effects are poorly understood.

Greenberg is correct that false positives are a problem and that diagnosing someone with a mental illness that they do not have can be very harmful. However, his dismissiveness of the problem of false negatives–people who do have mental illnesses but never get diagnosis or treatment–is stunning coming from someone who is a practicing therapist. Untreated mental illnesses are nothing to mess around with. They can lead to death, by suicide or (in the case of eating disorders) otherwise. Even if things never get to that point, they can ruin friendships, relationships, marriages, careers, lives. While I get that Greenberg has an agenda to push here, some acknowledgment of that fact would’ve been very much warranted.

In short, Greenberg seems to make the logical leap that many critics of psychiatry and the DSM do; that is, because there is much to criticize about them and because it’s unclear how valid the DSM diagnoses are, therefore depression is “a disease that we know doesn’t exist” and antidepressants are harmful (that’s a whole other topic, though).

Antidepressants may very well be harmful. Diagnostic labels may also very well be harmful, for some people. But I think the stronger evidence is that untreated mental suffering is harmful, and sometimes therapy just isn’t enough and cannot work quickly enough–for instance, for someone who is severely depressed to the point that they can’t possibly use any of the insights they may gain in therapy, or to the point that they are about to commit suicide.

I hope that one day we’ll have all the answers we need to minimize both false negatives and false positives. But for now, we don’t, and I worry that attitudes like Greenberg’s may prevent people from getting the help they urgently need, as much as they may simultaneously promote vital criticism and analysis of psychiatry and the DSM.

~~~

Note: I didn’t fact-check everything Greenberg said in the interview because I’m hoping that The Atlantic employs fact-checkers. But if you have counter-evidence for anything in that article, even parts I didn’t quote here, please let me know.

9 comments

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  1. 1
    Kele Lampe

    Interesting article. I have my own issues with psychiatry. I think it’s important for people who might be considering seeing any kind of mental heath practitioner to understand that psychiatrists don’t, in this day and age, make you lie down on a couch and tell them your dreams and stuff while they take notes. They are invested in prescribing drugs to find a chemical resolution, and they all have their “pet” drugs and they tend to over-prescribe and use very high dosages. There are also “trends” in popular diagnoses. I’ve struggled with depression, eating disorders dissociative disorders and all kinds of stuff as long as I can remember. A few years ago a psychiatrist gave me a Bipolar diagnosis. I’m kind of grateful for it, because I managed to qualify for disability and insurance on the basis of it. But I’m not sure I agree with it, particularly after noticing that Bipolar seemed to become all the rage around that time. And before that, I went years and years with various professionals telling me nothing helpful–everything from “you’re obviously making it up” (yes, and I’m sure that “making it up” led to several suicide attempts…) to “You’re looking for an excuse not to work at a real job” to…well. You get the idea.

    There’s still such a stigma on being treated for a mental illness. Friends and family and society want it to be something you can just decide to get over with positive remodeling. This is not helpful.

    I feel like i have more to say, but I’m not sure I;m capable of being coherent at the moment. Late at night and I need to sleep.

  2. 2
    Stacy

    Shades of Thomas Szasz.

    Greenberg is correct that false positives are a problem and that diagnosing someone with a mental illness that they do not have can be very harmful. However, his dismissiveness of the problem of false negatives–people who do have mental illnesses but never get diagnosis or treatment–is stunning coming from someone who is a practicing therapist. Untreated mental illnesses are nothing to mess around with.

    Thank you, Miri.

    Are there really people who go around building their identities around a diagnosis?

    What about those of us who suffer for years, who found no help in therapy, who are at least grateful that somebody acknowledged our suffering was real?

    A depression diagnosis gives people an identity formed around having a disease that we know doesn’t exist

    I read that and think, yeah, all my pain and dysfunction is unreal? Fuck you, Greenberg.

  3. 3
    karmacat

    I think your comments above are very good. I am a psychiatrist and I know how hard it is to diagnose mental illnesses sometimes. there are times I don’t how much an illness is biological vs psychological. There is a lot of research behind DSM 5 but of course it is very imperfect. The brain is wonderfully complex which makes it hard to study. As you say, just because there are problems with DSM and diagnoses, doesn’t mean one has to throw out all that we know so far.

    In terms of insurance requiring certain diagnoses, the problem is not with DSM 5 but with the insurance companies. It took them too long to acknowledge that eating disorders are “biological” and need to be covered by insurance.

    When I see an adolescent or young adult I sometimes give them a diagnosis of mood disorder, not otherwise specified or depression not otherwise specified. I think it prevents a patient from being pigeon-holed into a particular diagnosis too soon.
    I myself have chronic mild depression (dysthymia). It is very real to me and does respond to medications.
    With all his criticism of psychiatry, does Greenberg have any solutions? If not, then he just needs to shut up.

  4. 4
  5. 5
    karmacat

    In response to spinning the failure of biopsychiatry:
    1. Yes, there is a lot we don’t know, especially when it comes to individual brains. Deciding which medications comes down to some trial and error
    2. There is a lot of neuropsychiatry and genetic research on mental illness. There is some progress but obviously we need much better. But then you could say the same about the genetics of cancer. Every day one sees advances in medicine which in some cases are reversed at a later time.
    3. the “pharmaceutical-academic” complex is there because there is not enough money from government to fund a lot of research
    4. The real achievement with the newer antidepressants is the reduction of side effects rather than an increase in efficacy over the older drugs. to put it too simple terms: you can have a drug that works but causes you to sleep all day vs. a drug that works and allows you to function.
    5. There is a lot of research on which therapies work for with diagnosis, person, etc
    I could go on, but again the main point, as Miri, says is don’t throw the “psychiatry baby” with the research that is wrong

  6. 6
    konekon1nj4

    There are a lot of problems with the DSM, but it seems like sometimes it’s the best we’ve come up with so far. I might give the guy’s book a read depending on how long it is ;) There is a very interesting book called Unhinged by Daniel Carlat that I read a while back that touches on the difficulties in diagnosing people, how involved the insurance companies are in picking meds and the current face of psychiatric treatment and where he thinks it’s going. I found it to be pretty well reasoned and not inflammatory or railing against anything.

  7. 7
    SC (Salty Current), OM

    In response to spinning the failure of biopsychiatry:…

    There are a lot of problems with the DSM, but it seems like sometimes it’s the best we’ve come up with so far.

    So you’re not even going to read or engage with the materials with which you’ve been presented and to which you’re purportedly responding?

    At least do that. At least try to appreciate the import of the NIMH announcement. At least read and address one or two of the books or articles (at the very least the Marcia Angell pieces) listed here.

    Really, what is the point of these silly responses? Is our common purpose the development of a genuinely humanistic and reality-based approach to psychological distress or not?

  8. 8
    SC (Salty Current), OM

    …and not inflammatory or railing against anything.

    And what a horror that would be.

  9. 9
    jellybelly123

    After reading your post, i have found these books to be very interesting.
    Personally, i don’t have much interest or believe on DSM because according to me there are many mistakes in it’s listing, but overall your post inspired me to rethink about the mental illness.
    Thanks for sharing.

    Reference: Cluas Aspergers Support Group

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