Opioid painkillers such as Vicodin (hydrocodone) and OxyContin (oxycodone) are crucial medical tools that are addictive and widely abused. Tranquilizers and sleeping pills of the benzodiazepine class, e.g., Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam), are safe and effective in limited, short-term use, but are often taken too freely, leading to drug tolerance and withdrawal risks. Stimulants such as Ritalin (methylphenidate) and Adderall (amphetamine) ease the burden of ADHD, but are also widely used as college study aids as well as recreationally. All of these medications are available only by prescription. This means prescribers serve as gatekeepers, permitting access for medical needs and denying it otherwise.
This gatekeeping can be difficult. Doctors are imperfect lie detectors and can be fooled with a plausible story. Pain, anxiety, insomnia, and inattention are mostly invisible. The internet offers quick lessons in how to fake a medical history. Beyond the initial assessment, every physician has patients who repeatedly “lose” bottles of painkillers or tranquilizers and request more. Secretly seeing multiple doctors to obtain the same drug remains fairly easy. While a few doctors run illegal “pill mills” and flout the gatekeeper role, many more are simply too overworked to be vigilant with every patient.
None of us became physicians to fight the war on drugs. On the contrary, most of us are uncomfortable doubting our patients’ honesty. It’s stressful to worry about being too suspicious or too gullible, and it’s a waste of valuable time.
The possibility of tranquilizer abuse arose with a new patient of mine recently. My concern led to multiple phone calls to pharmacies and to consulting California’s CURES database online. I was convinced enough that something was amiss that I confronted my patient, who responded by calling me names, making vague threats, and leaving in a huff without paying for the appointment (and, of course, never coming back). Although the reaction seemed confirmatory, in truth I’m still not certain my suspicions were correct. Why did I put my patient and myself through such grief? Because I wanted to “do no harm.” Accepting the gatekeeper role requires scrutinizing and sometimes confronting the patient at the gate.
Let’s consider other drugs that are used both medically and recreationally — but unlike those mentioned above, do not involve a physician gatekeeper.
The best candidate may be cannabis. Currently legal in 25 states, medical marijuana requires a doctor’s authorization but not a prescription that specifies dosage, frequency, duration of treatment, or route of administration. By definition, a Schedule I drug like marijuana is not “FDA approved” for any medical use. Yet cannabis is very much like the Schedule II drug Adderall: it has a few solid medical uses, a much larger set of dubious or controversial ones, and a vast sea of mostly illegal recreational use. A lot of medical marijuana is used for relaxation or sleep, blurring the medical-recreational distinction in much the way Adderall does when used for studying. Purely recreational use is legal in four states as of this writing. Legalization is on the ballot this November in five additional states, including California where I practice.
I have never authorized medical marijuana, although several of my patients were approved by other physicians and use it regularly. Once a patient tells me he or she uses marijuana, whether doctor-approved or (for now) illegally, I can act in my preferred role as advisor. We can discuss risks and benefits, sativa versus indica, THC and CBD, all without me having to second-guess my patient’s story, make a paternalistic decision about whether to authorize access, or even cast judgment on the decision to use it.
In states where recreational cannabis is newly legal, it joins the three drugs already native to our cultural landscape. Adults consume alcohol, caffeine, and nicotine with nary a prescription, gatekeeper, or hoop to jump through. And although we rarely think about it, all three have medicinal effects. Alcohol can reduce stress, aid sleep, and may promote health in a number of other ways. Caffeine treats fatigue, migraine headaches, and possibly obesity. Nicotine eases Parkinson’s disease and perhaps schizophrenia, and helps with weight loss. While smoking rates are declining in the U.S., most Americans continue to use alcohol and caffeine often and for a complex mixture of reasons: taste, psychoactive effects, social custom, and sometimes for plainly medicinal purposes. Widespread use also leads to addiction in a significant subset of the population: caffeine becomes necessary and not just optional, and we go to extraordinary efforts to manage alcoholism. As tragic as this is, nearly everyone agrees that Prohibition was the greater evil.
I like that I’m an advisor, not a gatekeeper, for marijuana and the (other) legal vices. I also reject the gatekeeper role for stimulants by telling callers I don’t treat ADHD. This is trickier: my refusal to treat a legitimate psychiatric disorder is arguably too finicky. It can be hard for an earnest sufferer to obtain a thorough evaluation and treatment, even if paradoxically it is all too easy for a drug abuser to tell a sob story and score a prescription. Nonetheless, with stimulants as with medical marijuana, I’m uncomfortable making Solomonic distinctions where medical and non-medical uses lie so closely on a continuum.
In any event, I draw the line there. I continue to prescribe tranquilizers and sleeping pills for my patients who seem to need them. I may unwittingly abet substance abuse in some cases, but the alternative is to not prescribe any abusable medication, a stance that feels far too finicky. After all, medication gatekeeping is the norm for many physicians. Oncologists, surgeons, and ER doctors can’t tell patients they don’t treat pain. Surgeon general Vivek Murthy sent a letter to every U.S. physician in August urging us to help fight the “opioid epidemic” by limiting dosages and durations of opioid prescriptions, and by substituting non-narcotic alternatives — in essence, by being better gatekeepers.
The only way to avoid doctor-as-gatekeeper entirely is to make all drugs available without a prescription. The prospect of narcotics and amphetamines on the open market strikes most of us as extremely foolish, even though Prohibition and the failed war on drugs should give us pause. The other strategy is to embrace gatekeeping even more seriously, as Dr. Murthy advises. Careful comprehensive evaluation, “start low and go slow” prescribing, close monitoring using a system like CURES, and strictly limiting refills should drive down prescription drug abuse. Unfortunately, this takes more clinical time, one thing most physicians can’t spare, and a trading away of doctor-patient collaboration for something more wary and legalistic. As usual, physicians are asked to erode the traditional doctor-patient relationship, and do more work, to keep the system afloat. Meanwhile, patients suffer further small indignities and a colder encounter.
Alternatively, we could wait it out. The line between medical treatment and personal enhancement or optimization gets fuzzier all the time. Society may soon fail to distinguish treating an anxiety disorder and taking something to relax in the evening, or treating ADHD and simply maximizing one’s mental sharpness. The medical-recreational divide already looks more like a continuum for marijuana and stimulants, and is essentially gone with respect to alcohol, caffeine, and nicotine. If this trend continues, physicians may no longer be called upon to distinguish legitimate from illegitimate drug use. Our focus as medication gatekeepers may shift from the purpose of the prescription to its safety, making us more like pharmacists than judges.
Prior to the release of DSM-5 in 2013, I referred at times to the pocket copy of DSM IV parked in my office bookcase. The main reason was to enter the right diagnostic codes on insurance forms. I also sometimes quoted DSM criteria to show a patient that ADHD can’t arise in adulthood, that daily mood swings are not characteristic of bipolar disorder, or that six months of sobriety is still “early” remission. In other words, aside from fulfilling the documentation needs of third parties, I occasionally used DSM IV to disabuse a patient of a faulty self-diagnosis, and even more occasionally to ratify my own assessment in the eyes of my patient. Rarely if ever did I consult the handbook to make a diagnosis. By the time I reached for it, I already had a handle on what was going on.
DSM IV diagnostic codes were a subset of ICD-9-CM, a catalog by the World Health Organization of all diagnoses in medicine. DSM-5 uses these codes as well, but also provides the newer ICD-10 codes now required for virtually all insurance claims and similar documentation. While I could look up the ICD-10 codes I need in DSM-5, I haven’t bothered to buy a copy for the past three years. That’s right: I don’t own DSM-5. Instead I check a plain list of psychiatrically relevant ICD-10 codes and use the one for the diagnosis I have in mind. For three years I haven’t felt the need to consult DSM-5 to make a diagnosis, nor even to score rhetorical points with patients (which was never a very good reason to begin with).
I’m aware of the major changes in the new edition. I realize multi-axial diagnosis is obsolete and that many diagnoses were tweaked. ADHD can appear by age 12 now, substance abuse and dependence have collapsed into substance use disorders, autism is now a spectrum, and the controversial bereavement exclusion no longer exists. None of this makes a bit of difference in my daily work with patients.
One reason it doesn’t is that traditional dynamic psychotherapy has little use for diagnosis. The former highlights each patient’s uniqueness, while the latter lumps patients into groups. I can’t recall a single instance when I, or anyone I know, altered a psychodynamic therapy based not on the patient’s defensive style, relatedness, or stated goals, but on whether the patient met DSM criteria for a specific disorder. Within the confines of this form of therapy, DSM diagnosis doesn’t affect treatment. So let’s concede that dynamic psychotherapy is a special case and focus instead on treating the major disorders we used to call “Axis I.” In this medical-model, usually pharmacologic realm, accurate diagnosis obviously guides treatment. Here, at least, the DSM remains the indispensable “bible” or gold standard of psychiatric diagnosis, yes? And by not owning one, I must be navigating without a compass? Well, no, not really.
DSM III was useful to me in training, just as the newer fourth and fifth editions undoubtedly help more recent trainees. These manuals help beginners learn the jargon, the checklist criteria that officially define a disorder, the recognized variants and qualifiers. Diagnostic criteria help students and early-career professionals build internalized prototypes or templates of mental disorders that go well beyond a layperson’s vague impressions. We learn that (major) depression is more than sadness: it has a minimum duration and associated neurovegetative signs. We learn that bipolar disorder describes abnormal moods sustained over weeks or months, not moods that shift over an hour or a day. We learn that panic and anxiety aren’t the same thing, and that obsessive compulsive disorder is more than a personality style.
But this is just a starting point. After seeing many patients, our diagnostic prototypes take on lives of their own. We gradually form our own mental models of common diagnoses, views that may differ from the DSM. We decide the published criteria for a particular diagnosis are too wide or too narrow. Certain features compel us to call someone clinically depressed even though he doesn’t quite meet criteria. A patient who meets DSM criteria for schizophrenia strikes us as atypical, prompting diagnostic doubts and a more extensive medical work-up. A patient with generalized anxiety disorder has unmistakable thematic triggers, unlike other GAD patients who do not. For these and a thousand other reasons, we deviate from strict adherence to DSM categories. We make exceptions. We season our assessments with clinical experience. A DSM based on expert consensus — as opposed to something more empirical, like a reproducible test — invites debate. In the end, we privilege the nosology of our own experience over the official manual that approximates it.
DSM stands for “Diagnostic and Statistical Manual.” The use of criterion-based diagnosis since the arrival of DSM III in 1980 improved inter-rater reliability. Since then, clinicians around the world largely agree whether a particular patient “meets DSM criteria.” This has been a boon for research, where homogeneity of study groups is crucial. It says nothing, however, about validity, i.e., whether DSM categories accurately reflect how the real world is organized. This thorny issue brought the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH) into conflict a couple years ago, when the NIMH announced it would replace DSM diagnostic categories in its research with finer-grained, more elemental categories. The validity concern arises regularly in practice as well, whenever a clinician feels not all major depressive disorder is the same or should be treated that way, or that the DSM strikes the wrong balance in defining post traumatic stress disorder.
What, then, is the true utility of the DSM? It establishes a common language for professional communication and research. It offers the untrained and clinically inexperienced a starting point that approximates the clinical reasoning of experts who pick up on nuances missing from the DSM — and who, it must be said, sometimes disagree among themselves. It gives the popular press something to write about. It allows corporate MBAs to learn its terms and thus become “part of the health care team.” It serves as a glorified compendium of insurance codes. For patients, psychiatry’s “diagnostic bible” can reassure, threaten, challenge, or support. For psychiatrists, it can ratify or legitimize our assessments and opinions. However, for clinicians with significant real-world experience, one thing the DSM doesn’t do is aid clinical practice.
I write in response to a recent post on KevinMD and the comments that followed. A primary care physician named Ashley Maltz discussed advantages and disadvantages of a cash-based practice. I appreciate her evenhanded tone: she prefers this model yet expressed concern for patients who can’t use it. In the comments section, several physicians extolled the virtues of cash-pay, but patients were mixed. It’s attractive for those who can afford it, while it worries, and maybe angers, those who can’t.
I enjoy the personal and patient benefits of a mostly cash-pay psychiatric practice (I also see some patients under Medicare). I like running my own small business, keeping clinically useful paper charts as opposed to a ponderous EHR, and protecting my patients’ privacy. Billing is simple enough that I do it myself. There is also an argument for keeping the relationship dyadic, i.e., 2-person, in psychotherapy. Third party payers can complicate the therapeutic relationship in a domain where clarity is paramount. Most of my private practice colleagues likewise avoid insurance panels. It’s become the norm in my field.
Yet we’re all painfully aware that most of the seriously mentally ill can’t come to our offices. They are relegated to county clinics, training settings, and to the rare private practitioner who still accepts public insurance. Like Dr. Maltz, I’m saddened that
those on Medicaid or disability programs cannot be seen for cash by medical providers for medical care. Most of these people do not have the financial means to seek alternative types of care. Thus, they are seen in large community clinics with overworked providers and limited resources.
Some critics of cash-based psychiatric practice exaggerate, painting a picture of high-society shrinks getting rich off the worried well. They point to real or imagined $400/hr psychiatrists calming the Silicon Valley nouveau riche. Others like Allen Frances M.D. provide a more balanced critique, noting that individual psychiatrists gravitate toward more functional patients, but that we are only a small part of a very large puzzle. It appears that as a society we prefer not to pay for treatment of the seriously disturbed, but only for the jails and prisons they occupy after committing minor property and lifestyle crimes due to their condition.
Our situation in psychiatry is a harbinger for primary care. There’s no denying the advantages of cash-based practice; it serves both doctors and patients very well. Yet cash-based primary care practices, like psychiatric practices, exclude many patients who can’t afford them. They can’t comprehensively serve the primary care or psychiatric needs of a population. Even more obviously, almost no one can pay out of pocket for more elaborate medical care, such as major surgery or a lengthy ICU stay.
There’s a basic tension between health care as a private transaction and health care as a public good. Regarding the former, we can show our compassion by offering some free or low-fee care, or by treating some publicly insured patients under Medicare or Medicaid. This way we avoid elitism and do our part for the less fortunate. However, we must recognize that no matter how charitable we are as individual physicians, many more are in need of our services than our charity can accommodate. The private transaction model of medical care cannot save sick people from dying in the street. Universal access to health services is needed.
While taxpayer-funded Medicare and Medicaid cover many patients who cannot otherwise afford care, our current backstop is EMTALA, the 1986 federal law requiring hospital Emergency Departments to evaluate and treat emergencies regardless of ability to pay. According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated, costing hospital systems tens of billions annually. Much of this cost is shifted to paying patients, inflating medical bills for everyone else. One way or another, society (i.e., we) pay to keep our fellow Americans alive and relatively well. It would be far more economical, not to mention humane, to offer universal access earlier, before health problems progress to emergencies — just as it would be to treat the seriously mentally ill before they need to be imprisoned.
It’s no surprise that many patients who are otherwise sympathetic to the plight of demoralized, burned-out doctors draw the line at a cash-based care model that excludes them. In order to ally with these patients, those of us with cash-based practices should at minimum acknowledge the need for a two-tier model, public and private. Better yet, we need to think hard about who provides services in the universal-access public tier. Should this be all of us at some point in our careers, i.e., a type of “doctor draft” or public service requirement? Should these services be ceded to PAs and NPs? Or can we “let the market decide”, such that these services are provided by physicians who aren’t sharp, ambitious, or economically secure enough to hang a shingle — or for whatever reason prefer not to? These hard questions must be answered if we’re to be intellectually honest and admit that the physician’s role in society is more than entrepreneur.
Image courtesy of sheelamohan at FreeDigitalPhotos.net
Again and again in therapy I find myself emphasizing the distinction between feeling an emotion and acting on it. Many patients, and non-patients too, take undue responsibility for their emotions, as though feelings were volitional behaviors, the result of a choice. Often there is a stated or implied should: “I should feel this, not that.” Note how commonly people blame themselves for feeling, or not feeling, a certain emotion:
“I should be more grateful after all she’s done for me.”
“It’s wrong of me to get angry at other drivers, they’re just trying to get home too.”
“It’s silly to mourn the death of my dog. He was just a pet.”
When feelings are viewed this way, we hold ourselves to an impossible standard. We expect to control what is essentially not ours to control. If we prefer chocolate ice cream to strawberry, no act of will or rational choice can convince us otherwise. When someone or something strikes us as irritating or funny or repulsive, these reactions arise unbidden. We do not choose to feel depressed, and cannot opt to feel happy. Sexual attraction to one type of person, and not another, occurs whether we like it or not. It’s true that we can gradually temper negative emotions, particularly global ones such as depression and anxiety, by willfully altering our thinking — cognitive behavioral therapy (CBT) is based on this idea — and even more reliably by choosing situations and relationships that promote feelings we want. But on a moment-to-moment basis, feelings come and go of their own accord.
The mistaken belief that one can and should be in control of felt emotions leads to unwarranted moral condemnation, a sense that having certain feelings is the mark of a bad person. Self-condemnation of this sort is tragic and can last a lifetime. By the same token, it is unhelpful to criticize or overanalyze the feelings of another, e.g., one’s spouse or child. He or she didn’t choose those feelings, and may not know why they arose. Calling on another to account logically for feelings often has an aggressive edge; it banks on the fallacy that emotions are rational and controllable when they are not. Analysis of emotions is quite valuable — if done in the spirit of curiosity, not criticism.
Curiosity is the healthy response to a new awareness, including awareness of a previously unrecognized emotion. It is a new piece of self-knowledge. Emotions arise in the limbic system, the non-verbal, more primitive brain centers we share with other animals, not from the neocortex, the seat of rational thought. The neocortex “notices” and is affected by activity in the limbic system. This is why we can’t always immediately name or identify an emotion when we feel it, and why strong feelings can temporarily flood or short-circuit rational thought.
Actions are different. Unlike emotions, they are, or should be, essentially under our control. (Just as willful application of CBT can influence emotions, behavior driven by strong emotion sometimes feels compulsory, e.g., crying when feeling sad. However, both of these are exceptions that prove the rule: feelings aren’t chosen, behaviors are.) Anger or sadness or lust do not, in themselves, compel anyone to do anything. Our ability and responsibility to exercise choice occurs when deciding to act, not at the point of having the feeling.
Our actions have real consequences for ourselves and others. They can get us fired or arrested or divorced. They can hurt our loved ones and coworkers. This is why it is so crucial to differentiate behavior from internal feelings and emotional states. Yet many fail to make this distinction, and suppress or deny feelings, often imperfectly, out of fear of the consequences resulting from acting on that feeling. According to traditional psychoanalytic theory, unconscious effort to avoid awareness of these “dangerous” feelings results in anxiety and other symptoms. Much of the value of psychoanalysis and analytically based psychotherapy is experiencing emotions in a safe setting, by separating this experiencing from adverse behavior and its consequences. (When this separation fails to occur, the technical term is “acting out” if the adverse behavior occurs outside the therapy session, and the lesser-used “acting in” if it occurs within the therapy itself.)
Distinguishing feelings and actions is part of the “special sauce” of psychoanalysis and dynamic psychotherapy. As with free association, transference, the relative anonymity of the therapist, and other aspects of dynamic work, I believe nothing is gained by keeping patients in the dark about the process. When a patient speaks of emotions as though they were volitional actions, or fails to separate feelings from behavior, I point it out in the hope it leads to insight and greater self-knowledge.
Oneupmanship is the art or practice of successively outdoing a rival, staying one step ahead by proving superiority. It is straightforward competition, whether playful in tone, as in friends verbally sparring, or deadly serious. Presidential candidate Donald Trump employs oneupmanship incessantly, pointing out that he is richer, more successful, and more popular than his rivals and detractors. While his tactics are debatable, their intent is clear.
The converse is in need of a parallel term, and the obvious choice is onedownmanship (or onedownsmanship, with an “s” in the middle). This neologism appears sporadically in recent decades, including in a 1972 ad for an economy car, as an approach to conducting interviews in school consultations (Ingraham, 2000), and to describe faking outrage and injury in sports. These uses coalesce around the concept of gaining advantage by appearing weak, victimized, dim, or inferior. Unlike oneupmanship, it’s a tricky ploy, a surprise attack of sorts.
Onedownmanship is common, though it often goes unrecognized. Anyone who elevates a job decision to avoid making it oneself (“well, you’re the boss”) employs a version of it. As a medical intern, I was often asked to draw blood from the most difficult veins because I was “the doctor” — even though the nurses had far more experience drawing blood than I did. Any argument that starts with, “If you’re so smart [or experienced, skilled, etc] …” turns the superiority of one’s opponent against him. The Japanese martial art aikido relies on a form of onedownmanship, conceding that the attacker’s power is superior, yet ultimately and surprisingly neutralizing it. TV detective “Columbo” solved cases by feigning ignorance. Humblebragging is a new twist on onedownmanship.
Moving from these overt and often conscious examples, we enter a larger realm where onedownmanship may be partly or fully unconscious. Controlling others through weakness is a typical dynamic in alcoholism, where others are manipulated into codependency, and in dysfunctional families where an anxious or easily hurt person causes others to “walk on eggshells.” As I once wrote, sometimes a bull wanders into a china shop; other times the bull is minding its own business when someone builds a china shop around it.
Those who claim special entitlement by dint of physical or mental disability may be employing onedownmanship, although this highlights the trickiness of the concept: we may hurtfully “blame the victim” if we even entertain the possibility — and be unfairly manipulated if we don’t. The same holds at the larger societal level, where claims to special consideration based on one’s status as member of an ethnic minority or another historically disadvantaged group is cause for endless and heated political debate. A backlash deriding the “culture of victimhood” now stands in opposition to such claims.
Onedownmanship presents its targets with a dilemma. Ignore or discredit overt weakness and inferiority, and one risks being a thoughtless boor, hitting a victim when he’s down. This is its paradoxical power. As in the converse case of oneupmanship, onedownmanship is therefore often challenged by like means, creating a rivalry between two sides in the same stance. In the latter case a “race to the bottom” may occur, with each side claiming more disadvantage, weakness, and/or victimization than the other, e.g., “my minority group is more victimized than your minority group.”
Contests either up or down are normally bounded by healthy narcissism, i.e., self-pride. That is, the heights of self-promotion (oneupmanship) as well as the depths of self-denigration (onedownmanship) are limited by the shame accompanying either extreme. Pathological narcissism — which can appear either as excessive self-pride or none at all — erases these limits, allowing shameless oneupmanship or onedownmanship to proceed to the point of absurdity.
I don’t avoid reading opinions strongly critical of psychiatry. They help sharpen my reasoning skills. It’s always possible they might alter my views in some way. And like most everyone, I consider myself openminded and receptive to criticism. However, after years of reading Thomas Szasz, Robert Whitaker, and the screeds of the less articulate, after perusing the leaflets and poster displays of the protesters at APA conferences, I’ve heard most of the arguments by now. I rarely engage with such harsh critics. As I’ve written elsewhere, there has to be a shared foundation, some agreed-upon axioms, for a dialog to take place. Otherwise it’s just a shouting match.
My own views are pretty stable at this point. I’m critical of many aspects of psychiatry: I blog about sloppy thinking in the field, the limitations of DSM nosology, the overuse of pharmaceuticals. I teach psychiatry residents to think psychologically and how to practice ethically. But unlike anti-psychiatrists, I don’t consider psychiatry a hoax or an evil injustice. If I did, I’d find another career. And while it isn’t hard to cite cases of psychiatric mismanagement, it’s a good deal easier to cite cases of psychiatric benefit. We help people far more than we harm them. Truth be told, I’m proud to be a psychiatrist. If I wasn’t, I’d do something else.
Philip Hickey PhD is a retired psychologist who blogs on behaviorism and mental health. His articles are reposted on Mad in America, a popular website created by Whitaker that is highly critical of psychiatry. Dr. Hickey wrote a lengthy critique of my December 12 post on whether psychiatric disorders are brain diseases. I considered replying in the comments section on MIA, but the anti-psychiatric echo chamber there assures it would fall on deaf ears. So instead I’ll follow up here.
In composing my last post I was more concerned about slamming luminaries in my field than worrying about how anti-psychiatrists might react. The piece, after all, is critical of language by prominent psychiatrists. Consequently, I granted that schizophrenia and several other named disorders look primarily biological in nature, even though this hasn’t been proven. Dr. Hickey agrees with me on first impressions, which was all I was claiming. However, he then goes to great lengths to refute this rather trivial bone I threw to the biological psychiatrists. I could now respond to each objection point by point — schizophrenia does affect a diverse array of mental functions, not merely the few in the DSM criteria; neuroanatomical changes go well beyond mere “brain shrinkage”. But why bother? I’m not here to argue for the biological foundations of schizophrenia. Indeed, doing so too well weakens the main point of my prior post. Note the insidious dynamic: confronted by someone so “anti” I’m called upon to be more “pro,” even though this serves neither of us.
I also predicted, without offering much in the way of argument, that a few severe psychiatric conditions will eventually be shown to have biological causes. Dr. Hickey vehemently disagrees, and holds that behaviorism and learning theory account for these conditions. That’s wildly implausible, but no matter. The truth is, no one really knows.
Dr. Hickey wanders into the weeds of DSM diagnosis and labeling, a topic I didn’t address at all, other than to use the common terms for psychiatric maladies. I don’t object to cautious circumlocutions like “feelings and behaviors currently lumped under the controversial label ‘schizophrenia’.” It just takes longer to write. Whether schizophrenia is one disease or many (or not a disease at all), whether the DSM criteria are valid or way off-base, whether some of the features called schizophrenia are actually iatrogenic — none of this matters for my argument. The point remains that the clinical presentation we call schizophrenia looks like biological dysfunction even though its etiology remains unknown.
Dr. Hickey took pains to explain in great detail the limitations of reductionist thinking, how new properties emerge at higher levels of organization, and how it is a category error to refer, say, to psychology at a molecular level. This is because I misspoke in trying to convey the reductionist viewpoint. I wrote that, in theory, “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease.” That’s not true; a learned phobia is a ready counterexample. It’s particularly unfortunate that I made this mistake, as it confirms the worst fears of those who believe we psychiatrists are mired in primitive reductionism. Actually, Dr. Hickey and I agree here.
Now having said that, although some psychopathology arises solely psychologically, it’s also common for genetics or biochemistry to underlie aberrant psychological functioning. This is the case for the many known diseases such as brain tumors, neurosyphilis, and lead poisoning that were once wrongly thought to be purely psychological (or demonic). There is no reason to assume that all such discoveries are behind us. Rather than digging one’s heels into radical behaviorism, radical neurobiology, or radical something-else, isn’t it more honest simply to say we don’t know what the future will reveal?
I’ll end by noting that anti-psychiatrists object to any pathologizing of behavior as stigmatizing and dehumanizing. Unfortunately, it’s inevitable, and not just by psychiatrists. Paranoid psychosis — a behavioral description, not a diagnosis — may result from drugs, sleep deprivation, brain tumors, or extreme stress. Whatever the cause it’s still an unpleasant, dysfunctional state that differs markedly from the usual way human minds work. We can choose new, less stigmatizing names for such states, but we will never give up describing ourselves and others in value-laden terms. The conditions we call mental illnesses — and it’s interesting to ponder what exactly counts — are usually miserable for the sufferers, and arouse pity and fear in observers. It’s not realistic to imagine we’ll ever carefully tiptoe past naming such states.
I thank Dr. Hickey for his close reading of my article, and for calling it interesting and thought-provoking, probably the highest praise a psychiatrist can ever expect from such a critic. I note that he calls me a typical psychiatrist when he disagrees with me, atypical and rare when we agree. I would respectfully suggest that I’m not that rare. Most of the psychiatrists I know have no rigid orthodoxy, no ideological axe to grind. Most see only voluntary patients who come for relief of distress — and end up feeling relieved. All value psychotherapy whether or not they provide it themselves, and all add a healthy dose of common sense to their specialized training. Psychiatry has much to improve, but that will only happen when supporters and critics engage in dialog, not a shouting match.
Some maladies that attract psychiatric attention are unequivocally brain diseases. Huntington’s disease. Brain tumors. Lead poisoning. However, these are not psychiatric diseases. Huntington’s is a genetic abnormality diagnosed and treated by neurologists. Brain tumors are managed by neurosurgeons and oncologists. Lead toxicity is treated by internal medicine. Indeed, a long list of medical and surgical diseases include psychiatric features: stroke, anoxic brain injury, meningitis, lupus, diabetic ketoacidosis, and febrile delirium to name a few. One important job of the psychiatrist is to recognize such problems, treat the psychiatric manifestations when appropriate, and refer the case to one’s colleague — neurologist, internist, surgeon — for treatment of the underlying problem.
Of the conditions deemed inherently psychiatric, some seem rooted in biological brain dysfunction. Schizophrenia, autism, bipolar disorder, and severe forms of obsessive compulsive disorder and melancholic depression are often cited. It’s important to note that their apparently biological nature derives from natural history and clinical presentation, not from diagnostic tests, and not because we know their root causes. Schizophrenia, for example, runs in families, usually appears at a characteristic age, severely affects a diverse array of mental functions, looks very similar across cultures, and brings with it reliable if non-specific neuroanatomical changes. Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found. (The same type of reasoning applied to AIDS before the discovery of HIV, and to many other medical diseases.) A similar argument can be made for other putatively biological psychiatric disorders.
Lately, however, some big names in psychiatry have taken a more ideological stance, declaring that psychiatric disorders in general are brain diseases — right now, no further proof needed. Dr. Charles Nemeroff, widely published professor and chairman of psychiatry at the University of Miami Miller School of Medicine, writes:
In the past two decades, we have learned much about the causes of depression. We now know from brain imaging studies that depression, like Parkinson’s disease and stroke, is a brain disease.
Dr. Thomas Insel, recent director of the National Institute of Mental Health (NIMH) wrote:
Mental disorders are biological disorders involving brain circuits…
Psychiatrist and Nobel laureate Dr. Eric Kandel says:
All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases.
These claims by prominent psychiatrists agitate critics. No biomarker for any psychiatric disorder has yet been identified. Genetic vulnerabilities have been discovered, but nothing resembling a smoking gun. Functional brain imaging reveals biological correlates of mental impairment, not etiology, and no such imaging can diagnose a specific psychiatric condition. Our best account for most mental disorders remains a complex interaction of innate vulnerability and environmental stress, the “diathesis-stress model”. These psychiatric leaders know the research as well as anyone. How can they call psychiatric disorders brain diseases without scientific proof?
The brain mediates all mental activity, normal or not. Consequently, any psychiatric intervention — or influential life experience — acts upon the brain. This is not a new discovery. A century ago, Sigmund Freud wrote “Project for a Scientific Psychology,” in which he proposed that ultimately the mind would be understood biologically. No modern studies of brain tissue, no genetic testing, no advanced brain imaging were needed for the father of psychoanalysis to posit that mental activity arises from biology. It is a philosophical position, monism as opposed to Cartesian dualism, not a scientific finding. Note that Freud could then have made it a point to declare, as Drs. Insel and Kandel do now, that all mental disorders are biological diseases. No additional science was required even a century ago.
He didn’t because there was nothing to gain. The best treatments at the time were psychological, not biological. There was no grant money at stake, no research agenda to support. The status and livelihood of early psychoanalysts did not depend on their treatment being biological.
Psychiatric “brain disease” is neither an exaggeration nor a lie. It does not require scientific proof — and brain imaging has neither strengthened nor weakened the case. For as long as one is not a philosophical dualist, it is surely true. In theory, all psychology can be reduced to electrochemical events in brain cells. All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.
Without elucidating the causative mechanisms, however, this reductionism amounts to little more than political rhetoric. Calling psychiatric disorders brain diseases serves no clinical or research purpose, it only serves political ends: bringing psychiatry into the fold as a “real” medical specialty, impressing Congress and other funding sources, perhaps allaying stigma. As a tactic it smacks of insecurity and self-aggrandizement, wholly unbefitting a serious medical specialty.
Freud’s psychoanalysis acts on brain cells, and ultimately alters chemical bonds in those brain cells. We could rename psychoanalysis and psychotherapy “verbal neuromodulation.” But to what end? A reductionistic account of this sort, festooned with pseudoscientific verbiage, has no practical significance.
Brain research is a young field. It should be vigorously pursued for what will surely be learned. If history is any guide, many conditions currently considered psychiatric will eventually be explained biologically — and ironically, they will no longer be psychiatric conditions, as was the case with Huntington’s disease, brain tumors, lead poisoning, and many other diseases that now belong to other medical specialties.
Stumping for psychiatry as clinical neurobiology will be justified when basic research in this area affects clinical practice. Until then, “brain disease” is only a philosophical technicality, a spin, to give our clinical work and the institution of psychiatry an air of scientific credibility. Particularly in light of how diseases leave psychiatry once they are well understood, the field should embrace uncertainty, not preempt it with the premature use of brain disease language.
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