Science

'There Is No Definition of a Mental Disorder'

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Gary Greenberg's recent Wired article about the anxiously anticipated and repeatedly delayed fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DMS-5) begins with a revealing admission. "There is no definition of a mental disorder," Allen Frances tells him. "It's bullshit. I mean, you just can't define it….These concepts are virtually impossible to define precisely with bright lines at the boundaries." Frances should know. As the lead editor of the current DSM, Greenberg writes, he is literally "the guy who wrote the book on mental illness."

But the fact that there is no precise, workable, meaningful definition of mental disorders will not stop the APA from trying once again to catalog them. As Greenberg observes, too much is at stake to stop now, including psychiatry's legitimacy, drug companies' profits, and the ability of mental health professionals to get paid for their work by picking a code out of the APA's bible. Frances himself is not suggesting that the APA stop the "bullshit"—only that it proceed a little more carefully. He regrets that DSM-IV, the revision he oversaw, preciptated a 40-fold explosion in diagnoses of bipolar disorder in children, who ended up taking powerful psychotropic drugs with uncertain long-term effects "even if they had never had a manic episode and were too young to have shown the pattern of mood change associated with the disease." He worries that something similar might happen if DSM-5 includes a "pre-psychotic" disorder that psychiatrists will be keen to treat preventively with drugs. In a 2009 Psychiatric Times essay, Frances warned that an emphasis on early intervention would encourage the "wholesale imperial medicalization of normality," producing "a bonanza for the pharmaceutical industry" while imposing on patients the "high price [of] adverse effects, dollars, and stigma." Robert Spitzer, the lead editor of DSM-III, seems to have similar concerns about reckless definitions, complaining that the revision process has been excessively secretive.

For his part, Greenberg, a psychotherapist and the author of Manufacturing Depression: The Secret History of a Modern Disease, walks to the precipice of calling psychiatry a pseudoscience before turning back:

The authority of any doctor depends on their ability to name a patient's suffering. For patients to accept a diagnosis, they must believe that doctors know—in the same way that physicists know about gravity or biologists about mitosis—that their disease exists and that they have it. But this kind of certainty has eluded psychiatry, and every fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can't rigorously differentiate illness from everyday suffering. This is why, as one psychiatrist wrote after the APA voted homosexuality out of the DSM, "there is a terrible sense of shame among psychiatrists, always wanting to show that our diagnoses are as good as the scientific ones used in real medicine."

Since 1980, when the DSM-III was published, psychiatrists have tried to solve this problem by using what is called descriptive diagnosis: a checklist approach, whereby illnesses are defined wholly by the symptoms patients present. The main virtue of descriptive psychiatry is that it doesn't rely on unprovable notions about the nature and causes of mental illness, as the Freudian theories behind all those "neuroses" had done. Two doctors who observe a patient carefully and consult the DSM's criteria lists usually won't disagree on the diagnosis—something that was embarrassingly common before 1980. But descriptive psychiatry also has a major problem: Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have "major depression," no matter your circumstances or your own perception of your troubles. "No one should be proud that we have a descriptive system," Frances tells me. "The fact that we do only reveals our limitations." Instead of curing the profession's own malady, descriptive psychiatry has just covered it up.

The descriptive approach says nothing about etiology, and Greenberg suggests it is not necessarily helpful in determining treatment. He describes a conversation with a former APA president who had recently diagnosed a patient with "obsessive compulsive disorder" after seeing her for a couple of months. He did so purely for insurance purposes (something Greenberg himself admits doing in Manufacturing Depression). The psychiatrist tells Greenberg that the label did not change the way he treated the patient, but "I got paid."

Yet Greenberg is not hopeful about the National Institute of Mental Health's efforts to identify the brain abnormalities underlying "mental disorders," thereby transforming psychiatry into "clinical neuroscience" (which is what Thomas Szasz, a much more radical critic of psychiatry, says the field would be if it were a legitimate branch of medicine). In the end, Greenberg concludes that the "provisional" judgments embodied in the DSM are the best that can be accomplished for the foreseeable future. He notes that more rigorous branches of medicine also have evolving disease definitions. For example, "diabetes is defined by a blood-glucose threshold, one that has changed over time."

True enough, but the indicator for diabetes can be measured objectively with a biological test. While the causes of diabetes, whether Type 1 or Type 2, are not completely understood, there are clear risk factors and plausible theories that can be investigated further. The disease has a predictable course, and it can be reliably treated. How many of the "mental disorders" listed in the DSM satisfy these criteria? The "imperial medicalization of normality" that worries Frances (and Greenberg) is possible precisely because DSM descriptions are unmoored from the sort of evidence on which standard medical diagnoses are based. And while psychiatrists and other mental health practitioners concede among themselves the "provisional" nature of the DSM, that is certainly not the impression they give to the people they label.

I considered some of these issues in a 2005 review of Szasz Under Fire: The Psychiatric Abolitionist Faces His Critics.

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  1. “The authority of any doctor depends on their ability to name a patient’s suffering”

    I don’t know how many people call me batshit crazy (45%), only exceeded by the people who think I’m f*cking looney tunes (55%), not to mention the diagnosis of dipsh*t insane (65%) and finally the 78% who say I am mathematically delusional – the other 22% think I should handle the gubermint budget.

  2. I’ve had met some good psychiatrists, but their primary function seems to be to write prescriptions for things your PCP won’t.

  3. “There is no definition of a mental disorder.”

    Well, except for Bill O’Reilly.

    1. Someone whose conviction of his own moral superiority is as strong as steel, who characterizes anyone who disagrees with him as his enemy, who shouts at, berates, and abuses people, who shamelessly performs in petty television theater and calls it reasonable discussion- that person is more properly called an asshole.

  4. At some point, the DSM volumes at large will merely be trying to pathologize the natural differences and eccentricities in human personality. As some mental health professionals have joked, there’s no entry for “Asshole” in the DSM-IV.

    1. But there is probably serious consideration of adding a section on the diagnostic usefulness of gutting a live chicken, then divining the billing possibilities from the entrails.

    2. There was – aren’t they removing Narcissistic Personality Disorder?

      1. Discussed yesterday in Slate:

        http://www.slate.com/id/2279895/

        Then there’s dimension reduction?here, we try to boil down the many measurements to a few numbers that really matter. This is what we do when we boil down all the aspects of a baseball player’s performance to his batting average (or, nowadays, OPS and Wins Above Replacement). It’s what the NRC was charged with doing?given all the data about graduate programs, put them in order from best to worst. And it’s the way the DSM, in its latest edition, now proposes to reclassify personality disorders. Instead of partitioning patients into groups, they are now measured on six personality axes: negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy. The patient previously known as “the narcissist” will now be a high scorer on four facets of “antagonism”: callousness, manipulativeness, narcissism, and histrionism. In the new paradigm, there’s no breakpoint where one personality disorder stops and another begins?there’s such a thing as narcissism, but no such thing as a narcissist.

        1. Yes, but what does this mean for me!!!!!

        2. Sounds nice and mathematically rigorous, but the devil’s in the details of how those “facets” are scored.

          Rather than making a diagnosis using pure fluff, they will now produce a bunch of “personality coordinates” using pure fluff, and then make a diagnosis using the coordinates.

          1. Then determine therapy/treatment based upon the coordinates.

            1. tomayto / tomahto

          2. This. And, as Frances aptly points out, the description is the diagnosis. There is never a pathogen or cause identified or even sought for. It’s just a collection of behaviors or emotions bottled up with a tag on it and a pill to “get paid.”

            Tom Szasz is looking smarter every day.

        3. Whatever happened to CRAZY? Did they take it outa the dictionary?

          1. Robitussin!

  5. I’ve heard that M.D.’s often joke about “Psychiatry being a profession for those who couldn’t handle becoming a doctor.”

    And they do deserve the scorn they get, and more. This is a “profession” that brought back shock “therapy” in the 1980’s. It is still in use today.

    1. While there is a lot to about the lack of evidence for many of the psychiatric interventions, electroconvulsive therapy is actually the exception to that. The evidence for efficacy of ECT for severe is quite good, better than antidepressants in fact.

      Your point still stands though. I’ve often said that psychiatry is by definition destined to be without good explananions for why the diseases happen and why their treatments help. If a disease is well-understood from a scientific viewpoint it falls in the realm of neurology, not psychiatry.

      1. The second sentence should read:

        “The evidence for efficacy of ECT for severe depression is quite good…”

    2. JD is correct. So-called “electroshock therapy” does seem to relieve severe depression, at least for a little while. It is not a preferred treatment by any means, but it can be useful for patients who are in danger of harming themselves and who have been resistant to medications, and for pregnant women.

      The patient is given medications to prevent the sort of convulsions you’re thinking of, and to eliminate pain. If you think of that scene in One Flew Over the Cuckoo’s Nest, imagine pretty much the exact opposite, and that’s what it looks like.

      1. I’m aware the process doesn’t appear as disturbing as it used to. However, it still damages the brain. This may be the actual reason it “helps” – by wiping away bad memories, the patient feels better. It’s Eternal Sunshine of the Spotless Mind, only on a far more global scale.

        1. How does it damage the brain?

          1. By killing cells, as tends to happen in any seizure. But lots of medical and surgical treatments for various conditions work by killing or removing pieces of the body.

          2. The main side effects are permanent memory loss and “cognitive impairment”. If ECT doesn’t damage the brain, how do these occur?

            1. Oh, I see, BP. Yes, you are correct. I am unaware of any studies showing damage to brain structures as a result of ECT, but you are right about the side effects. The therapy itself is poorly understand and no one really knows why it works, so no one really knows why the side effects happen, either. I suppose brain damage could be a possible reason.

        2. ECT induces a very brief seizure (except with general anesthesia, so that no convulsions occur).

          It’s not that ECT erases memories that are the source of someone’s depression; people still remember the things that depress them. It’s more like hitting a reset button. But like the lineup of psychiatric medicines, there’s no great explanation for its mechanism of action.

  6. Scientologists are going to have a field day with this.

    1. Even bigger than the one for Knight and Day?

    2. That occurred to me as I was reading this. Tom Cruise might be owed a big, big apology…he took a raft of shit for saying pretty much what Frances is saying.

      1. As skeptical as I am of psychiatry, it is at least composed (in most part) of people trying to learn about the causes of people’s emotional overwhelm and find ways to help them.

        Cruise is part of a worthless fucking cult that sells a “cure” about as worthwhile as snake oil, only more expensive. Fuck him with a cactus.

  7. I’m just hoping Chocoholism makes the cut, so I can get on the disability.

    1. Well, I’m hoping for masterbation – since I am so severly disabled by it, I should get triple benefits, and a 48 inch monitor for all the porn sites I visit

  8. No clear definition of mental disorders?

    A million proud, self diagnosed “aspies'” heads are gonna asplode.

    1. One serious issue is the possibility that Asperger’s will be merged with the autism spectrum disorders in DSM-V. If that happens, guess which spot on the spectrum is going to get the lion’s share of money allocated for autism treatment?

      1. Why would the Aspies try to fund treatment? Its practically a merit badge in my profession.

      2. People who work in I.T.?

  9. Maybe they should rename it the Diagnostic and Statistical Manual of Pretty Serious Mental Disorders (DSPM-5).

    And then cut out all the piddly bullshit. If it isn’t a psychosis, it doesn’t fly.

    1. Oddly enough, “psychosis” is a sort of umbrella term. You can be diagnosed with psychosis, but I do not think it’s likely that you will be diagnosed with just psychosis (at least not in the longer-term); it’s a manifestation of another serious problem.

  10. Psychiatry is a pseudoscience. The Mad Pride movement has exposed many of its myths.
    http://www.mindfreedom.org

    1. Speaking of scientology…

  11. I was in a conservation with a school psychologist the other day. We were discussing how we are prescribing narcotics for children even though we can’t define the disease. Whereupon the psychiatrist chimed in:

    “The lack of a definition is not an excuse for withholding a prescription to those that need it.”

    1. “The lack of a definition is not an excuse for withholding a prescription to those that need it.”

      That’s about as sensible and rationale as “I don’t know what’s wrong, but I’m sure a few leeches will fix it.”

      Psychiatrists = Medieval doctors?

    2. The medication of children with powerful stimulants is one of the most shameful and appalling things in modern mental health care. Some children may need those drugs, sure. But I have been present at smallish elementary schools where the first four hours of the school nurse’s day involve calling children into her office and giving them amphetamines or their chemical relatives. It was sickening.

    3. At which point I’m sure you asked how one could know that it was needed without a definition.

      It could be that he meant that they had guidelines for issuing prescriptions based on symptoms and efficacy in treating those symptoms, despite no clear understanding of the physiological mechanisms that could definitively identify a specific cause for those symptoms. You can take anti-fever medication without being certain what is causing the fever.

      I’m being charitable, of course.

  12. Hmmm, I’m not allowed to post because Reason thinks I’m spamming. Right…

  13. We’re not too far from the day when a psychiatrist will be named Fed Chairman.

    1. For a few secs., I thought that was a name. Of course it could also be a description. And some other day a psychiatrist may be fed named chairmen.

  14. I am no fan of Szasz- mostly because I believe his demagoguery has the potential to harm truly vulnerable and suffering people- but I do feel there is a kernel, or even several kernels, of truth in his repudiations of psychiatry.

    This post and its links lay out at least one of them nicely: medical definitions of mental disorders are disturbingly nebulous. The checklist approach does not, as Jacob points out, does not diagnostically allow for intrapersonal variation between symptoms, which means that if you meet criteria A, B, and C, you may, at least clinically, be diagnosed with disorder X. However, the patient’s perception of symptoms is not something professionals ignore. I am not trained to diagnose a person with major depression merely because they meet criteria in the DSM. I must consider the symptoms within the context of the patient’s life, circumstances, and perception of them.

    The public at large expects medical diagnoses to be discrete; this is how most of have been raised our whole lives to perceive illness. Cancer, for example, is a thing. We may not know exactly what causes it, but once it is present, it is tangible. It may produce varying signs and symptoms, but we can say that those signs and symptoms are the result of the cancer doing something, somewhere, to your body. A doctor can show you a picture of your cancer, and say that the drugs or radiation he is giving you will have an action X upon it.

    That is not so easy in mental health care. We can’t take a picture of major depression with a diagnostic machine and say, “Here it is. Here is what we can do about it, and here is how the therapy (be it pharmacotherapy or psychotherapy) works.” Even in disorders producing signs that are more tangible than those of major depression- say, the delusions of an episode of manic psychosis- we can’t really image that process with a diagnostic tool. We infer based on the binary appearance of those signs. To me, that is a problem and a shortcoming, but it is not going to stop me from giving a person suffering from manic psychosis a medication that will help curb the symptoms.

    Professionally, I feel that some mental health disorders have been…commercialized? Injected into the public consciousness in such a way that being diagnosed with major depression is now commonplace, and swallowing pills for it is no big deal- like taking vitamins for your brain in order to deal with life. This is unfortunate. To me, being diagnosed with major depression should be as serious as being diagnosed with cancer. A grave thing, an unfortunate thing. Not an easy thing.

    Anyone who has watched somebody close to them be diagnosed with a mental illness, especially depression, and then watched that person proceed to hang his every shortcoming on that diagnosis knows how frustrating mental illness can be, how often the treatments don’t seem to work, and just how often professionals can’t seem to help. It is by no means a perfect science. Right now, it might not even be a science at all, but that doesn’t mean we shouldn’t stop trying. Professionals must embrace the biomedical model and continue to search for tangible etiologies of mental illness. We have a long way to go.

    1. Szasz “demagoguery”?

      Dude, you’re fucked in the head. Seek treatment for reading comprehension or something.

      1. I’m not your dude, little man. I’m a doctorally prepared mental health professional who admires Szasz a little and despises him a lot. He is brave but I believe he is wrong.

        1. I don’t think Szasz is brave. But he isn’t always wrong…not always (e.g., there is a need to be vigilant regarding the potential for abuse in psychiatry).

  15. And yet there is chronic pain. In some cases it can’t be linked to an identifiable lesion, and it is always diagnosed by (as) a symptom alone. It is a real condition that responds to drugs and sometimes other treatments.

    This occurred to me only this minute. It struck me that at least some libertarians are advocates against “mental illness” as a scam, and yet for treatment of pain, whose patients are sometimes suspected as scammers, and the treaters of whom are sometimes suspected to be unscrupulous narcotics dispensers.

    How about chronic fatigue? There’s a good one for you!

    1. You are correct, the etiology of chronic pain is in many cases unknown or poorly understood, yet we treat it. Maybe the willingness amongst some libertarians, as you mention, to treat chronic pain as it should be treated (that is, without regard to the need for escalating doses, because that is unavoidable with narcotic medication, and correctly distinguishing between dependence and addiction) is because pain is an experience everyone knows. Everyone has felt physical pain, and everyone knows that pain is at least unpleasant, and at most a horrifying and excruciating ordeal. We can empathize with physical pain because it is a universal experience.

      That is not so with mental disorders. They are intangible. Not everyone has been depressed, had hallucinations, or suffered from an anxiety attack. We are less able to empathize and identify with people who have had experiences we have not. Couple that with the spectre of a severely depressed person- someone who, say, lays on the couch all day, does not bathe or eat or change his clothes, who moans and pules about his cruddy life, and can only say to you, “I feel bad” when you ask him what’s wrong. That scene simply infuriates many people, even professionals. We cannot naturally empathize with this; doing so must be learned. It seems to me that many people want to react to a depressed person with a swift kick in the ass and a shout of “Fucking get over it, you whiny bitch!”, but we would not do that to someone with throat cancer who was in severe pain. We can see the throat cancer. We can smell the blood, the sweat, and the fear. And we can all feel pain.

      1. lays on the couch all day, does not bathe or eat or change his clothes, who moans and pules about his cruddy life, and can only say to you, “I feel bad” when you ask him what’s wrong.

        I resemble that remark.

      2. Plus, people with chronic pain are rarely treated against their will. That is the main objection raised on this website.

        The ethical question is, do psychiatric patients, who may indeed be unable to perceive reality, have a fundamental right to make decisions regarding their own care? Since psychiatry cannot describe definitive etiologies for these conditions, the definitions used have an arbitrary quality to them. Can the medical profession or society at large force treatments in these cases? Do patients who are psychotic have a fundamental right to decline treatment that can reverse a break from reality?

        1. The ethical question is, do psychiatric patients, who may indeed be unable to perceive reality, have a fundamental right to make decisions regarding their own care?

          That’s not a hard question to answer, at least where I practice. The answer is “Yes, they do.” An adult person does not automatically lose their rights because they happen to be psychotic, any more than you would lose your rights because you are severely intoxicated on some sort of medication. However, the ER staff may not exactly be concerned with having a long talk about your consent to the treatment if they need to put an NG tube into your stomach and fill it full of charcoal. It’s the same with an episode of acute psychosis- if the person is a clear and present danger to himself or other people.

          Now, if a psychotic person is not a clear and present danger to himself or other people, he cannot be forcibly medicated against his will. It may require forgetting what we’ve all seen in movies and TV and popular conceptions of what acute mental health care is like, but ethically, legally, if you are looney tunes psychotic, sitting in your room and talking to John Lennon on the CB radio and smoking rope with God and harming no one else, I cannot medicate you if you don’t agree to it.

          1. Define “psychotic” without relying on “everybody knows what a psychotic is.” If you don’t agree with someone, are they “psychotic?” Or are you? My answer is the one who has less power over another person or persons.

    2. No libertarian wants to ban psychiatric drugs or prohibit individuals from voluntarily providing or receiving psychiatric “treatment”.

      1. In fact, I suspect most libertarians are against even requiring prescriptions for psychiatric drugs.

        1. Libertarians should be against prescriptions (government permissions) for any drugs.

          Many psychiatric treatments are coercively imposed by agents of the state (psychiatrists), which is why even Szasz reluctantly supported a ban on shock “treatment.”

  16. I have a mental disorder. It is exists. I agree that these things are over disagnosed and medicated, and I am not a fan of psychiatry. Of course, as a libertarian, I do not agree with forced treatment. I really wish it did not exist. I have been living with something 30+ years.. Part of it may be semantics- IMHO there is likely physical evidence of some sort present in “mental” ilness cases. Maybe there is a real brain disorder there. Maybe I was born with an invisible brain tumor. who the fuck knows?

  17. These concepts are virtually impossible to define precisely with bright lines at the boundaries.”

    This doesn’t mean there aren’t definitions or that the definitions are not useful. The desire for things to be neat and tidy fails in most attempts to understand complex phenomena.

  18. There is interesting evolution of drug abuse in this country with the explosion of the Mental Illness Industry.

    More and more the abuser-type goes to Dr. Dealer for his fix, if he has insurance. If Abuser-type doesn’t have insurance, either he buys ‘other’ fixes from the street, or like a carp, he bottom-feeds on the pill-chum from the Officially Sunny Surface constantly falling into murky black market waters.

  19. Judges and prosecutors, lawyers and psychiatrists, all protest their passionate desire to know why a person accused of a crime did what he did. But their actions completely belie their words: their efforts are now directed toward letting everyone speak in court but the defendant himself — especially if he is accused of a political or psychiatric crime. — Thomas Szasz, The Second Sin

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