Good morning, this is the second of what I hope will be reasonably regular newsletters directed at the evolving biocognitive model of mental disorder, the goal being to provide a valid alternative to the current mess in psychiatry. Is psychiatry a mess? Well, Dr Alan Frances certainly thinks so. His blog for Psychiatric Times on December 3rd was entitled DSM-5 Is A Guide, Not A Bible-Simply Ignore Its 10 Worst Changes. Good advice.
I’ve been saying for decades that psychiatry is a mess, my main criticism being that psychiatry fails every known test of what constitutes a science. The core reason is that it doesn’t have a model of mental disorder. What is a model of mental disorder? Well, it’s rather like the idea that if you give antibiotics to a person, you have in your head a concept of what certain disease states are, that is, you have a model of their nature. If you give antibiotics to a person with cellulitis, you are doing so because you accept the model that there are microorganisms out there but, if they get in here, they can cause trouble, i.e. you accept Pasteur’s germ theory of the causation of sicknesses.
Over the years, we have expanded that particular model to include viruses (fast and slow), fungi, protozoans and other nasties, but Pasteur’s basic model remains intact. We have lots of other models of disease, of course, including congenital, traumatic, degenerative, neoplastic, autoimmune and so on. All of these constitute distinct clusters of illness with characteristic causative mechanisms. When students begin medical school, they learn about the normal processes of physiology, then learn how these can be deranged by a variety of causes. Knowing the exact pathology allows a definitive treatment program tailored for each model of illness and tweaked for each individual case.
These days, orthodox psychiatry trumpets that they have the secrets of mental disorder nailed. It is only a matter of time (and money) before their laboratories begin to pour out answers to ancient questions, and humanity can ascend to new levels of mental well-being. Indeed, reading the frequent opinion pieces by the Director of the US National Institute of Mental Health, Dr Thomas Insel, you could be excused for thinking psychiatry is only taking its collective breath before smashing through the barriers to a golden future (search Insel TR on PubMed, he churns out about fifty papers a year). Dr Insel (who is a neurophysiologist, by the way) often says things like “Mental disorder is brain disorder. Everything we need to know about mental disorder will be revealed by the ordinary processes of laboratory science.”
This, of course, is pure rubbish. There isn’t going to be a breakthrough in psychiatry in any laboratory, just because mental disorder is not the sort of thing that can be sorted out using scans or gene sequencers. How could such a highly-qualified, highly-paid person as DirNIMH make such a catastrophic error? Easy: he doesn’t have a model of mental disorder. He thinks he does, but he doesn’t. He’s not alone: I’ve just had yet another critical paper rejected by yet another prestigious journal but the reviewer was quite explicit in rejecting my criticism: “I don’t need a model of mental disorder to know that antidepressants work, just as I don’t need a model to know that antibiotics kill bugs.” I don’t know who he was but he is clearly a complete fool: if he didn’t have an implicit model of certain illnesses being the result of invasion by microorganisms, he wouldn’t use antibiotics in the first place. QED. He would use blood-letting, or seances, or diet or something, but not something that kills bugs. Everything we do is done in the implicit belief that it will work, meaning we only use bugkiller when we think bugs are the problem, i.e. we have a model of illness as caused by bugs (the outstanding success of this “bacteriological” view of illness has been integral in our acceptance of biological psychiatry as shown in Dr David Healy’s The Antidepressant Era).
Before Pasteur’s revolutionary work, there had been attempts to prevent infections, even though people didn’t know that was what they were. The tragic hero, Ignaz Semmelweiss, discovered that if obstetricians washed their hands in hypochlorite after they had performed autopsies, the death rate from puerperal fever plummeted. However, the establishment didn’t see it that way: they were convinced that disease was the result of an imbalance of humours, the Hippocratic model. They refused to accept that contagion could be spread by the tiny bits of putrescent material under the fingernails: How could anything so small kill a healthy person? It didn’t make sense to them in terms of their model, so they rejected it. They thought they could discover the cause of puerperal fever by doing more autopsies, so they ended up killing more women. The doctors could not accept that illness could be caused by their own dirty hands.
So it goes with mental disorder: when mainstream psychiatrists look at the mentally troubled, they don’t see people in pain, they see cases of deranged biology which need to be shoved in increasingly overlapping diagnostic boxes. And, as every fool knows, deranged brain enzymes or chemicals can only be fixed by drugs, certainly not by talking or (ha ha) by sympathy. Dr Insel himself isn’t above mocking the idea that mental disorder could have psychological causes. How does he explain post-traumatic states? Chemical imbalance of the brain. Personality disorder? Chemical imbalance of the brain. Depression? Chemical imbalance of the brain. If everything can be explained by the same cause, then it isn’t an explanation at all.
In fact, Dr Insel has recently seen the error of his ways and has now proclaimed that mental disorder isn’t due to deranged chemicals, it’s due to deranged brain circuits, whatever they are. However, the solution is the same: More laboratory research, more scans, more genetic tests, more drugs. That his solution may be part of the problem hasn’t yet occurred to him or any of his supporters. We will talk about this more.
In early December, a French court convicted a psychiatrist of manslaughter and sentenced her to twelve months in prison, plus a fine of about $11,000, after one of her patients murdered his elderly stepfather. She was found guilty on the basis that she knew her patient was dangerous but did not detain him in hospital (the prison sentence was suspended but remains in place). Just recently, the first of what promises to be many claims was lodged against the psychiatrist who saw the Aurora (Colorado) killer, James Holmes. The basis of the claim is that she knew her patient was dangerous but did not detain him in hospital.
I see these claims as destructive for two reasons. First, they assume something about the psychiatric process which is factually false, and second, they will have far-reaching, adverse effects on mentally-troubled people. The false assumption is that psychiatrists (or anyone, for that matter) can reasonably predict homicide (or suicide etc). No, we can’t. These events are so rare that no person or profession can claim to have a formula that allows the prediction to be made. For example, about half my patients express suicidal ideas when I first see them. In thirty years, not one of them has subsequently committed suicide, so forcing them all into hospital would have been a) pointless as they weren’t in danger, b) logistically impossible, c) very destructive to them, d) a denial of their rights and e) outrageously expensive, not to mention getting me a reputation as somebody who panics at the mention of suicide. People who say, “Oh, he should have been admitted to hospital” have obviously never tried ringing a mental hospital at night to get somebody admitted.
The adverse effect (The Law of Unintended Consequences) is that psychiatrists will now be far more inclined to reach for the committal orders than before. Err on the side of caution, that’s what they will say; if in doubt, lock him up. So more and more people will be detained, on less and less evidence, for longer periods, to get more drugs and ECT and, once in the system, they tend to never get out. I get a regular stream of emails from people, saying things like: “I agreed to go to hospital six years ago after I took an overdose, and they still have me under an order. I have to take drugs, I can’t leave the town, my money is sequestered, I can’t move, they come into my home at will, I can’t drink or even go into a bar. I have no life. Please help me get my freedom back.” But when being detained drives people to violence or suicide attempts, that is taken as proof that they need further detention, not as proof that they shouldn’t have been there in the first place.
Bizarrely, many people in this country are subject to continuing treatment orders on the basis of the risk of “reputational damage.” What this means is that if they don’t get the drugs, they will automatically go crazy and automatically damage their reputation. Nothing is automatic, not even homicide, and what reputation is left to a person who has been in the system for six years? The system is now sillier than any of the people it is supposed to be helping. Making psychiatrists responsible for their patients’ (occasional) crimes will only make matters worse for the vast majority of mentally-troubled people who never commit crimes.
On the other hand, last month saw the totally unnecessary death by suicide of the archetype of the nerdish computer genius, Aaron Swartz. The story is complicated but briefly, this brilliant but very erratic young man was charged with stealing after he downloaded millions of academic papers from an archive and made them available to the public. He faced 35yrs in prison for an offence that was no longer: the archive subsequently released them anyway. The case was pursued by the Massachusetts Federal Attorney, Carmen Ortiz and her assistant, Stephen Heymann, who took an intensely personal and hostile stance on what most people saw as little more than an undergraduate prank. The threat of imprisonment was too much for Swartz, who couldn’t comprehend the venom behind the prosecution.
What we can be sure of is that Ortiz and Heymann will not be held responsible for their actions. They will say (and Ortiz’s husband already has said on her behalf) “Oh no, it was his decision to kill himself, it had nothing to do with us.” So when governments actively drive people to suicide or homicide, that’s nothing and they don’t have to improve, but if psychiatrists don’t act to prevent suicide or homicide, that’s really something. The net effect is that, for the mentally troubled, the noose tightens and life will get that little bit worse.
Interestingly, my computer has been attacked by a virus this week (I use Linux and keep up to date so it’s normally not a problem). Somebody running advertising programs hacked in and stole my email address list, then sent spam to all of them. I’ve had several spurious emails this week from people I know, all spam from companies that use the NBC logo. Can I be assured that these pests will be hounded to death by Ms Ortiz and pardners in the pursuit of cyberjustice? I won’t hold my breath.
I will try to publish comments etc. but please keep them brief and reasonably polite.
As always, I cannot give any psychiatric advice to any person for any reason.
In chapter 16 of my new book I test the biocognitive model and the clinical syndrome of ADHD. I show that nearly all childhood and “adult” cases can be accounted for in terms of anxiety, personality, and the mislabeling of normal childhood. Two critical articles in this vein would be Zimmerman’s 1999 paper Is Comorbidity Being Missed and Morrow’s 2012 paper Influence of relative age on diagnosis and treatment of ADHD in children (FREE!!!).
In Comorbidity Missed, Zimmerman’s sample was an outpatient clinic made up of fee-for-service patients including Medicare but not Medicaid. 500 randomized patients were assigned to either SCID (long structured interview) or semi-structured interview (“routine” in their words). 96% of the “semi-structured” group were interviewed by psychiatrists. The combined samples (500 & 500) were approximately 60% female, 93% white, 64% some college, and 48% married with an average age of 39.Of the 500 regular interviews only ~200 anxiety disorders were diagnosed whereas SCID had ~550 (out of 500)! What is important to note is that the number of mood disorders were about the same between the two diagnostic arms (~350 each). Social (16 vs 143) and specific (4 vs 52) phobias had some of the highest rates of underdiagnosis. Zimmerman also has many other excellent papers regarding borderline personality disorder being misdiagnosed as bipolar disorder (see 2011 FREE! and 2010). They showed that “40% (20/52) of the patients diagnosed with DSM-IV borderline personality disorder reported having been misdiagnosed with bipolar disorder compared to slightly more than 10% (62/558) of the patients without borderline personality disorder.”
“A huge and long-term study from British Columbia looked at 937,943 children who were between six and twelve years of age at any time between December 1st 1997 and November 30th 2008. This compared the child’s month of birth with the risks of acquiring the diagnosis of ADHD and of being treated with stimulants, for boys and for girls. Methodologically, the study appears very sound. The researchers found that the risk of the diagnosis for boys born in December, the last month of the academic year, was 30% higher than for boys born in January, while for girls, the increase in risk was an astounding 70%. This means that children born in the month of December were at much greater risk of having a “genetic illness” than children who dragged their feet and arrived in January. Similarly, the risks of being prescribed stimulants was 41% higher for December boys while, for girls, the increase in risk was a completely improbable 77%. In boys, the rates of diagnosis and prescription were approximately three times those in girls. Boys, of course, are physically more active than girls and verbally less proficient until well into adulthood, differences which are never entirely obliterated in the community.” The best way to see this paper is to follow this link.
If anybody has a book they wish to recommend, let me know (better still, write a hundred words on why you liked it and I’ll post it).